Quality of care for frail older adults

Our successes in improving life expectancy has led to increased years of life lived with multimorbidity and dementia with increased support needs. Much of the support given to frail older people is provided by family and informal support networks with significant impact on their physical, psychological, and financial well-being. Demographic and societal changes are reducing the capacity of family to offer this care. Formal home-based, center-based, and long-term/residential/nursing home care services are predominately provided by untrained care staff working under supervision from nursing staff. Difficulties recruiting and retaining these staff is leading to major challenges to meeting the needs of older people (Chenoweth et al., 2010). This volume contains a number of studies focusing on ways to improve care provided by these services for frail older people. The approach underpinning these papers and many perspectives of good quality care for older people is the need to be person-centered where the older person identifies their own goals for care and assessment of need, employing a holistic and strength-based approach incorporating their interests, values, and capacities (Vernooij-Dassen and Moniz-Cook, 2016).

Using different methods, two studies examined factors that could enhance person-centered care in the nursing home (Dennerstein et al., 2017; Røen et al., 2017). Dennerstein et al. (2017) used a randomized controlled trial to investigate whether reading the life story of residents living in an Australian residential aged care facility improved knowledge of the resident. Staff either read file notes or the life story of residents who they supported. Staff completed the Knowledge of Resident Scale before and after reading the documentation. Both groups had significant improvements on eight of the ten questions on the scale and the overall score indicating that reading either form of documentation helped them learn more about residents. The staff who read the life story only showed greater improvement on the question “How well do you know the life history of the resident?” Findings suggest there was little benefit of reading the life history over file notes, although combining the two may have led to greater understanding of residents’ needs. Findings warrant exploration in a wider number of settings and amongst residents with dementia where staff may have greater difficulty accessing the person's life story. This study also raises concerns about the impact of care plan documentation on the quality of residents’ care. File notes were able to significantly improve staff knowledge of residents whom they were already caring for suggesting staff had not previously read these files. Our research in care homes has found that staff rarely have time to read care plans and updating them often becomes a tick box exercise (Moore et al., 2017), although action research approaches can help staff reflect on practice to introduce more meaningful assessment and review (Lea et al., 2012).

Røen et al. (2017) examined factors that affected person-centered care by surveying over a thousand staff from 45 Norwegian nursing homes. They examined a broad range of organizational, individual and environmental factors that could potentially predict person-centered care and found that staff job satisfaction was the most important predictor. Staff working in special units dedicated to dementia care reported higher levels of person-centered care than those working in general nursing home units. Staff with three or more years of health-related education, lower demands and role conflict, high mastery, empowering leadership, innovative climate, and perception of group work in addition to physical environment were also associated with higher self-reported person-centered care. The extent to which staff self-reported person-centered care or knowledge of the resident results in high quality care as experienced be residents and family, however, requires further research.

Another two studies focused on quality of care and the employment of staff from overseas in the home. Findings from both of these studies highlight that a relationship-centered approach where older people, their family carers and staff are able to establish relationships that engender trust and respect can enable the needs of the older person to be met collaboratively (Cohen-Mansfield et al., 2017; Tam et al., 2017). Tam et al. (2017) undertook qualitative interviews with a difficult to reach group of foreign domestic workers from Indonesia, Philippines, and Myanmar who provide live-in support for frail older people in Singapore. This study raised a number of concerns regarding the growing number of foreign workers who are filling workforce shortages to care for frail older adults in high income countries. The authors highlighted that the isolation, 24 h care provision, sleep disturbances, and lack of respite that these workers endured, led to levels of burden consistent with that experienced by family carers. Despite the similarities of their experience with family carers, these staff often did not have access to community respite services, education, or peer support programs and often had pressure from their employer and the client's family. When the family employed a team-based approach with the staff member to support the older person, staff reported positive relationships and found their job rewarding. Other staff had poorer experiences due to low support with more pressure and criticism from the family. The importance of education, particularly in dementia care, was evident to improve staff confidence and satisfaction. The authors provide potential solutions to the difficulties raised that provide useful guidance for similar services.

Cohen-Mansfield et al. (2017) approached assessment of quality of care from the perspective of the older person and their family through developing the Quality of Care Questionnaire. They were also concerned with quality of care for frail older people receiving full time in-home support by overseas workers in Israel. They identified two factors; one focusing on responsiveness to physical needs and the second reflecting the quality of the social interaction and relationship between the client and the care staff.

One of the strengths of the Cohen-Mansfield et al. (2017) study is that the authors distinguish this tool from a satisfaction survey arguing that satisfaction surveys also reflect the expectations of the person assessing satisfaction. Many services may evaluate their quality of care through the use of satisfaction surveys but these have limitations and may elicit overly positive responses from clients who are grateful for the support they receive. A more promising strategy for improving the responsiveness of care services is to meaningfully engage older people and their family carers in the development, evaluation, and ongoing monitoring of care programs (Giebel et al., 2017). This can help services to build better working relationships between older people, their family carers, and the staff who are supporting them.

There remains a lack of high quality research to describe interventions to improve the quality of care of frail older people (Cooper et al., 2017) and improve the recruitment and retention of aged care staff (Chenoweth et al., 2010). However, there is evidence that good quality care needs to address the goals and needs of the older person and their family carers, be provided promptly and with continuity by well-trained and supported staff and that this needs to be partnered with respect and positive social relationships between all involved. To provide good quality care, staff need to feel that their job is rewarding and that they are respected and appropriately rewarded for the work they do. Greater reliance on overseas workers may create obstacles in communication and cultural differences may hinder relationships, however, these obstacles can be overcome when hierarchical structures are broken down and adequate peer support, clinical supervision, and training is provided. Care organizations may be able to address these obstacles to improve the experience of their staff, however, a greater societal change is required to improve the status of working in aged care to enable career progression to promote innovation and motivation in this sector.