Up-skilling your aged care workforce

The skill and knowledge base of employees in the aged care industry must match the innovation their organisation is seeking. Louise Absalom and Trish McReynolds report.

In July 2000, a group of rural aged care facilities formed an aged care network to support each other in meeting the new upcoming aged care accreditation process – Aged Care Quality Association (ACQA). Since then, this not for profit, self managed organisation has continued to support its members to implement sustainable aged care quality management systems that will demonstrate improvements in quality of care and to share information at regular network meetings. However, within the networking forum, the challenge of sustainable organisational management continues as a common discussion point of merit. Identified factors often raised at networking meetings include the turnover of management staff, sustaining the matrix of staff and staffing skills, maintaining the correct staff to resident ratio mix without compromising the quality management system, and staff ability to be freed from regular duties to attend ongoing training and networking meetings.

Since 1997, and with the introduction of the Aged Care Act, the aged care industry has changed dramatically. The skills required by staff to meet the needs of aged care providers and maintain compliance is exhaustive. Gone are the days when Registered Nurses moved to aged care at the end of their careers. Registered and Enrolled Nurses need to be highly skilled to work in aged care, to support all the regulatory requirements required to maintain compliance and constantly improve. Newly trained nursing staff are not always prepared for the challenges they will face once appointed to a position within an aged care facility.

The current ACQA management committee consists of educators, nurse advisors, aged care auditors, aged care business proprietors, managers of aged care facilities and quality managers in both aged and acute care organisations. Below is a summary of an essay by Louise Absalom, Diversional Therapist (current committee member of the ACQA management committee), completed as part her Graduate Certificate in Adult and Vocational Learning, undertaken through the University of South Australia. We have included this review, as it outlines the challenges facing management, staff and training organisations in meeting the demands of employing, retaining and maintaining a trained, skilled aged care workforce. The article suggests that the complex adaptive systems model has the capacity to support organisational change and innovation through reinforcing values such as empowerment, respect, adaptability, and responsiveness to client need and by demanding a linear management model through increased motivation, interconnectedness, information flow, positive communication channels, feedback and self organising.

The Australian Bureau of Statistics (ABS) (2008) identifies that in 2007, there were 2.4 million people aged 65 to 84 years, with anticipated growth average of 2.7% per year to 2011, followed by accelerated growth averaging 3.5% per year to 4.0 million in 2022. The ABS (2009) further identifies that in 2006, 17% of this generation lived in aged care. However, the ABS (2005) also notes a 22% decline in workers within Residential Aged Care during the period 1986 to 2001.

Chenoweth, Jeon, Merlyn and Brodaty (2009) reviewed factors required to attract and retain nurses in aged care, concluding a variety of changes are necessary to support staff retention within what has been identified as a growth industry. These include a positive organisational philosophy, respect, valuing and empowerment of staff, effective leadership and communication, promoting a flatter hierarchical approach, as staff initiative in decision making within the organisaiton is encouraged. (Stamps, 1997; Resnicow and Page 2008).

Resnicow and Page (2008) suggest complexity theory, promoting selforganisation via nonlinear paradigms, creates a pathway for organisational change and innovation necessary to promote staff retention within aged care. Ligaro (2010) in considering the relationship between culture and learning highlights the education body has a responsibility to shape learners with the skills to reconstruct the learned concepts and ideas within the greater social and cultural dimension.

Literature review
Anderson, Ammarell, Bailey, Colon-Emeric, Corazzini, Lekan-Rutledge, Piven and Utley- Smith (2005), in their author manuscript, use a descriptive scenario highlighting that complexity theory has the capacity to support change within an organisational system based on care needs. Whilst simplistic in approach, the scenario demonstrates adaptability and responsive actions. Offering a realistic account of daily experiences within the chaotic environment commonly evident within aged care, the text emphasises the flexibility which can support quality care when an organisation operates as a complex adaptive system.

Kovach, Morgan, Noonan and Brondino (2008) state it currently takes an average of 15 years for a new clinical procedure to reach a use rate of 50%, proposing that to embrace innovative practice and positive change, the aged care facility must adopt a complex and adaptive system. In this article, a complex adaptive system approach was implemented in the form of an innovative pilot project over nine aged care facilities. The study analysed connectedness, organisational harmony, clinical leadership, and timeliness and understanding within the chaotic environment of dementia-specific units. Positive changes in the level of care resulted in pain reduction and improved nursing assessment and treatment, through affirmative organisational culture change and working conditions.

Scott and Steinbinder (2009), however, in their journal article discussing innovation cycle for small and large scale change, consider change from a more comprehensive perspective. The authors reflect on those political and social drivers within the health industry which now stand to inhibit and encumber innovative opportunity.

As with Kovach et al (2008) and Anderson et al (2005), Scott and Steinbinder (2009) view complexity theory and the introduction of complex adaptive systems of management as the means to facilitate the change process within the health care setting. Their reflective article challenges the underlying beliefs of the health care system and proposes that in order for change to be effective, new change models must be encouraged which support the input of all stakeholders within the system. The authors discuss a creativity process which leads the reader through an innovation cycle form brainstorming to prioritising, small scale testing and piloting. Acknowledging key improvements for future implementation, the authors proudly advertise the success of the innovation and resultant organisational change, which they declare is based on flexible interrelationships and open exchange of ideas within a linear management model.

Akerjordet and Severinsson (2008) in their literature review, suggest emotional intelligence offers nurse leadership an avenue for cross boundary communication, set within a social context. Emotional intelligence expresses core competencies reflective of the ability to identify, process and manage emotions enabling leadership in a knowledgeable, approachable and supportive manner. The authors also suggest that this leadership skill base has the capacity to reduce the threat some staff may feel within the change process or when faced with chaotic circumstances, therefore promoting the opportunity for creativity and ease of movement within organisational change.

Whilst verbose in nature, written from an educational philosophy perspective, Morrison’s (2008) report provides a thorough expose of complexity theory. In highlighting the focus of the relationship within complexity theory, Morrison (2008) draws attention to the interaction of individuals within a given working unit, describing co-evolution, connection, cooperation and competition as necessarily forcing development for mutual survival; that is, the behaviour of the complex system as a whole, being greater than the sum of its parts.

Discussion
Kovach, Morgan, Noonan and Brondino (2008), identify that hierarchical organisations promote closed and resistive cultures. In examining traditional management models, Kovach et al (2008) stress the current regulatory practice of reliance on rules and rule enforcement, stems from a hierarchical approach to management which does not support self-organisation. As with Anderson et al (2005), Kovach et al (2008) highlight the consideration of stakeholders within aged care, that is, that the organisation consists of people, either as managers, workers or recipients of care. Complexity theory, through removing traditional hierarchical models of management, promotes linear and open communication, diversity of practice, teamwork and timeliness of information transfer. Chenoweth et al (2009) referred to similar qualities as necessary in encouraging staff retention within aged care. Complexity theory, therefore, has a major role to play in advancing both staff continuity and client care. Both Kovach et al (2008) and Anderson et al (2005) refer to the capacity for improved quality of care, and new opportunities for improvement as a result of organisational openness, and response to the environment, thereby promoting a dynamic and evolutionary approach to aged care.

Anderson et al (2005) stress the basis for change is in open, communicating relationships, such as are promoted within the vigorous approach to change demonstrated within complexity theory; Kovach et al (2008) support this, and further add that this linear approach to self-organising has the capacity to promote innovation and timely innovative practice.

Scott and Steinbinder (2009) discuss communication based qualities of the complex such as unity and shared purpose, having flexible, permeable boundaries, and ease of information transfer. These qualities have also been identified by Kovach et al (2008) and Anderson et al (2005). Attwood, Pedler, Pritchard and Wilkinson (2003 p.145) add further support to the importance of effective communication, stating creativity and productivity are likely to depend on the quality of the relationships among people.

Scott and Steinbinder (2009 p.336) further advance the concept of multidimensionality, described as the ‘organisational flexibility to view the environment from many different perspectives and apply a variety of thinking styles and core competencies to issues and problems’. This approach removed hierarchical barriers, bringing together employees across all fields, in developing a cohesive approach to care. Models such as this have the capacity to place group members outside of their scope of practice, and therefore operating within a chaotic atmosphere. It is at this point where creativity has the capacity to thrive (Morrison 2008). The adoption of multidimensionality, therefore highlights leadership maturity within the complex adaptive system.

Recognising the evolutionary process of nurse leadership, from a top-down to a more collaborative approach, Akerjordet and Severinsson (2008) suggest emotionally intelligent nurse leadership inspires by creating a future vision, focussing emotions and motivation, and encouraging and allowing high performance; consequently leading to goal achievement. Whiteley (1995) acknowledges managerial change is required to lead into the chaotic, unpredictable nature of the global marketplace. Akerjordet and Severinsson (2008) support Scott and Steinbinder’s (2009) concept of multidimensionality, stating emotionally intelligent leadership encourages the development of adaptive ways of environmental interpretation and of offering improved social support. This ideology supports the interrelationship principles within complexity theory.

Whilst Anderson et al (2005) and Kovach et al (2008) highlighted the necessity for change supported by the tenets of complexity theory; neither article offered an operational framework. Similarly, Scott and Steinbinder (2009) promoted a comprehensive model of implementation, however did not allude to the management or leadership style necessary for successful application of the complex adaptive system. Yet each of these articles espoused the need for open communication, information flow, good connections and relationship building across what has previously been considered segmented and hierarchical organisational structures. These attributes are highlighted by Akerjordet and Severinsson (2008) as underpinning the emotionally intelligent leadership role. Therefore, emotionally intelligent leadership has the capacity to offer the means for guiding and supporting the successful implementation of complexity theory through the agency of complex adaptive systems. However, as the authors emphasise, a pedagogical method of thinking is essential in promoting the skill level vital for creating an environment supportive of change and empowerment through self-organising.

As with Anderson et al (2005), Kovach et al (2008) and Scott and Steinbinder (2009), Morrison (2008) promotes complexity theory as cyclic, endorsing feedback, and connectedness within open relationships, encouraging information flow and self organisation. He acknowledges that complexity theory is a relationship rich, process driven, evolutionary journey between the individual, the social group (e.g. work setting), and the wider society (in the case of aged care, this might include social, political, cultural and economic influences). Morrison (2008 p.22) also identifies complex adaptive systems as possessing the capability to ‘scan and sense the external environment’ in order to make internal adjustments in meeting demands, resulting in flexibility, change and ultimately in developing an awareness of power as indicated by Akerjordet and Severinsson (2008) to be necessary in the emotionally intelligent leadership role.

However, Morrison’s (2008) article progresses beyond simply noting the value of complexity theory, as he explores the relationship between complexity theory and education. He poses questions relevant to the discussion within the context of this review, in considering change and innovation in complex adaptive environments.

Morrison’s (2008) article identifies the relationship between the complex adaptive system and those training bodies responsible for imparting knowledge to future employees of these organisations. Scott and Steinbinder (2009) alluded to this in their discussion regarding multidimensionality. Training bodies, therefore, have an educational responsibility to ensure students graduate into the working environment with the capability to participate in organisational flexibility. Morrison’s (2008 p.23, 24) questions, whilst written with the formal learning environment in mind, transfer equitably to the training needs necessary to equip students for employment within a complex adaptive system and when exposed to chaotic demands. They include, ‘what does it mean to ‘know’ in a climate of uncertainty; how do we identify value rather than control; what are the risks and benefits in moving from imposed control to emergent order (self-organisation); what kind of feedback promotes emergence, self-organisaiton and connectedness; what does connectedness mean in practice; how can creativity, collaboration, autonomy and co-operation be promoted; how can nonlinearity be recognised and promoted whilst still ensuring high quality outcomes; and how can teachers [leaders] participate as equal partners in the collaborative process’?

Whiteley (1995) authenticates this understanding, affirming the future leader will need to develop skills in interpreting environmental impacts, empowerment, relationship building and enabling. Enriching the information transfer process with the knowledge to meet these questions will allow future students the capability to move into a complex adaptive systems with the confidence and participatory skills necessary to further support change and innovation processes within that complex adaptive systems, or when interpreting a chaotic situation. Akerjordet and Severinsson (2008) also refer to the leader who can motivate staff to engage in self-reflection in relation to learning, has the capacity to create openness to knowledge building, resulting in expansion of consciousness and attitudinal change.’

Conclusion
Statistics support that aged care is an area of workforce growth in the future. However, statistical evidence also suggests the issue of staff retention has the capacity to impact on continuity of care, thereby placing considerable pressure on aged care providers to maintain an appropriately skilled workforce. The aged care environment is, and will continue to be a chaotic, demanding workplace, defined by the degenerative nature of the ageing process.

This review conducted by Mrs Absalom, whilst limited in breadth of articles reviewed, has highlighted the appropriateness of incorporating complexity theory into a management regime. The complex adaptive systems model has the capacity to support organisational change and innovation through reinforcing values such as empowerment, respect, adaptability, and responsiveness to client need and by demanding a linear management model through increased motivation, interconnectedness, information flow, positive communication channels, feedback and self organising’.

The Aged Care Quality Association can now demonstrate that its innovative approach, implemented over the last 10 years, supports flexible interrelationships and open exchange of ideas within a linear management model. The management committee consist of members of the association. Network meetings provide feedback and changes to the program, based on members needs.

Furthermore, since May 2010, ACQA has been given the privilege of operating the Joanna Briggs Institute Aged Care Unit. This unit is one of the 67 international collaborating centres of the Joanna Briggs Institute. The Joanna Briggs Institute (JBI) is an international not-for-profit, membershipbased, research and development organisation based within the Faculty of Health Sciences at the University of Adelaide, South Australia, that collaborates internationally with over 60 entities across the world. The Institute and its collaborating entities promote and support the synthesis, transfer and utilisation of evidence through identifying feasible, appropriate, meaningful and effective healthcare practices to assist in the improvement of healthcare outcomes globally. The Joanna Briggs Institute Aged Care Unit is focusing on “Evidence Transfer” by supporting clinicians to make informed clinical decisions at the point of care by utilising the best available evidence produced by the Joanna Briggs Institute collaborating entities including clinical guidelines, clinical auditing and education available on the Aged Care Connect Node of the JBI Connect Plus website.

The ACQA, in collaboration with Joanna Briggs Institute Aged Care Unit, has also set up an Evidence Utilisation Group to support their members to conduct and publish the results of clinical audits and the implementation of evidence based guidelines.

The review conducted by Mrs Absalom has also highlighted that specific management skills are required to ensure success. At the same time, the skill and knowledge base of employees must match the innovation the organisation is seeking. Further reflection on the relationship between complexity theory and educational philosophy is suggested in continuing the development of the continuum of education, employment, organisational success and staff retention.

Louise Absalom

Louise Absalom (Diversional Therapist) and Trish McReynolds (Director Joanna Briggs Institute Aged Care Unit) are Committee Members of the Aged Care Quality Association.

As an adult educator (TAFE SA – Pt. Augusta Campus, offering Certificate Four and Diploma in Leisure and Health), Louise contributes to ACQA in a positive manner by offering a link between ACQA, TAFE (and therefore National Training Packages), the student body and residential aged care facilities. Her role also includes involvement in the vocational work placement process. Within these roles, Louise has a strong commitment to promoting the ethos of the quality process.

In 2010, Louise undertook a project manager position, facilitating education and quality management of A.M. Ramsey Village and Nerrilda Nursing Home, both facilities forming part of the Port Augusta City Council commitment to ageing.

Louise’s focus within aged care is clearly on Lifestyle and Leisure, and this has been supported by her completion of the Bachelor of Health Science (Leisure and Health) through Charles Sturt University. Louise completed a Graduate Certificate of Adult and Vocational Learning through Uni SA in 2010 and was appointed Vice President (1) to Diversional Therapy Australia in 2011.

Trish McReynolds

RN, BHltSc (Nursing), GCertBiometrics, External Aged Care Quality Assessor

Trish has been involved in aged care since 1998. Her interest in aged care quality management resulted in the establishment of ACQA as a notfor- profit, self-managed, aged care quality association. She is the network coordinator, educator and Public Officer of the association.

In December 2005 Trish was in the second intake of Aged Care Clinical Fellowships funded by the Commonwealth Department of Health and Ageing program that was facilitated by the Joanna Briggs Institute (JBI). Trish predominantly works as a consultant in aged care in quality management and nurse advising. In October 2009 she was appointed to the Department of Health and Ageing Administrator and Advisor panels.

Trish was appointed the Director of the the National Evidence Aged Care Unit in April 1010.The National Evidence-based Aged Care Unit (NEBACU): a collaborating centre of the Joanna Briggs Institute, Royal Adelaide Hospital and The University of Adelaide, Australia.

References

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