Both are valid questions and only one, really, that can be answered by those who were a part of the aged care industry before it was an industry. I don’t believe that care has ever left the industry and will preface this article with the belief that aged care nurses are amongst some of the most dedicated compassionate people on the planet. I have been left wondering, why do we spend so much time justifying the provision of care?
It’s not a healthy habit to look back all of the time, and as a good friend of mine says “hindsight is a beautiful thing, but it is 20/20 vision out of your backside!” Sometimes, however, we need to look back to lessons learnt to ensure we are not destined to make them again.
Just recently a glimmer of hope, a ray of sunshine through the jungle of red tape and documentation that is the aged care landscape – it came in the form of a seminar on proposed changes to aged care in the form of CDC or consumer directed care, which has the potential to restore the time to care to a care industry, but more on that later.
I am a third generation registered nurse in my family. All of whom have been in the aged care industry. My grandparents started the journey in 1964 here in Melbourne launching, in what was then Perpetua Private Hospital in North Carlton, a 10 bed converted house, providing quality care to the aged. After a few years, they expanded to 16 beds which was a huge commitment for them. It was a very “Florence Nightingale” inspired type establishment, with my Irish Grandmother every bit the stern Matron walking around with the white glove ensuring the home was kept in tip top condition.
My grandfather (a pioneer in men becoming registered nurses), was the Director of Nursing. He was trained at Whipps Cross Hospital in London, and worked at the Repat hospital here in Melbourne before branching into the private sector. In those days the Repat was very much a military run hospital with principles that drove his determination, discipline and structure was the key to good care.
As nursing was in those days, you were very much subservient to the doctors who were the gods of all they surveyed, but as a nurse you were there as the carer, cleaner, housekeeper, basically a jack of all trades. On top of this, you were a friend, companion, and emotional support for the patient and their respective families. Nurses were more than just workmates or compatriots to each other, they were pseudo-family and relied on each other for support as their jobs were not likely to be open for discussion or decompression when they got home. Nursing historically was a very female dominated industry, and with this, they went home to run their households as well.
Patients were cared for without exception, everyone was showered, cleaned and up and on the move early. Beds were made with hospital corners, and rooms with four or even six patients in them looked ship shape before the nurse left the room. Everyone had breakfast lunch and dinner, with morning afternoon tea and supper provided. Meals were prepared by a cook, not a chef, who was an amazingly talented woman (who I still see) who could conjure meals from nothing and have everyone fed from the patients to staff and even the delivery men. Resident choice was not a big thing, nor was it expected, as the care model was well as straight down the line as my matron grandmother was.
Jump forward twenty years, my parents are now in charge of the same facility, still a private hospital as aged care was not yet really an entity all on its own. In fact, this was seen as a third or fourth rate level of nursing. My mother and father now holding the reins, my father a registered nurse trained at Repat under the hospital based system, funnily enough had my grandfather not have worked for them my father would never have been trained as it literally was the only place that would take him, as nowhere had facilities to accommodate men, imagine that now!
This is the era of my childhood, and in my mind the golden age in the care for the elderly. I grew up in the house next door and being around the elderly was a privilege that I look back on with a glowing hue. The nurse was very much still in charge of the day to day clinical side of the home, but my mother who was not a qualified nurse but very much a “nurses nurse” (she was trained by my grandparents) and was there to ensure all care was carried out to a tee. Every man was shaved, ears and eyes were cleaned. Men had ties on and hats and women were made up hair up and nails painted and all were ready to take on the day, even if there really wasn’t much on for the day.
I would on a daily basis make my way across the yard to the side door and begin my rounds of the day by asking Theresa the cook for breakfast, yes the same cook as worked for my grandparents was still going strong, and she never disappointed. I’d then make my rounds visiting the now twenty patients or, as I saw them, my twenty grandparents that I had at my fingertips. I’d sit on their beds and talk sometimes I’d just sit and watch, but here some thirty plus years later I can still tell you their names and their visitors’ names and can picture their faces smiling and happy to receive me and my siblings for a chat or a cuddle. I was recently reminded by my father that your Christmas’s, birthdays, and well every significant day of the year was spent surrounded by these people as our lives were intertwined with theirs and we would all celebrate together in the lounge or dining room.
The nursing staff seemed to be busy all the time, another remnant of the Florence Nightingale school of nursing, a nurs, after all, should always look busy, even if they are not! Behind the cloak however was a bunch of amazing nurses who just knew everything when it came to these patients, from when they wanted to get out of bed to what they liked to wear on which days, when they would be down as an anniversary of a loved one came around, to when they were raring to go because “its Wednesday and my sister visits every Wednesday at 10am”. It was a pleasure to watch these women, and few men from time to time go about their duties, laughing and carrying on and lifting the spirits of the whole home as they went about what was a difficult and pre no lift policy era, often back breaking job.
It was during these times that the government started down the road of centralising financial control which has developed into a monster. For those that are old enough to remember, these are the days of CAM SAM funding, which then morphed into RCA, then RCS funding then into ACFI which we are dealing with now, but I digress, financial control is an article all on its own, and a matter of discussion for a different time.
During these formative years I developed my love for nursing and from as long as I can remember it’s all I wanted to be! And forward a further ten years, 1993 and here am I, a nursing assistant on my first day at my parents’ nursing home, now relocated out to Donvale and doubled in size. Still not considered an aged care facility, it had to commit to “private hospital” guidelines. A beautiful home, with all the mod cons, bells and whistles but something was missing, the history in the walls the smells of years of bleach and homeliness that two generations of care and love had instilled in the corridors was absent. The care, the very essence that was nursing was not gone, in fact it was picked up and transplanted some twenty five kilometres to the east, and this was my time.
I was a nursing assistant there working in the same section of the home for about three years looking after the same patients now called residents every day, taking care of their every need. I knew these people’s routines down to the particulars that no one outside of a trusted confidant should know, like from when a hair wash was to be performed, to building a French bun, no mean feat let me tell you, well to a teenager who never really cared for such things as a hair brush. My knowledge of these special people was intimate to say the least, I knew their senses of humour, I knew details of their lives that no one even in their families was privy too. I was entrusted with pearls of wisdom and in turn shared my own thoughts secrets and life experiences in a truly symbiotic and fruitful relationship. I look back at this time and say this is when aged care wasn’t a job it was a lifestyle that you got paid for.
Then came the day fun and aged care parted ways. It was the late 1990’s around 1997-98 from memory without googling it. Aged Care was given specificity and the world and everyone in it (Aged Care Related) was ecstatic, the Aged Care Act was enabled, building codes were introduced and everything was looking amazingly bright, then reality hit! With the changes came a stark reality, red tape would inevitably entwine everything you did and documentation would be a load all on its own. I remember it as quite a dark time as my father went from being the director of nursing to an advisor for the standards committee as the whole industry was picked up and thrown upside down under the guise of quality! Seemingly overnight the idea of care was not what you provided to the individual, but what you documented that you did. This seemed to slowly but surely develop into a beast with the standards accreditation agency as its head and its powers to create havoc in the mind of even the staunchest and compliant provider, knew no bounds.
Funnily enough at around this time the point of changes in the way aged care worked was driven home by my elderly grandmother Lily, now living in Perpetua in The Pines in Donvale and suffering from dementia, but still mobile and still very much the Matron, probably more so than she had been for the last 30 years, following me around on my shift, scalding me because there was dust on railings, and that the beds were not as straight as they should be or that she hadn’t seen a nurse all shift!( No one was wearing white by this time!) She would enter resident’s rooms other than her own and leave them looking spotless, and the beds were made so you could bounce a 20 cent coin off them and blemish would not occur. I remember thinking to myself at the time, wow how things have changed, but it was a privilege to see an old time nurse at work, even though she was well past her prime, she never forgot her basic nursing skills.
In discussion with my father, we reminisced over the changes in documentation from when he started nursing until now. He told me of the time in the 1970’s through 1980’s Nursing care plans were a one page tick sheet, it had about 40 questions on it and any exceptions to the care were documented in the nursing notes. It was a great way to nurse because at any time on a shift you could go to the bedside and validate what had happened on your shift, or go to the carer and validate what had happened on an earlier shift. After a while, it became a requirement to document on each patient on each day, so you would have days on end of notes reading “ISQ”, or IP Stat Quo (Condition unchanged). Overtime we have over complicated our documentation forcing screeds of information to be documented about a person detailing every minute of their lives, and in the case now, having so much documented on a care plan, that there is no way one could read it and still be able to actually provide care on each shift!
At around this time I left, I travelled the world and then went to university to complete my Bachelor of Nursing, now a profession as you earn a bachelor degree, I can still hear my grandmother asking “how they can teach you care in a classroom, in my day you learnt care by giving care!” I left aged care seemingly for good now fully ensconced in the acute setting, learning the Alfred way.
A few years past and an opportunity was presented to me offering a management position in aged care, not something I thought I wanted but it was a challenge, firstly as a quality manager then on to being a director of nursing myself. I look back now and remember a feeling of destiny as I accepted the challenge thinking ‘This is in my blood.’ I watched and sat helplessly as my role went from ensuring my residents and staff were happy and healthy to sitting behind a desk and pushing paperwork around and making sure that systems were being adhered to and process, followed. I went from being a nurse to a detective and a bureaucrat that had no time for my residents and spent all my time going from spot fire to spot fire.
I did this for 15 years and day by day fell out of love with aged care, until it finally happened, I couldn’t face it another day, the profession I loved was now gone and this juggernaut of paperwork process and procedures stood in its place, all under the guise of quality and person centred care. This in my mind was a complete falsehood, all it did was make sure the documentation was thorough and exhaustive, but missed the point completely. Good documentation doesn’t equal good care, it equals time spent away from care, simply put it took the focus away from what is important in the care industry, “THE PERSON WHO NEEDS CARE!”
Now in 2018, no longer a facility manager, but still in aged care under a different guise. I find myself excited as a new approach offers a means to return to actual care, to real honest to goodness old fashioned care, even though it will be all new and improved. Consumer directed care although its actual form is yet to be determined, offers a possibility that the days of the overwhelming oppression caused by accreditation and quality systems may have a use by date. It offers the chance for homes to be self-regulated. We move on to a platform where clients have choice. Choice to move if they feel their care or services are not being provided to their satisfaction, Choice of options in lifestyle and choice in how their money is spent, as the client now receives the funding from the government not the provider. The government it seems has finally decided to relinquish the idea of centralised financial control.
You see sometimes you have to look backwards to see the values that you need to move forward in an industry. Even when a young Florence Nightingale was wearing her whites and starch filled her hats, care was always at the crux of everything she stood for. We lost our way when we had to justify care for money from the government, and care was replaced not at the coal face by those who actually did the face to face work, but by those who we elected to govern the country, who’s policy was to make providers accountable, by linking funding to documentation, this made documentation the goal with care a bi-product, talk about putting the cart before the horse!
This new system allows for a complete shift in the way we care for our elderly. We can actually provide what they need rather than what we say they need, or what the government says they need. Duty of care from the nursing staff will not be compromised, so your assessed needs will still be met, but the client resident or patient will get actual control over what they want. Yes it’s going to be a generational change, rostering and head offices will be shaken to their very core and business plans will need to be screwed up and thrown away only to be rewritten over and over until it works, but we will be providing what our elderly deserve just as we will deserve when we get to that stage in our lives, the dignity of true choices in life and quality truly client driven care in our golden years.
To sum up, aged care seemed to have it right before it became an industry. It was then recognised as an industry and it lost itself in the red tape that only government interference can provide. Finally, we have the recognition that the person who wants care should be the driver of the care they need, and the industry stands on the precipice of change, the last twenty years or so I see as a labour from which we should see aged care reborn in a whole new and exciting guise. Where care is once again made the focus, and choice is more than just a passing phrase that sounds good for accreditation purposes. So yes, I think we are on the right path for a prosperous aged care future.
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Great article Eamonn… really well said…