Mar 05, 2020

A rotten culture among staff is ruining aged care


On a plane on my way back from Sydney to Queensland, I was going through the normal processes of fitting in to the seat and getting comfortable. As the plane settled for take off, it was impossible not to overhear the conversation one row behind between a woman and a man who were talking about working in aged care.

As usual, when you hear the term “aged care” being discussed, your ears prick up. 

A woman was discussing the attributes of the home she works in, the attributes of the “poor”  management (as they have gone through a number in the past 12 months) and the people inside the home, staff, residents and families. 

The woman disclosed the daily grind of aged care work and the attributes of residents, their diagnoses, their behaviours, their family’s attitudes and that of the management not supporting the staff or the residents. 

She also discussed the new aged care standards and the impact (according to her) on the role and the outcomes she needed to reach. This was being done in detail and as the other party asked questions, she disclosed more and more.

Aged care worker showed “disdain” for aged care

What struck me more than the open breaches of confidentiality and trust was her use of negative language and the obvious disdain she had for the role, residents and the home.

She stated she loved her residents, but… 

This woman sounded like she was from the hard end of life and had a colourful yet uneducated level of communication. Without prejudice (as I come from a broken socioeconomic home background) I understand that many people who work in aged care come from the school of hard knocks. 

I understand that this type of work attracts strong-willed and courageous people who speak their minds and actually see the work they do as beneficial for the community. 

I also understand that being overworked and underpaid brings a discourse to workers who will take any opportunity to be the voice they believe should be heard. 

So, I listened as much as I tried not to. The volume was very loud and strangely the rest of the plane was more than usual quiet and attentive. I guess the subject matter and details were like hot gossip or a session of MAFS.

What did it for me was her comments on the use of restraints and the change in laws “so now we can’t medicate them down at night and knock’ em out, so we can get on with our work. We have to just put up with their behaviours.”

What kind of a culture allows this disrespect?

In the baggage collection area, I just had to approach her and said, “Hi. Excuse me. My name is Dr Drew Dwyer and I couldn’t help but overhear your conversation about where you work in aged care.”

The woman looked at me. I continued. “I work in aged care too and I think you need to check yourself and the way you speak about our industry and your service. In my opinion it was appalling to say the least.”    

The women just stared through me and said nothing. I then walked away.

This conversation made me uncomfortable and agitated, as the level of disrespect, in my opinion, was over the top, and uncalled for in a tight open public space like a plane. The language use was bad enough and then when she was discussing the characteristics of clients and their vulnerability, I felt ashamed that this was happening.

There were four things that forced me to reflect while she was talking: 

  • Why is this woman talking like this on a plane about the care of our elderly?
  • What kind of a culture in an organisation has allowed this level of disrespect to the values in care?
  • Am I at fault too for not saying something now in the public and making a spectacle of myself and her? 
  • Man, we have so long to go before we make the right changes.

The culture of aged care is tired and beaten

The incident tells me several things, things that I know are the truth about our industry.

  • The culture of the aged care workforce is tired and beaten. 
  • We have got a long way to go to make the real and necessary industry changes for better care and outcomes in care sectors.
  • The value of leadership is not espoused by those leading the industry.
  • There is a tendency not to want to ‘rock the boat’.

Induction and probation are needed to create an education and transformation process to get the right staff in the right job. We are still recruiting the wrong people into the aged care workforce. The workforce is so undervalued it attracts the wrong demographic of workers. Pay peanuts, you get monkeys, as they say.

A poor culture leads to poor care outcomes

A poor culture in aged care sector creates the ‘iceberg’ phenomenon: you only see the 20% of the culture on the surface, but underneath is the other 80% of the subculture – and this is what can ‘sink the ship’.

Poor culture will lead to a lack of empathy for the person we serve and the people in our teams. 

It creates a division from the mission and separates the leaders from the pack. 

Poor culture can lead to poor outcomes in care for the following reasons:

  • Ignoring the needs and wants of individuals and groups
  • Seeing consumers as a burden rather than having a mission to serve
  • Takes our fingers off the pulse – we miss the important observations and data that needs to be collected and reported 
  • Creates a task-orientated mentality rather than respecting the time to give care
  • It disrespects the most valuable resource – staff – and sets a tone for disruption
  • It changes the focus of the shared mission to that of the management mission
  • It places a barrier to open disclosure and conflict management 
  • It silences the real leadership in care settings
  • It devalues the roles and responsibilities that are needed for discipline and accountability.

Poor culture is a reflection of poor leadership

There are numerous ways that a poor culture can arise in a service but, in general, it rises because of poor leadership. 

Aged care today is still filled with bullying and harassment, although in different forms than it used to be. It’s embedded in the subculture of the iceberg. 

There is a lack of highly experienced and respected clinical leaders. The best clinical leaders are registered health practitioners, those who are legally bound by the law to meet the standards, those who are registered, and have a responsibility to the greater good. Those for whom there are consequences for their actions if things go wrong.

The reality is, the culture is only as good as those who lead the people with an understanding and empathy of what it takes to work in aged care.

Should we accept some negative attitudes from aged care staff?

I cannot agree that we simply accept anyone who wants to have a job or that our industry has no choice and that a person’s pay or background reflects their attitude to work. 

People – if they are led well, have a genuine passion to succeed, and the right values – can be transformed. It’s what all people should want out of their work. 

Aged care has now, more than before, the opportunity to look for new workforce leaders – and this includes frontline staff. They could be older workers looking for change or part-time retirement, older women and men who want to make a difference in people’s lives or give back, the semi-retiree or baby boomer looking for a career change or an organisation that shares their values. We could coach our millennials. 

But I’m often told we don’t have the time nor the budget. 

Transforming an organisation

So how do we transform a whole organisation to be proactive and demonstrate leadership at all levels of the business? 

The first level of leadership is ‘values leadership’, the process of the organisation and its senior management opening the dialog between its key stakeholders and its system of management, policy and procedures. 

A healthy objective is to seek feedback from the teams in order to establish the values and principles across the board for all key stakeholders and design that value system that can reflect the whole organisation and its people, consumers included. By doing this the whole organisation understands that their values are acknowledged and known.

The next area is building ‘transactional leadership’. This process is the development of the leaders who have a KPIs aligned with the development and maintenance of healthy workplaces. 

Finally, ‘transformational leadership’ is the vehicle that moves to a new paradigm of care. Organisation would do well to develop a transformational leadership learning and development program within their service. 

To help bring staff along for the change, make them accountable: I use the Toyota mentality. Turn the organisation upside down and allow their input to workplace systems and processes to build the space they want to see and operate in (within reason and regulation). 

Communication and having the right values enables leaders to transform at all levels. The workforce that has helped aged care staff design the system they now have must be valued and supported, which requires mentoring, education and leadership.

I look for change champions at all levels in the workforce. They are there, but often not identified. 

Dr Drew Dwyer has over 25 years of experience as a professional nurse, nurse leader and educator. He is currently the Principal Consultant in Gerontology, Disabilities and Community Services for the Frontline Care Solutions group and the Australasian College of Care Leadership & Management. He also holds an Adjunct Associate Professor position at the University of Queensland School of Nursing, Midwifery and Social Work (UQSoNMSW).


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  1. Well.done for standing up to a bully. Thank you for such a well written article that shares solutions to challenges, not just highlighting the problems.

  2. A very well written article which depicts in great detail issues and the reasons things are not working in Aged Care.
    I have emailed Dr Drew and thank him for his very valuable contribution.
    Amina Schipp

  3. Thank You ,
    Well said.
    I worked as a nurse, then trained as a Diversional Therapist.
    I loved my work and often looked at the clock and should have been long gone, as well as gave time for outings
    Many hours where spent talking to families and friends especially those when the loved one had dementia
    .one of my jobs was to make our resident known to staff as a person who had a life who cried and laughed.
    Our staff cared for folk and would be heard commenting lovingly.
    My self I was good at my position.
    Unfortunately my education let me down I found it difficult writing reports,even though I took lessons from tafe.
    I now find my self with Parkinson’s and family not near. I hope I recieve kindness as I’m broke and will not have a say where I go.

  4. The first step is to change the language we use. For example “behaviours” is a terrible term! It needs to be removed from aged care terminology, starting with ACFI! “Behaviours” implies deliberate acts, and in most cases they are not, especially in dementia care. They are SYMPTOMS of neurological disturbance and should be called that. I insist on this where I work.

    Aged care staff don’t receive a lot of education on the importance of confidentiality beyond a single subject at TAFE, so naturally they don’t realise the vulnerability of the residents. There’s no mentoring or guidance once you’re in there, because there’s no money for it. The level of care is gradually declining as funding declines.

  5. Thank you, Drew.

    I also see a culture of “blaming down” where staff all the way down are blamed, criticised and eventually sacked.

    I see a lot of rules and memos of what NOT to do and only a few dedicated leaders who guide, mentor and set the standard of expectations with clear outcomes. We are working with providers to develop innovative and creative solutions so all levels of staff gain more clarity of what good looks like.

    So many of the front line staff I immerse with have a heart of gold. Some tell me that they have moved away from their core values to a resigned “why bother” when they are not listened to, have extra tasks put upon them and sometimes reduced roster hours.

    It is particularly tough for regional and remote providers and staff who have limited opportunities and options.

    Lets find the good in every heart, draw it out and help it flourish.

  6. Drew is correct but I doubt anyone of importance is listening.
    Aged Care is managed by Governments and Agencies which have been completed captured by the lobbyists for an industry that sucks up Government dollars to solve every problem.

    Transparency is what we need. No foreign ownership. No tax havens. No agency meetings with lobbyists without a consumer representative and a meeting transcript.
    No expansion of existing providers which have facilities failing standards.

    Transparency would be nice.

  7. Very interesting article which accurately describes what has been developing in aged care over the last 20 years. With the system we have we have devalued and excluded community and the workforce has been dis-empowered. For those within the system and many in the community, the immediate reaction is to call for more leadership and more management. The cult of leadership that our country has adopted has grown at the same time as civil society and communities have been pushed aside. They have been ‘managed’ rather than engaged.

    If we look at this from outer space we might see that the disasters of the 20th century were all due to leaders who brainwashed others to follow them and their ideas. It was other citizens who understood and then became involved, responded and even went to war to address the problems.

    Perhaps we should look at this in the same way. This problem could not be so pervasive if the problem did not lie with leaders and management – the culture established by free market (neoliberal) and managerial thinking. Calling for more leadership and management may simply compound the problem and further exclude community.

    An alternate view is that each one of us and each community is ultimately responsible for the welfare of their fellows, particularly the more vulnerable – the ethic of love thy neighbour as thyself. Anyone caring for them is doing so as our agent. They should be directly responsible to us and we have a responsibility to ensure that they provide the care that we as responsible citizens expect. Leaders and their managerial strategies have created a bureaucratised centrally controlled system that has taken away our capacity to hold our agents to account.

    Rather than call for leaders and managers we should be building community structures that work with the providers of care in our communities and insist that they do what we want. We might be wiser to decentralise and move the management and oversight of care into local communities and develop government. structures that support and enable them.

    Our value systems are developed within society as is our empathy and our altruism. It comes with involvement and in doing so the development of social capital. It is not integral to leadership or managerialism but leaders and managers will embrace it if they are forced to engage with and be accountable to their communities.

    What I am suggesting is that we should avoid our gut responses and instead challenge them and start thinking of alternatives. The market/leadership/managerialist model that has become the norm since the 1980s has not served community and the social fabric of society well. This is most apparent in vulnerable sectors like aged care.

    It is challenging to think differently but perhaps it is time we did so. Rebuilding an engaged, involved and responsible society might be a good start and the way to do that is to give them a role and some power to make change. This is where and how we develop a different sort of ‘leadership’ structure.

    Would be interested in comment from others and particularly Drew!

  8. Oh! For goodness sake. All this hogwash! I will say one thing. There are certainly people working in aged care that really shouldn’t be there. But you could say that for any industry. There are bad doctors and lawyers and teachers out there that shouldn’t be in the industry let’s be honest. To make this big song and dance about 2 carers behaving disrespectfully on a plane in a small.confined area not caring who hears what they say well, they aren’t important and what they say should not be taken that most carers are the same. The truth is most aged care workers love their residents and work so damb hard for their measly fortnightly wages! Most are women and most are foureign women. Looking after the elderly is seen as “women’s work” meaning any uneducated non English speaking or down on your luck person can do it! The fact is most of these same women are intelligent hard working individuals that for whatever reason decided to work with our most vulnerable in society. As we all know, lowly paid jobs seem to be looked upon by most with alot of criticism. Easy targets for the community and white collar workers not to mention leaders in our country. I am sick of hearing relatives say “I don’t know how you do it.” Well in the end our residents become like family members to most of us. But here we go again. Sounds like “women’s work.” I am not ashamed of what I do. So there!! But I am disgusted that carers are not paid what they are surely worth to the community and the families. We are always short staffed and are always picked on by young 20 something year old CMs. A CM actually came into work one morning to see if the staff had brushed the resident’s teeth by checking toothbrushes to see if they were wet. 18 high care resins on 2 wards of 18 each and only 2 staff working that morning!! Can you imagine?? All the double assists for 2 staff?? People turn a blind eye on carers and the mountains the have to climb each day to look after your loved ones. .CMs focus on what hasn’t been done, not was has been done under extraordinary time restraints and pressu res!! They may well have to hire more foureigners to work in aged care as I see so many wonderful staff leaving all the time. $50 cash in hand here and there to get the regular “overtimers” staff to do yet another double shift due to shortages. Nobody really cares about us and the elderly. We are at the lower end of society. We are hidden from society until you need us. We will do our upmost best to love you and care for you no matter if you have schizophrenia or other mental health diseases or are obese requiring up to 4 staff sometimes to care for you or you are that sweet little lady everyone secretly would love to take home with you. I believe carers should have no less than $30 an hour for the love of their job.

  9. Thank you so much for your article Drew. I have just started in Aged Care as a personal carer and I love the work. I do not need the work, as I have plenty of work to go to besides aged care, it’s just that aged care is a deeply meaningful and humanitarian role and something I want to be involved in.
    However I am finding the understaffing very difficult, and the physical aspect and responsibilities of caring for so many people with little staff very disheartening. My body hurts and I am a person who sincerely cares and therefore my nervous system is on edge as I try my best to care properly for every resident on my shift but feel as though I’m treading water.
    I loved reading your take on this very important matter. I hope good changes are made very soon.
    Sadly, I don’t think I am going to be able to last in the industry as it stands right now.

  10. Aged care is about profit. Profit from an already underfunded health dollar. There will be no improvements until this system of aged care is abandoned.
    I worked in aged care as an RN. I went from job to job as I became unpopular and unsafe working in a profit driven business model of care.
    My mum is now living in an aged care home. Last night she was struggling with a health related issue. One staff member told mum off severely, her bell was unplugged and she was told to clean herself up after struggling to get to the commode on time.
    I disagree with the manner in which you spoke with this caregiver. You identified yourself as a doctor, this put you as someone in a position of power within this rotten system. If you want a genuine conversation with some one don’t at the onset of a potential discussion establish your power and authority. You talked about “our industry” and her responsibilities as a worker within this system. The words you heard on the plane were words likely created from working within this rotten system. This woman may have been debriefing due to trauma suffered while working within ‘your industry’. Maybe she wanted people to hear what she needed to say.
    The problems are not about leadership. The problems are about greed, underfunding and the low status of older people in society.
    Why do you define aged care provision as an industry? Industry is about creating wealth from a product. Older people appear to be the product from which companies create wealth throughout the aged care sector.

  11. I have mixed emotions from this article.

    I am a fit mature aged woman who just finished my TAFE course in Individual Support. The course offers a half day introduction to the manual handling equipment and how to doff and don PPE with dummies and of course goes over the new aged care standards, confidentiality, etc and then you must obtain so many hours of work experience where supppsedly you will get hands on training on manual handling and proper use of equipment etc etc.

    I moved from a professional management job to one where I could use my love for people to do some good knowing the pay was below a grocery clerk.

    I have worked for home care and aged care companies. The hands on work experience has changed me forever. I saw no real leadership / mentorship from the clinical managers, the RNs or the PCA’s. I witnessed 3 falls within 40 hours of working. The falls were due to lack of staffing and lack of education along with indifference.

    The inductions to facilities are videos and then a written worksheet. You can take the tests over and over again until you make the required outcome. You then go to the floor to work and see that hardly anyone does the right thing. You aren’t encouraged to do the right thing either.

    I went to the last facility on such a high and now I cannot sleep properly as I saw the lack of any empathy from 80 percent of the staff from the top down.

    Respect was given and priority given to those who still had their facilities and were paying direct for their care and had families who were interested in their care but apart from that the remaining were treated almost with complete indifference.

    Elderly ones just want a smile and a small bit of conversation to get them through their last days. They know they will be dying. They are to be treated with respect by the standards. Simple to do but ITS NOT PUT INTO PRACTICE!!!!

    The reasons for it are many and varied which I think this author is trying to reflect from his perspective – however if a Doctor is just going to humiliate a PCA and not provide real mentoring or solutions then how does that PCA change.

    I was seen as a trouble maker because I would chit chat with the residents whilst doing their personal care, when I requested that proper equipment and manual handling was used, when I voiced my concerns about how paperwork was completed including incident report forms. I was told over and over again that there wasn’t any time to chit chat that residents had to be “trained” (meaning ignored or bullied so you could get the personal care done quickly). Correct manual handling was “too difficult.”

    The final straw for me was when I asked the facility manager (who was the only one visible on the floor on an evening shift as she was on the computer after hours last day of the month doing paperwork) I was one of 2 other staff for 60 residents and was there for “experience” and just needed her help getting into a utility room to clean up faeces out of a bedpan she stared at me and said why are you asking me go find your coworker. She knew we were short staffed just like every time I was there, she was just focused on completing her paperwork. I fobbed this off initially because I’ve been there I understand the hierarchy BUT in this profession we are led by example. Full stop.

    I then saw that the FM, the CM, each RN only had time for paperwork. There is so much paperwork.

    But they see the PCAs as mere slaves and do not mentor when it comes to conflict, confidentiality, incident report forms, manual handling, all the basic fundamental elements that have to be right or the ship sinks.

    They turn a blind eye.

    I see this as a consequence of their gradual lack of care because if they care they will not be able to sleep at night or have meaningful family relationships.

    Also just read the book “This is Going to Hurt” about one English doctor’s experience in the NHS and his decision to leave the profession.

    The issues in healthcare are complicated and multi faceted and not appreciated by government because it’s a large issue which cannot be solved easily especially when funding and profit do not make sense when it comes to proper human care. This is a problem in every modern day society and country.

    The sad thing is we all will need a carer as it comes to the end of our life.

    How will you be treated? How do you want to be treated?

    I see that some try to do the right thing but just like in any industry the bullies are the loudest and the ones who get the most shifts. The leadership at the top does not see through to the real issues and do not lead or educate properly. This is because there isn’t enough time, processes or staff.

    Perhaps though a basic premise was that a person had empathy before they joined the healthcare profession and psychological tests were given to ensure staff did not have anger management issues or had never been treated properly as a child or at least knew how to complete a form in English?

    Absolutely disgusting and disheartening.


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