Waitematā aged-care nursing

Waitematā District Health Board has set up a gerontology nurse specialist team to focus on the care of older people. The team takes a collaborative approach to supporting aged residential care, with the rate of admissions to hospitals from aged-care facilities having slowed since the team started up.

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Integrated approach to aged care

Title: Showcasing Aged Care Nursing. Waitemata – Building Strong Relationships in Aged Care.

[In this part of the video, it cuts between an interview with Dr Jane O’Malley and shots of the people living in rest homes, and the nurses caring for them.]

Dr Jane O’Malley, Chief Nurse: Since we’ve got a hugely ageing population, we’re predicting a 30% growth in older people, particularly those over the age of 85, which is going to have a big impact on our health services.

Now, many older people live out in the community. But those that are more frail, with more complex conditions live in older persons’ residential care, aged– sorry, rest home care and hospital care. Frequently, the registered nurse is the only person on shift. And so they work in relative professional isolation. They’re very skilled at what they do. But what we know is that where they have support from district health boards, they get a lot out of that. It gives them confidence in what they do. But it also improves the quality of care. And that’s something that we were keen to showcase.

So these videos are about the relationships between advanced practice nurses and district health boards, nurse practitioners, and clinical nurse specialists and their relationship with registered nurses and care providers in residential care.

It also highlights, I think, the leadership that’s available out there in aged care. Some of the leaders in aged care are doing fantastic things, working around new models of care. The role of the leader is critical in setting the culture and supporting the staff to do the work they do. And I think you’ll see in the videos wonderful leaders doing great things.

[In this part of the video, it cuts between an interview with Michal Boyd and shots of Michal discussing the Registered Nurse Care Guides for Residential Aged Care with another staff member.]

Michal Boyd, Nurse Practitioner Waitemata DHB: Our highest-need older people are in residential aged care. We knew that from the OPAL study that we did, where we knew that the dependency level has vastly increased over the last 20 years. And so that we wanted to have some way of supporting residential aged care in the harder job that they have to do now.

If we’re going to go out and do education, we knew that we wanted to do what’s called the geriatric giants. What are the most common things that put older people at risk?

Now, the people that know that the best are the people that work in residential aged care. They know this really, really well. So, there was a couple of things that we wanted to do with the care guides. And number one is to come up with a succinct, two-page algorithm-type publication to say these are the major things to remember when you’re thinking about incontinence, when you’re thinking about diabetes, when you’re thinking about falls, any of those kind of major issues for older people. We wanted it to be very easy, user friendly, easy to use, and quick. One of the ideas was to make sure that it was the best evidence we could come up with in a really user-friendly manner.

Now, the other part to this that’s really important is that the workgroup, the Residential Aged Care Integration Programme workgroup. That’s residential aged-care nurses and managers that come along with the gerontology nurses. So that, it allowed us to ground the care guides into real life. Because they said, oh, no, this wouldn’t work, or this is a better way to do it. So we GNSs would go out and get the evidence, bring it back. And then they would say, oh, this works, this doesn’t work. And then we did millions– many, many iterations– of a care guide until we got to something that really worked really well.

Waitematā District Health Board (WDHB) has a new approach to aged care. It evolved from the gerontology nurse specialist (GNS) team that was set up in 2004. The GNS team was developed to work alongside geriatricians. It assesses and provides care management for complex patients in the community and in aged residential care (ARC) facilities.

The Residential Aged Care Integration Programme (RACIP) emerged after Dr Michal Boyd, a nurse practitioner, was appointed as clinical leader of Community Services for Older People. Michal developed RACIP to strengthen the partnership between DHBs and aged-care providers. The aim was to provide better services through a more connected approach to caring for older people.

‘We’d go into these facilities and do the assessments, but we weren’t using our gerontology expertise to support the nursing staff. We thought that it would be really good if we integrated with the aged-care providers because we’ve got a lot of specialist gerontology knowledge and they’ve got a lot of knowledge about looking after frail older people in aged care. So it’s about working together – combining our skill sets,’ Michal says.

From the outset, the GNS team knew that they needed to work on a partnership basis to make the programme work. This included gaining the trust and confidence of the aged-care facility staff. ‘It’s really important that we acknowledge their skills and knowledge – we’re just here to support them and to help integrate aged care and DHB services,’ Michal says.

A Memorandum of Understanding (MoU) was drawn up so that both the DHB’s GNS team and the aged care providers knew what to expect from each other.

All of the nearly 60 ARC facilities in the DHB catchment have signed the MoU. ‘It’s all voluntary. None of the facilities have to work with us, but they have all chosen to, which is great,’ says WDHB nurse practitioner Janet Parker. ‘It wasn’t just about us coming into the facility to provide support. It was about the facility actually allowing us to do this. The MoU is about defining where we all stand, and it has given us a good starting point.’

Under the MoU, one member of WDHB’s gerontology nurse specialist (GNS) service is assigned to each facility to help build a strong relationship.

Linda Venables is regional manager for Radius Care. She recognises the benefits of developing a positive working relationship.

‘Having our own GNS nurse has been great because you’ve got support on the end of the phone whenever you need it,’ Linda explains. ‘I can ring our GNS nurse, and she knows us, and if we make a call, we probably really do have a problem.’

Janet Parker is the GNS team member assigned to Radius Taupaki Gables rest home. She says that the one-on-one relationship also enables the GNS team members to get ‘the flavour’ of each facility. ‘It’s just like giving individual patient care; there are individual needs within each of the facilities.’

Moreover, Linda Venables believes that the DHB’s programme has contributed to lowering staff turnover rates at Radius Taupaki Gables rest home. Low turnover also means that the benefits of training and staff development are retained and care for residents remains consistently high.

Popular care guides establish a successful relationship

Title: Showcasing Aged Care Nursing. Waitemata – Building Strong Relationships in Aged Care.

[The video starts with Janet, a nurse practitioner, talking to a rest home nurse before the nurse assesses a resident.]

Janet: Crackles? Are they fine crackles or coarse crackles? Are they when Gloria breaths in or out? And what part of the lung are you hearing them over?

[The video now cuts between an interview with Janet, shots of Radius Taupaki Gables rest home, and Janet working with the nurse from before.]

Janet Parker, Nurse Practitioner Waitemata DHB: So here in Waitemata, we have a programme that’s called the Residential Aged Care Integration Programme that was developed initially by Dr. Michal Boyd. And we’ve developed it over several years now. We started back in 2007.

And it addresses the service gaps for people who live in residential aged care. So the team of gerontology nurse specialists, including the wound care nurse specialists, provide clinical advice and support for the staff in residential aged care with their complex residents. And we also go in and we provide formal education, one on one, and also in group sessions on a number of topics all around common gerontological problems, so things such as hydration and nutrition, cardiac disease, respiratory disease, and all based on the RN care guides. So basically we’re there to support the facility.

We’re separate from the auditing arm of the DHB. We don’t participate in any audits or any follow up with audits. We’re there for facility staff. And over the years we’ve built up a relationship of trust with them.

Focus on education is very targeted. What we found was nurses need to know, and caregivers, what the evidence is for what they’re doing and the language that they need to use to communicate what they’ve found to their GP and to other clinicians who are coming in.

[The last part of the video is just an interview.]

Laurel Winwood, Nurse Manager, Taupaki Gables: The relationship with the DHB is very different than it was eight years ago. Eight years ago, it was very separate from the facility. The resident went in for acute care and came back to us. There wasn’t much overlap.

Now we have a good relationship with the DHB. We can talk to the staff at the hospital. There’s excellent handover. And we are involved in their care there. They will phone us when they go into ED for added information. And we are finding that the admissions are shorter.

A working group set up by Waitematā District Health Board (WDHB) produced two practical clinical guides for aged-care environments:

Assembling the guides helped establish a cooperative relationship between the WDHB gerontology nurse specialist (GNS) team and aged residential care (ARC) facility nurses. As WDHB nurse practitioner Dr Michal Boyd jokes. ‘We’d take the scenarios we developed back to the facility nurses, and they’d tear them apart.’ But the intensive process was worthwhile. The guides are now used by facilities across New Zealand.

The working group also helped develop other resources, including the Medicines Care Guides, developed in conjunction with the Ministry of Health and The University of Auckland.

WDHB nurse practitioner Janet Parker believes that the learning on the job that accompanies the care guides’ use is the key to their success. ‘When we go into facilities and we’re teaching someone, we always go back to the resources. It’s not just theory - it’s the clinical application of learning.’

Radius Taupaki Gables rest home participated in the GNS team’s wound and skin-care upskilling project in 2010. The GNS team assessed every resident, and staff received extra training in wound care and how to handle extremely fragile skin, a problem that is common in frail residents. ‘Previously Radius Taupaki Gables may have had up to eight skin tears a month. Now they only have two or three,’ says Linda Venables, regional manager for Radius Care.

She says making specialised staff available is the best support a DHB can offer an ARC facility. ‘It allows us to be flexible in teaching programmes and empower aged-care staff through educating and training.’

Laurel Winwood is nurse manager at Taupaki Gables. She says that the strong DHB partnership also helps reassure families. ‘They can feel confident that their loved ones are receiving quality care. There was one family member who was really struggling to come to terms with her dad’s dementia. Our GNS nurse came in and helped us talk with the family. Sometimes they just need that extra expertise. … The family can trust the facility a lot more knowing we’re hooked into the hospital and they’re not out on a limb with us.’

Meaningful activities important in dementia

Title: Showcasing Aged Care Nursing. Waitemata – Building Strong Relationships in Aged Care.

[The video starts with a group of residents and family members singing. Then it switches to interviews, intercut with shots of the group from before.]

Tina Chivers, Manager, Seadrome Residential Home: Dementia is a progressive illness, and these days, people refer to it as brain failure, a bit like kidney failure, heart failure, which really makes it easier to understand. We see a deterioration of the personality, really. And so the person that families and friends once knew really begins to disintegrate. So it’s a whole social, emotional issue for people.

[Interview with a woman, with her husband seated in the background.]

Woman 1: Oh, terrible. Terrible. I cry. I still do. I still cry, because I’m in the house on my own now. We’ve got our own home, and I’m there every day and every night. And I come up here about three times a week and see him.

[The video goes back to the interview with Tina, intercut with the waiata and the arts and crafts sessions.]

Tina Chivers: Good dementia care, I believe, means making people who come into residential care comfortable, making it home-like as possible, and maintaining their identity.

When they come into care, you see another side of their personality, and you see the creative side, often. People become involved in activities. Meaningful occupation’s really, really important. So people may be involved in art, and we have a book club.

The DHB supports us. They support us on several levels. There are gerontology nurses that will come in, if we request, if we need help with further assessments, giving lots of information. Updating us to changes, updating us with research, and often courses that are available.

[Interview with a woman, with her mother seated in the background, intercut with shots of a balloon- and glitter-decorated tree in the garden.]

Woman 2: And to see the way that they work with the person’s personality in situations that get awkward. In the beginning, I must admit dementia was a word that we didn’t really think about, or know about. So we sort of slowly got used to the fact, but when we saw that they couldn’t cope together, my parents, we knew that something had to be done. So I accepted it as part of life.

And I must admit, Tina came to our home and spoke to us, and was really instrumental in us feeling, this is somewhere Mum can go and feel like she’s still in a family situation.

[Back to the interview with Tina.]

Tina Chivers: We often, when we show people around dementia unit for the first time, they’ll say, my mother, father isn’t like these people here. And so quite a bit of time is spent, when they first come and look around, talking about that. And often we talk to them before they go into the dementia unit, what to expect.

[Back to the interview with the second woman, intercut with shots of the garden again.]

Woman 2: It’s very hard when you drive away and you think, oh my god, why isn’t it different? And you realize, well, no. In fact, it’s probably, this is Mum’s journey, and you just have to accept it, and you’ll have your own journey when the time comes.

Because we’re Croatian, so it was very important to Mum that she has her identity around her and everything, so they straight away said to me, have you got any music, or have you got anything that you’d like to bring?

And that was important, because Mum is-- in her own home, she has a lot of things around her, personal little bits and pieces, so that’s why we try to bring it into her room here. And they play Croatian music, which is very happy. Mum loves festive, and joyous, and dance music, don’t you, Mum?

So, you know–

Woman’s mother (referring the interviewers): I love this pair here. They’re both lovely girls. Lovely.

[Back to the interview with Tina, intercut with a still of the pamphlet: Dementia: Decision-making journey – Where to from here? Information for family members of people with advanced dementia living in residential care. At the end of the video, it cuts back to the waiata again.]

Tina Chivers: Yes. I think the new pamphlet for dementia is excellent. The DHB initiated it, and people from residential care, the Alzheimer’s Foundation have joined that group, and together have developed information for families. And I think that’s where the gap is for families, is having information, knowing what to expect next. What the journey is going to be for people with dementia.

‘Activities play an important role in helping people with dementia,’ says Seadrome Residential Home and Continuing Care Hospital nurse manager Tina Chivers.

Facility staff, including registered nurses, occupational therapists, caregivers and a diversional therapist, develop individual care plans for up to 50 residents at the dementia facility.

‘We see ourselves as providing person-centred and relationship-centred care,’ says Tina. ‘We’re really trying to assess capabilities, needs and interests and design an activity programme around that.’

Staff produce balanced programmes, which include art, music and cultural activities, as well as simpler tasks and sensory experiences. Music groups, including a choir, cultural activities, a ‘blokes’ group, garden and book clubs, a craft group and daily t’ai chi and morning walks are just some of the activities rotated through the programmes.

A monthly hāngī and a Pacific Island feast are part of a regular schedule of events. Staff have also organised Croatian and Scottish days and try to accommodate as many cultures as possible in the activities.

The cultural sessions open up connections between residents. ‘When you see older people dancing, you see this look in their eyes, and you have this feeling that they’re back in Samoa; they’re back in Tonga. The music, the rhythm, the dance have taken them somewhere else,’ Tina says.

Di Macgregor works part time for the Waitematā District Health Board (WDHB) as Māori adviser on their gerontology nurse specialist (GNS) team. Di has begun establishing a partnership between Seadrome and Te Reo pupils from a local high school. In 2013, the students began making fortnightly visits to Seadrome to spend time with Māori residents as part of their NCEA Te Reo programme.

‘For both sides, using the language is great,’ Di says. ‘They will also have the opportunity to work with the residents on waiata, karanga, harakeke (weaving) and use their language in a normal way for the day’.

The facility also looks to the DHB for support, including when a resident needs hospital care. WDHB nurse practitioner Janet Parker says that the facility’s staff really understand dementia, but support is still beneficial, particularly when you take a holistic approach to nursing. ‘It’s a second pair of eyes, and I can talk directly with a geriatrician if that’s needed,’ she explains.

Dementia and the importance of advance care plans

Families now have access to more information about advanced dementia care thanks to a new resource produced by Waitematā District Health Board’s (WDHB’s) gerontology nurse specialist (GNS) team.

Two nurses standing in the garden looking at the pamphlet.
Dementia care nurse manager Tina Chivers with Janet Parker and a new resource developed to help families.

WDHB nurse practitioner Janet Parker says the new pamphlet aims to assist families with some of the complex issues that arise with advanced dementia. ‘We looked at all the resources that were available, and there’s some really good stuff, but they were all about the person with dementia at home or when it’s time to go into care.

‘This pamphlet sows the seed that dementia is an end-stage illness – and that advance care plans, or end-of-life planning, are required and important decisions have to be made around a person’s care,’ Janet says. ‘We will follow this with a booklet that will provide more detail, for example, about what happens when a family member with dementia stops eating.’

End-of-life discussions can be very difficult for clinicians. ‘No one particularly wants the job, and it can be made harder when the person you’re talking with may not understand they’re dying,’ Janet says. ‘You need to find your way with the family and work out where the person is at. After that, you might be able to leave behind some information for them to consider.’

Aged-care nurses have a key role to play in advance care plans. Janet believes that training in initiating end-of-life planning conversations and recognising when someone is ready to talk are important functions for staff and can help them feel more comfortable in their role.

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