Assessing Aged Care Workers’ Understanding Of Person-Centered Care

With the aged care sector under the spotlight and currently undergoing a Royal Commission in Australia, it is a timely reminder of the value that aged care workers have in our society. Recent years show that there are over 3,000 aged care providers, over 366,000 people in the aged care workforce and that by the year 2050 it is predicted that 3.5 million Australians will be accessing aged care providers and services. The estimate is that by this time, the aged care workforce must amass to 1 million workers.

Aged care workers (ACW) are put under immense pressure and responsibilities to do their job effectively, performing work that is demanding, time-pressured. and, quite frankly, underpaid. However, the role ACWs perform is one of increasing demand and necessity with the global population aging – a feat for humankind – but also an issue that needs attention. The dependency of old and very old people is intensifying, and ACWs have become integral to supporting this population. ACWs support and care for people in residential care facilities and in the care recipients’ own homes. Before even reaching the workforce required to support the expected needs of the population by 2050, we currently have an issue with retaining our current ACWs.

Among the aforementioned challenges faced by ACWs, there is also burnout which is an emotional response to chronic stress that is emotionally draining. Some authors have suggested this is due to the role being psychologically demanding, underappreciated, and limited career advancement. In Australia, workers who engage with care recipients are placed under the umbrella term of a direct care worker, however, the following study differentiates nurses and allied health professionals from ACWs (also known as person care workers) for specific reasons. Much aged care research has focused on nurses and allied health professionals, and often in acute care settings, but with little focus on ACWs. The reason this is important to separate the different titles is that allied health professionals and nurses are more often concerned with clinical issues, managing medication, and supervisory roles whereasACWs are the ones who spend the most quality time with care recipients. These workers ensure that the people they care for meet their activities of daily living (ADL), which is an intimate role. They get to know the likes, the dislikes, the history, the family, the aches, the diets, the cognitive state, and the overall person.

During the Humanistic movement of psychology in the late 1950s, the American Psychologist Carl Rogers founded the Person-Centered Care (PCC) approach to therapeutic counselling contending that a person-centered approach to care was based on acceptance, care, and empathy and enhanced through active listening and sensitivity with the emphasis being on the well-being and quality of life as defined by the individual. This theory was adapted by Professor Thomas Kitwood in the 1990s and was applied specifically to dementia care. Kitwood believed that ACWs could adapt to the challenges of dementia by viewing and grasping the meanings conveyed by care recipients via reflection, anticipation, expectation, and creativity (see Kitwood, T. (1997). Dementia Reconsidered. McGraw Hill. Berkshire: England). In short; to see the individual’s personhood.

Clinical Psychologist, Professor Dawn Brooker, again adapted the paradigm to the new culture of care that condenses Kitwood’s concept of PCC to 4 key elements: value (V), individuality (I), perception (P), and psychosocial needs (S); known as the VIPS Framework (Brooker, D. (2007). Person-Centred Dementia Care. Making Services Better. Jessica Kingsley Publishers. London: England). Collectively, Brooker considers these 4 factors to encompass what PCC means when working with care recipients, especially those with dementia. It should, however, be noted that while PCC is considered the cornerstone of good dementia care, it is also applicable to all care recipients and can be linked back to Rogers’ first use of the paradigm in therapeutic settings. PCC as a guiding practice is found in national and international documents governing how care is provided.

So, if PCC epitomizes good dementia care, could it then be assumed that ACWs providing that care both understand and practice this care? This is not exactly the case.

Through semi-structured interviews with 12 ACWs working in 2 non-profit residential care facilities providing both high and low care for residents with and without physical and psychological issues in South Australia, a study was conducted to understand ACWs’ knowledge of PCC and the barriers and facilitators to practicing it in the workplace. Using content analysis by applying participants’ understanding of PCC to the 4 key elements of the VIPS Framework, it was found that of these 12 participants, only 1 had a complete understanding, 1 ACW had no understanding at all, and the rest ranged from minor to strong understanding. See table 1. Through thematic analysis, the salient, yet unsurprising, theme of insufficient time was found to act as a constant barrier to the practice of PCC while, upliftingly, teamwork was found to be the key theme that enables it.

Table 1. Aged Care Worker’s Level of Person-Centred Care Understanding (Minor = 1of 4 key factors identified, moderate = 2 of 4, strong = 3 of 4, complete = 4 of 4)

Collectively, the ACWs had a reasonable, yet incomplete understanding of PCC and what it means in practice. This is concerning as it is often espoused as being practiced by care providers, but it does not appear to comprehensively occur in real-life practice by the ACWs. There seemed to be a mismatch of understanding that PCC is a practice and not an option; some workers asked if they could do PCC, highlighting a discrepancy with knowing and practice. Consequently, the study found that a large portion of ACWs are culturally and linguistically diverse (CALD) and their treatment of older people is ingrained in their culture as a practice that does not technically come under the term PCC. The ACWs may well be performing excellent PCC but simply not have the training and explicit theoretical knowledge of the paradigm of care. In fact, in some instances, several CALD ACWs stated that because they have no family near them, they consider the older people they care for to take that place.

While the study recruited only 12 ACWs, data saturation was met, meaning that despite their experience levels, cultural background, and location of work (regional or metropolitan) they were sharing the same stories. For example, “the greatest barrier we all have is time, and that’s not an excuse, that’s a fact” (Oppert et al, 2018) and “teamwork is huge. Teamwork is my thing. For me to do my job properly, I need to have people who will work with me” (Oppert et al, 2018). What bolsters the findings from this study is that simultaneously a similar study was being performed in Ireland (Colomer & de Vries, 2016) that also found ACWs are lacking in both knowledge and training of PCC practices, indicating this issue is not restricted to a small sample from Australia, but is indeed a global issue.

It is clear that further education for ACWs is required by trainers and providers and we suggest the use of Brooker’s VIPS framework for its simplicity and practicality. There may be no significant salary increase for ACWs coming any time soon, but aged care providers and management can find alternative methods for improving practices, training, worker retention, and, ostensibly, reducing burnout. Tapping into ACW motivation has the potential for ACWs to form stronger bonds with care recipients which could protect against dissatisfaction. While the technical skills of ACWs are vital to care, it is the emotional connection with care recipients – that empathetic relationship – which represents the meaning of PCC and preserves peoples’ personhood.

We strongly encourage care providers to tap into the facilitation of teamwork in the aged care environment and to test out better matching of residents with ACWs to reduce barriers to the practice of PCC like insufficient time. Practicing authentic PCC can enable more care recipient autonomy and wellbeing with the added benefit of making the work even more rewarding for ACWs while reducing the negative aspects of the valuable work they perform.

References:

1. Australian Government Department of Health, 2016–17 Report on the operation of the Aged Care Act November 2017 (ROACA 2016–17). https://agedcare.health.gov.au/sites/default/files/documents/09_2018/aged_care_workforce_strategy_report.pdf
2. There are 902 in residential aged care, 702 providers of home care packages and 1,523 organisations funded to deliver Commonwealth home support services. See Australian Institute of Health and Welfare, Services and places in aged care, 2016–17 , https:// www.gen-agedcaredata.gov.au/www_aihwgen/media/2017Infographics/Services-and-Places-Infographic-2016%e2%80%9317.pdf?ext=.pdf (accessed 30 May 2018).
3. Productivity Commission, Caring for Older Australians, August 2011. See: https://www.pc.gov.au/inquiries/completed/aged-care/report (accessed 21 June 2018).