All
healthcare assistants, exclusive of the night staff and 39 of 41 residents
participated in the study. The profiles of the healthcare assistants are shown
in Table 1, and that of the residents in Table 2.
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| Journal of the New Zealand Medical Association,
06-May-2005, Vol 118 No 1214
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Quality of residential care for older people: does education
for healthcare assistants make a difference?
Barbara Smith, Ngaire Kerse, Matthew Parsons
Currently it is estimated that 28,000 adults over the age of
65 years are in residential care in New
Zealand.1 In residential care, older people are
primarily cared for by healthcare assistants (nurse aides, nurse assistants,
caregivers)—less than 25% of whom have vocational
qualifications,3 thus confirming the belief of
Foner4 that healthcare assistants are
essentially untrained personnel reliant on the employer to provide training and
professional supervision.
Healthcare assistants work without the obligation imposed by
registration or enrolment, without a professional code of ethics, and without
professional codes of practice enforced in courts of
law.5 It is also a low-income workforce, and a
significant number in the Auckland region have English as a second
language.3
Ministry of Health contracts allow everyday supervision of
healthcare assistants to be provided by a licensee who may not be a health
professional.6 The mandatory employment of a
registered nurse for at least 8 hours a week does not guarantee that the
healthcare assistants will have access to professional guidance and advice.
Older people are in long-term residential care because they are increasingly
dependent on others to meet basic needs, and often have a multisystem reduction
in physiological capacity that makes them uniquely vulnerable to external
stressors.7 Quality of care is largely
dependent on healthcare assistants, as they provide the majority of
care.8
Most healthcare assistants learn to care for these older
people ‘on the job’ and develop their skills and knowledge from
experience and observation of other healthcare assistants. To assist in the
provision of competent and compassionate care for a very vulnerable group of
older people, ample opportunity exists to provide educational programmes that
assist healthcare assistants in obtaining necessary knowledge and skills. It can
be disputed, however, that healthcare assistant education by itself is
sufficient to improve the quality of care for older people in residential
care.9,10 This study, therefore, evaluates an
educational programme for healthcare assistants.
MethodsDesign—The
impact of an educational programme for healthcare assistants was established by
assessing the quality of care before and after the education programme
implementation.
Study
population—All residents and staff in one medium level dependency
rest home in the Auckland area participated in the project. Residents in a rest
home are at a variable level of dependency, invariably needing assistance with
instrumental activities of daily living and some personal activities of daily
living.
Written consent was obtained from all residents, all
healthcare assistants, and other staff in the home. Ethics approval for this
project was gained from the Auckland Ethics Committee.
Demographic data were obtained from the healthcare
assistants and residents. The reduced item Barthel Index
(BI)11 and the Abbreviated Mental Test Score
(AMTS)12 were completed on each resident.
Quality
assessment—Non-participant time-sampling observation was used for
the data collection of the quality of care provided by healthcare assistants to
residents. An independent gerontology nurse assessor observed six residents (and
their care) at a time over 4-hour time periods. The assessor rated the care
given to each resident as either appropriate
and adequate; appropriate and
inadequate; not appropriate but
adequate; or inappropriate and
inadequate using the Quality Assessment Project (QAP) scoring system
developed by Norman and Redfern.1 Numbers of
each type of care were totalled and expressed as a percentage of total care
observed.
Figure 1. The Quality Assessment Project (QAP) scoring
system
Cell 1 is inappropriate and inadequate care—e.g.
hot fluids left for a resident out of reach, the fluids slowly grow cold, and
then removed with out the resident having drunk anything. Cell 2 is
inappropriate and adequate care, Cell 3 is appropriate and inadequate care, and
Cell 4 is appropriate and adequate care (e.g. a resident was served a hot meal,
the healthcare assistant cut up the food and helped the resident eat the food,
and chatting to them throughout the meal
The observer also took contemporaneous longhand
recordings to describe the activities being observed. This method of observation
identified care that was given and also care that was omitted. Each activity was
later coded as one of 11 activities of daily living. The observer interspersed
the observations with periods of
event-sampling13 that provided narrative
examples of observed interactions with the residents. This combination of
methods was used at baseline and on completion of the educational programme.
Sample
size—Thirty residents (in groups of six per session) were observed
every 6 minutes for 1 minute over ten 4-hour periods. It was estimated that this
would generate sufficient observations to detect a relevant change in the
distribution of scores observed before and after the intervention period (alpha
80%, p<0.05).
The educational
programme—The content of the teaching sessions was based on the
Activities of Daily Living (ADLs)14 for
residents, but was significantly influenced by the wishes of the healthcare
assistants to know more about the everyday challenges faced by the residents in
their care.
Case studies of residents were used to enable
healthcare assistants to relate their knowledge of the resident to the
explanation of the particular needs of that resident. Experiential teaching
techniques enabled the healthcare assistants to experience (in some degree) the
difficulties that frail residents faced, and to identify the care practices that
could be used to ameliorate those
difficulties.15
Visual tools such as photographs of various
situations16 and story
telling17 became the bases for discussion. The
emphasis was on doing, experiencing, discussing, and team
problem-solving—rather than didactic teaching. The healthcare assistant
programme was delivered in ten 1-hour sessions. Focus groups were used to inform
the development of the education sessions.
The topics for each session were:
A strict sequence was observed to
ensure that each part of the study was discrete and completed before the next
phase started.
The sequence of the course was:
Analysis—The
distribution of pre-education programme QAP scores was described and then
compared with the post-programme scores distribution using the chi-squared test.
QAPs were also correlated with the BI and AMTS to identify characteristics that
may influence the quality of care
ResultsTable 1. Demographic characteristics of the 15
healthcare assistants who participated in the study
The 15 healthcare assistant staff made up 7.2 full-time
equivalent (FTE) positions. All of them were invited to join the programme of 10
teaching sessions but only the four full-time staff members consistently
attended the 10 sessions. Two of the remaining staff members attended two
sessions only. Two of the attendees worked as team leaders. All healthcare
assistants attended the two focus groups.
Table 2. Demographic profile of the 39 residents who
participated in the study
AMTS=Abbreviated Mental Test Score.
QAP scores before and after the education programme are
shown in Table 3.
Appropriate and adequate care observed after the educational
programme was more frequent than before (chi-squared=11.426, p=0.001).
Inadequate and inappropriate care was less frequent after the intervention
(chi-squared=12.05, p=0.0005). (See Table 3.)
Table 3. Changes in quality scores before (Pre) and
after (Post) an educational programme
QAP1=inadequate and inappropriate, QAP2=inappropriate and
adequate, QAP3=appropriate and inadequate, QAP4=appropriate and
adequate.
Subgroup analyses by
disability and cognitive level—The study also sought to examine
whether or not the functional dependency of the resident influenced the care
that they received. Those with a BI score below 5/20 received 21% improvement in
the incidence of appropriate and adequate care after the education programme
(chi-squared=32.99, p≤0.001). A 20% reduction in inadequate and
inappropriate care for this group of residents was also observed. This indicated
that the most functionally dependent residents received the greatest improvement
in quality of care.
Figure 2. Reduced-item Barthel Index (BI) assessment of
residents related to their Quality Assessment Project (QAP) scores
 QAP1=inadequate
and inappropriate, QAP2=inappropriate and adequate, QAP3=appropriate and
inadequate, QAP4=appropriate and adequate; Pre=before education programme
(intervention), Post=after education programme (intervention).
The other resident activities that showed significant
improvement in quality of care were those of the residents who were scored as
the most independent (chi-squared=10.198, p=0.017). For residents in the other
Barthel groups, there was minimal change from pre- to post-intervention.
A previous study suggested that healthcare staff are much
more likely to interact with residents who are deemed to be only moderately
confused.18 To test this hypothesis, the
resident AMTS scores for the testing of cognitive function were correlated with,
the QAP scores before and after the education programme. Although there is no
recognised consensus for the interpretation of the scores, it is generally
believed that a score of less than 8 out of 10 suggests significant cognitive
impairment.12
Figure.3. Abbreviated Mental Test Scores (AMTS) of
residents related to Quality Assessment Project (QAP) scores
 QAP1=inadequate and
inappropriate, QAP2=inappropriate and adequate, QAP3=appropriate and inadequate,
QAP4=appropriate and adequate.
Figure 3 shows a non-statistically significant trend for
those residents with an AMTS score of two and under, towards an improvement in
appropriate and adequate care, and a five percent increase in inappropriate and
inadequate care (chi-squared=3.712, p≥3.5). For those residents with an
AMTS of 5–7 there was a 22.75% decrease in those activities assessed as
inappropriate and inadequate in the post intervention observations compared to
the pre intervention observations (chi-squared=31.42, p≤0.001). In the
group of residents most cognitively able, (AMTS 8–10), there was an
increase in inappropriate and inadequate care scores (chi-squared=19.047,
p≤0.001).
Resident interactions with
staff—Resident interactions with healthcare assistant comprised the
majority of staff-resident interactions. Registered and enrolled nursing staff
interactions with residents were rare.
DiscussionFollowing completion of the
education programme, there was significant increase in the proportion of care
that was judged appropriate and adequate provided by healthcare assistants to
residents than before (chi-squared=11.426, p=0.001). There was similarly a
decrease in inappropriate and inadequate care after the programme
(chi-squared=12.05, p=0.0005).
Ovreteveit19 defined
quality as a service that gives people what they need as well as what they want,
and to do so at the lowest possible cost. Safe, appropriate, intelligent and
individualised care is possible in residential care facilities for older people
with ongoing staff education and support. Such care can bring much comfort to
older people in the latter years of their lives and to their families. Other
studies that have evaluated programmes in residential care have also shown some
impact on outcomes.20,21 These programmes were
specifically designed to alter particular facets of care.
The fact that more dependent residents received the most
change in care scores was interesting, as high resident dependency is believed
to be negatively correlated with the quality of
care.22 This shows that, even in the most
difficult situations, there is potential for improved care.
In this study there was little input into resident care from
the registered nursing staff. The paucity of qualified nursing staff
interactions with the residents was surprising and not totally explained by the
Hawthorne effect of behaviour changing when being observed. Most of the
nurses’ time seemed to be absorbed by talking with family, writing
reports, working with the visiting medical officer, and dispensing medications.
The presence of the observer did not appear to obviously influence the quality
of care provided by the healthcare assistants, although this was difficult to
quantify.
There were obvious limitations to this study. There was a
small sample size of both residents and healthcare assistants. Two methods were
used (i.e. non-participant time-sampling was interspersed with event sampling)
but the observer used the mix in both pre- and post-periods of observation.
There was a lack of consistency on the observation of the residents’
activities. For instance, some residents who were observed with great frequency
in the first observational period were not observed with the same frequency in
the second period.
Not all the consenting residents were observed; only 82%
being observed (not the 95% that was sought). The difficulties that the observer
experienced were in part due to the long periods of resident inactivity. Another
difficulty was that the residents were relatively mobile, while the observer (by
necessity) remained relatively immobile.
The assessor was also not blinded, as she knew that there
had been a programme in place in the rest home. Nevertheless valuable
information was gained through the observation about the quality of
residents’ care. The contemporaneous long-hand recording supporting the
quality scoring, thus provided valuable information about the care that the
residents actually received.
The attendees at the 10 teaching sessions were self-selected
and very enthusiastic. All the education sessions related in some way to the
people in the rest home. The teaching was experiential and highly interactive
rather than didactic. Perhaps the key to improving quality of care is to target
healthcare assistants who have the will and aptitude to benefit from the further
education recognised by the New Zealand Qualifications Authority, and then
enable them to work as team leaders and resource people, reflecting their better
education and responsibilities in a graded pay structure.
It is not clear which part of the intervention was the most
effective. Whilst it is likely that the staff delivered more appropriate care as
a result of the increased understanding of gerontological issues through the
education, it is also possible that the presence of the observer was also an
influence in itself. Perhaps as Sheridan10
suggests, the presence of a registered nurse observer on the floor was necessary
to improve quality.
The teaching of the healthcare assistants improved the
quality of care in the short term, but whether this improvement was sustained is
not known. The quality of residential care has many facets. From the residents
point of view the primary determinant of quality is considered to be staff
attitude23—not only what care is
delivered but how it is delivered.
For healthcare assistants, the recognition by other staff
and management that they are doing a valuable job well, and that they are valued
as staff and individual, are considered recognition of their
worth.5 From a management perspective, however,
a financially viable residential care facility that continues to attract
residents and maintain high occupancy rates are indicative of success.
Currently, two agencies provide caregiver education
distance-learning packages, but this is a cost incurred either to the employer
or to the healthcare assistant. Similarly, some institutions provide healthcare
assistant training at a cost to the learner.
Hence there is no dedicated government funding for the
education of healthcare assistants who work in residential care, but there is a
requirement that all healthcare assistants who work in dementia care have
appropriate training.
ConclusionThis study showed that quality of
care, as judged by an expert gerontological nurse using standardised
observational techniques, was improved after an educational programme for
healthcare assistants. This is one of the few healthcare assistants programmes
formally evaluated to show such improvements in quality of care. Its findings
show that there is potential to improve care in residential care, and healthcare
assistant education programmes need to be disseminated throughout New Zealand.
The effectiveness of the programmes currently in place also need to be
evaluated.
Author information:
Barbara M S Smith, Researcher in Gerontology, School of Nursing; Ngaire Kerse,
Associate Professor, School of Population Health; Matthew Parsons, Senior
Lecturer, School of Nursing, Faculty of Medical and Health Sciences, University
of Auckland, Auckland
Acknowledgements:
The School of Nursing and the Department of General Practice and Primary Health
Care (University of Auckland) supported this study with project cost funding.
Correspondence: Ms
Barbara Smith, School of Nursing, University of Auckland, PO Box 92-019,
Auckland.
References
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