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Education and training in residential dementia care in Australia: needs, provision and directions

Education and training in residential dementia care in Australia: needs, provision and directions Abstract This paper summarises existing education and training in dementia for aged care ementia is one of the most significant mental health risks associated with getting older. While the prevalence of dementia is only 1 % among 60-65 year olds, the prevalence has been estimated to be 24%among people over 84 years.’ With the greying of the Australian population, the number of elderly people with dementia is increasing, so that within the next 10 years, the estimated number of people with dementia will increase from 159,000 in 1996 to 194,000 in 2006.2 About half the people with dementia are currently cared for by relatives and friends in their own homes, with support from community service workers, while people with significant behaviour disorders associated with dementia and those without community supports are cared for in residential care, chiefly hostels and nursing homes. People living in nursing homes have significant disabilities and are very dependent. It is estimated that at least two-thirds of residents in Australian residential care have some form of cognitive impairment, mostly attributable to dementia.3 Aged care workers with formal qualifications mostly c o m e from nursing backgrounds, with diversional therapists, occupational therapists, physiotherapists and psychologists employed to a lesser extent. However, the bulk of hands-on care is provided by workers with few or no formal qualifications. The question we have addressed in this paper is, how well trained in dementia care are the aged care workers who provide residential aged care? We have examined the need for education and training in residential dementia care; summarising the provision of education and training in residential dementia care; and discussing where training in this area should head in the future. Staff training has long been a contentious issue in the aged care industry and with the increased dependency needs of residents in 1998 VOL. 22 NO. 5 workers in Australia. The majority of aged long-term care, education and training are becoming more important. There is substantial evidence that staff training makes an important contribution to the quality of dementia programs and resident outc~mes.~Yet recognition of the need for any training at all has only come slowly. In many ways, the continuing debate about the need for training epitomises the value placed on aged persons in our society. Past practice reflected the view that qualified staff were not required to meet the needs of elderly clients in residential facilities and one just needed a ‘kind heart and commonsense’ - hence the lack of prescription regarding qualifications for residential care staff. Geriatrics continues to have low prestige as a career choice. The preferences for more prestigious specialties and societal expectations about aged care are perpetuated by lack of interest in the area among academics and educators, whose interests in turn determine the emphasis of their courses. A study by EdeI5 in the United States revealed that faculty staff within schools of nursing had limited expertise in the area of gerontological nursing and this became an obstacle to content inclusion in the program. This lack of expertise also impacts on graduate programs inAustralia, where nurses who choose to pursue the area of dementia care have difficulty in locating an appropriate supervisor and often lose interest in gerontics as they progress through their courses.6 Davis’ saw lack of suitably qualified academic staff as a major contributing factor to students not choosing to work in the geriatric area. Yurchuck & Brewers found that many nurse educators teaching in specialty areas that included the care of elderly persons still did not see the need to have ‘gerontologyspecific’ skills. This was also consistently reported by a variety of individuals interviewed for this paper, especially in the area of dementia care. care workers have no formal qualifications, while those with formal qualifications are mostly from a nursing background. Only half of nursing staff have attended any dementia care training. Existing training is either service based and provided in-house or by private consultants, or tertiary institution based and provided by academics and professional educators. There is considerable in-service and one-off servicebased training being provided around Australia, but few of these training exercises are linked to competency standards or staff appraisal.While there are some formal courses addressing training in dementia care available in every state of Australia, the emphasis on dementia care within generalist tertiary institution courses for aged care workers varies considerably. (Aust N Z J Public Health 1998; 589-97) 22: Correspondence to: Sandy Ward, Accademic Unit of Psychogeriatrics, Department of Psychological Medicine, Monash University, Heatherton Hospital, Kingston Rd, Heatherton, Victoria 3202. Fax: (03) 9551 2330; e-mail: Sandy.Ward 0 med.monash.edu.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Doyle and Ward Table 1:Percentage of staff who attended seminars or training courses in the 12 months before the survey (n=1,851). ToDic Fire drill Lifting Dementia Continence Pressure care Dignity and privacy Attitude to change Bereavement Physiotherapy Confidentiality Sensory loss DeDression Freedom of choice Infestation Culture Rehabilitation Security Religious issues tual disability within any training cumculum. In NSW, Snowdon, Vaughan and MillerI4 found that 28% of a sample of 58 nursing homes in Sydney provided no on-going education to their staff about dementia or other psychiatric problems. In this paper, we report on three additional sources of information about dementia training for aged care workers. Methods First, a survey of 1,851 nursing home staff was undertaken about measuring quality of care.I5 The survey covered 98 nursing homes in Melbourne, Hobart and Adelaide. Homes were chosen using a stratified random sampling procedure. The response rate was 81% of homes and 51% of staff within the nursing homes, which was reasonable for a mail survey. In one question, respondents were asked to identify which of 19 topics they had attended courses or seminars on in the previous 12 months, one of the topics being dementia. The survey was carried out between May and July 1995. Second, service-based dementia training projects throughout Australia were reviewed, including 35 demonstration projects which were set up as part of the National Action Plan for Dementia Care during 1993-95. Third, tertiary institution-based training was reviewed by surveying selected nursing courses in tertiary institutions throughout Australia. In 1995, the authors sent a mail survey to the main tertiary education institutions throughout Australia in order to develop an inventory on the dementia care courses available. This was followed up by telephone interviews during March to August 1995. It was not possible to rigorously evaluate the courses or to make any assessment of the quality of the dementia course content. It must be acknowledged that the accuracy of the resulting information relied on the respondents’ cumculum knowledge and some respondents did not have an indepth knowledge of cumculum content. However, the survey provided an overview of the situation. The focus was predominantly on nursing faculties within the tertiary sector as this was the main discipline providing formal dementia education to aged care workers. Identified need for dementia care training A study by Deakin University in 1989 found that few registered nurses (RNs) working in aged care had specialist gerontological qualifications - a considerable number had post basic qualifications in midwifery.’ RossiterIo reported the results of a survey undertaken in NSW which indicated that only 4.7% of all R ” s had post-registration qualifications. Bumside” also identified a lack of appropriately skilled professionals who could meet the mental health needs of the older population. The lack of clinical expertise in the predominantly untrained workers also puts registered nurses and those with expertise gained through formal training under considerable pressure to supervise appropriately, as well, of course, as putting pressure on the unskilled worker. Rossiterlo referred to the importance of training nonprofessional staff and highlighted the stress that can result, for both the worker and the person with dementia, if workers do not have any knowledge or understanding, especially in the area of dementia care. Yet the availability of dementia training has been low in all states of Australia. Until 1990, there was no dementia care-specific training available in Western Australia to meet the already present and ever-growing need for dementia care.I2 Koenigi3identified training needs for those working with people with an intellectual disability and dementia in South Australia. He identified a lack of gerontology-related training in a survey of aged care,workers - respondents did not have a good knowledge of aging or dementia care needs. He found that 93.9% of survey participants highlighted their need for aged and dementia care-related training and assessment and observational skills. Koenig also emphasised the need for the review, analysis and promotion of positive attitudes to ageing and intellec- Results Survey of quality of care In our survey of the quality of care in Australian nursing homes, we found that 48% of nursing home staff (n=1851) from a sample of 98 homes in Melbourne, Hobart and Adelaide had attended a seminar or course on dementia and its treatment during the preceding 12 months.15 Overall, training in dementia was more common in homes in Tasmania, where 69% of staff (n=ll7) had attended a course or seminar, followed by South Australia (48%, n=596) and Victoria (46%, n=ll86). When staff were divided into professional backgrounds, it was found that 42% of enrolled nurse respondents (n=505) had received training in dementia, compared with 53% of senior nursing staff (n=736) and 5 1% of personal care assistants (n=469). Compared with other areas of training, dementia was addressed more than depression or cultural issues, but not as well as fire drill or lifting (Note that staff were only questioned about training in the format of seminars or courses: other training formats could also have addressed the topics shown). 1998 VOL. 22 NO. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Education and training in residential dementia care in Australia Review of service-based training In reviewing training provided outside the tertiary education sector (i.e. service-based training), we found the most popular forms of training in the residential care facilities were those provided inhouse and by a private educator; peak bodies and professional organisations were the inost frequently used and tertiary education institutions were least used in charitable organisations.Ih Some of the main peak bodies and professional organisations who provide dementia care are the Alzheimer’s Association (national); Aged Care Australia (national); The James McCusker Training Centre (WA), Age Concern; Mayfield; College of Nursing (NSW); Alzheimer Education; Churches of Christ; Hammond Group (NSW); Private Geriatric Hospitals Association of Victoria; ADARDS (Tasmania). There is also a plethora of private consultants in dementia education in Australia. While some service-based courses offered by consultants have been evaluated, there is no minimum standard required of private trainers. Educators can apply to have their course accredited by the Vocational Education, Training and Employment Commission. However, consultants, peak bodies and professional organisations are not obliged to register their courses with any authorised body. A number of special Australian Federal Government initiatives have provided funding for special education or training for the aged residential care sector. ‘The Training and Resource Centre for Residential Aged Care (TARCRAC) provided in-service training and acted as a resource centre for nursing and care staff in nursing homes during 1991, but the initiative foundered in its implementation. One of the main identified obstacles was the reliance on a facilitator to promote its use - facilities where it was utilised generally already had an in-house staff educator, suggesting that the initiative missed the staff with the greatest need for training. A National Action Plan for Dementia Care (NAPDC) was initiated by the Australian Commonwealth Department of Health and Family Services to be implemented during 1992-97. Education and training was identified as a key component of the plan. The Dementia Demonstration Projects were established under this plan in an attempt to raise awareness about dementia care needs and enable good care practices to be disseminated among care providers. Individual aged care fac es were given funding to demonstrate to other facilities in their area their good dementia care practices. A total of 35 facilities were funded in 1993-94, 57 facilities in 199495 and six facilities in 1995-96.’’ While the main intent of the program was residential care workers, community care workers were also included. The workshops and seminars run by these projects addressed a need for basic information for those working with people with dementia, especially for workers with little or no formal training. They were also effective in raising awareness and developing more effective networks among service providers. However, coverage was patchy, with aged care workers in some geographical areas being overwhelmed with dementia education, while others still lamented the lack of accessibility to training or education programs. Some project officers employed to demonstrate their excellent clinical care found that their skills as educators did not allow them to 1998 VOL. 22 NO. 5 communicate easily.” Demonstration projects also found that organisations often wanted ‘quick fix’ solutions which required a minimal amount of time to gain the necessary skills and to implement the interventions. Few staff saw the need to have an education that broadened their perspective and enabled them to transfer learning to a variety of situations rather than be episode focused. As with all education initiatives implemented from outside the aged care organisations, the effectiveness of the training was dependent on the acceptability of the new training to management and management’s willingness to incorporate the training into their on-going care. In 1995, the Dementia Demonstration Projects were scaled down, with only six projects being funded in 1995-96, to be superseded by a similar initiative, the NationalTraining Initiative, which started in the second half of 1996. The new initiative is designed to provide residential care staff throughout Australia with basic information on dementia and there is less emphasis on individual care practices than the demonstration project initiative. Training initiative educators all have experience in training, but are not necessarily involved in hands-on care in the manner of their demonstration project predecessors. Education will generally be of a similar format, with outside experts teaching aged care workers basic information about dementia care. Survey of tertiary-based training We surveyed tertiary education institutions to determine what their nursing courses included about dementia (Appendix 1). We found that dementia training was included or alluded to in generic courses, but the emphasis it received was generally determined by whether those responsible for the content had a particular interest or commitment to dementia. Many course co-ordinators indicated that dementia is referred to during discussions of related topics and any topic in which mental health might have relevance would have dementia mentioned. In postgraduate programs, students can sometimes elect to take dementia up as an alternative study option, even though it is not a component of the course content. In some instances, it was acknowledged that in postgraduate studies it is a dilemma for those running the courses, in that their own background and expertise in this area is limited and they lack confidence especially in the area of cognitive assessment. One organisation did state that dementia was beginning to get more attention in their faculty because it was now seen as an area that would attract future research funding. Undergraduate nurses in the tertiary sector undertake a generalist program and with limited time frames and an expanded curriculum it is not possible to cater for specialist topics. Educators in the field commented that these service-based needs should be met with university-based continuing education programs. However, this is an area that has not expanded because of lack of funding. Faculties/ departments would have to be assured of large participant numbers and at the very minimum the courses would have to be cost neutral to the organisation. Opportunities do exist for additional study of specific topics with electives, although it is not known how many would self-select to study dementia without encouragement from their teachers. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Doyle and Ward Some nurse educators who were interviewed felt that, like the psychiatric component of nursing education programs, gerontology had been written out of many cumcula, that content was minimal and did not address many of the relevant issues that would confront students in their clinical practice. Cumculum content was very much determined by the educators and unless the subjects of gerontology and dementia had a strong advocate, their inclusion was limited. Discussion Our survey of the quality of care in nursing homes showed that only about half of the staff had any recent training about dementia care and as trained staff may have been more likely to respond to the mail survey, it is probably an over estimate of the extent of training in the workforce. Given the prevalence of dementia, it is surprising that the topic is not given greater prominence in training aged care workers. This review has shown that there has been considerable activity in dementia training in some areas, such as service-based training, but research is limited on the effectiveness of training methods that are currently employed to improve dementia care. The high cost of training demands more rigorous review of these programs. Courses in tertiary institutions have been relatively slow to respond to the need for specific information about dementia among their graduates. We found that there is considerable diversity in the availability of courses that provide strong dementia care components for aged care workers throughout Australia. Despite its size, Tasmania is relatively well placed for dementia training, as we found that more staff had attended courses in our survey and the tertiary education offered in that state appeared to have a strong dementia component. Initiatives funded by the NationalAction Plan for Dementia Care should lead to an upsurge in the proportion of the aged care workforce that has been exposed to dementia training. However, this increase in activity depends on the organisational structures maintaining and reinforcing the educational principles being taught in order to achieve long-term improvement in the workforce, so that new staff who are employed after the current initiatives finish can reap any benefits. The education and training of staff has to be on-going and an integral component of the organisational structure - short, sharp exposure to education such as one-off day seminars are often cost ineffective because they do not lead to enduring outcomes. It is yet to be seen whether the latest Commonwealth government National Training Initiative leads to long-term improvement in dementia care. We found considerable fragmentation in the training available to aged care workers. A stronger educational infrastructure for aged care would address this problem. The question that arises is: whose responsibility is it to develop a training infrastructure? In the absence of a co-ordinated response from the tertiary education sector (TAFE and university), private consultants are proliferating and appear to be able to make money from their endeavours, while the tertiary education sector remains wary of committing funds. To get any long-term benefit from training initiatives, there needs to be better co-ordination between service-based, TAFE and university training, which can only come from improved standards and accreditation. National competency standards for direct cafe workers in aged care services have recently been developed by the National Community Services and Health Industry Advisory Training Board and are currently waiting for ratification. A knowledge of dementia is a component of some of the core competency standards. Once the competency standards have been ratified, existing courses will need to be re-written to address the components of the competency standards. Competency standards will be then able to be used to inform training programs for staff in aged care services. Ultimately, however, staff need to be rewarded for increasing their qualifications and participating in training, something which current service-based initiatives have ignored. Aged care workers come from a society that views ageing and residential care in a negative way and administrators and educators have to promote a positive view of ageing for staff to feel that education is worthwhile and beneficial to their work. The education of staff in residential care needs to be viewed as a dynamic, synergistic process which can often cause upheaval within the work environment as old practices are challenged and new methods of care implemented. This factor alone could explain why it is often avoided or not given priority. Nursing and other health professional courses need to respond to the changing health care needs of the community by their graduates being given the opportunity for retraining in areas of need, such as aged and dementia care. Finally, a basic issue raised by this study is how to incorporate specialist training, such as dementia care, into the context of wider public health or aged care training. Educators need better access to up-to-date information on specialist areas, such as dementia care, and better monitoring of courses to ensure that the right balance is achieved within the structure of the courses to meet the changing needs of the community. Better links need to be made between training for workers in different settings, so that, for example, health professionals trained in the acute sector are able to translate their skills appropriately to community and residential care. Better dementia training is tied up with the need for better basic aged care training in general. As with other public health areas (such as child care) which have moved from a largely untrained workforce to increasing coverage of basic training for the workforce, the barriers to development of a trained workforce in aged care will be fiscal and attitudinal - society needs to be prepared to pay for the better quality of care that flows from a better trained workforce and prepared to view aged care as worth the effort. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Education and training in residential dementia care in Australia: needs, provision and directions

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Publisher
Wiley
Copyright
Copyright © 1998 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1998.tb01444.x
Publisher site
See Article on Publisher Site

Abstract

Abstract This paper summarises existing education and training in dementia for aged care ementia is one of the most significant mental health risks associated with getting older. While the prevalence of dementia is only 1 % among 60-65 year olds, the prevalence has been estimated to be 24%among people over 84 years.’ With the greying of the Australian population, the number of elderly people with dementia is increasing, so that within the next 10 years, the estimated number of people with dementia will increase from 159,000 in 1996 to 194,000 in 2006.2 About half the people with dementia are currently cared for by relatives and friends in their own homes, with support from community service workers, while people with significant behaviour disorders associated with dementia and those without community supports are cared for in residential care, chiefly hostels and nursing homes. People living in nursing homes have significant disabilities and are very dependent. It is estimated that at least two-thirds of residents in Australian residential care have some form of cognitive impairment, mostly attributable to dementia.3 Aged care workers with formal qualifications mostly c o m e from nursing backgrounds, with diversional therapists, occupational therapists, physiotherapists and psychologists employed to a lesser extent. However, the bulk of hands-on care is provided by workers with few or no formal qualifications. The question we have addressed in this paper is, how well trained in dementia care are the aged care workers who provide residential aged care? We have examined the need for education and training in residential dementia care; summarising the provision of education and training in residential dementia care; and discussing where training in this area should head in the future. Staff training has long been a contentious issue in the aged care industry and with the increased dependency needs of residents in 1998 VOL. 22 NO. 5 workers in Australia. The majority of aged long-term care, education and training are becoming more important. There is substantial evidence that staff training makes an important contribution to the quality of dementia programs and resident outc~mes.~Yet recognition of the need for any training at all has only come slowly. In many ways, the continuing debate about the need for training epitomises the value placed on aged persons in our society. Past practice reflected the view that qualified staff were not required to meet the needs of elderly clients in residential facilities and one just needed a ‘kind heart and commonsense’ - hence the lack of prescription regarding qualifications for residential care staff. Geriatrics continues to have low prestige as a career choice. The preferences for more prestigious specialties and societal expectations about aged care are perpetuated by lack of interest in the area among academics and educators, whose interests in turn determine the emphasis of their courses. A study by EdeI5 in the United States revealed that faculty staff within schools of nursing had limited expertise in the area of gerontological nursing and this became an obstacle to content inclusion in the program. This lack of expertise also impacts on graduate programs inAustralia, where nurses who choose to pursue the area of dementia care have difficulty in locating an appropriate supervisor and often lose interest in gerontics as they progress through their courses.6 Davis’ saw lack of suitably qualified academic staff as a major contributing factor to students not choosing to work in the geriatric area. Yurchuck & Brewers found that many nurse educators teaching in specialty areas that included the care of elderly persons still did not see the need to have ‘gerontologyspecific’ skills. This was also consistently reported by a variety of individuals interviewed for this paper, especially in the area of dementia care. care workers have no formal qualifications, while those with formal qualifications are mostly from a nursing background. Only half of nursing staff have attended any dementia care training. Existing training is either service based and provided in-house or by private consultants, or tertiary institution based and provided by academics and professional educators. There is considerable in-service and one-off servicebased training being provided around Australia, but few of these training exercises are linked to competency standards or staff appraisal.While there are some formal courses addressing training in dementia care available in every state of Australia, the emphasis on dementia care within generalist tertiary institution courses for aged care workers varies considerably. (Aust N Z J Public Health 1998; 589-97) 22: Correspondence to: Sandy Ward, Accademic Unit of Psychogeriatrics, Department of Psychological Medicine, Monash University, Heatherton Hospital, Kingston Rd, Heatherton, Victoria 3202. Fax: (03) 9551 2330; e-mail: Sandy.Ward 0 med.monash.edu.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Doyle and Ward Table 1:Percentage of staff who attended seminars or training courses in the 12 months before the survey (n=1,851). ToDic Fire drill Lifting Dementia Continence Pressure care Dignity and privacy Attitude to change Bereavement Physiotherapy Confidentiality Sensory loss DeDression Freedom of choice Infestation Culture Rehabilitation Security Religious issues tual disability within any training cumculum. In NSW, Snowdon, Vaughan and MillerI4 found that 28% of a sample of 58 nursing homes in Sydney provided no on-going education to their staff about dementia or other psychiatric problems. In this paper, we report on three additional sources of information about dementia training for aged care workers. Methods First, a survey of 1,851 nursing home staff was undertaken about measuring quality of care.I5 The survey covered 98 nursing homes in Melbourne, Hobart and Adelaide. Homes were chosen using a stratified random sampling procedure. The response rate was 81% of homes and 51% of staff within the nursing homes, which was reasonable for a mail survey. In one question, respondents were asked to identify which of 19 topics they had attended courses or seminars on in the previous 12 months, one of the topics being dementia. The survey was carried out between May and July 1995. Second, service-based dementia training projects throughout Australia were reviewed, including 35 demonstration projects which were set up as part of the National Action Plan for Dementia Care during 1993-95. Third, tertiary institution-based training was reviewed by surveying selected nursing courses in tertiary institutions throughout Australia. In 1995, the authors sent a mail survey to the main tertiary education institutions throughout Australia in order to develop an inventory on the dementia care courses available. This was followed up by telephone interviews during March to August 1995. It was not possible to rigorously evaluate the courses or to make any assessment of the quality of the dementia course content. It must be acknowledged that the accuracy of the resulting information relied on the respondents’ cumculum knowledge and some respondents did not have an indepth knowledge of cumculum content. However, the survey provided an overview of the situation. The focus was predominantly on nursing faculties within the tertiary sector as this was the main discipline providing formal dementia education to aged care workers. Identified need for dementia care training A study by Deakin University in 1989 found that few registered nurses (RNs) working in aged care had specialist gerontological qualifications - a considerable number had post basic qualifications in midwifery.’ RossiterIo reported the results of a survey undertaken in NSW which indicated that only 4.7% of all R ” s had post-registration qualifications. Bumside” also identified a lack of appropriately skilled professionals who could meet the mental health needs of the older population. The lack of clinical expertise in the predominantly untrained workers also puts registered nurses and those with expertise gained through formal training under considerable pressure to supervise appropriately, as well, of course, as putting pressure on the unskilled worker. Rossiterlo referred to the importance of training nonprofessional staff and highlighted the stress that can result, for both the worker and the person with dementia, if workers do not have any knowledge or understanding, especially in the area of dementia care. Yet the availability of dementia training has been low in all states of Australia. Until 1990, there was no dementia care-specific training available in Western Australia to meet the already present and ever-growing need for dementia care.I2 Koenigi3identified training needs for those working with people with an intellectual disability and dementia in South Australia. He identified a lack of gerontology-related training in a survey of aged care,workers - respondents did not have a good knowledge of aging or dementia care needs. He found that 93.9% of survey participants highlighted their need for aged and dementia care-related training and assessment and observational skills. Koenig also emphasised the need for the review, analysis and promotion of positive attitudes to ageing and intellec- Results Survey of quality of care In our survey of the quality of care in Australian nursing homes, we found that 48% of nursing home staff (n=1851) from a sample of 98 homes in Melbourne, Hobart and Adelaide had attended a seminar or course on dementia and its treatment during the preceding 12 months.15 Overall, training in dementia was more common in homes in Tasmania, where 69% of staff (n=ll7) had attended a course or seminar, followed by South Australia (48%, n=596) and Victoria (46%, n=ll86). When staff were divided into professional backgrounds, it was found that 42% of enrolled nurse respondents (n=505) had received training in dementia, compared with 53% of senior nursing staff (n=736) and 5 1% of personal care assistants (n=469). Compared with other areas of training, dementia was addressed more than depression or cultural issues, but not as well as fire drill or lifting (Note that staff were only questioned about training in the format of seminars or courses: other training formats could also have addressed the topics shown). 1998 VOL. 22 NO. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Education and training in residential dementia care in Australia Review of service-based training In reviewing training provided outside the tertiary education sector (i.e. service-based training), we found the most popular forms of training in the residential care facilities were those provided inhouse and by a private educator; peak bodies and professional organisations were the inost frequently used and tertiary education institutions were least used in charitable organisations.Ih Some of the main peak bodies and professional organisations who provide dementia care are the Alzheimer’s Association (national); Aged Care Australia (national); The James McCusker Training Centre (WA), Age Concern; Mayfield; College of Nursing (NSW); Alzheimer Education; Churches of Christ; Hammond Group (NSW); Private Geriatric Hospitals Association of Victoria; ADARDS (Tasmania). There is also a plethora of private consultants in dementia education in Australia. While some service-based courses offered by consultants have been evaluated, there is no minimum standard required of private trainers. Educators can apply to have their course accredited by the Vocational Education, Training and Employment Commission. However, consultants, peak bodies and professional organisations are not obliged to register their courses with any authorised body. A number of special Australian Federal Government initiatives have provided funding for special education or training for the aged residential care sector. ‘The Training and Resource Centre for Residential Aged Care (TARCRAC) provided in-service training and acted as a resource centre for nursing and care staff in nursing homes during 1991, but the initiative foundered in its implementation. One of the main identified obstacles was the reliance on a facilitator to promote its use - facilities where it was utilised generally already had an in-house staff educator, suggesting that the initiative missed the staff with the greatest need for training. A National Action Plan for Dementia Care (NAPDC) was initiated by the Australian Commonwealth Department of Health and Family Services to be implemented during 1992-97. Education and training was identified as a key component of the plan. The Dementia Demonstration Projects were established under this plan in an attempt to raise awareness about dementia care needs and enable good care practices to be disseminated among care providers. Individual aged care fac es were given funding to demonstrate to other facilities in their area their good dementia care practices. A total of 35 facilities were funded in 1993-94, 57 facilities in 199495 and six facilities in 1995-96.’’ While the main intent of the program was residential care workers, community care workers were also included. The workshops and seminars run by these projects addressed a need for basic information for those working with people with dementia, especially for workers with little or no formal training. They were also effective in raising awareness and developing more effective networks among service providers. However, coverage was patchy, with aged care workers in some geographical areas being overwhelmed with dementia education, while others still lamented the lack of accessibility to training or education programs. Some project officers employed to demonstrate their excellent clinical care found that their skills as educators did not allow them to 1998 VOL. 22 NO. 5 communicate easily.” Demonstration projects also found that organisations often wanted ‘quick fix’ solutions which required a minimal amount of time to gain the necessary skills and to implement the interventions. Few staff saw the need to have an education that broadened their perspective and enabled them to transfer learning to a variety of situations rather than be episode focused. As with all education initiatives implemented from outside the aged care organisations, the effectiveness of the training was dependent on the acceptability of the new training to management and management’s willingness to incorporate the training into their on-going care. In 1995, the Dementia Demonstration Projects were scaled down, with only six projects being funded in 1995-96, to be superseded by a similar initiative, the NationalTraining Initiative, which started in the second half of 1996. The new initiative is designed to provide residential care staff throughout Australia with basic information on dementia and there is less emphasis on individual care practices than the demonstration project initiative. Training initiative educators all have experience in training, but are not necessarily involved in hands-on care in the manner of their demonstration project predecessors. Education will generally be of a similar format, with outside experts teaching aged care workers basic information about dementia care. Survey of tertiary-based training We surveyed tertiary education institutions to determine what their nursing courses included about dementia (Appendix 1). We found that dementia training was included or alluded to in generic courses, but the emphasis it received was generally determined by whether those responsible for the content had a particular interest or commitment to dementia. Many course co-ordinators indicated that dementia is referred to during discussions of related topics and any topic in which mental health might have relevance would have dementia mentioned. In postgraduate programs, students can sometimes elect to take dementia up as an alternative study option, even though it is not a component of the course content. In some instances, it was acknowledged that in postgraduate studies it is a dilemma for those running the courses, in that their own background and expertise in this area is limited and they lack confidence especially in the area of cognitive assessment. One organisation did state that dementia was beginning to get more attention in their faculty because it was now seen as an area that would attract future research funding. Undergraduate nurses in the tertiary sector undertake a generalist program and with limited time frames and an expanded curriculum it is not possible to cater for specialist topics. Educators in the field commented that these service-based needs should be met with university-based continuing education programs. However, this is an area that has not expanded because of lack of funding. Faculties/ departments would have to be assured of large participant numbers and at the very minimum the courses would have to be cost neutral to the organisation. Opportunities do exist for additional study of specific topics with electives, although it is not known how many would self-select to study dementia without encouragement from their teachers. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Doyle and Ward Some nurse educators who were interviewed felt that, like the psychiatric component of nursing education programs, gerontology had been written out of many cumcula, that content was minimal and did not address many of the relevant issues that would confront students in their clinical practice. Cumculum content was very much determined by the educators and unless the subjects of gerontology and dementia had a strong advocate, their inclusion was limited. Discussion Our survey of the quality of care in nursing homes showed that only about half of the staff had any recent training about dementia care and as trained staff may have been more likely to respond to the mail survey, it is probably an over estimate of the extent of training in the workforce. Given the prevalence of dementia, it is surprising that the topic is not given greater prominence in training aged care workers. This review has shown that there has been considerable activity in dementia training in some areas, such as service-based training, but research is limited on the effectiveness of training methods that are currently employed to improve dementia care. The high cost of training demands more rigorous review of these programs. Courses in tertiary institutions have been relatively slow to respond to the need for specific information about dementia among their graduates. We found that there is considerable diversity in the availability of courses that provide strong dementia care components for aged care workers throughout Australia. Despite its size, Tasmania is relatively well placed for dementia training, as we found that more staff had attended courses in our survey and the tertiary education offered in that state appeared to have a strong dementia component. Initiatives funded by the NationalAction Plan for Dementia Care should lead to an upsurge in the proportion of the aged care workforce that has been exposed to dementia training. However, this increase in activity depends on the organisational structures maintaining and reinforcing the educational principles being taught in order to achieve long-term improvement in the workforce, so that new staff who are employed after the current initiatives finish can reap any benefits. The education and training of staff has to be on-going and an integral component of the organisational structure - short, sharp exposure to education such as one-off day seminars are often cost ineffective because they do not lead to enduring outcomes. It is yet to be seen whether the latest Commonwealth government National Training Initiative leads to long-term improvement in dementia care. We found considerable fragmentation in the training available to aged care workers. A stronger educational infrastructure for aged care would address this problem. The question that arises is: whose responsibility is it to develop a training infrastructure? In the absence of a co-ordinated response from the tertiary education sector (TAFE and university), private consultants are proliferating and appear to be able to make money from their endeavours, while the tertiary education sector remains wary of committing funds. To get any long-term benefit from training initiatives, there needs to be better co-ordination between service-based, TAFE and university training, which can only come from improved standards and accreditation. National competency standards for direct cafe workers in aged care services have recently been developed by the National Community Services and Health Industry Advisory Training Board and are currently waiting for ratification. A knowledge of dementia is a component of some of the core competency standards. Once the competency standards have been ratified, existing courses will need to be re-written to address the components of the competency standards. Competency standards will be then able to be used to inform training programs for staff in aged care services. Ultimately, however, staff need to be rewarded for increasing their qualifications and participating in training, something which current service-based initiatives have ignored. Aged care workers come from a society that views ageing and residential care in a negative way and administrators and educators have to promote a positive view of ageing for staff to feel that education is worthwhile and beneficial to their work. The education of staff in residential care needs to be viewed as a dynamic, synergistic process which can often cause upheaval within the work environment as old practices are challenged and new methods of care implemented. This factor alone could explain why it is often avoided or not given priority. Nursing and other health professional courses need to respond to the changing health care needs of the community by their graduates being given the opportunity for retraining in areas of need, such as aged and dementia care. Finally, a basic issue raised by this study is how to incorporate specialist training, such as dementia care, into the context of wider public health or aged care training. Educators need better access to up-to-date information on specialist areas, such as dementia care, and better monitoring of courses to ensure that the right balance is achieved within the structure of the courses to meet the changing needs of the community. Better links need to be made between training for workers in different settings, so that, for example, health professionals trained in the acute sector are able to translate their skills appropriately to community and residential care. Better dementia training is tied up with the need for better basic aged care training in general. As with other public health areas (such as child care) which have moved from a largely untrained workforce to increasing coverage of basic training for the workforce, the barriers to development of a trained workforce in aged care will be fiscal and attitudinal - society needs to be prepared to pay for the better quality of care that flows from a better trained workforce and prepared to view aged care as worth the effort.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Oct 1, 1998

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