Implementing the Teaching Nursing Homes Initiative: Scoping Study

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1 Implementing the Teaching Nursing Hmes Initiative: Scping Study BRIDGING EDUCATION, RESEARCH AND CLINICAL CARE THE TEACHING NURSING HOME: DISCUSSION PAPER DR KATE BARNETT With assistance frm Prf Jennifer Abbey & Ms Jnquil Eyre REPORT PREPARED FOR: Better Practice Sectin Aged Care Wrkfrce & Better Practice Prgrams Branch Office f Aged Care Quality and Cmpliance Dept f Health and Ageing, Canberra February 7 th 2011 AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 1

2 CONTENTS FOREWORD... IV CONTEXT FOR THE DISCUSSION PAPER... IV THE PROJECT TEAM... IV THE PROJECT MANAGEMENT TEAM... IV ACRONYMS... IV KEY FINDINGS THE TEACHING NURSING HOME: ORIGINS AND FEATURES OF THE MODEL ORIGINS OF THE TNH MODEL TNHP Gals Features f aged care facilities participating in the TNHP initiative Features f TNHs in the Veterans care sectr KEY FEATURES OF THE TNH MODEL Intended benefits f the TNH mdel Identified benefits f the TNH mdel Guiding Principles fr a TNH Case Study 1: ACU Natinal & RSL LifeCare -Evidence based enhanced clinical care VARIATIONS OF THE MODEL Case Study 2: Including acute care hspitals and fcusing n families, an Ohi affiliatin OTHER INTERNATIONAL EXAMPLES OF THE TNH MODEL The TNH in the Netherlands Physician fcused apprach The TNH in Nrway the Netwrk apprach THE TEACHING NURSING HOME: CURRENT CONTEXT IN AUSTRALIA AGED CARE WORKFORCE ISSUES: POTENTIAL RELEVANCE OF THE TNH MODEL GOVERNMENT INITIATIVES TO SUPPORT IMPROVED CLINICAL EDUCATION ISSUES ASSOCIATED WITH CLINICAL EDUCATION IN AGED CARE System-level issues Addressing negative student attitudes/ageist attitudes/ negative view f aged care Case Study 3: Quality clinical educatin in Tasmania ENABLING FACTORS ACHIEVING GOOD PRACTICE IN CLINICAL PLACEMENT Case Study 4: PACE: Gd practice in clinical educatin ATTENTION TO PLANNING AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper i

3 3.3 INFORMED PARTICIPATION AND MUTUAL UNDERSTANDING Understanding the impact n partners f the TNH affiliatin SHARED COMMITMENT BY TNH PARTNERS AND STRONG LEADERSHIP Case Study 5: Hammndcare and UNSW linking research and multiple care sectrs FORMALISATION OF AFFILIATIONS BETWEEN EDUCATION AND AGED CARE PROVIDERS CLINICAL PRACTITIONERS AND SUPERVISORS INTERDISCIPLINARY FOCUS Case Study 6: Interdisciplinary fcus: A TNH affiliatin in SA PHYSICAL INFRASTRUCTURE Case Study 7: ACH Grup and Flinders University f SA purpse designed quality learning envirnment ADEQUATE AND SUSTAINED RESOURCING CRITICAL MASS CHALLENGES AND ISSUES ASSOCIATED WITH A TNH ETHICAL AND LEGAL ISSUES DISINCENTIVES FOR AGED CARE PROVIDERS DISINCENTIVES FOR EDUCATION AND TRAINING PROVIDERS MANAGING DIFFERENT CULTURES, CAPACITY AND EXPECTATIONS THE IMPORTANCE OF CONTINUITY OF PERSONNEL OVERCOMING AGEIST ATTITUDES OTHER LESSONS LEARNED FROM THE LITERATURE IN APPLYING THE TNH MODEL PROVISION FOR EVALUATION CRITERIA FOR SELECTING A NURSING HOME SITE FOR A TNH The TNH as a Hub Case Study 8: An interdisciplinary netwrk f TNHs in Texas Lessns frm Nrway: the TNH Lighthuse Netwrk CONCLUSIONS BIBLIOGRAPHY TABLES TABLE 1: TNH STAKEHOLDERS AND THE BENEFITS OFFERED TO EACH TABLE 2: BARRIERS TO TNH AFFILIATION (MEZEY ET AL 1997) AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper ii

4 Australian Institute fr Scial Research The University f Adelaide 230 Nrth Terrace, Adelaide Suth Australia Published August 2011 ISBN: Suggested citatin: Barnett K, Abbey J & Eyre J (2011) Bridging Educatin, Research and Clinical Care the Teaching Nursing Hme: Discussin Paper, Australian Institute fr Scial Research, The University f Adelaide DISCLAIMER: This reprt describes current state f play and des nt attempt t evaluate current practice. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper iii

5 FOREWORD CONTEXT FOR THE DISCUSSION PAPER In late December 2010, the Department f Health and Ageing (DHA) cmmissined the Australian Institute fr Scial Research (AISR) at The University f Adelaide t prvide research and analysis t infrm the implementatin f the Teaching Nursing Hmes Initiative. THE PROJECT TEAM Dr Kate Barnett, Deputy Executive Directr, AISR (Prject Leader) wrking in cllabratin with AISR Research Assciates Prfessr Jennifer Abbey and Ms Jnquil Eyre. THE PROJECT MANAGEMENT TEAM A small team frm the Department f Health and Ageing s Better Practice Sectin f the Aged Care Wrkfrce & Better Practice Prgrams Branch, Office f Aged Care Quality and Cmpliance is managing the prject. Ms Eliza Hazlett, Directr, Better Practice Sectin Ms Anandhi Raj, Assistant Directr, Better Practice Sectin Ms Trish Deane, Better Practice Sectin ACRONYMS ACWC Aged Care Wrkfrce Cmmittee CRP Cmmunity f Research and Practice DEEWR Department f Educatin Emplyment and Wrkfrce Relatins DEST Department f Educatin Science and Technlgy DOHA Department f Health and Ageing HWA Health Wrkfrce Australia NHWT Natinal Health Wrkfrce Taskfrce TNH Teaching Nursing Hme TNHP Teaching Nursing Hme Prgram NTNH Nrway Teaching Nursing Hme NIA Natinal Institute fr Aging RACF Residential Aged Care Facility VET Vcatinal Educatin and Training AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper iv

6 KEY FINDINGS The Mdel Althugh there are many facets t a TNH, the essence f the mdel is the linking f the separate spheres f research, clinical care and educatin and training thrugh an affiliatin r partnership between a residential aged care facility (RACF) and an educatin r training prvider. It is the research cmpnent that usually distinguishes a TNH frm ther RACFs. Mst f the TNH mdels invlve partnerships between university schls f nursing and RACFs, but sme als include acute care hspitals. The TNH mdel, with its fcus n cllabrative educatin and cperatin between clinicians, teachers, researchers, students and managers, can be designed t supprt interdisciplinary training fr and delivery f aged care (particularly invlving nursing, medicine and allied health prfessins). Hwever, in practice, mst f the initiatives reviewed have fund it difficult t achieve this fcus, r have pursued an affiliatin based n a single discipline usually nursing r medicine. This is a gap which new TNH mdels shuld seek t address, given current Australian aged care wrkfrce evidence-based knwledge abut the imprtance f hlistic care f lder peple and the benefits f multidisciplinary team wrk. Althugh there are certain cre features f the TNH mdel, its applicatin can be expected t vary with lcal cnditins, the expertise brught by its partnering rganisatins, and the needs f students and residents. Benefits f the TNH Mdel The TNH prvides the pprtunity t simultaneusly address multiple challenges that relate t the aged care wrkfrce, aged care delivery, and educatin and training prvisin. The chart belw summarises the key benefits that can be ffered by a TNH, based n research and evaluatin findings, and the key stakehlder grups affected by them. Stakehlder Educatin/ training prvider Aged care prvider Students Residents (& Families) Aged care wrkfrce Benefits Increased invlvement in ageing research that is based n clinical placement in a RACF. Greater pprtunity t prvide high quality educatin and training. The TNH mdel supprts effective wrking relatinships between aged care service and educatin prviders, which is critical t effective clinical educatin Increased invlvement in research and expsure t clinical practices that enhance quality f care. Increased prfessinal develpment due t relatinship with educatin prvider. Enhanced learning pprtunities based n clinical experience with an educatin and aged care prvider affiliatin cmmitted t achieving greater quality f care, research and greater quality f educatin/training Imprved quality f care. Reduced turnver f staff, therefre, greater cntinuity f care. Opprtunity fr the aged care wrkfrce t be trained in a setting designed t meet the needs f lder peple (as ppsed t an acute care setting).enables aged care thery and practice t be integrated (when ften is fragmented which has a negative impact n wrkfrce preparatin). The TNH has been fund t enhance recruitment and retentin f aged care wrkers because f the enhanced prfile as a centre f excellence in research, training and care prvisin that many TNHs have achieved. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 1

7 There is an interactive effect between these sets f benefits as the TNH mdel is cmprised f mutually influencing inputs. Benefits in ne dmain will enhance thse in anther - fr example, a cmmitment t evidence-based clinical care supprts, and is supprted by, research that relates t the aged care envirnment and in turn, supprts imprved quality f care. Affiliated RACFs that achieve these utcmes will be mre attractive t students and ptential and current wrkfrce members than will RACFs withut this prfile. Impact n clinical educatin The TNH mdel supprts effective wrking relatinships between service and educatin prviders and such relatinships are critical t the design and delivery f clinical educatin. Given the shared respnsibility fr clinical educatin acrss the health and educatin and training sectrs, mechanisms fr effective engagement between the sectrs are critical, and the TNH prvides such a mechanism. Research findings frm a series f recent Australian studies reprted in this discussin paper and illustrated in lcal case studies, strngly supprt the TNH mdel as a means f prviding best practice clinical placement in aged care settings and thereby enhancing the training capacity f the aged care sectr as a whle. Critical Success Factrs in achieving quality clinical placement in aged care Critical inputs at the preparatin and planning phase Adequate preparatin f students prir t entry int a RACF clinical placement; A clear and realistic statement abut the desired learning bjectives tgether with infrmatin abut assessment arrangements and the allcatin f respnsibilities and a briefing that explres expectatins f students rle in the RACF setting; Clear infrmatin abut student knwledge and skills and learning utcmes prvided t the RACF; The need fr clearer rle and functin definitin, especially that f supervisrs; Dcumentatin f RACF and educatin prvider rles and respnsibilities; Infrmatin t students abut the lgistical rganisatin f the placement including (fr example, transprt and parking availability, site rientatin, an intrductin t site staff, details f the clinical teaching rles and respnsibilities, arrangements fr accessing clinical teacher/academic advisr, schedules fr debriefing); Ensuring that adequate resurces, including free time, are available fr the supervisry/ teaching/ preceptr rle. Prvisin f training in supervisr skills, where needed, and issues assciated with access t training such as release and cst, and availability in sme circumstances. Infrastructure and physical resurces that are cnducive t student learning (eg dedicated spaces fr tutrials, lectures, feedback sessins etc). Critical inputs at the implementatin and evaluative phases timely and bjective feedback n perfrmance; structured and regular pprtunities t debrief and reflect during and after the placement; Prmting an understanding f the benefits fr site staff frm their invlvement with the students and the training rganisatin. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 2

8 At the brader systems level fur key benefits have been identified in the literature: enhanced recruitment and retentin is assciated with TNHs that have effectively linked research, educatin and clinical care and achieved psitive utcmes in all three dmains; an enhanced prfile is develped f the aged care sectr as a lcatin fr clinical placement and ultimate emplyment, and an enhanced prfile is develped fr teaching and research fcused n the care f lder peple and fr educatin prviders invlved in these activities thrugh a TNH; disseminatin f TNH learnings t ther RACFs can extend their impact and prvide leadership fr the aged care sectr as a whle; preventin f hspitalisatin and reduced length f stay in hspitals can arise frm the increased capacity f RACFs t prvide medical care and health preventin services (where the mdel has been extended t partner with acute care prviders and/r has invlved training and emplying physicians in RACFs). At the service delivery level (fr bth aged care and the educatin and training f the aged care wrkfrce) a number f specific benefits and challenges have emerged frm the literature review. These are discussed in detail in the reprt and are summarised belw in terms f cmpeting Incentives and Disincentives affecting the tw key stakehlders aged care service prviders and aged care educatin and training prviders. Benefits assciated with a TNH The research literature identifies a range f ptential benefits and psitive utcmes assciated with Teaching Nursing Hmes. The TNH mdel, with its fcus n cllabrative educatin and cperatin between clinicians, teachers, researchers, students and managers, can be designed t supprt interdisciplinary training fr and delivery f aged care. This supprts current directins in gd practice in aged care. It can als play a rle in addressing issues relating t the prvisin f quality clinical educatin pprtunities, as this is ne f its key purpses. Furthermre, the mdel supprts effective wrking relatinships between service and educatin prviders and such relatinships are critical t the design and delivery f clinical educatin. Evaluatin has fund evidence f imprved learning cnditins fr students. The TNH enables faculty members t identify practice issues, t research these and t feedback new knwledge int the educatin system. By wrking within a RACF, the faculty member has the pprtunity t enhance the quality f teaching, t identify research pprtunities (including mtivating aged care staff t undertake small scale research studies) and t imprve patient care. Students benefit frm being taught by faculty members with direct and recent clinical experience. Enhanced quality f care has been identified by researchers. RACFs and their residents have been fund t benefit frm the implementatin f evidence-based practice and participatin in clinical care fcused research (fr example, in the areas f cntinence management, falls preventin and wund management). In additin, imprved decisin making and care planning has als been identified in TNHs. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 3

9 Evaluatin has fund that aged care staff s cmpetence increases, and RACFs share these learnings with ther nn-tnh facilities (fr example, thrugh cnference presentatins), thereby having a wider systems-level impact. The prfile f research int chrnic illness and the specific needs f frail lder peple may increase. Having access t high care need clients enables researchers t undertake cntrlled clinical trials. The United States TNH prject sites funded by the Rbert Wd Jhnsn Fundatin were fund t have achieved a five-fld increase in funded research activity. In turn, this cntributes t increasing the educatin partner s standing in the academic cmmunity as a centre f excellence. The TNH can vercme ageist barriers t training and wrking in aged care, and instead generate psitive attitudes t lder peple and t wrking in aged care, depending n psitive clinical placement pprtunities being enabled (that is, characterised by apprpriate training and supprt in an envirnment fcused n quality care). Evaluatrs have fund marked increases in TNH students taking up aged care pst-graduate psitins and increased enthusiasm by participating staff t cntinue wrking in the facilities invlved. Recruitment and retentin have bth been fund t be facilitated by an effective TNH. Attitudinal changes have als been identified within schls f nursing participating in Teaching Nursing Hme prjects, nting a mve twards greater curse cntent specialising in ageing and aged care, and increased clinical research and publicatins relating t care f lder peple all f which has a psitive impact n students attitudes t lder peple and t careers in aged care. Where the TNH cllabratin has been extended t include lcal acute care hspitals, the mdel has been fund t prevent hspitalisatin and reduce length f stay in hspitals due t the increased capacity f RACFs t prvide medical care and health preventin services. Challenges assciated with the TNH mdel The literature identifies mre psitive than negative utcmes arising frm the TNH mdel. Hwever, there are challenges assciated with the mdel and there is a need t address these in bth the planning and implementatin phases f a TNH. There are a number f ethical and legal issues assciated with a TNH.A key challenge fr TNHs is balancing the rights f patients with the research and publishing requirements assciated with teaching and educatin. There are als a range f ethical issues assciated with undertaking research with residents f RACFs, particularly thse with high level care needs and/r thse nt able t prvide infrmed cnsent. In additin, the duty f care requirements f aged care prviders and their legal liabilities mean that relatively untrained students can present a risk t fulfilling thse requirements withut specific supervisin, rientatin and ther measures. Such issues require clarificatin in develping a teaching nursing hme and underscre the imprtance f a frmalised agreement between affiliatin partners. A number f disincentives t participating in a TNH exist fr aged care prviders. Participating in a TNH invlves fur majr challenges, the first three f which require dedicated resurcing in rder AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 4

10 t be managed. The furth invlves a tensin that will impact differently depending n the individual. The wrklad invlved leads t reluctance by aged care prviders t accept placements (in the absence f resurces t enable them t d s). There can be insufficient available aged care facility staff t mentr and supervise students. It cannt be assumed that aged care prviders will have the supervisry skills required, and hence resurcing is needed t prvide access t training and assciated csts (such as backfilling). Inapprpriate physical infrastructure can als cnstrain the capacity fr supervisin. An nging challenge has been fund in pursuing tw very different rles (clinical care and educatin/training) simultaneusly. Disincentives als exist fr educatin and training prviders. Fur main challenges have been identified that relate specifically t clinical placement. There is an nging trade ff between the learning requirements f students and the need t find sufficient clinical places t meet the accreditatin requirements f different prfessins. The matching f students t placements requires significant individualised attentin that educatin prviders are increasingly unable t prvide, and there is cnsiderable ptential fr mismatch. The cmplexity f the health and educatin and training sectrs brings administrative and financial challenges in negtiating clinical placements. Educatin and training prviders have fund that their clinical respnsibilities at the affiliated RACFs cnflict with their teaching and research respnsibilities and the need t pursue these fr tenure purpses. Managing different cultures, capacity and expectatins is anther challenge that faces any cllabratin, including a TNH. Aged care prviders and educatin and training prviders perate in different envirnments, with different cultures and different sets f skills and experience. Cmbining these differences can bring significant benefits arising frm the diversity f capacity invlved, but the literature has als identified that thse differences can cause difficulties if they are nt addressed. In particular, there is a need t ensure that partners understand each ther s gals, peratinal issues, expectatins, career gals and experience in wrking with lder peple. Withut a prcess t address gaps in this knwledge, difficulties will be faced as partners attempt t recncile divergent rles. The issue f cmmunicatin becmes extremely imprtant in ensuring that different rganisatins with differing cultures, mdes f perating and experience can wrk effectively tgether. The need fr rganisatinal stability and cntinuity f persnnel has been identified by several ther studies reviewed. Enablers f the TNH mdel There are a number f factrs that can be cnsidered t be enablers f the TNH mdel. There was a trend in the research reviewed t identify the fllwing ten: A number f features f gd practice in clinical placement in aged care settings (f which there are many sub-features that als acts as enablers). Attentin t the planning stage f the TNH. Frmalised affiliatins between thse invlved. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 5

11 A shared cmmitment by TNH partners t the gals f such a mdel. Infrmed participatin by TNH partners. Mutual understanding by TNH partners. Ensuring that clinical practitiners are available t prvide supervisin and training fr students. An interdisciplinary fcus that supprts a hlistic view f care fr lder peple. Chice f RACF sites with sufficient critical mass t ffer diversity f learning experiences. Apprpriate physical infrastructure fr n-site training and educatin. Resurcing t supprt a TNH Cllabratins f any kind require skills, cmmitment t a shared purpse, and a significant investment f time especially in the early stages when thse invlved are learning abut each ther s perating cnditins, drivers and cnstraints, and thereafter t ensure that the cllabratin is sustained. It is difficult t achieve this withut dedicated resurcing, and t meet ther features f a TNH which the research literature has identified as essential. These invlve: Educatin/training prvider staff t train and supprt RACF staff (eg in supervisin and teaching skills) and t visit the facility regularly. The RACF needs t backfill when their staff are prviding training and supprt t students, r participating in meetings with their educatin partner. Supervisr training and resurcing is a critical enabler f best practice clinical placement, and therefre, f an effective TNH. Prvisin f apprpriate physical infrastructure t supprt the linking f clinical care, research and educatin. The research findings indicate that the TNH mdel hlds significant ptential t bring abut enhanced quality f aged care, educatin and training f the aged care wrkfrce, and research t prvide an evidence base fr these imprvements. The mdel can benefit individual participants and stakehlders, as well as the brader aged care and educatin systems. Much depends n hw it is planned, resurced, implemented and evaluated. Hwever, sufficient evidence exists abut lessns learned t date regarding enablers and barriers and this infrmatin is readily transferable t the Australian cntext. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 6

12 1 THE TEACHING NURSING HOME: ORIGINS AND FEATURES OF THE MODEL The Teaching Nursing Hme (TNH) is mst simply defined as an aged care facility in which there exists synergy between clinical care, educatin and research (Katz et al 1995: 507). 1.1 ORIGINS OF THE TNH MODEL The rigin f TNHs is usually traced t the early 1960s - particularly in relatin t veterans nursing hmes (see Sectin 1.1.3) and affiliated veterans hspitals (Rubinstein et al 1990: 74) - being assciated with effrts in the United States t imprve knwledge abut lng term care f lder peple and t increase the number f qualified aged care prviders. Hwever, it was the prvisin f funding thrugh tw majr prgrams in the USA during the 1980s that led t recgnitin and fcus fr this mdel. The first directr f the Natinal Institute fr Aging (NIA), Rbert Butler, established a teaching nursing hme prgram that was research based and designed t increase knwledge abut the ageing prcess and disease preventin, thrugh multidisciplinary cllabratin. Originally riented t medical training, the prgram was bradened t affiliate with nursing schls and was designed t prvide clinical placements fr undergraduate students, fster cllabrative research, and encurage cntinuing educatin amng nursing hme staff (Chilvers & Jnes 1997: 464; DEST 2004: 16; Neville et al 2006: 4 citing DEST 2004; Wallace et al 2007: 5). Althugh fcused n imprving aged care training, the NIA prgram s primary purpse was t stimulate clinical research in nursing hmes (Mezey & Lynaugh 1989: 773) and in the prcess, t build an interface between the aged care system and university schls in the training f aged care prfessinals. It is this research fcus which was seen t distinguish a TNH frm ther nursing hmes (Arnsn 1984: ). Butler described the TNH mdel as a pwerful institutinal resurce prviding an rganisatinal fcus fr geriatric research and training (1981: 1435). These fur gals were articulated fr the NIA prgram, and all remain relevant in the current care system: I. Fster systematic clinical investigatin f disease prcesses in lder peple and develp diagnstic techniques and methds f treatment specific t their needs. II. Train different prfessins in geriatric care. III. Establish a research base fr imprving care in nursing hmes, designing cmmunity and clinical services that defer r prevent institutinalisatin, and rehabilitating and rapidly returning patients t their wn hmes. IV. Devise and demnstrate cst-cntainment strategies (Butler 1981: 1436). Interestingly, althugh fcused n nursing hmes, Butler was clear that the majrity f care fr lder peple actually ccurs utside f this setting, and expected the prgram t prvide learning pprtunities that cvered a range f needs and services, including preventive health care and health prmtin. The TNH was thus cnceived as a hub fr a range f in-huse and utreach services, rather than an exclusive fcus n residential care services. The elements f the visin Butler expressed are ften identified in the subsequent literature as critical success factrs (this will be explred later in this literature review see Sectin 3). In the five years frm 1982 t 1987, the Rbert Wd Jhnsn Fundatin (a private rganisatin in the USA) als funded a similar initiative - the Teaching Nursing Hme Prgram (TNHP). Taking its inspiratin AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 7

13 frm the mdel f educating medical students by prviding clinical training in teaching hspitals, the Prgram was designed t pilt clinical training fr nursing students in residential aged care facilities (RACFs) while prmting research and imprved care within these facilities (Brnner 2004: 2). Hwever, in cntrast t the NIA initiative, its primary fcus was n restructuring and enhancing clinical care. Where the NIA mdel fcused n physicians and linked with medical schls, the TNHP fcused n nursing and linked with nursing schls (Mezey & Lynaugh 1989: 773: Kaeser et al 1989: 38; Liebig 1986: 199, 213). The idea fr the mdel is attributed t Linda Aiken, a nurse wh had returned t study and btained a dctrate, and wh became a prgram fficer at the Fundatin in She had seen the success f affiliatin arrangements between medical schls and veterans hspitals and she and her clleagues believed that nursing educatin wuld be significantly imprved thrugh similar assciatins with nursing hmes, while the latter wuld benefit frm the linkage f academic nursing with actual care (Aiken et al 1985: ) TNHP GOALS The TNHP had these eight gals, which like thse f the NIA prgram, remain relevant tday: Exemplify the hallmark f a nursing hme prfessinal learning envirnment. Aspire t create an envirnment that mdels a culture f learning. Seek t transfrm perceptins and images in academia and the cmmunity as the ptential f nursing hmes t prvide exemplary care and fster quality f life. Educate tmrrw s leaders and wrkfrce in institutinal lng term care. Prmte interdisciplinary educatin and practice. Test and disseminate evidence-based practices. Prmte culture change that fcuses n persn-directed care. Leverage existing resurces t imprve cmpetencies f direct prviders, nursing hme leadership, and faculty (Mezey et al 2008: 10) FEATURES OF AGED CARE FACILITIES PARTICIPATING IN THE TNHP INITIATIVE C-spnsred by the American Academy f Nursing, and administered by the University f Pennsylvania s Schl f Nursing, the TNHP initiative received applicatins frm 53 schls and frm these, 11 were selected fr the pilt. The successful schls f nursing wrked with 12 nursing hmes, which althugh diverse, shared these characteristics: Prvisin f a higher than average level f care (als fund in Australian research by Rbinsn et al: 2008). Prvisin f a greater than average prprtin f skilled nursing facility beds. Were larger than average in size. Had 24 hur registered nurse cverage. All except ne were nt-fr-prfit rganisatins (Brnner 2004: 5-6; Aiken et al 1985: 199; Mezey et al 1997: 134). AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 8

14 1.1.3 FEATURES OF TNHS IN THE VETERANS CARE SECTOR A survey f TNHs perating in the veterans care sectr in the USA (Rubinstein et al 1990), where the mdel has been evident since the 1960s and evlved independently f the NIA and TNHP initiatives, fund that cmpared with standard veteran aged care facilities, the TNHs had the fllwing features: They were significantly larger in size. They admitted and discharged significantly mre patients per ccupied bed. They placed a significantly larger prprtin f discharged patients in nn-institutinal cmmunity settings. Care csts were slightly, but nt significantly, higher despite significant increases in levels f prfessinal staffing and amunts f training prvided. There was a trend fr TNHs t have higher staff t patient ratis in a number f staff categries including nurses, nurse practitiners, clinical specialists, physician residents and scial wrkers. TNHs were significantly mre likely t be receiving cverage frm medical and surgical staff at the adjining veterans hspital (nte: this invlvement with an acute care prvider has always been part f the veterans TNH mdel). Academic activities f all kinds were mre cmmn in TNHs than nn TNHs. This included having in-service educatin prgrams, frmal staff lectures, staff wh publish in the prfessinal literature and present at scientific cnferences, and research activities f varius kinds (Rubinstein et al 1990: 75). 1.2 KEY FEATURES OF THE TNH MODEL It is difficult t establish clear definitins f the TNH frm the literature, hwever, a number f writers supprt the fllwing features and shw agreement n the fundamental cncept f this mdel and its linking f the separate spheres f research, clinical care and educatin and training (Chilvers & Jnes 1997: 463). Citing early wrk by Mezey et al (1984), Wallace (1984), Ciferri & Baker (1985), Huey (1985) and Kaeser et al (1989) they identify the fllwing characteristics f TNHs: An affiliatin between nursing hmes and academic institutins Having the gals f Prmting quality patient care Increasing knwledge in the care f lder peple requiring lng term care Educating health prfessinals regarding lng term care f lder peple Reducing the gap between thery and practice thrugh research Prviding educatin and clinical experience fr students (Chilvers & Jnes 1997: ). The TNH mdel prvides the pprtunity fr the aged care wrkfrce t be trained in a setting designed t meet the needs f lder peple. The training f the wrkfrce prviding this care varies frm ne prfessin t anther, but amng health prfessinals the setting in which clinical skills and knwledge are develped has been mre likely t be in an acute care envirnment, rather than an aged care facility. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 9

15 Traditinally, residential aged care facilities (RACFs 1 ) have nt played a central rle in clinical develpment, and have nt been clsely r frmally linked with the educatin and training prviders respnsible fr the certificatin and develpment f their wrkfrce. Hwever, care fr lder peple ccurs in a range f settings their wn hmes, cmmunity based services and aged care facilities, and t a far lesser extent, in acute care settings (Liebig 1986: 196). Geriatric care has been criticised fr being taught in a fragmented way with the cnsequent need fr a place where the elements f geriatric thery and practice can be integrated. The acute-care hspital is a pr setting fr such integratin; the nursing hme is cnsidered t be far mre apprpriate (Liebig 1986: 199). Older peple stay fr shrter perids in acute care than they d in cmmunity r residential aged care services. Fr the student undertaking a clinical placement, the aged care service ffers an pprtunity t wrk with lder peple ver an extended perid f time and in a setting designed with their needs in mind. If that aged care service ffers a diversity f prgrams the student can experience a range f service prvisin mdes and a wider spectrum f aged care needs. Refer t Sectin 0 fr detailed discussin f enablers f the TNH mdel, including prviding an interdisciplinary fcus (Sectin 3.7) INTENDED BENEFITS OF THE TNH MODEL In reviewing the literature, it is apparent that the mdel can als be understd in terms f its fur key stakehlders and the intended benefits fr each. These are summarised in Table 1. Table 1: TNH Stakehlders and the benefits ffered t each Stakehlder Educatin/training prvider Aged care prvider Intended Benefits Increased invlvement in ageing research that is based n clinical experience in a RACF, and greater pprtunity t prvide high quality educatin and training. Increased invlvement in research and expsure t clinical practices that enhance quality f care. Increased prfessinal develpment due t relatinship with educatin prvider. Students Residents (and their Families) Enhanced learning pprtunities based n clinical experience with an educatin and aged care prvider affiliatin cmmitted t achieving greater quality f care, research and greater quality f educatin/training Imprved quality f care There is an interactive effect between these sets f benefits as the TNH mdel is cmprised f mutually influencing inputs. Benefits in ne dmain will enhance thse in anther - fr example, a cmmitment t evidence-based clinical care supprts and is supprted by research that relates t the aged care envirnment and in turn, supprts imprved quality f care. Affiliated RACFs that achieve these 1 This paper will use the term RACF t dente the different levels f care, high and lw, in mst residential aged care facilities tday. The term nursing hme will be used in reference t the early TNH examples. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 10

16 utcmes will be mre attractive t students and ptential and current wrkfrce members than will RACFs withut this prfile IDENTIFIED BENEFITS OF THE TNH MODEL The research literature identifies a range f ptential benefits and psitive utcmes assciated with Teaching Nursing Hmes. The TNH mdel, with its fcus n cllabrative educatin and cperatin between clinicians, teachers, researchers, students and managers, can be designed t supprt interdisciplinary training fr and delivery f aged care (Chilvers & Jnes: 1997). It can als play a rle in addressing issues relating t the prvisin f quality clinical educatin pprtunities, as this is ne f its key purpses. Furthermre, the mdel supprts effective wrking relatinships between service and educatin prviders and such relatinships are critical t the design and delivery f clinical educatin (NHWT 2009: 4; Rbinsn et al: 2008). The TNH enables faculty members t identify practice issues, t research these and t feedback new knwledge int the educatin system (Chilvers & Jnes 1997: 466). By wrking within a RACF the faculty member has the pprtunity t enhance the quality f teaching, t identify research pprtunities (including mtivating aged care staff t undertake small scale research studies) and t imprve patient care (Layng Millnig: 1986). Students benefit frm being taught by faculty members with direct and recent clinical experience. Evaluatin f the mdel in Nrway has fund that aged care staff s cmpetence increased, and that they shared these learnings with ther nn- TNH facilities. It als fund evidence f imprved learning cnditins fr students (Kirkevld 2008: 284). The prfile f research int chrnic illness and the specific needs f frail lder peple may increase. Having access t high care need clients enables researchers t undertake cntrlled clinical trials. The United States TNH prject sites funded by the Rbert Wd Jhnsn Fundatin were fund t have achieved a five-fld increase in funded research activity (Aiken: 1988). In turn, this cntributes t increasing the educatin partner s standing in the academic cmmunity as a centre f excellence (Mezey & Lynaugh: 1989). The TNH enables the generatin f psitive attitudes t lder peple and t wrking in aged care when it prvides psitive clinical placement pprtunities (that is, characterised by apprpriate training and supprt in an envirnment fcused n quality care) (Wallace et al 2007: 5; Neville et al 2006: 3-4). Prviding a variety f clinical experiences with lder peple and grading thse experiences, starting with the well elderly and finishing with the care f the sick and critically ill, seems t prmte interest in wrking with frail lder peple (Abbey et al 2006a: 15 citing Haight et al 1994; Spier & Yurick 1992). Timing f the placement can als be critical t achieving this utcme, with negative views f aged care likely t develp if students are placed befre they have develped advanced skills r knwledge, r if they are unable t access clinical settings where they can bserve best practice in aged care (Neville et al 2006: 2). Attitudinal changes have als been identified within schls f nursing participating in Teaching Nursing Hme prjects, nting a mve twards greater curse cntent specialising in ageing and AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 11

17 aged care, and increased clinical research and publicatins relating t care f lder peple all f which has a psitive impact n students attitudes t lder peple and t careers in aged care (Gamrth 1990: 151; Lindemann 1995: 79) INTERNATIONAL FINDINGS ABOUT TNH BENEFITS Internatinal experience cnfirms that the abve intended benefits have been translated int utcmes. USA and Australian research studies have fund TNH prgrams have resulted in a marked increase in students taking up aged care pst-graduate psitins (LeCunt 2004; Leppa 2004; Trssman 2003; Hllinger-Smith 2003; Burke & Dnley 1987); implementatin f evidence-based practice and participatin in research in the areas f cntinence management, falls preventin and wund management (Kethley 1995: 99; Lindemann 1995: 79; Wallace et al 2007: 7 - citing Quinn et al 2004; Trssman 2003; Ppejy et al 2000; Mezey & Fulmer 1999). Evaluatin f the utcmes f the TNH mdel in the Netherlands has identified the fllwing: enhanced quality f care in RACFs; prvisin f an nging patient-dctr relatinship f the kind assciated with general practitiners (this mdel was fcused n physicians and lcated them in nursing hmes); imprved decisin making and care planning; preventin f hspitalisatin and reduced length f stay in hspitals due t the increased capacity f RACFs t prvide medical care and health preventin services (Hek et al 2003: 248). Evaluatin f the TNH mdel in Nrway identified these psitive utcmes: increased aged care staff cmpetencies; increased quality f care; disseminatin f TNH learnings t ther RACFs thus extending impact and prviding leadership fr the aged care sectr (the Nrwegian applicatin f the mdel established a netwrk f TNHs, ne in each regin in rder t achieve systemic change); imprved learning cnditins fr students; increased enthusiasm by participating staff t cntinue wrking in the facilities invlved (Kirkevld 2008: and citing Hagen et al: 2002) GUIDING PRINCIPLES FOR A TNH Imprtant t the TNH mdel and its successful implementatin, is a clear set f guiding principles that are accepted by bth partners. Research undertaken by Mezey et al (2008: 10) has identified the fllwing nine principles: Quality f care and quality f life fr residents An ethical learning affiliatin/partnership Mutual accuntability Shared and sufficient resurces t supprt the gals f the TNH Valuing, supprting and disseminating best practice learnings arising frm the affiliatin AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 12

18 Reciprcity between partners reflected in a frmalised affiliatin (that includes structures such as jint decisin making and cnflict reslutin) Meaningful research, teaching and clinical rles are supprted Cmmitment t transparency and quality imprvement. An Australian example f the TNH mdel, with the benefits its partners have identified, fllws belw in Case Study 1 Sectin This case study als illustrates the psitive utcmes that can emerge when aged care research and practice are linked, with each infrming the ther in line with TNH gals CASE STUDY 1: ACU NATIONAL & RSL LIFECARE -EVIDENCE BASED ENHANCED CLINICAL CARE Case Study 1: Linking research, educatin and aged care Affiliatin partners: ACU Natinal and RSL LifeCare The affiliatin between RSL LifeCare and Australian Cathlic University (ACU Natinal) has been in place since RSL LifeCare is a nt fr prfit rganisatin that is based in Narrabeen, New Suth Wales and nw is a large prvider f care fr sme 4,000 lder peple frm the veteran cmmunity, delivering services acrss a cntinuum f care and fr a wide range f needs. There were a number f drivers fr this affiliatin. RSL LifeCare had lng recgnised the imprtance f prviding learning pprtunities fr its staff as part f their emplyment, and access is prvided fr them t a range f prgrams delivered by a variety f educatin prviders. There was als a gal t build upn clinical placement arrangements fr undergraduate students and t develp research that wuld ultimately yield benefits fr the veteran and wider cmmunity. A TNH mdel ffered the mechanism t achieve these gals. Negtiatins were undertaken with ACU Natinal that fcused n develping a full teaching and research partnership thrugh the vehicle f an endwed chair. In mid 2005 the RSL LifeCare Chair f Ageing was established and Dr Tracey McDnald was appinted Prfessr f Ageing. The Chair is fully funded by RSL LifeCare, and is leading the develpment f a unique mdel f registered nurse practice in the aged care setting, the researching f links between residents quality f life and their functinal capacity within an allied health therapy prgram. Additinal areas f fcus include mental health assessment and training f staff and students, effective cmmunicatin with peple with dementia, feeding and psitive mealtime experiences fr peple with advanced dementia, wund care, falls preventin and injury reductin in cnfused lder peple, and the effects f recreatin prgrams n sleep patterns. The appintment f the Prfessr f Ageing has significantly extended RSL LifeCare s links t the research cmmunity, bth in Australia and internatinally. Fr example, there are research based links t the University f Sydney s Departments f Psychlgy and Rehabilitatin, and the University f Technlgy Exercise Science Department. Industry linkages have als been established with aged care peak bdies and natinal nursing peak rganisatins. Internatinally, links have been made with the United Natins Scial Plicy Divisin, with invlvement in plicy develpment n scial integratin and in implementing the Madrid Plan f Actin n Ageing. The affiliatin prvides a range f clinical learning pprtunities fr undergraduates in fields that include palliative care, mental health, cmmunity health, health prmtin and rehabilitatin, gerntlgy and sub-acute care nursing. Students have prvided psitive evaluative feedback abut these pprtunities. The learning needs f staff are als addressed. Fr example, a fully funded Graduate Certificate in Aged Care Nursing was ffered t 12 RSL LifeCare registered nurses wh cmpleted their studies at ACU Natinal in 2005, with tw f these graduates then graduating with a Master f Clinical Nursing degree in The Chair f Ageing als prvides supervisin fr Ph D students wh cnduct their research at the RACF. AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 13

19 Acknwledging that the csts t the RACF are substantial, the Bard f RSL LifeCare has nevertheless cmmitted t an eight year cntract t fund the Chair f Ageing fully at arund $300,000 per annum (cvering the cst f the Prfessr s appintment and that f a research assistant, plus varius IT related inputs) with an ptin t review and renew the partnership fr a further five years frm Lng term cmmitment f this nature supprts innvatin and a cnfidence t explre and trial better appraches t care. RSL LifeCare als cnsiders that the benefits that can and are being achieved justify the investment being made. These benefits are dcumented in its strategic planning prcesses, and include the fllwing: Fcusing research n the health, care and treatment f lder war veterans Establishing and sustaining RSL LifeCare as a leading aged care rganisatin Being regarded by staff as an emplyer f chice, with this being reflected in retentin rates Being viewed psitively by existing and incming residents and their families, and the wider cmmunity. The affiliatin als surces funding frm a range f ther surces including the Department f Health and Ageing, the wider aged care industry, and charitable surces. A significant amunt f expenditure has als been allcated t develping teaching physical infrastructure, including wireless cnnectivity thrughut the RACF and prviding students with laptps. Frm the perspective f the University, the affiliatin is seen as bringing a range f benefits in relatin t its teaching and research activities, with a functinal link in place between the RACF and the Faculty f Health Sciences. Fr bth partners, the affiliatin ffers the pprtunity fr evidence-based imprvement in capacity. The achievements f the affiliatin are reflected in RSL LifeCare receiving multiple natinal awards fr its prvisin f care. Surce: Interview with Prf Tracey McDnald and written case study infrmatin prvided by RSL LifeCare. 1.3 VARIATIONS OF THE MODEL Althugh there are certain cre features f the TNH mdel, its applicatin can be expected t vary with lcal cnditins, the expertise brught by its partnering rganisatins, and the needs f students and residents. Fr this reasn, a ne size fits all apprach is nt apprpriate t the implementatin f the mdel. In reviewing different applicatins f the TNH mdel, Chilvers and Jnes identified that typically the affiliatin invlved RACFs and either schls f nursing r schls f medicine (1997: 464), but that the methd f affiliatin appeared t be influenced by financial resurces (citing Cifferi & Baker 1985 and Kaeser et al 1989). This has been fund t prduce tw appraches the ne with funding invlving jint appintments between the RACF and educatin prvider and the ne withut such resurcing adpting an exchange apprach. These tw appraches were fund t predminate, but with variatins t each (Budden 1994; Layng Millnig 1986). Exchange mdels have tended t perate infrmally and with limited funding supprt (Chilvers & Jnes 1997: 466; citing Ciferri & Baker 1985). Fr a perid f time, faculty members may wrk exclusively in the RACF and a member f the RACF staff wrks exclusively within the faculty. Rles are clearly defined with the faculty member respnsible fr the care f, and generating research pprtunities, frm a case lad. The faculty member may prvide a rle mdel and catalyst fr research, but the sustainability f this rle is likely t be limited nce the faculty member has left the RACF (Chilvers & Jnes 1997: 466; citing Wykle & Kaufmann 1988). The main benefit f this apprach is that it enables faculty members t identify practice issues, t research these and feedback new knwledge int the educatin system (Chilvers & Jnes 1997: 466). AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 14

20 Mst f the TNH mdels invlve partnerships between university schls f nursing and RACFs, but sme als include acute care hspitals (which has been the mdel f veteran specific TNHs since the 1960s as discussed in Sectin (Rubinstein et al: 1990). See als Sectin describing the Netherlands applicatin f the TNH, which als appints physicians as part f the RACF wrkfrce (rather than as visiting specialists). Case Study 2 - Sectin 1.3.1, exemplifies such a cllabratin and is als unique by prviding specifically fr the needs f residents families. As such the cllabratin als included scial wrk practitiners and had a strnger multidisciplinary fcus than many TNHs funded by the TNHP CASE STUDY 2: INCLUDING ACUTE CARE HOSPITALS AND FOCUSING ON FAMILIES, AN OHIO AFFILIATION Case Study 2: Extending the partnership t include acute care hspitals, and prviding a fcus n families Affiliates: Carrll Manr & the Cathlic University f America Schl f Nursing, Ohi Funder: Rbert Wd Jhnsn Fundatin Prgram: Teaching Nursing Hme Prgram (TNHP) Thse invlved in implementing the affiliatin between Carrll Manr and the Cathlic University f America Schl f Nursing fund that six years after its initiatin, the TNH prject had been a catalyst fr change bringing abut the fllwing Where previusly attracting nursing students int aged care had been difficulty, students cmpeted fr clinical placement at Carrll Manr. A Research and Educatin Cmmittee cmprising nursing hme staff, residents and schl f nursing faculty was established t apprve prpsals fr student placement and fr clinical research at the facility. The fcus n research had seen facility staff increasingly using scientific methds in their wrk and early indicatins that research was enhancing decisin making. This TNH mdel als prvided fr the needs f family members f residential aged care facility clients. A prgram knwn as Family Circle cmbined nursing and scial wrk activities prviding infrmatin, educatin and supprt t families. This interdisciplinary initiative als prvided learning experiences fr students n placement. The cllabratin was extended t include a lcal hspital which had prvided the nursing hme with greater access t a range f services, supprted clser wrking relatinships between physicians and nurse practitiners assciated with the TNH. This had the brader impact f increasing the facility s capacity t prvide skilled care than wuld therwise have ccurred in a hspital (Burke & Dnley 1987: 37-39: Dnley 1986: 78). Critical Success Factrs Retrspective analysis has identified these factrs as being crucial t this TNHP affiliatin. These factrs are smewhat interdependent. Bradening f the cllabratin t include a lcal hspital which increased access t services and supprted a wider range f wrking relatinships. The appintment f nurse practitiners t wrk with facility staff, students and physicians frm lcal health services and the participating hspital. Cmmitment by stakehlders at all levels frm senir management t frnt line delivery and teaching staff t the TNH and its underpinning principles. These included valuing research and educatin as a means t imprving nursing care f lder peple and supprting the rights f lder peple. Expressin f that cmmitment in a frmal agreement that specified mutual respnsibilities and rles (Clarke & Walsh 1988: ; Burke & Dnley 1987: 37-39: Dnley 1986: 76-77). AISR (2011) Implementing the Teaching Nursing Hmes Initiative: Scping Study Discussin Paper 15

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