The Winston Churchill Memorial Trust of Australia Report by Donelle Rivett 2007 Churchill Fellow An investigation of teaching nursing home models promoting university, health service and aged care provider collaboration. I understand that the Churchill Trust may publish this report, either in hard copy or on the internet or both, and consent to such publication. I indemnify the Churchill Trust against any loss, costs or damages it may suffer arising out of any claim or proceedings made against the Trust in respect of or arising out of the publication of any report submitted to the Trust and which the Trust places on a website for access over the internet. I also warrant that my Final Report is original and does not infringe the copyright of any person, or contain anything which is, or the incorporation of which into the final report is, actionable for defamation, a breach of any privacy law or obligation, breach of confidence, contempt or court, passing-off or contravention of any other private right or of any law. Signed: Donelle Rivett Date: 26 th June 2008 1
Contents INTRODUCTION 3 EXECUTIVE SUMMARY 4 Highlights 4 Recommendations 4 Implementation and Dissemination 4 FELLOWSHIP PROGRAM 5 TEACHING NURSING HOME 6 Models of Teaching Nursing Homes 6 Preceptor Based Model 7 Project Based Model 7 State Programs 8 Partnership Program 9 Key Features of a Teaching Nursing Home 10 CONCLUSION 11 RECOMMENDATIONS 12 2
Introduction My fellowship provided me with a wonderful opportunity to travel and visit a number of teaching nursing home programs in the USA and UK. As well as viewing teaching nursing home programs, I was able to view a number of different aged care environments and settings. This report provides a summary of the teaching nursing home programs and applicability to the Australian aged care environment. I had an opportunity to meet many wonderful and inspiring academics, nurses and carers who displayed a passion for their industry and a desire to see the continual improvement of the care for the aged. My thanks go the Churchill Trust for this opportunity and once in a lifetime experience. Thank you also to my family and their unwavering support in all that I do. 3
Executive Summary Donelle Rivett Manager Research Review & Development The Bethanie Group Inc 13B Stewart Street, Scarborough, WA, 6019 08 9245 3237 donellerivett@hotmail.com The aim of the fellowship was to investigate models of teaching nursing homes that promoted university, health service and aged care provider collaboration. I visited a number of different programs that provided an opportunity to consider model design and principles for the development of a teaching nursing home program in Australia. The teaching nursing homes viewed ranged from small projects to large multiple partnered state programs. Arising from this was a number of principles considered essential to develop a successful program. Teaching nursing homes have an unique opportunity to promote quality of care for residents and education and research to promote and develop the aged care workforce and aged care service provision. The experience was further enriched with the opportunity to attend the Annual Meeting and Exposition of the American Association of Homes and Services for the Aged (AAHSA) and to view a number of different aged care programs. Highlights Opportunity to view aged care services and programs in the USA and UK Viewing the Florida State Teaching Nursing Home program and the Miami Jewish Hospital and Home for the Aged. Meeting Professor Nancy Watson and her team at the University of Rochester. Viewing student programs at the Heritage Homes and Mennonite College of Nursing Recommendations Raise awareness of the teaching nursing home concept and the potential benefits to aged care providers, universities and aged care funding bodies. Identify universities and aged care providers who wish to explore opportunities to develop a teaching nursing home program. Establish a teaching nursing home network at a national level to share information between aged care providers and universities. Commence negotiations with funding bodies and a university to develop a pilot teaching nursing home in Perth, Western Australia. Implementation and Dissemination Principles will directly influence the development of a teaching nursing home in collaboration with a university in Perth, Western Australia. Findings will be disseminated through articles and presentations submitted to industry groups and associated publications. 4
Fellowship Program 12 th - 19 th October 2007, Oxford, UK Guidepost Trust Institute of Public Care Oxford Brookes University 21 st 24 th October 2007, Orlando, Florida, USA Annual Meeting and Exposition American Association of Homes and Services for the Aged (AAHSA) 26 th October 12 th November 2007, Normal Illinois, USA Mennonite College of Nursing, Illinois State University Joe Warner Teaching Nursing Home Project Heritage Manor Nursing Home Bloomington Heritage Manor Nursing Home Normal Heritage Manor Nursing Home El Paso Heritage Manor Nursing Home Colfax 12 th 18 th November 2007, Rochester, New York, USA School of Nursing, University of Rochester Kirkhaven Nursing Home State University New York (SUNY) Brookdale St Ann s Community Independent Living for Seniors PACE 17 th 28 th March 2008, Miami Florida, USA Florida State Teaching Nursing Home Miami Jewish Hospital and Home for the Aged Douglas Gardens North Florida PACE Centres 31 st March 1 st April 2008, Lubbock Texas, USA Garrison Geriatric Education and Care Centre Texas Tech University Health Science Centre Garrison Institute on Ageing 5
Teaching Nursing Home The teaching nursing home concept originated in the USA in the early 1980s as a specific way to improve the standard of nursing home care. The Robert Wood Johnson Foundation, a private foundation with an interest in improving the delivery of long term care, funded a number of demonstration projects that promoted collaboration between universities and nursing homes. The underlying assumption was that the involvement of nursing schools and the introduction of highly skilled nursing into the nursing homes, would significantly improve resident care, help to recruit and retain clinical staff, and more effectively use nursing and medical services in the care of residents. The program ran from 1982 1987, after which only two of the participating projects indicated their willingness to continue with aspects of the affiliation. While the initial projects ceased to operate after the funding period, it is generally acknowledged that the teaching nursing home project was a pioneer program in the geriatric nursing area. The initial pilot projects were beset with difficulties, namely the culture gap between nursing home and academic nursing school, and the frequent staff turnover. Despite these problems, there was a general belief by participants that it had been successful and had opened new areas in the expanding field of gerontology. Over the last five years, the recognition of the importance of this style of teaching collaborative program in aged care has resulted in a reinvigoration for the teaching nursing home model. As evidenced by the programs that I had the opportunity to visit, the concept of improving quality of care through strong academic and research linkages remains important. Models of Teaching Nursing Homes During my Fellowship visits I had the opportunity to view a number of different types of teaching nursing home models. Some models were primarily nursing and student focused, while others promoted interdisciplinary collaboration as part of the change management and education program. The models ranged from small single time limited projects to large statebased programs. All models had the primary goal of improving the quality of care delivered to aged people within residential care settings. For the purposes of the report I have classified the models viewed as: Preceptor based models primarily aimed at improving student knowledge and experience in geriatric care. Project based models small time limited projects that addressed specific areas of quality care improvement. State wide models large, multifaceted programs addressing a number of areas. Collaborative partnership model long term partnership program with a nursing home(s) and university. 6
Preceptor Based Model The preceptor based model primarily offers students a learning and clinical practicum environment in a nursing home. The goal of this program is to provide a clinical practicum and mentoring activities with expert nurse preceptors that would increase awareness and attractiveness of a career in aged care. The Joe Warner Teaching Nursing Home Project is a joint initiative of the Mennonite College of Nursing at Illinois Statute University (MCN at ISU) and Heritage Enterprises, an aged care provider. The program has been designed to provide nursing students with practicum based education, providing hands-on and clinical experience within an aged care environment. The goals of the program are to: Increase the number of aged care clinical work and education experiences for nursing students Increase the number of mentoring experiences in an aged care environment for nursing students; and, Increase the numbers of graduate nursing students employed in aged care. The nursing students are preceptored by a geriatric care specialist from the university. The learning environment in the nursing home is supplemented by liaison nurses from the aged care provider, who provide a mentor relationship for the student nurses. Significant planning and education of the mentor nurses has been supported by academic staff at MCN to create positive clinical environments and assist with the bridging of academia and practice. While the use of practicum in many health care environments is standard for nursing training, this model is different in that there are targeted goals and outcomes with a partnership approach to the provision of the preceptoring in aged care. The partnership between Heritage Enterprises and MCN offers an alternative model for university and aged care provider collaboration. This model is primarily designed to provide enhanced education opportunities for nursing students to extend their geriatric nursing education and training. Project Based Model The project based model of a teaching nursing home is a small time limited partnership program between a university and an aged care provider. These small projects are designed to both improve quality of care and translate research into practice. The University of Rochester School of Nursing and Kirkhaven Nursing Home (New York) provided an excellent example of a project based model where graduate students and care staff worked together to implement a project designed to improve care quality. Graduate students (nursing and social work) partnered with Certified Nursing Aides (CNAs) to develop a project and implement the care outcomes. The graduate students worked as mentors to the CNAs and for the graduate students, this provided an opportunity to develop leadership and interdisciplinary appreciation. For the CNAs the project provided empowerment in the decision making process of care. What stood out in this example of a teaching nursing home was the empowerment of the CNAs and the development of their leadership skills. CNAs deliver the majority of care within a nursing home environment and are most likely to embrace or reject changes in the delivery 7
of quality of care. Interviewing the graduate students involved with the program highlighted their appreciation of the program and the mentor support provided from the sponsor university staff. They gained an appreciation for the work undertaken by the CNAs and a bottom up approach to change management and culture development. These small projects targeted the development of leadership skills at various levels within the nursing home and as an introduction to aged care and leadership development for graduate students. State Programs The Florida Teaching Nursing Home commenced in 2000 via a state legislative house bill to establish an integrated long term care (LTC) training curriculum program for physicians and to initiate an on-line geriatrics university. The program has since expanded to provide interdisciplinary geriatric training and education programs. The goals for the Florida Teaching Nursing Home program are to: Create and promote interdisciplinary education and research in aged care Research, implement and disseminate best practices for targeted aged care concerns Exchange awareness and image of the aged care continuum, including community-based services Initiate a dynamic process of statewide standardisation of aged care that promotes and protects the interests of care recipients and providers. The teaching nursing home program is managed through the Stein Gerontological Institute (Miami Jewish Hospital and Home for the Aged) and of significance has the been the establishment of a number of working relationships with nursing homes, the four Florida medical schools and several Florida nursing schools providing an interdisciplinary environment for education and research. A number of strategies have been implemented to achieve the goals including: Identification and development of education and resource materials for geriatric care Creation of two on-line websites (www.geriu.org and www.ltc.geriu.org) Delivery of aged care training initiatives via online education modes and forums Aged care research initiatives Development of models to support quality improvement in the aged care environment One of the strong suits of this program was the accessibility and practical base of the education and learning materials. There was a strong emphasis on the development of online learning materials utilising the skills of education content and web-based design specialists. The interactive nature of the materials was a positive aspect and useable by all levels of care staff. The model provides an excellent example of the use of technology to disseminate information to a wide audience on the care of the aged. 8
Partnership Program Garrison Geriatric Education and Care Centre The Garrison Geriatric Education and Care Centre was a good example of an aged care provider and university partnership. The care centre is a purpose built teaching nursing home developed as a collaborative partnership between Sears Methodist Retirement Systems (aged care provider) and Texas Tech Health Science Centre (TTHSC). The facility, administration and resident clinical care is managed by the aged care provider, with construction of the facility on land provided by TTHSC. The purpose built facility has incorporated a number of design features such as telemedicine equipped examination rooms, tech-linked classrooms and faculty and student offices and conference centres. The goals of the collaboration are to: Educate health professionals committed to pursuing excellence in geriatric care Demonstrate innovative, high quality aged care for practitioners, students and aged care providers Provide a site to conduct clinical and behavioral research designed to advance geriatric and aged care The centre provides geriatric practicum for a wide range of health disciplines with medicine, nursing, pharmacy and allied health with the aim for all students at TTHSC undertaking a geriatric rotation. Aligned with the care centre is the Garrison Institute of Ageing and the Geriatric Education and Training Academy, both institutes aimed at improving education, training and research initiatives. The collaboration has had a number of outside benefits with the securing of external funding to provide CNA training programs in Texas. Expanding the Teaching Nursing Home Project The Expanding the Teaching Nursing Home project was built on the foundation of the Joe Warner Teaching Nursing Home concept. The project has been designed to expand the teaching nursing home culture as a state demonstration project. The program further develops the partnership between MCN and Heritage Enterprises. The primary aim of this program is to promote geriatric nursing as an attractive career choice for nurses and to promote retention of nurses currently in the sector. Collaborative partnership, mentoring and education opportunities are used to develop geriatric trained specialists and promote professional career development. This program has been implemented at a number of nursing homes in the Illinois. The goals of the program are to: Develop and implement standardised best practices for aged care Develop mentoring and learning experiences to improve cultural career attractiveness to aged care Facilitation of collaborative partnerships between the nursing home and university 9
Produce registered nurses with Master of Science (Nursing) with a gerontology specialty The program has utilised a number of strategies since commencement including: Development of learning modules for continuing education and utilizing interactive web-based learning programs (insert web address) Promotion of geriatric research within MCN and the nursing home. Sponsored seminar programs Development of a preceptor and mentor program for new graduate nurses Developed new graduate programs (Masters) at MCN with a gerontology specialty For the aged care provider the presence of this program at their sites has proved to be an attractor for new staff, many seeking employment as a result of the mentor program developed. The key features present in both these program examples are a long term and equal commitment to the program by the university and aged care provider, and a multidimensional approach to education and training aimed at retaining and promoting aged care as a career pathway. Key Features of a Teaching Nursing Home Each of the teaching nursing home programs viewed provided a different perspective and model type. The program staff provided considered insight into the strengths and weakness of their programs, what worked well and what they would have done differently. As part of the review, I have identified a number of key features that would promote success of a teaching nursing home in Australia: 1. Equitable partnership between nursing home and academic partnership - The more successful models demonstrated a strong and equal partnership and responsibilities between the aged care provider and academic institution, along with a strong commitment to see the teaching nursing home develop. Clear roles and responsibilities for academic staff and nursing home clinical staff were documented, along with decision making responsibilities. A commitment to research sharing, presentations and publications was evident in a number of programs. 2. Promotes evidence based practice and innovation - The translation of research into practice and practice into research is a strength of the teaching nursing home program. The program provides an opportunity for rigorous development and evaluation of quality care services and best practice development. 3. Education and research projects promote participation for all levels of staff - The type of quality initiatives, research and evaluation must reflect the interdisciplinary nature of a nursing home and the different professional groups. Programs that support both a top down and bottom up approach to quality care initiatives and best practice implementation are more likely to enhance the learning culture of the program. 10
4. Engagement in preceptor and mentoring activities - One of the attractors to aged care providers participating in a teaching nursing home program is the ability to retain staff both within the nursing home and the industry. Preceptor and mentoring activities of new and current staff promote a culture of learning and development. 5. Philosophical and leadership approach Teaching nursing homes are sustained where they enhance the care mission of the nursing home and the academic institution. Leadership of both partner groups need to support openness to innovation, a commitment of resources and a strong focus for quality improvement. 6. Utilisation of interactive technology - Very early in my observations it became quite apparent of the importance and the use of technology and web based interactive media as part of the teaching nursing home program. Utilising technology provides greater access and dissemination of education, training and outcomes from the teaching nursing home program. 7. Emphasis on the interdisciplinary aspect of the teaching nursing home Aged care is provided in an interdisciplinary environment requiring the expertise of many professional groups, highlighting the need to provide a teaching nursing home environment that promotes collaboration with all disciplines. Conclusion The ageing of Australia s population and the increasing demand for age care services highlights the need for both a well-educated workforce and quality evidenced based care services into the future. While only a small percentage of older people in Australia require residential care services, the increasing acuity levels necessitate a higher level of care to be provided by aged care staff. It is well recognized within the industry the difficulty in attracting qualified and direct care staff and in Western Australia this effect is greater as a result of the mining led economic boom. In addition, the image of the aged care sector has traditionally proved a deterrent to recruitment and retention of staff. These factors highlight the imperative to develop programs that attract, retain and educate the aged care workforce. From the teaching nursing home models viewed and subsequent research it is evident that the programs have generated improvement in care quality and enhanced reputation of the services and a number of programs have demonstrated improvements in retention and attraction of workforce through mentoring programs. Finally, of the teaching nursing homes viewed, an increase in academic faculty interest and research, and development of geriatric specialist education programs had resulted from the collaborative. The result is that teaching nursing homes have a unique position within the aged care and university sectors to enhance interdisciplinary education, best practice and research that is critical to the ongoing development of the aged care workforce. A teaching nursing home model is an innovative concept that could easily be replicated in the Australian aged care environment. Since the introduction of the Aged Care Act (1997), aged care providers have placed significant resources to improve and implement quality care initiatives within their services. Linkages and partnerships with universities to introduce clinical experts and promote care quality and workforce development is the next logical step as part of this process. In conclusion, I am hopeful that the outcomes and recommendations from this paper will continue to stimulate discussion around the development of a teaching nursing home and the 11
potential improvements to education of the aged care workforce and quality of care for residents. Recommendations To further the development of teaching nursing homes in Australia it is necessary to: Raise awareness of the teaching nursing home concept and the potential benefits to aged care providers, universities and aged care funding bodies. Identify universities and aged care providers who wish to explore opportunities to develop a teaching nursing home program. Establish a teaching nursing home network at a national level to share information between aged care providers and universities. Commence negotiations with funding bodies and a university to develop a pilot teaching nursing home in Perth, Western Australia. Findings from the fellowship will be disseminated through articles and presentations submitted to industry groups and associated publications. The principles developed will directly influence the commencement of a teaching nursing home in collaboration with a university in Perth, Western Australia. 12