EBPRAC Round 2 Projects

Page last updated: 21 September 2016

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The EBPAC initiative aims to encourage and support the uptake of evidence-based, person-centred, better practice in Australian Government subsidised aged care services, through a focus on improving staff knowledge and skills and developing supporting resources, to improve outcomes for aged care recipients.

Behaviour Management - Flinders University

Addressing Behaviours of Concern in the Bush: Sustainable Evidence Based Practice in Rural and Regional Residential Care

Project Overview

The project aimed to address behaviours of concern by focusing on using non-pharmacological approaches. The project was led by Flinders (initially by Monash) University and was conducted in seven rural residential aged care facilities in north-west Victoria.

What was done?

The project worked towards creating more dementia friendly physical and social environments. It used existing evidence specific to person-centred care which modified the built environment and used the physical and social environment to both address behaviours of concern and to prevent the development of behaviours of concern for people with dementia.

The evidence-based resources used by the project were Quality Dementia Care Standards: A Guide to Practice for Managers in Residential Aged Care Facilities, and Quality Dementia Care: Practice in Residential Aged Care Facilities developed by Alzheimer’s Australia and Dementia Friendly Environments in Residential and Respite Settings produced by the Victorian Department of Health.

Project activities focused on philosophy of care, leadership, management support, staff skills and the environment. Key activities included:

  • Appointing a best practice manager external to the residential aged care facilities (RACFs), to support, guide and advocate for champions and staff within the facilities.
  • Selecting a best practice champion and assistants from the staff of the facilities to provide internal leadership.
  • Providing support, guidance and advocacy for champions and staff through an external best practice manager.
  • Developing of evidence-based resources and materials.
  • Educating staff at each facility on evidence-base and the translation of knowledge into practice (face to face training, e-learning and micro-training).
  • Conducting an environmental audit to prioritise environmental modifications most likely to impact on behaviours of concern.
  • Undertaking a policy audit to ensure that facility policies were supporting a person-centred approach to care. Introducing the use of an online guide to assist RACFs in deciding on appropriate physical and social environmental modifications.
  • Developing and introducing documentation to help support changes in practice.

What was achieved?

  • Behaviours of concern were reduced in all participating facilities.
  • Overall, needs-based problem solving was widely and regularly used, and staff became less reliant on chemical restraint to address behaviours of concern.
  • Psychotropic drug use decreased over time at all participating residential aged care facilities (RACFs).
  • Post assessment of collected data showed a significant increase in five out of seven facilities in the area of resident autonomy. This indicated person-centred care principles in practice.
  • Many staff, across all levels of the organisation, were educated in a person-centred approach to care, needs-based problem solving, physical environmental changes, well-being, ill-being and dementia.
  • A range of environmental modifications were completed by participating facilities that ranged from painting doors and rearranging furniture through to enhancing garden areas. Several facilities secured additional funds to do further modifications that will continue the development of more dementia friendly environments.
  • Life story programs were used in all facilities, with five of the seven locations embedding it into their regular practice. Staff became more creative and innovative in their interventions with residents as their knowledge was based on residents’ unique needs.

What was the impact for residents?

  • Less verbal disruptions, physical aggression, repetitive actions or questions, resistance to care, problems associated with eating, wandering and intrusiveness, and sleep disturbances.
  • Less daytime sleeping.
  • Mealtimes became less rushed.
  • More meaningful occupation of residents.

Personal detractors and personal enhancers are episodes when a care worker interacts with a person with dementia, in a way which can either uphold or undermine their personhood and one or more of their psychological needs. Overall, across participating RACFs:

  • Personal enhancers increased by 40%, therefore staff could more readily affirm residents’ personhood, meet their psychological needs and enhance well-being.
  • Personal detractors decreased by 20%, reducing the potential of staff to undermine residents’ personhood and well-being.

What was the impact for staff?

  • Increased ability to identify ways to build on their current knowledge and skills and apply the new knowledge to their workplace.
  • A better understanding of best practice dementia care.
  • Staff were more proactive in changing care routines in response to the needs of a resident.
  • Staff were less likely to feel rushed because of facility routines, they were more likely to feel they are able to allow the residents that they look after to make decisions for themselves.
  • Staff now feel they now have enough time to read social histories.
  • Staff were given more opportunities to learn about individual residents. This became important in providing their care and understanding how to use what they know about residents to meet their needs and individualise care.
  • Staff used needs based problem solving to address behaviours of concern and this helped prevent the development of behaviours of concern.

What resources are available?

A best practice in Dementia Care Learning CD, produced for use as in-house, small group education and individualized learning. The CD comprises 19 sections with activities that deepen knowledge and provide practice opportunities in the workplace. The activities are a variety of:

  • direct learning tasks via video clips, short case studies or external web links to information that require the learner to listen, read and respond briefly to specific questions;
  • tasks that require the learner to study video clips and/or readings and reflect on the issues raised within the context of their own work routines, environment or practice applications; and
  • activities that require the learner to apply specific learnings to their own care practices and residents in their care.

A second ‘micro-training’ CD provides 20 one minute video messages emphasising core messages of best practice in dementia care covered in the education. Each message is followed by a question for staff to discuss briefly together. The purpose of the micro-training is to provide staff with daily contact with the core ideas from the e-learning CD.

Supportive documentation to assist in implementing best practice, including:

  • a ‘well-being checklist and clinical pathway’;
  • a needs based problem solving poster;
  • a matrix linking core messages in micro training to outcomes in accreditation standards; and
  • the Person-Centred Policy Lens: a policy review tool.

The Victorian Department of Health, Dementia friendly environments in residential and respite settings: a guide, is available online at the Victorian Department of Health website

What could be adopted in my service?

Examples of small changes that facilities could make to have a positive impact on residents’ behaviour include:

  • Encourage staff to greet residents when entering their room.
  • Create focal points for the residents to have spontaneous activity, independence and rest, e.g. place chairs in garden areas.
  • Improve the resident’s eating experience and the orientation of common spaces. For example provide coloured table cloths and new placemats for the dining room.
  • Improve the flow of walking and ease of access e.g. install doors or improve access to doors where necessary.
  • Provide for meaningful activities and visual/tactile stimulation e.g. tools for a men’s shed, chickens, new plants.

Behaviour Management - HammondCare

Reducing behaviours of concern in residential aged care by working with staff, families and the physical environment

Project Overview

This project took a person-centred approach to reducing residents’ behaviours of concern by focusing on non-pharmacological interventions, education and training for staff in seven residential aged care facilities across Victoria and New South Wales. The project was led by HammondCare and Uniting Aged Care Victoria and Tasmania.

What was done?

The project aimed to develop a comprehensive understanding of the origins of behaviour and the feelings associated with behaviour from the perspective of both the resident and staff.

The approach taken by the project to reduce behaviours of concern comprised of four elements:

  • Modifying the physical environment.
  • Training staff regarding the causes and possible remediation strategies for behaviours of concern.
  • Establishing a safe psychological environment for staff to explore their feelings and discover new ways to approach people with behaviours of concern.
  • Facilitating family support groups.

The project defined behaviours of concern as behaviours that cause concern and/or distress to residents, staff and/or families, that are not limited to ‘positive’ behaviours such as aggression but can include depression, apathy and withdrawal.

The sources of evidence used by the project were:

  • User Rights Principles 1997 R, Crookes P & Sum S (2008) A review of the empirical literature on the design of physical environments for people with dementia. Primary Dementia Collaborative Research Centre, University of New South Wales.
  • Hallberg IR, Norberg A & Erikson S (1990) Functional impairment and behavioural disturbances in vocally disruptive patients in psychogeriatric wards compared with controls. International Journal of Geriatric Psychiatry. 5(1): 53-61.

The project included a range of activities, including:

  • An Environmental Audit Tool was used in each facility to evaluate the physical design of the environment. The results of the audit were used to highlight the physical areas in the facilities that might be improved. The audit was also conducted at the end of the project to evaluate the changes.
  • Training for staff education was conducted over two days. It covered several topics including philosophy of care, an understanding of behaviours of concern, communicating with residents, families, the environment, case conferencing and telling the resident’s story. It has provided an opportunity for staff to get to know their mentor.
  • Mentors worked in consultation with facility staff to identify key residents with behaviours of concern which became the focus of mentoring sessions.
  • Fortnightly and ad-hoc mentoring sessions were held where staff could talk about events such as being spat at, hit or called very hurtful names. The mentors managed each case and led staff to alternative ways of understanding and responding to the behaviours.
  • Care plans were developed on individual emotional and physical needs rather than the problems they presented – “a genuine care plan rather than a management plan.”
  • Family support groups were established, enabling family members to become partners in the process of reducing behaviours of concern.
  • Pre and post assessments were undertaken on several of the project’s interventions. For example, data was collected on the physical environment, resident behaviour, staff knowledge and attitudes, staff strain, staff views on the process and results of intervention, family satisfaction with care and family support.
  • A toolkit was developed to support the environmental audits, staff training, mentoring, family support and evaluation.

The main vehicle for change was the process of mentoring. Mentors were highly skilled clinical educators who:

  • Worked closely with nominated individuals in each facility.
  • Delivered education and training in both clinical aspects as well as change management techniques.
  • Facilitated the family/carer support groups.

What was achieved?

  • The project was successful at reducing behaviours of concern.
  • Project outcomes were achieved without significantly impacting on the efficiency or workload of the staff.
  • Environmental audits undertaken early in the project resulted in improved personal, social and open spaces within facilities, and reduced distracting/unnecessary stimulation for residents.
  • An assessment of 171 staff who attended the education sessions showed that staff knowledge improved over the course of the training. Through the provision of mentoring, staff were provided with training and clinical expertise as well as professional and personal support.

What was the impact for residents?

  • Steady and significant decline in levels of challenging behaviours.
  • Significant improvement to depression levels in residents.
  • Improvements to the physical environment.
  • Greater family involvement in the residents’ care.

What was the impact for staff?

  • Knowledge significantly increased both for experienced/qualified staff and those less experienced and with literacy problems.
  • Mentoring was highly valued with many staff wanting the mentoring support to continue after the conclusion of the project.
  • Staff felt supported, listened to, valued and empowered.
  • Staff felt less strained at work.
  • Staff felt an increase in calmness and objectivity.
  • A significant reduction in staff feeling they did not understand the residents.

What resources are available?

The project’s toolkit includes information about environmental auditing, staff training (student handbook, trainer’s manual, and presentations), mentoring, family support and evaluation of outcomes. The toolkit includes a DVD produced by the Aged Care Channel and a booklet about the experiences of the project mentors.

The audit tool can be used to audit the environment, identify areas of need and develop action plans, preferably with some specialist input.

The educational materials can be used in all facilities.

The use of the material on mentoring will be dependent on the availability of a suitably qualified mentor.

The material on the establishment of family groups can be used in most facilities, preferably with a mentor involved.

A web based downloadable and free project toolkit will be available from the Hammond Care website from August 2011.

What could be adopted in my service?

Examples of small environmental changes facilities could make that could reduce behaviours of concern in residents include:

  • Use colour and features (e.g. shadow boxes) to create different identities in different corridors and distinguish between doors and other parts of corridors.
  • Provide domestic style dining tables and chairs.
  • Leave lights on in corridors and social spaces to encourage use.
  • Introduce new light fittings to vary lighting ambiance.
  • Introduce new bedspreads.
  • Introduce raised garden beds and provide shade to outdoor areas to encourage use.
  • Place items of interest on tables in the dining room.
  • Introduce some new pieces of furniture and create more private areas within dining/lounge rooms.

Behaviour Management - University of Technology Sydney

The EN-ABLE project - evidence based responses to need driven behaviours associated with dementia

Project Overview

The central goals of the EN-ABLE Project were to support residential aged care staff to adopt an evidence based approach to dementia care, and to evaluate how feasible and effective care models are, using a collaborative and supportive approach. The project was conducted in six residential aged care facilities across New South Wales, Victoria and Queensland.

What was done?

The project aimed to reduce agitation, aggression, apathy and risky wandering in the residential aged care setting, through applying the evidence based Person-Centred Care (PCC)1 and the Need-Driven Dementia Behaviour (NDB)2 models. The EN-ABLE approach to implementing PCC and NDB occurred through the support of a staff ‘Champion’ who volunteered in each facility.

Champions learned how to facilitate the use of PCC and NDB from expert EN-ABLE trainers over 20 weeks, through a train-the-trainer model.

The TEAM3 (Translation of Evidence into Aged care Methods) approach was used to help staff participate in practice improvement.

The TEAM approach engaged staff most affected by the change process to inform and guide them in using PCC and NDB for the 97 residents who displayed agitation, apathy, aggression or risky wandering.

Champions and their colleagues worked systematically to identify:

  • residents’ NDBs;
  • possible triggers for targeted NDBs;
  • care approaches that might reduce or eliminate triggers; and successes, by recording observed resident outcomes.
  • Quality of care and outcomes for participating residents and staff were compared before and after implementation of the EN-ABLE approach to dementia care.
  • The feasibility and impact of the EN-ABLE approach was evaluated through focused interviews with each facility’s executive and managerial staff, residents’ families and Champions.

What was achieved?

  • Managers, champions and staff had enough time and support to begin to use the evidence based PCC and NDB models in their own ways through the TEAM framework.
  • Positive outcomes were achieved for residents with improvements in NDBs, quality of life and well-being.
  • Most staff participants expressed satisfaction, including the Champions.
  • Most staff continued to use the PCC and NDB care approaches after the Project ceased, with support and guidance by Champions.

What was the impact for residents?

Small levels of restraint were being used.

  • Reduced incidence and severity of resident agitation, aggression and risky wandering.
  • Aggression declined significantly, on average by 28 percent.
  • Agitation dropped by 15 percent.
  • Risky wandering declined by 10 percent in four facilities.
  • More engagement in recreation/diversional activities and social conversation with staff.

What was the impact for staff?

  • Learned more about each resident’s interests, needs, likes, dislikes, moods and reactions to different stressors.
  • Learned how to consider the dynamic nature of NDBs in relation to changing contexts and the residents’ personal characteristics and life experiences.
  • Improved attitudes towards residents with NDBs and knowledge of the principles and practices of PCC.
  • Improved quality of care, with staff being able to identify and meet residents’ NDBs more readily.
  • Satisfaction with the EN-ABLE approach – considered a feasible approach to implementing evidence-based care.

What resources are available?

An EN-ABLE Toolkit resource was developed to assist facilitators/educators and staff to implement the EN-ABLE approach to evidence-based dementia care. It includes eight separate sections:

  • Introduction to the EN-ABLE approach.
  • Education program on PCC and NDB and how to implement evidence-based dementia care, with sample delivery instructions.
  • Champion’s guidelines.
  • Resident assessment guide, with key assessment tools and instructions, as well as algorithms for addressing NDBs.
  • EN-ABLE Implementation and Evaluation Guide, with a clinical audit tool and a facility audit tool.
  • Guide to EN-ABLE, Dementia and NDB resources, including relevant articles on the evidence of the PCC and NDB models in dementia care, and community resource details.
  • Electronic versions of presentations, resident assessment tools, facility measures and the clinical audit tool.
  • Wall poster of the key points of the EN-ABLE training concepts.

The project website contains information about the project plus links to resources to assist in caring for residents with dementia.

What could be adopted in my service?

Examples of small changes that facilities could make to have a positive impact on residents’ behaviour include:

  • Change the environment, initially using colour, pictures and murals.
  • Use behaviour charts regularly.
  • Develop individualised behaviour intervention/care plans.
  • Use positive communication strategies.
  • Use cognitive assessment tools on admission of residents.
  • Review personal histories when residents display NDBs.

References:

  1. Kitwood T. (1997) Dementia reconsidered. The person comes first. Buckingham: Open University Press.
  2. Algase, D., Beck, C., Kolanowski,. A, Whall, A., Berent, S., Richards, K. & Beattie, E. (1996) Need-driven dementia-compromised behavior: An alternative view of ‘disruptive behaviour’. American Journal of Alzheimer’s Care & Related Disorders 77(6):10-19.
  3. Winbolt, M., Nay, R., & Fetherstonhough, D. (2009). Taking a TEAM (translating Evidence into Aged care Methods) approach to practice change. In R. Nay & S. Garratt (Eds.), Older people: Issues and Innovations in care. 3rd ed., pp. 442-455. Sydney: Churchill Livingstone.

Infection Control - PivotWest

Infection control collaborative – closing the gap between evidence and practice using the collaborative methodology

Project Overview

The Infection Control Collaborative (ICC) project was a quality improvement initiative for Residential Aged Care Facilities (RACFs), aimed at reducing the number of infections for residents.

The ICC Project was undertaken by a consortium led by Macedon Ranges and North Western Melbourne Medicare Local formerly known as PivotWest (Western Division of General Practice) in eight RACFs in Victoria.

What was done?

The ICC Project was designed to translate best practice guidelines for Infection Control (IC) in RACFs into current practice, and to create resources to support the adoption of best practice across RACFs.

The Guidelines used as an evidence base for the project were the Australian Government Department of Health and Ageing (2004) Infection Control Guidelines for the Prevention and Transmission of Infectious Diseases in the Health Care Setting.

The project used a quality improvement approach to implementation, based on the Improvement Foundation Australia’s Collaborative model, to:

  • Select evidence based criteria for the measurement of rates of infection.
  • Select and define clinical indicators for study.
  • Develop a robust measurement system to support improvement in infection control.
  • Provide training, resources and support for RACFs to identify successful strategies for quality improvement in infection control.
  • Identify change principles and ideas or examples of best practice, and use them to motivate Collaborative participants and stimulate innovation.
  • Provide electronic systems and train staff in their use so the RACFs could measure, report and share their successes.
  • Provide information that clearly demonstrates areas that RACFs should target in order to improve IC policies, practices and procedures.
  • Demonstrate quality improvement activities that lead to improved care for RACF residents.

The project involved a range of activities, including:

  • An expert reference panel was formed to set the aims and measures for the Collaborative.
  • A local team was nominated from each participating facility to participate in the project.
  • Three learning workshops were held where the local teams came together to share their experiences.
  • A Plan-Do-Study-Act (PDSA) model was used to frame improvements undertaken by the RACFs, and evidence of these was collected by the former PivotWest team over the period of the study.
  • The Infection Control Collaborative Program Handbook was developed to guide the facilities in how to approach the implementation.
  • Education and training were provided for RACF staff in evidence-based prevention and treatment of infections.
  • Interventions were collaboratively shared between participating RACFs.
  • Residents and staff were vaccinated against transmissible infections.

What was achieved?

The ICC Project achieved a number of its objectives including:

  • Strong uptake of the education and training program with participation estimated at more than 70 percent of RACF staff.
  • Enhanced communication with staff and managers from participating RACFs.
  • Development of PDSAs and testing of interventions by RACF staff.
  • Consultations with consumers (residents and families).
  • Consultations across the aged care sector.
  • Increased awareness of the importance of preventive improvements including hand hygiene training (hand-washing and appropriate use of alcohol-based gels and disposable gloves) for preventing and countering infections.
  • Awareness of the benefits of intensive environmental cleaning to prevent cross-contamination and the transmission of communicable infections, such as gastro and respiratory tract infections (including influenza).
  • Improved care to prevent wounds and wound infections, including the use of innovative methods of wound care that enhance healing and reduce pain and suffering.

What was the impact for residents?

Residents benefited from increased staff awareness of activities to reduce the number of infections in residential aged care facilities.

Improved hydration to help prevent urinary tract infections.

What was the impact for staff?

Demonstrated improvement in the knowledge and skills of staff participating in the project resulted in:

  • A better understanding of the benefits of evidence based prevention and treatment of infections.
  • An opportunity to share successful interventions with other participating RACFs.
  • The acceptability of vaccination as a preventive against influenza-type illnesses.
  • Useful knowledge and skills relating to infection control in the ongoing care of residents.
  • Awareness of the importance of improved hydration and care to prevent urinary tract infection.
  • Improved care to prevent wounds and wound infections.
  • Staff expressed strong satisfaction with the opportunity to represent their RACF at meetings and exchanges.
  • Increased opportunity for personal continuing professional development.

What could be adopted in my service?

Examples of small changes that facilities could make to reduce the number of infections and have a positive impact on outcomes for residents include:

  • Complete an IC-related risk assessment for residents entering RACFs.
  • Reduce overloading of linen skips (to reduce the incidence of soiled linen touching staff clothing).
  • Encourage visitors to wash their hands when entering a facility.
  • Provide chest physiotherapy for residents with signs of infection.
  • Reinforce the wearing of hair nets by staff in the kitchen.
  • Consider annual staff vaccinations against influenza.
  • Capacity-building (training, succession planning) in relation to IC in RACFs.

Additional resources to support the aged care sector to improve staff knowledge and skills in the area of infection prevention and control can be found at Infection control webpage on the Departments website.

Palliative Care - Murrumbidgee General Practice Network

Encouraging best practice palliative care in residential aged care facilities from rural and remote communities within NSW, South Australia and Victoria

Project Overview

The purpose of this project was to address the identified theory gaps that exist between the Guidelines for a Palliative Approach in Residential Aged Care, and what is actually delivered within residential aged care facilities (RACFs). Fourteen facilities in 12 locations across NSW, VIC and SA took part in the project.

What was done?

The project aimed to bridge the gap in palliative care in rural and remote RACFs by adopting a multi-disciplinary evidence-based framework for end-of-life care and providing access to education for aged care staff.

The project emphasised four guidelines from the Australian Government Department of Health and Ageing (2006) Guidelines for a palliative approach in residential aged care (enhanced version):

  • To provide a palliative approach in the resident’s familiar surroundings if adequately skilled care is available. This reduces the need for transfer to an acute setting and avoids potential distress to the resident and their family/carer (Guideline 3).
  • To provide a palliative approach through multidisciplinary coordinated care (Guideline 4).
  • To provide a systematic implementation of advance care planning involving communication between the resident, family and doctor which increases satisfaction with the care provided (Guideline 7).
  • To develop comprehensive advance care plans that include ongoing assessment, respond to changes in the resident’s health and increases satisfaction with care (Guideline 9).
  • In addition to the guidelines the project drew upon the following evidence-based resources:
  • Palliative Care Outcomes Collaboration (PCOC) benchmarking tools.
  • Brisbane South Palliative Care Collaborative and Lyell McEwin End of Life Care Pathways.

Key activities included:

  • Collecting data before and after project implementation by conducting focus groups and interviews with families and healthcare providers. Collecting data on demographics and several indicators of quality of care through a one day “census” of residents in RACFs, both before and after the interventions.

Providing education to aged care staff in the following areas:

  • Active Learning Modules, Palliative Care Australia;
  • ‘Respecting Patient Choices’ including ‘Train the trainer’ – offered in two of the GP divisions;
  • PCOC – use of assessment tools – offered in 2 of the GP divisions;
  • Program of Experience in the Palliative Approach; and
  • TAFE Certificate III and IV accredited training modules.

Implementing End of Life Care Pathways as a trial for the evidence-based framework.

Developing and distributing a quarterly project newsletter to all RACF staff, residents and families/carers. The newsletters communicated the scope and aim of the project, profiled each participating facility, promoted the project and educated in regard to strategies.

What was achieved?

  • Improved access to education for aged care staff and enhanced skill and confidence for staff to address a family’s needs.
  • The education was appropriately suited to the needs of the participants.
  • Communication increased between care staff and family members regarding end of life care.
  • Staff confidence increased around end of life care issues.
  • The use of Advance Care Planning was encouraged.

What was the impact for residents?

  • Each individual had attention when needed, through a targeted approach to care needs.
  • Implementation of End of Life Care Pathways and Advanced Care Plans led to increased communication and understanding of the situation for residents and their families.
  • Families reported being happy to be included in Advanced Care Planning and with the palliative care being provided by the facility.

What was the impact for staff?

  • Improved access to education for aged care staff in accordance with their needs.
  • Enhanced skills and confidence of staff members to address family needs when planning end of life care through education surrounding Advanced Care Planning.
  • Increased staff confidence in their interactions with GPs both when planning and implementing Advanced Care Planning.
  • A more standardised framework for advanced care plans.
  • Staff members embraced the End of Life Care Pathways which improved communication and provision of prompts for holistic care.
  • Improved awareness of community palliative care nursing services.

What resources are available?

Developing new resources was not a focus of this project. Instead, existing resources were adapted for use in the project, including tools to assist with data collection and to inform staff about how to conduct multidisciplinary team meetings.

Resources used or adapted throughout the project included:

  • Ten things to know about grief
  • A pamphlet produced for staff members to assist families and carers dealing with grief and loss.
  • Therapeutic Guidelines Palliative Care version 3, 2010
  • A guide distributed to participating facilities and GPs to enhance the education provided by the project.
  • Lyell McEwin EoLCP
  • An End of Life Care Pathway now used by a number of facilities.
  • Jelly Bean’s Secret, Molly Carlile, Innovative Resources 2004
  • A book aimed at discussing death and dying with children.
  • Advanced care planning DVD
  • A DVD produced by Hunter New England Health to assist with Advanced Care Planning.

What could be adopted in my service?

Examples of small changes that facilities could make to have a positive impact on residents’ care towards the end of their life include:

  • Provide access to bereavement support to help staff members deal with the emotional strain of End of Life Care.
  • Conduct debriefing sessions after a resident passes away.
  • Adopt End of Life Care Pathways with appropriately qualified staff, and involve GPs in the implementation process.
  • Increase the communication between families and staff over End of Life Care Pathways.

Palliative Care - North East Valley Division of General Practice

A good death in residential aged care – optimising the use of medicines to manage symptoms in the end-of-life phase

Project Overview

The aim of the project was to implement evidence-based use of medicines to manage symptoms in the end-of-life phase for residents in aged care homes. The project was conducted in 14 aged care facilities in South Australia and Victoria.

What was done?

This project aimed to achieve improvements in care that will contribute to a ‘good death’ for residents of residential aged care facilities (RACFs).

The project was designed around evidence based guidelines including:

  • Guidelines for a palliative approach in residential aged care - enhanced version. Australian Government Department of Health and Ageing (2006) Canberra.
  • Therapeutic Guidelines: Palliative Care, 2005 and 2010.
  • The Australian Medicines Handbook and the AMH, Drug Choice Companion: Aged Care.
  • The end-of-life care pathway – Brisbane South Palliative Care Collaborative.

Key activities included:

  • Establishing palliative care committees.
  • Using the Change Management Framework - a tool developed to support assessment and planning of palliative care policies and processes.
  • Incorporating change management strategies throughout all activities.
  • Introducing the Residential Aged Care End of Life Care Pathway (the pathway), adapted and evaluated by Brisbane South Palliative Care Collaborative.
  • Developing and delivering education modules to GPs, RACF staff (registered nurses, enrolled nurses and personal care workers) and pharmacists via academic detailing (otherwise known as educational outreach visits).
  • Group education.
  • Promoting existing educational options including the Program of Experience in the Palliative Approach (PEPA), and the Palliative Care Australia online opioid education module for GPs.
  • Developing region specific lists of support services, and a clinical resources folder.

What was achieved?

  • The pathway was implemented to a variable degree across all RACFs – most successfully by those that were most engaged with project activities and incorporated the pathway as part of policy and routine care.
  • The pathway was found to be an effective way of supporting the consistent provision of quality care at the end of life.
  • The pathway supported the de-prescribing of non-essential medicines and the prescribing of prn (as required) medicines.
  • Education was delivered to:
    • approximately 50 percent of registered nurses;
    • approximately 30 percent of personal care workers;
    • 17 pharmacists; and
    • 22 percent of GPs, who attend almost half of all residents in the RACFs.
  • Evaluation forms completed by all groups showed that the modules were very well received and that positive practice change was anticipated.
  • The project resulted in positive practice change, both in terms of medicine management and through use of the pathway.

What was the impact for residents?

  • A significant decrease in residents transferred between hospital and the RACF prior to death.
  • Improved accessibility of residents’ goals of care at the end-of-life to GPs and locum medical services.
  • Improved communication and support for informed choice by residents and families.

What was the impact for staff?

  • Improved clinical skills & confidence, including recognition, assessment and monitoring of symptoms, and knowledge of medicine use at the end of life.
  • Enhanced ability to conduct conversations with families about symptom management and medicine use at the end of life, including access to printed resources.
  • Improved collaboration between RACF staff and GPs, including improvements in the processes RACFs have in place to communicate with GPs.
  • Improved collaboration with palliative care services and pharmacists.
  • Access to a palliative care committee or similar support network.
  • An intention to change practice from 78 percent of GPs returning evaluation forms to the project team.

What resources are available?

Some resources developed for the project, available on the NEVDGP website include:

The Clinical Resources Folder compiled by the project provides printed resident/relative information which includes:

  • Multilingual / multicultural resources with order forms.
  • Website information such as Care search, Palliative Care Australia, National Palliative Care and relevant accreditation standards.
  • A copy of the appropriate clinical services list (region specific).
  • A short-list of medicines commonly used to manage symptoms at the end of life
  • the Essential palliative care medication lists for community pharmacists and general practitioners (WA Cancer & Palliative Care Network, Government of Western Australia, Department of Health, 2010)

What could be adopted in my service?

Examples of changes that facilities could make to have a positive impact on symptom management at the end of life include:

  • Assess the palliative care needs of residents.
  • Implement an end of life care pathway.
  • Incorporate the use of end of life pathways into routine policies and procedures.
  • Establish a palliative care committee or interest group to support the provision of end of life care.
  • Ensure RACF staff have access to up-to-date evidence based information that is also made available for residents and families about end of life care.

Palliative Care - University of Queensland

Implementation of a comprehensive evidence based palliative approach in residential aged care - CEBPARAC

Project Overview

The project aimed to implement and evaluate a comprehensive evidence-based palliative approach in residential aged care. The project was led by the University of Queensland and conducted in nine residential aged care facilities (RACFs) across New South Wales, Queensland, South Australia and Western Australia.

What was done?

The project team worked with the aged care facilities to translate existing evidence based guidelines (palliative care and pain management) into policy and practice, including documentation.

The Guidelines used as an evidence base for the project were the:

  • Australian Government Department of Health and Ageing (2006) Guidelines for a palliative approach in residential aged care - enhanced version.
  • Australian Pain Society (2005) Pain in residential aged care facilities: management strategies.
  • Registered Nurses' Association of Ontario Toolkit (2002) Implementation of clinical practice guidelines.

The project included the following key activities:

  • Developing the Palliative Approach Toolkit which translated evidence into an easier format to put into practice.
  • Producing a DVD, All on the same page, which provides information for residents, family members, nursing staff and GPs on advance care planning and palliative care case conferences in residential aged care.
  • Providing education to all nursing and care staff working in the RACFs using newly developed and existing training materials.
  • Training staff to convene palliative care case conferences and use end of life care pathways.
  • Establishing, training and supporting link nurses in each RACF and developing a self-directed learning module from existing training modules to support the nurses.
  • Providing information to the community about how aged care facilities support dying residents and their families. This was done through via resident committees, brochures and newsletters.
  • Promoting the use of existing GP on-line training modules on a palliative approach by local GPs.
  • Implementing the Brisbane South Palliative Care Collaborative Residential Aged Care End-of-Life Care Pathway (RAC EoLCP) for residents requiring terminal care.

What was achieved?

  • Improved resident care and family satisfaction to a palliative approach to resident care.
  • Improved staff confidence, knowledge and skills to provide a palliative approach for residents and families through the project’s education program.
  • Increased opportunities for residents’ wishes regarding care decisions, including place of care, to be respected, through a systematic approach to advance care planning.
  • Increased capacity of organisations to deliver palliative care.
  • Links were made between key processes that are the feature of the model of care and existing funding mechanisms such as ACFI and Medicare Items for General Practitioners.

What was the impact for residents and family?

  • Improvements in the clinical care of residents in the areas of symptom management, advance care planning, bereavement care and care in the final days of life.
  • Enhanced communication among staff, residents and families.
  • Improved management of residents’ end-of-life symptoms.
  • More referrals to specialist services (palliative care, pain management) and care in the final days of life.
  • More opportunities to participate in palliative care case conferences and to engage with General Practitioners.
  • More opportunities to learn how aged care facilities support dying residents and their families.
  • More opportunities for grieving families to receive bereavement care.

What was the impact for staff?

Significantly enhanced skills in how to use an end of life care pathway and how to organise and facilitate a palliative care case conference for residents with a prognosis of less than six months.

  • Around 70% of nurses were more confident to independently react to and cope with residents’ nausea, vomiting, constipation or pain. They are felt more confident in supporting upset residents or family members.
  • Around 65% of nurses strongly disagreed that:
  • aged care facilities are not good places to die;
  • when a resident dies they feel something went wrong; and
  • feeding tubes should be used to prevent starvation at the end of life.

What resources are available?

The project developed the ‘Palliative Approach Toolkit’, featuring six key domains of care and accompanying education resources. It outlines a step by step approach for each RACF to implement the model with the resources provided.

The toolkit is comprised of: Three modules:

  • Integrating a palliative approach for managers.
  • Key processes in a palliative approach.
  • Clinical care.

Education products including:

  • 2 DVDs – ‘Suiting the needs’ and ‘All on the same page’.
  • Three self-directed learning packages.
  • A calendar of posters that can be rotated to cue key messages of a palliative approach.
  • Five educational flip charts: The presentations are mapped to the clinical care topics and target care staff.

The toolkit also includes copies of the following resource materials:

  • Therapeutic Guidelines: Palliative Care version 3 (Existing resource).
  • Palliative Care Australia Standards (Existing resource).
  • Brochure – Now What? Understand Grief (Existing resource).
  • Brochure – Understanding the Dying Process (Existing resource).
  • Guidelines for a Palliative Approach in Residential Aged Care – Enhanced Version (Existing resource).

What could be adopted in my service?

Examples of small changes that facilities could make to have a positive impact on residents’ palliative care include:

  • Conduct palliative care case conferences for residents with a prognosis of less than six months.
  • Arrange monthly reviews of palliative residents by specialist palliative care nurses.
  • Use end of life care pathways for residents who are terminally ill.
  • Promote advance care planning.
  • Leave exhaust fans on in bathrooms to prevent feelings of claustrophobia.
  • Combine appropriate drug and non-drug treatment strategies for pain or dyspnoea.

Where can I get more information?

For further information regarding this project visit the University of Queensland and Blue Care website

​A HTML version of the Implementation of a comprehensive evidence based palliative approach in Residential Aged Care (CEBPARAC) project is also available.

Wound Management - Queensland University of Technology

Creating champions for skin integrity

Project Overview

The objective of the project was to implement evidence-based practice in wound management for residents in residential aged care facilities (RACFs).

The project was led by the Queensland University of Technology and conducted in seven residential aged care facilities across New South Wales and Queensland.

What was done?

The focus of the project was to enable RACF staff to preserve skin integrity through the application of evidence-based practice to assessment, prevention and management of wounds.

The project team developed, trialled, implemented and evaluated a model of practice for wound care called Champions for Skin Integrity (CSI), including a wound management education resource.

The project used the Australian Wound Management Association Standards for Wound Management (published in 2002 and updated in 2010) as the main source of evidence and drew on a wide range of other sources, including published guidelines, for more detailed evidence where possible.

Key activities included:

  • Synthesising the evidence into summaries of individual topics which were used as the basis for ‘tip sheets’ and flow charts to provide simple messages about wound management.
  • Meetings at each aged care facility to establish relationships and plan activities to implement the project.
  • Developing role descriptions of wound care champions.
  • Establishing wound care networks and linking clinicians in each facility.
  • Developing and adapting resources to address identified barriers and enablers.
  • Conducting education seminars, skills development workshops and one-on-one education during a six month implementation phase.
  • Engaging the project team with residential aged care facilities to establish relationships, plan activities, identify and refine goals, discuss progress and continue communication campaigns.
  • Conducting pre and post assessment of how facilities prevented, assessed and managed wounds, through surveys, audit and interviews, and providing results and feedback to those involved.
  • A two day final workshop for the champions on clinical leadership skills, change management and setting goals for future sustainability of project outcomes.

What was achieved?

  • A significant reduction in wounds and the severity of wounds in aged care facilities.
  • Increased implementation and documentation of evidence-based practices for the prevention, assessment and management of wounds.
  • Increased staff confidence with wound management and an improved learning culture.
  • Improved staff knowledge, skills and implementation of evidence-based wound management.
  • Increased staff awareness of their roles in evidence-based wound care at all levels.

What was the impact for residents?

  • Increased use of pressure reducing strategies to prevent pressure ulcers.
  • Increased use of strategies to prevent other types of wounds (skin tears and leg ulcers).
  • Less prevalence and severity of wounds, including pressure ulcers, skin tears and leg ulcers.
  • Residents appreciated the opportunity to improve their knowledge and awareness to be able to implement appropriate wound prevention and management strategies themselves.

What was the impact for staff?

  • Improved knowledge of prevention strategies and management of skin tears, pressure ulcers and leg ulcers, in addition to wound assessment, wound care and skin care.
  • Increased use of evidence-based strategies to prevent and manage pressure ulcers, skin tears and leg ulcers.
  • Changes in wound assessment and management practices.
  • Increased documentation of pressure risk assessments, risk assessments for other wound types, wound assessments and management of current wounds.
  • Higher awareness in all levels of staff of their roles in prevention and/or management of wounds.
  • Over 90% of staff agreed the project resources were easy to understand and use.
  • Multi-disciplinary wound care networks and contact with link clinicians were initiated in each facility, making it easier for facilities to access expertise when needed.

What resources are available?

The CSI resource kit is available for potential Champions in other residential aged care facilities. The kit provides information on the roles and processes of the Champions and the CSI model, and also contains the education and self-evaluation interactive DVD and all resource material for use in education and practice. The kit includes:

  • An interactive DVD with 8 self-directed education modules, a self-guided quiz at the completion of each module, and links to all the project resources.
  • Summaries of evidence-based guidelines on prevention, assessment and management, skin tears, pressure ulcers, arterial leg ulcers, venous leg ulcers, diabetic foot ulcers and maintaining skin integrity.
  • Information brochures, tip sheets and flow charts on prevention, assessment and management of the above wound types.
  • A one page Skin Integrity prevalence audit tool.
  • A Champions for Skin Integrity Resource Folder including the resources above, information on roles and processes and links for further information.
  • A Dressings Resource Folder on appropriate dressing types (with samples) and application according to type of wound.

Wound Care in Residential Aged Care Facilities website

What could be adopted in my service?

Examples of small changes that facilities could make to have a positive impact on wound prevention include:

  • Use soap-free body wash rather than soap.
  • Moisturise the skin of residents after showering or twice a day.
  • Use protective padding on equipment including wheelchair footplates.
  • Use pressure relieving mattresses.
  • Regular position changes.
  • Daily ankle and calf muscle exercises.
  • Source wound care expertise in your local area.

More information?

For further information regarding other EBPAC projects see the Department of Health website.

Screenshot of EBPRAC Round 2 - Cover