Deaf, Daft and Demented: Improving Attitudes to Elderly Care

The woman on the radio sounded distraught. She was calling a phone-in show from the hospital where her frail, elderly Dad was being treated. Treated perhaps, but not being cared for. The caller described a ward full of elderly, infirm patients marooned in their beds trying to reach water jugs across the Grand Canyon of space between them and an impossibly far away bedside cabinet. Others pressed the call button repeatedly for commodes or help with moving up in the bed. Nobody came. 

The presenter Shelagh Fogarty suggested a shortage of staff. Apparently not. The caller described a large group of ward staff lolling around the Nurses Station chatting about Facebook. The phone-in took place on the back of a recent RCN report calling for minimum staff levels on elderly care wards. The RCN survey was itself a response to a catalogue of horror stories surrounding the care of older people. In the same week a Which? Magazine ‘secretshopper’ sting highlighted (yet again) serious failings in domiciliary care. It makes sad if not unfamiliar reading. Missed medication. Missed food and drink. Soiled beds. That sort of thing.

So what are the reasons for this constant torrent of bad news? There are plenty of ‘big picture’ factors involved, and others more eloquent than I have written about some of them elsewhere with the precision of front-line experience. But let’s look at one specific and rather uncomfortable area from my own perspective as a trainer.

It’s one of those elephants in the room that doesn’t get much of a public airing, and goes something like this. 

Care of the elderly is far and away the least popular of the health and social care specialities, and attracts the sort of staff who might just as well be earning a Gold Star for assembling Big Macs.

For as flawed as the bigger picture may be, it is still individual care staff leaving patients to dessicate or care home residents to sit in their own faeces. Whenever I hear one of these reports I imagine myself visited by The Ghost of Christmas Yet to Come, aged by forty years and placed in a nursing home by a family who have ignored my Living Will request to be shot at the merest suggestion of double incontinence. I have a memory span of thirty seconds, and I’m muttering to myself, probably because nobody else will listen. My Inco Pad fills with the end result of my soft diet lunch. A couple of care assistants haul me into a wheelchair and whisk me off to the nearest shower hose, deep in conversation over Kate Middleton’s choice in shoes. 

So in this Dickensian nightmare I’m quite literally at the arse end of the care sector, but back in the real world does it really follow that elderly care attracts the bottom of the pile in terms of it’s staff?

Speaking as a trainer working with hundreds of care staff over the years, most certainly not. But I do often see a demoralised workforce working long hours for poor pay and even poorer conditions. With the best will in the world it’s not hard to see how patients or clients eventually come to be seen not as valued individuals but as names on a job sheet spiralling ever downward  toward ever-increasing neediness and ultimate death.

So what do we do? Do we throw more centralised funding at our local authorities and privatised care providers?  Even if such fanciful thoughts had the slimmest of chances of becoming reality, I suspect this would achieve little in terms of progress beyond a healthier shareholding for their employers.

What about better training for care staff? For as long as I’ve been in the business training has been a luxury expense in an industry long governed by the bottom line of the profit/loss equation. ‘Stack it High, Sell it Cheap’ used to be the mission statement for Tesco but is now the essential business model for elderly care, where training is often seen as a costly irrelevance to short term profit. But could more and better quality training really improve the care and attitudes toward our vulnerable elderly? 
A few years ago I collaborated with some local colleagues on designing and facilitating a BTEC Short Course Award: Caring for the Older Person with Mental Health Problems. It was a fairly simple programme consisting of three classroom-based modules focussed on Dementia, Depression and Challenging Behaviour. We worked with a varied collection of staff from both nursing home, residential and domiciliary settings. Some of our candidates were managers, while most were front-line carers. Almost all were terrified at the prospect of taking a test at the end of each day although Exam Phobia faded quickly once our candidates realised how much they already knew and what they were capable of.

We looked at how depression, so endemically common among older people in care and yet so seldom tackled, can be quite easily identified by care staff using the sort of rapport and person skills that comes inevitably when helping a resident put on their socks every morning.  We looked at magnified images of protein plaques and discussed how these lead to memory loss. We looked at how awareness of the sensory and cognitive deficits of dementia can help us communicate much more effectively and reduce distress. Not only did our candidates earn a recognised qualification but challenged, examined and re-evaluated  how they worked with older people. Now let’s not pretend this was Dead Poets Society but the fact I’m talking about this award it in the past tense irks me more than Robin Williams. And that’s a lot of irk.

We were able to deliver the award only with the help of a generous funding pot from the now defunct Business Link Dorset. Once the funding dried up, so did the course, and we certainly didn’t have the resources to evaluate the shop-floor efficacy of the training. But on anecdotal evidence at least, investment in a reasonably cheap and effective project yielded greatly improved levels of care and support inspired by more positive attitudes and a greatly enhanced sense of self-worth among our groups. With potentially business-ruining CQC reports easily available online and a traditionally high turnover of staff, you don’t really need a degree in health economics to work it out. It’s just good business to have better trained staff.

In the meantime we’ll continue to hear an unending tide of bad news stories and radio phone-ins about staff who have become demoralised and dispirited when they could, with a little time and effort, be taking a fresh look at the work they do as something which is as skilled and satisfying as any of the ‘sexier’ areas of the care and support industry.  

It could certainly beat flipping a burger.

Coffee. Biscuits. Powerpoint: Does Social Care Training really do the business?

This article first appeared on The Guardian’s Social Care Network

With social care budgets trimmed to the bone, how do we make sure the little money still  available for staff training gives maximum ‘bang for buck’ and becomes more than just a tick-box exercise?

Dear Reader

If you’re reading this then there’s a reasonable chance you work in health and social care and that you’re a veteran of the training room. And by training I don’t mean a Degree or Diploma, nor the Fire Lecture or the Food Hygiene course that taught you how to boil an egg. I mean the sort of workshop type training typically delivered over a day or two, focussing on a particular subject or skill with the intention of making you better at your job and better able to deliver services to vulnerable people. 

I hope the course left you inspired and invigorated, filled with new skills and knowledge. But there’s also another significant possibility. That it was little more than a chance to catch up with a few bods you haven’t seen the last Clinical Supervision workshop. Not to mention of course the free coffee and a chocolate bourbon.

The course may have been terrible/boring/poorly facilitated/ inappropriate. Tick any which applies. Or it may have been thoroughly enjoyable and a great means of meeting new people and networking. 

But (and it’s rather a big ‘but’) answer this question; ‘Did that course actually change the way you do your job?’ If the answer is usually ‘Yes, and in a good way’ then great. But if it’s ‘No, it was rubbish’ or even ‘No. But it was quite interesting’ then perhaps we need to be thinking about ways and means of delivering training that is both value for money, and effective.

Ask any group of health and social care staff how to resolve a particular issue and the probability is that ’more training’ will loom very large in the responses, as they often do following independent inquiries. ‘More training’ so often seems to be the panacea to all the ills of health and social care work, but is there an evidence base to suggest throwing a few workshops at failures in adult protection is the path to practice redemption? No. At least not according to a PhD student Lindsey Pike.

Lindsey’s doctoral thesis asks the same sort of question I’ve asked you here. It explores the remarkably under-researched question of how training actually impacts practice at the front-line of care and support, specifically focussing on safeguarding adults training in one particular county. Her findings are telling.

To summarise, Lindsey’sw  work shows that lots of resources, effort and administration are being ploughed into costly training which doesn’t, at the end of the day, result in improvements in safeguarding skills on the shop-floor- unless training is embedded within a positive training culture and transfer climate. Transfer climate refers to “those situations and consequences in organisations that either inhibit or facilitate the use of what has been learned in training back on the job” (Burke & Hutchins, 2007, :282). A positive transfer climate would be one where delegates attend relevant, timely training, with a clear idea of what they need to gain from it, and support and opportunity to use their learning in practice.

I know that both myself and others from both the UK and further afield are starting to think about a move on from the ‘Coffee Biscuits Powerpoint’ model, which ticks the box on a manager’s To Do list but achieves little else in terms of making us better at our jobs or providing better services. So what’s the answer? I suggest that traditional classroom-based training can be worth so much more when combined with three key features. 

Firstly, tightly-knit integration of the one or two-day course with an organisation’s own policies and procedures, client groups and focus of attention.
Secondly, training could and should be followed up by some form of one-to-one or small group meeting to allow participants to ‘nail down’ whether the course made an impact on their practice. And who should be doing this follow-up? Well, preferably the trainer who delivered the course. But what if the trainer is now hundreds of miles away? Well there is of course Skype or one of the many e-learning packages out there. But there is an even better solution. 
Localised training delivered by local practitioners who’ve been ‘skilled-up’ by a competent, focussed ‘Train the Trainer’ package is, I think, a genuine and realistic alternative to the ‘expert from afar’ model. Delivering good training is a considerable skill, but not so much a considerable skill it can’t be learnt, especially when training skills are backed up by the sort of expertise and experience in health and social care so valued by course participants.

Connor Kinsella is an author and training consultant at JCK Training:

Connor would like to acknowledge the contribution of Lindsey Pike to this article. Lindsey is currently working with Research in Practice for Adults:

‘Just a little scratch': Care, Compassion and the Health Care Professional

He was once much better accustomed to putting words to music, but a recent hospital experience and a little nudge from me brings you a short but telling little addition to the ‘dignity in care’ issue from Frank Kinsella, my Dad.

Christmas 2004. A small group of elderly cancer patients sit in a Waiting Room at a well-known London hospital.  One patient begins to sing ‘Silent Night’. Then another.  And another. In her wheelchair one obviously ill lady without the energy to sing raised her bowed head to reveal a smile of pleasure. And maybe hope.

Remarkable? Yes. But completely unexpected? No. Such was the atmosphere created in that particular hospital, from the point of reception to the moment of departure, that all things seemed possible. Hope was conveyed in ready smiles and familiar greetings.

March 2012, and onto another hospital for a blood test. The two electricians working in the long corridor were more than helpful in providing directions, even to the point of one of them descending from his long ladder to provide exact information. So far  so good. The tall young lady with the short old lady got into the lift. “Do you know which level we need for Phlebotomy?” they asked. Smiles all round and inconsequential but friendly chatter. A little further and still good. Another long corridor and there ahead was a welcome sign indicating that the friendly electricians directions were on the button. Unfortunately that was the end of either’ friendly’ or ‘welcome’.

The blood test department was filled to overflowing. The  many who stood were envious of the seated and made any recognition of the correct ‘procedure’ difficult at very least. Behind the mostly hidden desk the blondish head brusquely indicated the general direction of the equally difficult to see ticket machine, from which a number was required.  The desk was apparently for selected patients and perhaps the blondish head resented those without the gift of psychic perception who presented themselves at the desk.

The white uniforms called out the numbers and Number 38 was directed to a booth with a cursory wave of a disinterested  arm and no eye contact.  The conversation went something like this: (Smile) “Is the department always as busy as this?” Reply: (No eye contact) “Mornings.”  The blood was easily taken, the only cost a sense of civility and a feeling of well-being.

Thoughts turned inexorably to one particular nurse who trained at that hospital and worked there for many years. For much of that time she worked under the long shadow of Matron, for whom order, cleanliness and high standards were not a ‘mission statement’ but just how things should be done. But to both Matron and the nurses who worked under her long shadow attitude and compassion were at least as important as a clean trolley.  They would have been sadly disappointed at this blood test clinic. Disappointed that so little compassion was evident and relief from anxiety absent, not least for those with more serious illnesses.

Of course the department was busy every morning and perhaps the working conditions for the white uniforms were not perfect. Of course those who waited for their number to be called were sometimes a little confused, or difficult or even occasionally a little smelly.

The white uniforms were presumably healthy. They were without pain or cause for serious concern. It could be reasonably assumed that the only real pressure in their comparatively secure situation is choosing lunch or affording a night out in hard times. It could equally be assumed that those taking numbers from the machine did have real life or death concerns, but were regarded as just that. Numbers.

Those who trained there as nurses in a bygone era may take some consolation in the fact that the white uniforms are not nurses. Maybe the white uniforms are only trained in the mechanics of taking blood and hopefully the nurses are selected and trained in both the mechanics and the compassion. It’s said that a smile or a kind word can go a long way.  Sadly it seems that they don’t always travel the short distance from one hospital to another, and sadly the the Matron, the Nurse and the Christmas Carols are no longer with us. But they have left such loud echoes behind them.