Implications for care provision in the SCU 109

Through sharing their stories, the ARG members progressively embraced a more collaborative agenda. As they considered how the context of care on the SCU impacted on the provision of care for both residents and family caregivers, key issues were revealed with respect to end-of-life care, pain management, and the capacity of staff to support residents’ family caregivers.

5.3.1 Impact of the care context on resident care provision

The ARG narratives suggested that the quality of resident care was severely undermined by heavy workloads and staffing issues. For example, Catherine explained that in order to meet heavy work demands, her practice was essentially task-orientated and routine-based. She described it as ‘repetitive’ and ‘remote control’. Elizabeth argued that ‘there is no time for one-on-one care’. In recognition of this concern, Catherine agreed and stated that at best ‘you might catch [a resident] as they are wandering past you to have a chat’. In response to these accounts of practice, Judy described person-centred care as ‘a joke’ within the reality of day-to- day practice.

Through the emerging narratives of the group it was revealed that in order to negotiate heavy workloads, especially during periods of short-staffing, ‘shortcuts’ were taken when attending to routine resident care tasks. While Catherine recognised that this situation was ‘not very satisfactory’, she reluctantly acknowledged that in

order to adhere to a ‘time schedule’ and meet work demands, ‘you…have to skip things, so you take the shortest way out’. Woven throughout the ARG members’ stories were numerous examples of the usual shortcuts that were taken in practice. For instance Elizabeth stated:

... like the last few weeks … we haven’t got to do any toileting after lunch and we used to always toilet [Residents] straight from the dining room … we haven’t been able to do it because we’ve still had residents to [provide care for].

Catherine explained how some residents, who were at risk of sustaining a fall if left unsupervised, would be physically restrained at busy times during the day. She stated ‘we’ve got restraints, we can’t watch them, they are left out in the lounge room when we are doing care work’. Moreover, Anne highlighted how some bed-bound residents may not have their care needs met until well into the afternoon, as such ‘laying [sic] in bed all night and all day’ if the unit was short-staffed. In recognition of such circumstances Judy summed up the impact of heavy workloads on resident care as ‘horrendous’ and highlighted that some of these situations did not escape the watchful eyes of some family caregivers and indeed reinforced their desire to be even more vigilant.

Care staff in the ARG emphasised how short-staffing and heavy workloads had a profound impact on their capacity to provide dignified, comfort-orientated care to dying residents. For example Catherine stated:

…[staffing impacts] greatly; we can’t be with the [dying] resident, quite often when we are short-staffed we don’t have time and we just don’t get back to them, so they are left lying there…they are just left there in the beds until we can get back to them…and sometimes we don’t…cause you are so flat out looking after the others.

Catherine and Elizabeth, both PCAs, highlighted the importance of ‘being there’ with the resident during the dying process and doing ‘little things’ to comfort the person. However, their narratives also indicated that they were often frustrated in their efforts to achieve these goals, as Catherine explained in the following account:

When we had a spate of running short [-staffed], we had a few [residents] dying and they were left. I mean they got the best care we could give them but it wasn’t enough I don’t think.

After reflecting on Catherine’s comments, Elizabeth agreed that the care provided to dying residents is often ‘too rushed’ and not of a sufficient standard. Overall, the ARG’s narratives suggested that, due to resourcing inadequacies in the SCU and increasingly complex care, task-oriented care and taking shortcuts had become an established part of practice. However, there was a resounding opinion amongst ARG members that this could not be considered ‘good practice’ but rather the best that could be done under then-current workplace conditions. For example, Judy stated ‘it’s not the way you want to work…you want to do [more], you want to have more time…’ In contrast, Anne recalled experiences of working at the RACF in previous times when there was better staffing regimes and care was not as complex. She stated:

I can remember working… having a fantastic time…it might have been a production line, but they were all showered by 10:30…and there was always a plan of what staff would be doing with … residents for the rest of the day. Two would take a group walking around the park, around the gardens, two would be doing hair…it is where job satisfaction came in…Now this is where [job satisfaction] is lacking…

Other ARG members indicated that their current practice was professionally dissatisfying and disempowering. Elizabeth’s comment suggests the unsustainable nature of the care environment,‘You do go home feeling guilty, feeling that you haven’t done what you’ve set out to do…the thing is, physically and mentally we can’t [cope]!’.

The maintenance of effective pain management for residents was also raised by the ARG as a significant problem associated with staffing issues on the SCU. Elizabeth explained how the presence of casual nursing staff on the unit often resulted in residents not having their pain adequately managed. She recounted:

You come back after 5 days off and somebody is in pain and you look back through the daily organiser and there has been different trained staff each day, so that’s why you know [residents] are not getting [PRN pain medication].

Similarly, Catherine argued that pain management ‘seems to be at its worst’ during periods of high turnover of casual staff unfamiliar with the residents. Indeed ARG members argued that relying on casual staff to recognise a resident in discomfort and administer analgesia was often problematic; as it usually required intimate knowledge of the residents and his/her behaviour. Without this level of familiarity, members explained that casual staff were less likely to detect the presence of pain. Anne recounted:

…for 3 or 4 weeks now the resident had been having QID Panamax2 (analgesia) or TDS, either or, it’s a PRN order. Last week …, no-one (casual staff) actually gave the PRN medication to him, so every day until…when I came back no-one had given him [medication].

As a further complicating factor, members also highlighted that there was ad hoc approaches to pain assessment for residents in the SCU. Anne explained that if analgesia was being administered to a resident, even on an ‘as necessary’ basis, it was not unusual for nursing staff to administer the medication without assessing the resident. She explained that a recent entry for analgesia on the resident’s drug chart functioned as a cue for nursing staff to re-administer the medication. Anne argued that this system of medication administration was flawed, but surprisingly not with respect to absence of an adequate pain assessment. Rather, she explained that at the beginning of each month a new drug chart was commenced, which meant that the record of analgesic administration for the previous month was removed and filed. As a result, she recalled a resident requiring regular PRN analgesia who was not administered it on the first of the month or for five subsequent days until at which point he started to display obvious symptoms of pain and discomfort.

Finally, ARG members highlighted problems with the accessibility of GPs in relation to effective symptom management and continuity of care. For example, Heather explained that not being able to access a resident’s GP in a timely manner had significant implications for the co-ordination of end-stage care. She stated:

…being so far away from the GP and then just trying to get things organised for a symptom that has just suddenly come on, sometimes that’s a little bit tricky…See I needed some Midazolam for a lady the other night…by the time

2 _{Also known as Paracetamol (acetaminophen). It is simple analgesic with anti-pyretic}

I got it, got around to getting the order [from the GP] …I came down and she’d died.

Moreover, GP accessibility was also considered by members as a key factor that impacted on their capacity to provide care for residents in their familiar surroundings, especially when they were dying. For example Heather explained:

..you just have a condition on the unit that you just can’t deal with, there is not a Doctor on call …if you want some Lasix or something … you’ve still got to get an order for it, and if you can’t talk to the GP concerned then you’ve got to talk to the after-hours GP and…they don’t know the scenario… they’ve got to get in touch with the original GP and then… it all might be too late, things have escalated and you’ve got to get the person out [to hospital]. The implications of the above scenario being that a resident is transferred to an emergency department which as Heather explained may be ‘bogged under’ and they are subjected to a ‘three or four hour wait’ before being assessed. This type of management caused a great deal of angst among the group members who held a strong conviction that dying residents should be able to remain in familiar surroundings without having to undergo the disruption of being moved and the inadequate care processes that often accompanied this.

5.3.2 Capacity of staff to support family caregivers

With ARG members having recognised the complex needs of family as shaping their practice, resourcing issues were identified as restricting their capacity to provide support and establish partnerships with family caregivers, consistent with a palliative approach to care.

Nurses in the ARG explained that they were frequently faced with a shortage of time as a result of chronic staff shortages and challenging workloads. As such, they recognised that their capacity to provide emotional support to family caregivers was undermined by these competing demands. In the following account, Anne highlights the dilemma of spending time with family caregivers who require support, while attempting to negotiate heavy workloads. She stated:

…we’ve got a new resident and…her daughter is really grieving at the moment. I spent about half an hour on Monday night with her on the

phone…and…I’m trying to get off the phone, knowing that I had to be down on [another unit]…and this is it, you just don’t have the time.

Judy also reported a similar tension in her practice:

They [family caregivers] are seeking out people to talk to…I’ve got to watch myself on a Monday morning, ‘cause Mondays are always hectic and I seem to be caught with this lady [a family caregiver] every Monday morning and she doesn’t look like she wants to move from the office and I’m thinking, ‘hey I’ve got a lot of work to do today’…

The potential consequences of this situation were further highlighted by Anne when she explained that information given to family caregivers on issues related to dementia or their relatives’ care was predominately provided in an informal and reactive manner. She stated:

…[the new resident’s family caregiver] said, ‘oh mum wanders of a night, I’m really worried that mum will wander of a night’, and I explained to her, that this is the whole reason, this unit is designed for people who wander, I said ‘don’t worry she’ll be one of six that will be up wandering’… that is what they need to know that this is normal.

Consistent with ARG members’ emerging understandings that their interactions with family caregivers were structured in reactive ways, Judy argued that there was not enough time in her day to provide family caregivers with information about dementia in a more formal or rigorous manner.

Reflective of the competing tensions that shaped ARG members’ practices, their accounts suggested that there was a relative absence of partnership between staff and family caregivers in the SCU. The implications of these circumstances were evident in a comment by Judy who described her experiences of interacting with family caregivers as akin to being ‘on pins and needles’. Amid these competing conditions Judy reflected that interactions with ‘difficult’ family caregivers who were considered by the staff as ‘anxious and not coping’ were largely avoided in order to minimise the intrusion of those family members on staff time.