Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report

3.4 - The nature of the changes in practice

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At the beginning of the evidence-based practice movement ‘evidence’ was largely conceptualised as the findings from randomised controlled trials. In general, a much broader definition is now used, encompassing ‘evidence’ from research, clinical experience, patient/resident preferences and the local context, including what might be considered as local evidence derived from quality improvement activities (Kitson, Harvey et al. 1998; Pearson, Wiechula et al. 2007). Good examples of the use of local evidence can be found in the EBPRAC program with audits, the results of which were then fed back to facilities to guide future actions, and Plan-Do-Study-Act cycles which relied on collection of monthly data to evaluate past actions and guide future actions. ‘Evidence’ is not something that is fixed but rather is constantly evolving and subject to new interpretations (Walter, Nutley et al. 2003; Greenhalgh, Robert et al. 2004)

In an important study in the UK two teams of researchers reflected on their research across seven studies using similar case-study-based methods (consisting of 49 individual case studies) and considered how innovations are diffused and adopted in clinical practice including the issues of what makes information credible (and hence used) and why people decide to use new knowledge. They identified some common themes: having robust evidence is not sufficient for getting the evidence adopted; the interpretation of evidence is socially constructed; evidence is differentially available for different professions; there are different views on what constitutes credible evidence and professional networks shape behaviour with reliance on trusted colleagues for advice (Dopson, FitzGerald et al. 2002).

The consequence of taking the broader approach to conceptualising ‘evidence’ referred to above is that clinicians require answers to four questions to aid their decision-making:

• Is the evidence-based intervention feasible in the local context?
• Is the intervention appropriate (i.e. will it ‘fit’ the context of care delivery)?
• Is the intervention meaningful (the extent to which the intervention is experienced positively by the patient)?
• Is the intervention effective? (Pearson, Wiechula et al. 2007).

Based on the interviews conducted with facility staff and members of project consortia the strength of evidence, or even the presence of ‘evidence’, does not appear to have been a major factor influencing staff to change their practices, particularly for those providing the bulk of ‘hands on’ care. Rather, what has been influential are the answers to two very pragmatic questions, which are effectively a condensed version of the four questions referred to above:

• Does it (the proposed change) make sense?
• Will it work?

‘Will it work’ is framed in terms of potential benefits for staff or potential benefits for residents. Evidence has a role to play in answering both questions but in itself is not sufficient. This finding is best summarised in the following comments in response to a question about the importance of evidence:
(For) the really critical thinking registered nurses and the care managers, I think it’s important for them. For the enrolled nurses and the personal carers, I don’t think they probably connect it. I think what makes a difference for them about what it is they’re going to do in their clinical practice is if it makes sense and if it works and it doesn’t matter what the evidence says. (P)
I don’t think in every day work routine in aged care, evidence really means much of anything to those who are actually doing the hands on stuff. (P)
You have to know what the reasoning is behind the change and if that matches what you think makes sense to good care and help, that will make a difference. (F)
All they can see is how it’s going to work for them in a practical sense, not the philosophical stuff. (F)
Why the change? What’s the purpose of it, where is it heading? How does it impact on me? And that’s what people want to know. (P)
This suggests a need for caution in using the concept of evidence-based practice to change practices:
I think it's about demystifying evidence based practice, it's about relating it to what they do know in their settings. I think that's probably been one of the biggest lessons learnt and I think if you disseminate this project to others focusing on evidence based practice and transference of that into every day clinical practice is probably not the best way to go about it. I think it's about we want to improve care for residents and even then that makes them sound as if they're not doing it the right way now, improve is not even the right word - it's how can we help residents better. (P)
The ‘evidence’ used in the EBPRAC program included the full spectrum of what might be considered evidence i.e. more than just the evidence from research. Some of the EBPRAC projects effectively created their own evidence either by taking several different sources of evidence and creating something new or generating new evidence as part of their project. In addition, local knowledge was created, all of which is consistent with the dynamic nature of evidence as reflected in the literature.
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Many projects had a strong focus on what are described in Section 2.1 as the ‘key processes’ in caring for residents, primarily assessing residents and care planning. For the pain management project resident assessment was critical – pain is ‘hidden’ and can’t be managed effectively unless it is assessed. The rationale for the oral health project was based on the idea that general practitioners and registered nurses can competently undertake oral health assessments, something that has not traditionally been part of their role. Improving nutrition requires a mechanism to screen and assess the need for improved nutrition; reducing falls requires a means of assessing the risk of falls; managing wounds requires a mechanism for assessing the type and severity of wounds. In some cases this meant adjustment of assessment tools already in place, in others the introduction of new assessment tools.

The process of assessment is closely linked to the issue of how the care of residents is planned. Care planning, particularly the use of end-of-life care pathways, was a key component of the three palliative care projects and featured in other projects as well. The changes to assessment and care planning as part of the EBPRAC projects took place within the context of the existing systems of resident assessment and care planning within facilities. The focus of the evaluation has not been on these existing systems but it appears that the act of assessment can be seen as more of a task than an opportunity to reflect on what the resident needs and that care planning can be highly structured, rather than continually responsive to the changing needs of residents:
The trouble is that care planning has become a tool to gain funding and demonstrate quality for accreditation and it doesn’t reflect the real world of the workers anymore … The trouble is we do a lot of assessments, we collect a lot of data but nobody actually analyses that data and draws a conclusion from it. (P)
As we continue to specialise and focus on all the different aspects of care, it becomes just a bigger and bigger Ben Hur, than the care plan which shouldn't be a library book [but] is, because everything has its full and broad assessment and goals and interventions. (F)
Care plans are not a ‘living document’, they reside in filing cabinets, are seen only by staff completing the ACFI and do not reflect the type of changes attempted in this project. (T4)
One of the key issues is the process of making the connection between resident assessment and care planning, which some of the EBPRAC projects did in various ways, by formal case conferencing, by more informal review meetings, through the use of mentoring and by establishing local teams e.g. wound care networks, pain management teams. The ability to make these connections is linked to staffing, particular existing roles and responsibilities:
Part of the problem is, you know, the staffing. RNs are the ones that are trained to make those connections and you can have one RN for 50 residents and how the hell would they ever have time to do that. So then you are reliant on the personal carers and the enrolled nurses to actually report those things. Personal carers can’t make those connections and so it’s a system failure and they do absolutely, they spend a lot of time writing care plans and a lot of time assessing, but less time actually linking what they’re assessing to the management strategies. (P)
Given the ubiquitous nature of documentation in residential aged care it is surprising that there is little evidence to guide how best to structure such documentation. Care plans are seen not just as a means of planning resident care but also as a form of contract with residents’ families setting out what care will be delivered and as necessary for funding and accreditation purposes. It is worth noting the results of a recent systematic review which identified that ‘if documentation is designed to serve purposes other than the planning, delivery and evaluation of care, the quality of care will be compromised’ (Pearson and Peels 2009, p 120). The results from the evaluations of the EBPRAC projects include a variety of recommendations about documentation, including use of particular assessment and care planning tools. There may be some merit in undertaking some more broad-ranging work to review the whole question of documentation in residential aged care and how best this might be structured, including what evidence-based tools should be used.

End-of-life care pathways implemented by the palliative care projects were generally well-received. The pathways did what care plans (however named) are meant to do – provide clear direction and ensure all those providing care are ‘on the same page’:
Most of the feedback has been that it’s a really good prompt to do things … they're all on the same page and they're all doing the same thing. (P)
I think the pathway was a much better way of doing it, because by the end when someone is close to death, and everyone is on the same page, it makes it so much easier to get the GPs on board. (F)
For the RNs it gives them confidence, they say that when they’re not around, which is a lot of the time, that the personal carers have a very clear checklist of things that they should look for, for somebody that’s dying, particularly the physical checklist. People have to sign or tick that they’ve actually gone to the resident and actually looked at those things. They like the fact that it signals to the family member that things are at the terminal stage, so this person is dying and so it gives them an entree to have that conversation. (P)
When it came to making changes in the care received by residents the picture across all the projects was one of lots of small changes, rather than major changes. In many cases the changes were refinements to existing practices or reinforcement of what is ‘best practice’, rather than the introduction of something completely new. Examples of such changes are included in the summaries of each project (Appendices 1-13). These changes are best described as ‘incremental’, as referred to elsewhere in this report (Section 3.5.3).

This is not to say that small changes can’t make a difference, well-captured in this comment in one of the project final reports:
Hanging a picture can make a difference. Moving a chair can make a difference. Opening or closing a curtain can make a difference. Doing something is important. Even if something can only be started, it is worth painting that one wall in the lounge. (HC behav final report, p 21)
Or this comment from a facility manager:
A drink of water stops lots of things. It stops urinary tract infections, skin tears, constipation and falls and things, low blood pressure has stopped - it is such an important thing to do, and that has just allowed our carers to have that much more sense of value about their positions.
Many of the changes require uptake by all staff, which is quite a different situation to healthcare more generally where implementation of evidence-based practice can be reliant on a small number of clinicians e.g. a surgeon using a new surgical technique. Whether it is a range of strategies to improve nutrition and hydration, use of an end-of-life care pathway or use of particular techniques to manage difficult behaviour, to give three examples, implementation is reliant on involvement across all staff and all shifts.
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