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

3.9 - Stakeholder engagement, participation and commitment

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3.9.1 Facility staff and other providers

The importance of engaging the right stakeholders and achieving their commitment to change is referred to repeatedly in the literature (NHS Centre for Reviews and Dissemination 1999; Walter, Nutley et al. 2003). The template for the six-monthly project progress reports included two questions which asked projects to rate the degree of participation they expected from different categories of staff and the degree of participation they achieved from those categories of staff, based on their experience over the proceeding six months. The questions asked for answers on a five-point scale: no participation, little participation, some participation, moderate participation, significant participation.

Across all projects in both rounds the degree of participation from the various stakeholder groups closely matched expectations (Table 11), except for one project where participation was slightly less than expected for most categories of staff.

Table 11 Extent to which stakeholder participation met expectations – percentage of all stakeholder groups across all projects

Actual participation compared to expected participation	T1	T2	T3	T4
Actual participation less than expected participation	10%	13%	15%	21%
Actual participation equalled expected participation	87%	73%	72%	69%
Actual participation greater than expected participation	3%	13%	13%	9%
Total	100%	100%	100%	100%

When participation was less than expected or difficulties engaging stakeholders were encountered it tended to involve one or more of the following: (1) individuals in key positions; (2) particular facilities or (3) a stakeholder group in a specific project. Many of these difficulties proved intractable, reported by projects for more than one time period and in some cases for the whole project, indicating how difficult it can be to improve stakeholder engagement if it is lacking at the outset. Generic barriers to participation (lack of time, difficulties obtaining backfill staff to release people to attend meetings) were mentioned more frequently by projects than specific barriers engaging individuals or particular facilities.

Figure 3 shows the number of projects where the actual participation of the stakeholder groups over the lifetime of the projects (at T1, T2, T3 and T4) was either ‘moderate’ or ‘significant’. Facility managers had the most participation in the first six months after which they were joined by registered nurses, enrolled nurses and personal carers as the main groups participating.
Figure 3 Stakeholder participation over time - number of projects with moderate or significant participation

The information below is a description of data provided in Figure 3 above.

	T1	T2	T3	T4
Volunteers	-	1	-	1
Registered nurses	2	11	11	10
Physiotheripists	-	-	1	-
Pharmacists	-	1	1	3
Occupational therapists	-	-	-	1
General practicioners	-	2	4	3
Facility managers	8	11	12	13
Enrolled nurses	1	11	11	10
Domestic and kitchen staff	-	3	3	3
Dieticians	1	-	-	1
Personal carers	1	10	12	10
	Number of projects

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Participation by general practitioners remained low throughout, although generally in line with expectations, with participation described in various ways, from ‘difficult’ and ‘sub-optimal’ to ‘high’. There was more general practitioner engagement in the three palliative care projects and the oral health project than other projects.

There were a small number of instances where engaging registered nurses was difficult but not enough to discern any patterns. The reasons given when this did occur included registered nurses being protective of their status and position or simply not having the time to engage with any aspect of the project because of their workload, described by one facility manager:
We had one RN to 40 residents here so the availability of the RN to attend was quite minimal. (F)
Engagement in project activities occurred for a variety of reasons - some people engaged because they were inherently motivated to do so, some became engaged as a result of the information or the education they received, some were influenced by their peers and some engaged when they started to see some clear benefits:
I guess it always comes back to information, getting people on side with information and probably the attitude. (F)
I think the significance of having those small groups and mini educational sessions has been quite significant in bringing people along and bringing people on board. (P).
Some staff were reluctant to get involved in the early stages. They were encouraged by success in reducing behaviours as well as personal and professional affirmation from the sessions. (T4).
How we are trying to change that is getting the people at the floor level more involved, so they can champion each other and do that peer support stuff, which I think is very influential. (F)
This suggests some important reasons why staff did not engage - because of their individual nature (they are not motivated to do so); because they do not see any benefits for either themselves or the residents; because they simply do not have the knowledge or skills to engage (e.g. poor literacy skills); because they do not have the confidence to engage or they don't see it as their role to participate in the change.

Ten of the projects, either in interviews or progress reports, raised the issue of developing trust between various stakeholders - trust between project staff and facility staff, trust between facility staff and general practitioners, trust between managers and staff. In some cases trust was an existing quality arising from previous relationships (e.g. lead organisations and facilities who had worked together previously) and in other cases it was important to build up a degree of trust early on in the life of a project.

3.9.2 Residents

Two of the four key priorities for the EBPRAC program set out the expected involvement of residents in the program:

• Improving quality of clinical care for residents in Australian Government funded aged care homes taking into account resident preferences.
• Communication of the changes required as part of this project to the residents and their families.

One of the questions in the project progress reports asked project leaders to rate the extent to which residents had influenced the project in the preceding six months. The results are summarised in Figure 4 across the four six-monthly progress reports (designated T1, T2, T3, T4).
Figure 4 Extent to which residents influenced projects over time, summary of all projects

The information below is a description of data provided in Figure 4 above.

Extent of resident influence	T1	T2	T3	T4
No influence	6	1	1	1
Little influence	5	6	3	2
Some influence	-	3	6	7
Moderate influence	1	2	2	2
Significant influence	1	1	1	1
	Number of projects

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During the first six months, for all except two projects, residents had little or no influence. This level of influence increased as time went on, although only three projects achieved more than ‘some’ degree of resident influence during the lifetime of their project.

Activities took place in all projects to communicate with residents, in some cases by facility staff rather than those working on project teams. The design of three projects did not involve direct contact with residents. The focus of communication was keeping residents informed rather than seeking to involve them in what was happening. Various approaches were undertaken to achieve this including the use of posters, brochures, newsletters, speaking at resident meetings and media releases to local newspapers. Cognitive difficulties made communication with some residents difficult.

Interaction between residents and facility staff was increased in some instances depending on the nature of particular projects. Examples include:

• residents reminding staff to do something that had changed as a result of a project (e.g. application of moisturiser to residents’ skin after showering)
• staff discussing with residents the various options for managing their pain
• staff obtaining residents’ opinions and preferences regarding management and prevention of wounds
• staff getting to know residents more so that they are better able to understand and address behaviours of concern.

One project included residents in palliative care case conferences.
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