Дисертації з теми "Residential Aged Care Facilities (RACFs)"

Aged care residents are at increased risk of infections due to their frailty and comorbidities. This study aimed to identify and reduce the risk of antibiotic-related misadventure in this population. Particular medicines were associated with use of antibiotics, suggesting compromised immunity via numerous mechanisms. Potential interactions between antibiotics and residents’ other medicines were also identified, and may increase morbidity in this vulnerable group. Expanded scope of antimicrobial stewardship in aged care facilities is recommended.

Diabetes care of the elderly in residential aged care facilities has often been unstructured and non-standardised, with disparities in both the practice and knowledge of health care workers caring for this vulnerable group. Poorly controlled diabetes can contribute to a range of adverse events, including impaired wound health and cardiovascular events. The purpose of this study was to establish if current Australian diabetes management guidelines for the elderly are being met in residential aged care facilities in Queensland and identify areas for clinical practice improvement.A cross-sectional, descriptive design was employed to measure demographic data, perceived and actual diabetes-related knowledge, availability of diabetes management and care guidelines, and facilitators and barriers to meeting diabetes related care. A sample of 109 health care workers from residential aged care facilities completed a postal survey.Diabetes guidelines shown to be available in residential aged care facilities were aimed at care planning, with guidelines for both screening and monitoring of diabetes and diabetes care specific skills more available in private aged care and high care classified facilities. Limited monitoring of outcomes of diabetes care were evident. Overall, participants perceived their diabetes knowledge as “good”, however deficits were found in the level of actual knowledge on diabetes complications and medication management. Ratings for perceived and actual diabetes knowledge was higher with older aged health care workers by those employed in their current position the longest.Furthermore, a positive relationship was shown between perceived and actual diabetes knowledge with years of experience in aged care, employment status (RNs/ENs, AINs and other health care workers) and education status (grade 12 schooling, Technology and Further Education and university award). Diabetes – related knowledge was shown to be the most significant facilitator as well as barrier to diabetes care provision. Factors affecting perceived level of confidence in providing diabetes self-management education included experience in aged care, employment position and level of education.The contribution of this research to the area of study was to provide important data on the availability of diabetes guidelines and protocols and diabetes knowledge base. Data has also been provided for the availability of diabetes guidelines and protocols in different facility types and with different classifications of care as well as data for the perceived level of confidence in providing diabetes care in residential aged care facilities. Study findings indicate a need for an increased focus on diabetes care in residential aged care to improve health outcomes.

The need to address the issue of quality in aged care service provision in Australia has received increasing emphasis in recent decades. Particularly since the 1980s, the federal government has played a key role in ensuring that this is the case through the implementation of various reforms and regulatory strategies. In 1998, the national standards monitoring system which had been in place since the mid 1980s was replaced with a new system based on an accreditation model. In contrast to the former system which was wholly controlled by government and involved one-off inspections by government standards monitors, responsibility for managing the new system has been devolved to an independent body, the Aged Care Standards and Accreditation Agency. One of the Agency's primary functions is to assess compliance with the accreditation standards. A key component of the new system is its emphasis on continuous improvement which has been incorporated into the accreditation standards. As a consequence, the new system requires a much greater level of involvement and commitment by providers than previously. In order to continue receiving government funding all facilities had to be accredited by January 1st 2001. This study represents an evaluation of the accreditation system based on the views and experiences of service providers in Western Australia. It explored a number of issues relating to the basic philosophy and principles underlying the new system, the implementation process, the accreditation standards that are used as a basis for assessing service quality and the overall impact of the system on providers. It also sought providers' views about the strengths and limitations of the system and any areas in need of change or improvement. A descriptive design, using in-depth interviews as the method of data collection, was adopted for the study.Participants from three levels of service provision, namely, facilities, organisations and peak bodies were selected on a stratified purposive basis. A total of 45 informants were interviewed. The findings indicated that, overall, as a regulatory approach the accreditation system was generally supported by providers and was regarded as having a number of positive features, particularly in comparison to the previous system. At the same time a number of concerns were identified. These related in particular to the assessment process, specifically the lack of consistency amongst assessors and the self assessment tool, and to the extent of information and guidance provided by the Agency. Concerns regarding the latter's role in relation to, and extent of independence from, the federal government were also identified. The study also found that the introduction of the system had impacted on providers in a variety of ways, both positive and negative, but particularly in terms of the demands on staff and financial resources. A number of 'broader' level factors, such as funding, nursing shortages and other often competing demands (e.g. assessing residents according to the Resident Classification Scale) were also felt to be impacting on providers' capacity to meet the requirements of the system. These concerns, along with concerns about the way in which the system would develop in the future, appear to have created a degree of uncertainty and in some cases apprehension amongst many providers. Although this study has focused on the experiences of Western Australian service providers, evidence from other reviews of the accreditation system where providers' views have been sought has indicated a widespread similarity in perceptions. This suggests, therefore, that there is a need for further review and refinement of certain aspects of the system as it moves into the second round.

The need to address the issue of quality in aged care service provision in Australia has received increasing emphasis in recent decades. Particularly since the 1980s, the federal government has played a key role in ensuring that this is the case through the implementation of various reforms and regulatory strategies. In 1998, the national standards monitoring system which had been in place since the mid 1980s was replaced with a new system based on an accreditation model. In contrast to the former system which was wholly controlled by government and involved one-off inspections by government standards monitors, responsibility for managing the new system has been devolved to an independent body, the Aged Care Standards and Accreditation Agency. One of the Agency's primary functions is to assess compliance with the accreditation standards. A key component of the new system is its emphasis on continuous improvement which has been incorporated into the accreditation standards. As a consequence, the new system requires a much greater level of involvement and commitment by providers than previously. In order to continue receiving government funding all facilities had to be accredited by January 1st 2001. This study represents an evaluation of the accreditation system based on the views and experiences of service providers in Western Australia. It explored a number of issues relating to the basic philosophy and principles underlying the new system, the implementation process, the accreditation standards that are used as a basis for assessing service quality and the overall impact of the system on providers. It also sought providers' views about the strengths and limitations of the system and any areas in need of change or improvement. A descriptive design, using in-depth interviews as the method of data collection, was adopted for the study.
Participants from three levels of service provision, namely, facilities, organisations and peak bodies were selected on a stratified purposive basis. A total of 45 informants were interviewed. The findings indicated that, overall, as a regulatory approach the accreditation system was generally supported by providers and was regarded as having a number of positive features, particularly in comparison to the previous system. At the same time a number of concerns were identified. These related in particular to the assessment process, specifically the lack of consistency amongst assessors and the self assessment tool, and to the extent of information and guidance provided by the Agency. Concerns regarding the latter's role in relation to, and extent of independence from, the federal government were also identified. The study also found that the introduction of the system had impacted on providers in a variety of ways, both positive and negative, but particularly in terms of the demands on staff and financial resources. A number of 'broader' level factors, such as funding, nursing shortages and other often competing demands (e.g. assessing residents according to the Resident Classification Scale) were also felt to be impacting on providers' capacity to meet the requirements of the system. These concerns, along with concerns about the way in which the system would develop in the future, appear to have created a degree of uncertainty and in some cases apprehension amongst many providers. Although this study has focused on the experiences of Western Australian service providers, evidence from other reviews of the accreditation system where providers' views have been sought has indicated a widespread similarity in perceptions. This suggests, therefore, that there is a need for further review and refinement of certain aspects of the system as it moves into the second round.

This thesis explores dementia care for migrants living in residential care facilities. To begin, this thesis considers how culturally sensitive dementia care influences the participation and engagement of migrants with dementia. Using mixed studies - systematic review, barriers, and facilitators supporting the engagement and participation of migrants with dementia are considered. The review findings highlight the need to consider that culturally sensitive care must extend beyond issues of language and should also incorporate broader aspects of culture, such as environmental design and culturally based activities. The second study considers the case of Indian migrants with dementia living in Australia. To this end, an exploratory mixed methods design was adopted to explore critical elements for providing culturally sensitive dementia care for older Indian migrants living in Sydney’s residential aged care facilities. Three different participant groups were involved in the research discussion by means of the nominal group technique (NGT). Each group discussion was then summarised and prioritised with the six key ideas by using participants’ votes. Research study findings were represented by summarising common key ideas and opinions provided by participants involved in the NGT. Results indicated that language, provision of traditional food, multilingual staff, and cultural activities comprise the key elements for providing culturally appropriate dementia care to older Indian migrants living in aged care facilities. Overall, this thesis suggests that, when it comes to providing dementia care, aged care facilities should understand that every culture possesses its own ways of providing care to loved ones. Rather than providing general care to everyone, aged care facilities should instead cater their care by recognising residents’ choices and preferences.

Malnutrition is reported to be common in hospitals (10-60%), residential aged care facilities (up to 50% or more) and in free living individuals with severe or multiple disease (>10%) (Stratton et al., 2003). Published Australian studies indicate similar results (Beck et al., 2001, Ferguson et al., 1997, Lazarus and Hamlyn, 2005, Middleton et al., 2001, Visvanathan et al., 2003), but are generally limited in number, with none conducted across multiple centres or in residential aged care facilities. In Australia, there is a general lack of awareness and recognition of the problem of malnutrition, with currently no policy, standards or guidelines related to the identification, prevention and treatment of malnutrition. Malnutrition has been found to be associated with the development of pressure ulcers, but studies are limited. The consequences of the development of pressure ulcers include pain and discomfort for the patient, and considerable costs associated with treatment and increased length of stay. Pressure ulcers are considered largely preventable, and the demand for the establishment of appropriate policy, standards and guidelines regarding pressure ulcers has recently become important because the incidence and prevalence of pressure ulcers is increasingly being considered a parameter of quality of care. The aims of this study program were to firstly determine the prevalence of malnutrition and its association with pressure ulcers in Queensland Health hospitals and residential aged care facilities; and secondly to estimate the potential economic consequences of malnutrition by determining the costs arising from pressure ulcer attributable to malnutrition; and the economic outcomes of an intervention to address malnutrition in the prevention of pressure ulcers. The study program was conducted in two phases: an epidemiological study phase and an economic modelling study phase. In phase one, a multi centre, cross sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. The effect of nutritional status on the presence of pressure ulcer was also determined via logistic regression. Logistic regression analyses were carried out using an analysis of correlated data approach with SUDAAN statistical package (Research Triangle Institute, USA) to account for the potential clustering effect of different facilities in the model. In phase two, an exploratory economic modelling framework was used to estimate the number of cases of pressure ulcer, total bed days lost to pressure ulcer and the economic cost of these lost bed days which could be attributed to malnutrition in Queensland public hospitals in 2002/2003. Data was obtained on the number of relevant separations, the incidence rate of pressure ulcer, the independent effect of pressure ulcers on length of stay, the cost of a bed day, and the attributable fraction of malnutrition in the development of pressure ulcers determined using the prevalence of malnutrition, the incidence rate of developing a pressure ulcer and the odds risk of developing a pressure ulcer when malnourished (as determined previously). A probabilistic sensitivity analysis approach was undertaken whereby probability distributions to the specified ranges for the key input parameters were assigned and 1000 Monte Carlo samples made from the input parameters. In an extension of the above model, an economic modelling framework was also used to predict the number of cases of pressure ulcer avoided, number of bed days not lost to pressure ulcer and economic costs if an intensive nutrition support intervention was provided to all nutritionally at risk patients in Queensland public hospitals in 2002/2003 compared to standard care. In addition to the above input parameters, data was obtained on the change in risk in developing a pressure ulcer associated with an intensive nutrition support intervention compared to standard care. The annual monetary cost of the provision of an intensive nutrition support intervention to at risk patients was modelled at a cost of AU$ 3.8-$5.4 million for additional food and nutritional supplements and staffing resources to assist patients with nutritional intake. A probabilistic sensitivity analysis approach was again taken. A mean of 34.7 + 4.0% and 31.4 + 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, metropolitan location of facility and medical specialty, in particular oncology and critical care. Malnutrition was found to be significantly associated with an increased odds risk of having a pressure ulcer, with the odds risk increasing with severity of malnutrition. In acute facilities moderate malnutrition had an odds risk of 2.2 (95% CI 1.6-3.0, p<0.001) and severe malnutrition had an odds risk of 4.8 (95% CI 3.2-7.2, p<0.001) of having a pressure ulcer. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in an acute facility was 2.6 (95% CI 1.8-3.5, p<0.001). In residential facilities, where the audit results were presented separately, the same pattern applied with moderate malnutrition having an odds risk of 1.7 (95% CI 1.2-2.2, p<0.001) and 2.0 (95% CI 1.5-2.8, p<0.001); and severe malnutrition having an odds risk of 2.8 (95% CI1.2-6.6, p=0.02) and 2.2 (95% CI 1.5-3.1, p<0.001), for Audits 1 and 2 respectively. There was no statistical difference between these odds risk ratios between the audits. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in a residential aged care facility was 1.9 (95% CI 1.3-2.7, p<0.001) and 2.0 (95% CI 1.5-2.7, p<0.001) for Audits 1 and 2 respectively. Being malnourished was also found to be significantly associated with an increased odds risk of having a higher stage and higher number of pressure ulcers, with the odds risk increasing with severity of malnutrition. The economic model predicted a mean of 3666 (Standard deviation 555) cases of pressure ulcer attributable to malnutrition out of a total mean of 11162 (Standard deviation 1210), or approximately 33%, in Queensland public acute hospitals in 2002/2003. The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be 16050, which represents approximately 0.67% of total patient bed days in Queensland public hospitals in 2002/2003. The corresponding mean economic costs of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 were estimated to be almost AU$13 million, out of a total mean estimated cost of pressure ulcer of AU$ 38 526 601. In the extension of the economic model, the mean economic cost of the implementation of an intensive nutrition support intervention was predicted to be a negative value ( -AU$ 5.4 million) with a standard deviation of $AU3.9 million, and interquartile range of –AU$ 7.7 million to –AU$ 2.5 million. Overall there were 951 of the 1000 re-samples where the economic cost is a negative value. This means there was a 95% chance that implementing an intensive nutrition support intervention was overall cost saving, due to reducing the cases of pressure ulcer and hospital bed days lost to pressure ulcer. This research program has demonstrated an independent association between malnutrition and pressure ulcers, on a background of a high prevalence of malnutrition, providing evidence to justify the elevation of malnutrition to a safety and quality issue for Australian healthcare organisations, similarly to pressure ulcers. In addition this research provides preliminary economic evidence to justify the requirement for consideration of healthcare policy, standards and guidelines regarding systems to identify, prevent and treat malnutrition, at least in the case of pressure ulcers in Australia.

Malnutrition is reported to be common in hospitals (10-60%), residential aged care facilities (up to 50% or more) and in free living individuals with severe or multiple disease (>10%) (Stratton et al., 2003). Published Australian studies indicate similar results (Beck et al., 2001, Ferguson et al., 1997, Lazarus and Hamlyn, 2005, Middleton et al., 2001, Visvanathan et al., 2003), but are generally limited in number, with none conducted across multiple centres or in residential aged care facilities. In Australia, there is a general lack of awareness and recognition of the problem of malnutrition, with currently no policy, standards or guidelines related to the identification, prevention and treatment of malnutrition. Malnutrition has been found to be associated with the development of pressure ulcers, but studies are limited. The consequences of the development of pressure ulcers include pain and discomfort for the patient, and considerable costs associated with treatment and increased length of stay. Pressure ulcers are considered largely preventable, and the demand for the establishment of appropriate policy, standards and guidelines regarding pressure ulcers has recently become important because the incidence and prevalence of pressure ulcers is increasingly being considered a parameter of quality of care. The aims of this study program were to firstly determine the prevalence of malnutrition and its association with pressure ulcers in Queensland Health hospitals and residential aged care facilities; and secondly to estimate the potential economic consequences of malnutrition by determining the costs arising from pressure ulcer attributable to malnutrition; and the economic outcomes of an intervention to address malnutrition in the prevention of pressure ulcers. The study program was conducted in two phases: an epidemiological study phase and an economic modelling study phase. In phase one, a multi centre, cross sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. The effect of nutritional status on the presence of pressure ulcer was also determined via logistic regression. Logistic regression analyses were carried out using an analysis of correlated data approach with SUDAAN statistical package (Research Triangle Institute, USA) to account for the potential clustering effect of different facilities in the model. In phase two, an exploratory economic modelling framework was used to estimate the number of cases of pressure ulcer, total bed days lost to pressure ulcer and the economic cost of these lost bed days which could be attributed to malnutrition in Queensland public hospitals in 2002/2003. Data was obtained on the number of relevant separations, the incidence rate of pressure ulcer, the independent effect of pressure ulcers on length of stay, the cost of a bed day, and the attributable fraction of malnutrition in the development of pressure ulcers determined using the prevalence of malnutrition, the incidence rate of developing a pressure ulcer and the odds risk of developing a pressure ulcer when malnourished (as determined previously). A probabilistic sensitivity analysis approach was undertaken whereby probability distributions to the specified ranges for the key input parameters were assigned and 1000 Monte Carlo samples made from the input parameters. In an extension of the above model, an economic modelling framework was also used to predict the number of cases of pressure ulcer avoided, number of bed days not lost to pressure ulcer and economic costs if an intensive nutrition support intervention was provided to all nutritionally at risk patients in Queensland public hospitals in 2002/2003 compared to standard care. In addition to the above input parameters, data was obtained on the change in risk in developing a pressure ulcer associated with an intensive nutrition support intervention compared to standard care. The annual monetary cost of the provision of an intensive nutrition support intervention to at risk patients was modelled at a cost of AU$ 3.8-$5.4 million for additional food and nutritional supplements and staffing resources to assist patients with nutritional intake. A probabilistic sensitivity analysis approach was again taken. A mean of 34.7 + 4.0% and 31.4 + 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, metropolitan location of facility and medical specialty, in particular oncology and critical care. Malnutrition was found to be significantly associated with an increased odds risk of having a pressure ulcer, with the odds risk increasing with severity of malnutrition. In acute facilities moderate malnutrition had an odds risk of 2.2 (95% CI 1.6-3.0, p<0.001) and severe malnutrition had an odds risk of 4.8 (95% CI 3.2-7.2, p<0.001) of having a pressure ulcer. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in an acute facility was 2.6 (95% CI 1.8-3.5, p<0.001). In residential facilities, where the audit results were presented separately, the same pattern applied with moderate malnutrition having an odds risk of 1.7 (95% CI 1.2-2.2, p<0.001) and 2.0 (95% CI 1.5-2.8, p<0.001); and severe malnutrition having an odds risk of 2.8 (95% CI1.2-6.6, p=0.02) and 2.2 (95% CI 1.5-3.1, p<0.001), for Audits 1 and 2 respectively. There was no statistical difference between these odds risk ratios between the audits. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in a residential aged care facility was 1.9 (95% CI 1.3-2.7, p<0.001) and 2.0 (95% CI 1.5-2.7, p<0.001) for Audits 1 and 2 respectively. Being malnourished was also found to be significantly associated with an increased odds risk of having a higher stage and higher number of pressure ulcers, with the odds risk increasing with severity of malnutrition. The economic model predicted a mean of 3666 (Standard deviation 555) cases of pressure ulcer attributable to malnutrition out of a total mean of 11162 (Standard deviation 1210), or approximately 33%, in Queensland public acute hospitals in 2002/2003. The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be 16050, which represents approximately 0.67% of total patient bed days in Queensland public hospitals in 2002/2003. The corresponding mean economic costs of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 were estimated to be almost AU$13 million, out of a total mean estimated cost of pressure ulcer of AU$ 38 526 601. In the extension of the economic model, the mean economic cost of the implementation of an intensive nutrition support intervention was predicted to be a negative value ( -AU$ 5.4 million) with a standard deviation of $AU3.9 million, and interquartile range of –AU$ 7.7 million to –AU$ 2.5 million. Overall there were 951 of the 1000 re-samples where the economic cost is a negative value. This means there was a 95% chance that implementing an intensive nutrition support intervention was overall cost saving, due to reducing the cases of pressure ulcer and hospital bed days lost to pressure ulcer. This research program has demonstrated an independent association between malnutrition and pressure ulcers, on a background of a high prevalence of malnutrition, providing evidence to justify the elevation of malnutrition to a safety and quality issue for Australian healthcare organisations, similarly to pressure ulcers. In addition this research provides preliminary economic evidence to justify the requirement for consideration of healthcare policy, standards and guidelines regarding systems to identify, prevent and treat malnutrition, at least in the case of pressure ulcers in Australia.

This thesis presents the results of a study that explores the experience of care assistants who care for residents in the final stages of life in residential aged care facilities in metropolitan Perth. Care assistants, with little formal training and no regulation, play a pivotal role in the direct care of dying residents in these facilities. Yet little was known about the palliative care role and the impact that caring for residents in the final stage of life has on this health care group. The literature relating to end of life care in residential aged care facilities revealed limited research in this area. In particular, there is a lack of studies that relate specifically to the care assistants' role and their experiences of end of life care. Research to date has focused on the context of palliative care in residential aged care facilities, the workplace environment, how to provide a dignified death, relationships and the central role of the care assistant. This study used a qualitative narrative inquiry research design.

Background: In response to the need for more comprehensive quality assessment within Australian residential aged care facilities, the Clinical Care Indicator (CCI) Tool was developed to collect outcome data as a means of making inferences about quality. A national trial of its effectiveness and a Brisbane-based trial of its use within the quality improvement context determined the CCI Tool represented a potentially valuable addition to the Australian aged care system. This document describes the next phase in the CCI Tool.s development; the aims of which were to establish validity and reliability of the CCI Tool, and to develop quality indicator thresholds (benchmarks) for use in Australia. The CCI Tool is now known as the ResCareQA (Residential Care Quality Assessment). Methods: The study aims were achieved through a combination of quantitative data analysis, and expert panel consultations using modified Delphi process. The expert panel consisted of experienced aged care clinicians, managers, and academics; they were initially consulted to determine face and content validity of the ResCareQA, and later to develop thresholds of quality. To analyse its psychometric properties, ResCareQA forms were completed for all residents (N=498) of nine aged care facilities throughout Queensland. Kappa statistics were used to assess inter-rater and test-retest reliability, and Cronbach.s alpha coefficient calculated to determine internal consistency. For concurrent validity, equivalent items on the ResCareQA and the Resident Classification Scales (RCS) were compared using Spearman.s rank order correlations, while discriminative validity was assessed using known-groups technique, comparing ResCareQA results between groups with differing care needs, as well as between male and female residents. Rank-ordered facility results for each clinical care indicator (CCI) were circulated to the panel; upper and lower thresholds for each CCI were nominated by panel members and refined through a Delphi process. These thresholds indicate excellent care at one extreme and questionable care at the other. Results: Minor modifications were made to the assessment, and it was renamed the ResCareQA. Agreement on its content was reached after two Delphi rounds; the final version contains 24 questions across four domains, enabling generation of 36 CCIs. Both test-retest and inter-rater reliability were sound with median kappa values of 0.74 (test-retest) and 0.91 (inter-rater); internal consistency was not as strong, with a Chronbach.s alpha of 0.46. Because the ResCareQA does not provide a single combined score, comparisons for concurrent validity were made with the RCS on an item by item basis, with most resultant correlations being quite low. Discriminative validity analyses, however, revealed highly significant differences in total number of CCIs between high care and low care groups (t199=10.77, p=0.000), while the differences between male and female residents were not significant (t414=0.56, p=0.58). Clinical outcomes varied both within and between facilities; agreed upper and lower thresholds were finalised after three Delphi rounds. Conclusions: The ResCareQA provides a comprehensive, easily administered means of monitoring quality in residential aged care facilities that can be reliably used on multiple occasions. The relatively modest internal consistency score was likely due to the multi-factorial nature of quality, and the absence of an aggregate result for the assessment. Measurement of concurrent validity proved difficult in the absence of a gold standard, but the sound discriminative validity results suggest that the ResCareQA has acceptable validity and could be confidently used as an indication of care quality within Australian residential aged care facilities. The thresholds, while preliminary due to small sample size, enable users to make judgements about quality within and between facilities. Thus it is recommended the ResCareQA be adopted for wider use.

Background: People with dementia living in residential aged care facilities are at risk of being deprived of occupational engagement. The link between occupational therapy and meaningful engagement of residents with moderate to advanced dementia has been established. Concepts regarding person-centered dementia care are adopted as the guiding principle for service providers in this field. However, it is unclear how occupational therapists embrace the essence of person-centered dementia care when promoting meaningful engagement of residents with moderate to advanced dementia. This study thus aims to explore how person-centered dementia care is presented from an occupational therapy perspective. Methods: Thirty peer-reviewed articles were used as the source sample for this study. A critical interpretive synthesis was conducted to critically consider the power structure underpinning occupational therapy practice in residential dementia care. Evidence pertaining to occupational therapy practice was integrated and analyzed using concepts regarding occupational justice and themes of doing, being, becoming, belonging, and co-occupation to generate synthesis. Results: This synthesis indicated that occupational therapists enhance occupational justice in residential dementia care by increasing access to meaningful engagement and enabling participation of residents in doing, being and belonging at the level of co-occupation where interdependence between residents and mainly staff members is 28 fostered. However, the becoming domain of occupation has not been comprehensively addressed. Thus, the needs of residents for continual growth and development as occupational beings have not been fully addressed by the current occupational therapy practice in residential dementia care. Conclusion: This finding suggests expanding the role of occupational therapists to empower people with moderate to advanced dementia to enact and build on continuing opportunities for agency.

This thesis provides the first inquiry into the use of creative activities in dementia care in residential aged care facilities in Australia. The study used descriptive method design, incorporating a mix of quantitative and qualitative approaches to explore the incidence and the characteristics of these activities from the carers' perspective. Information about the use of creative activities and the appreciation of these activities by residents and carers is essential to the provision of dementia care and treatment to improve the quality of life of people with dementia.

This research adopted a social interpretive framework informed by symbolic interactionism and dramaturgy. The key finding was that a social order of practice was constructed in the residential aged care facilities through participant interpretations of spatial and temporal frames within the RACF setting. The participants used space and time to organise and mediate the ways in which they worked with people with dementia who wander.

This study of residential aged care health workers’ knowledge, attitudes and confidence in providing care to an older person with a stoma was conducted to identify characteristics of the learners and educational needs to effectively provide stoma care. The findings will be valuable to inform development of an educational program aimed at aged care health workers’ to give appropriate and confident stoma care to residents.

The main purposes of this thesis were to evaluate a high-intensity functional weight-bearing exercise pro­gramme, regarding its applicability (attendance, achieved intensity, adverse events) as well as its effect on physical functions and activities of daily living (ADL) among older people living in residential care facilities, with a special focus on people with dementia. Furthermore, a main purpose was to systematically review the applicability and effects of physical exercise on physical functions, cognitive functions, and ADL among people with dementia. A high-intensity functional weight-bearing exercise programme that includes lower-limb strength and balance exercises in standing and walking, was evaluated in a randomised controlled trial among 191 older people, dependent in ADL, living in residential care facilities, and with a Mini-Mental State Examination (MMSE) score of ten or more. One hundred (52.4%) of the participants had dementia. Participants were randomised to an exercise programme or a control activity, consisting of 29 supervised sessions over 3 months, as well as to an intake of a protein-enriched energy supplement or a placebo drink immediately after each session. The effect on physical functions was evaluated using the Berg Balance Scale, usual and maximum gait speed, and one-repetition maximum in a leg press machine measuring lower-limb strength. The effect on ADL was evaluated using the Barthel Index. These outcome measures were followed up at 3 and 6 months by blinded assessors and analysed using the intention-to-treat principle. The evaluation of the applicability of the high-intensity functional weight-bearing exercise programme showed that there was a high rate of attendance, a relatively high achieved intensity in the exercises, and all except two adverse events were assessed as minor or temporary and none led to manifest injury or disease. No statistically significant differences were observed in applicability when comparing participants with dementia and participants without dementia. In addition, the applicability of the programme was not associated with the participants’ cognitive function. Significant long-term effects of the exercise programme were seen regarding functional balance, gait ability and lower-limb strength in comparison with the control activity. The intake of the protein-enriched energy supplement did not increase the effect of the training. Age, sex, depression, dementia disorder, nutritional status, and level of functional balance capacity did not influence the effect on functional balance of the high-intensity functional weight-bearing exercise programme. There were no significant differences between the groups regarding overall ADL performance. Analyses for each item revealed that a significantly smaller proportion of participants in the exercise group had deteriorated regarding indoor mobility at 3 and 6 months. For people with dementia, there was a significant difference in overall ADL performance in favour of the exercise group at 3 months, but not at 6 months. In a systematic review, randomised controlled trials, evaluating the effects of physical exercise among people with dementia, were identified according to pre-defined inclusion criteria. Two reviewers independently extracted predetermined data and assessed methodological quality. Ten studies were included in the review and the majority of the participants were older people with Alzheimer’s disease living in residential care facilities. Four studies reached “moderate” methodological quality and six “low”. The results showed that among older people with Alzheimer’s disease in residential care facilities, combined functional weight-bearing exercise over 12 months at an intended moderate intensity seems applicable for use regarding attendance and adverse events and there is some evidence that the exercise improves walking performance and reduces ADL decline. Furthermore, there is some evidence that walking exercise over 16 weeks performed individually, where the participant walks as far as possible during the session, reduces decline in walking performance, but adverse events need to be evaluated. In conclusion, among older people who are dependent in ADL, living in residential care facilities, and have an MMSE score of 10 or more, a high-intensity functional weight-bearing exercise programme is applicable for use and has positive long-term effects on functional balance, gait ability, and lower-limb strength and seems to reduce ADL decline related to indoor mobility. An intake of a protein-enriched energy supplement immediately after the exercise does not appear to increase the effect of the training. In people with dementia, the exercise programme may prevent decline in overall ADL performance, but continuous training may be needed to maintain that effect. The positive results regarding applicability and effects of combined functional weight-bearing exercise among people with dementia is confirmed when the scientific literature is systematically reviewed. It seems to be important that exercise interventions among people with dementia last for at least a few months and that the exercises are task-specific and intended to challenge the individual’s physical capacity. Whether physical exercise can improve cognitive functions among people with dementia remains unclear. There is a need for more exercise studies of high methodological quality among people with dementia disorders.

An aging population is one common challenge faced by many developed countries including Australia. The Australian government has realised that the existing healthcare system must be improved to provide better support longer-term for the healthcare needs of this population. This research examines one such opportunity by suggesting a reform on how the care needs of residents living in Australian residential aged care facilities (RACF) are assessed. A recent study has shown that the current assessment system, known as the Residential Classification Scale (RCS), is subjected to high administrative procedural overhead costs and significant deviations in assessment results. This thesis documents a technical feasibility study of a novel method aimed to solve issues related to the time demands and subjectivity of the RCS through the design and implementation of a Wireless Sensor Network (WSN). This WSN is engineered to unobtrusively collect data from wireless sensor nodes either embedded in the RACF environment or attached to the resident??s body. The collected data can be potentially used to provide automatic and accurate care level assessments for the resident. The methodology of preparing and conducting the experiments to prove the hypotheses is justified and described, including the experimental instruments and procedures involved. The results show that this WSN surpasses similar research systems in terms of its application scale, the number and types of sensor nodes involved and the complexity of its hardware and firmware architectures. The major contributions of this thesis are: ?? The WSN developed satisfies certain technical requirements to be declared fit for use in a mock Australian RACF. ?? The WSN provides high sensor detection accuracies (between 88% and 100%), superior location tracking capability (94.75%) and activities of daily living inference capability over similar studies. Opportunities for further improvements of this WSN include: ?? Fine tuning the detection accuracy of Passive Infra-red (PIR) motion sensors. ?? Minimising the down time of the sensor nodes due to firmware memory leak. ?? An extra location tracking mechanism to improve location accuracy determination.

Residents of residential aged care facilities live out the last days of their lives in an institutional environment. These facilities can potentially liberate and/or constrain. The voice of actual residents has been little explored to date. Critical gerontology, which underpins the study, demands that researchers endeavour to understand the lived experience of the older person.
This thesis focuses on the impact of the built environment on older people (without dementia) who live in residential aged care facilities. Based on original research undertaken in Victoria and some of the latest thinking from Australia and overseas the study was undertaken using mixed methods. The research involved a review of the literature, in depth small group interviews with residents, staff, family and carers, and surveys and a best practice forum with architects and managers.
The research identified and explored the key areas of concern for each of these stakeholders, considering how residential aged care services could do more to improve the quality of life for residents through the built environment. Three key areas emerged from the study. Firstly, the journey the residents make in their time in the RACF and how the built environment impacts on their quality of life in place and over time. Secondly, the ‘frames of reference’ the key informants to the study hold are explored and how they can impact on the design process. Finally, by analysing the data collected and placing the resident at the centre, a model is proposed which holds potential and significance in relation to the development of RACFs in the future

Background: Chronic pain is a common problem in people with dementia living in residential aged care facilities (RACFs); however, it is often under-recognised and untreated due to the cognitive impairment of residents, and lack of knowledge and communication among care providers. Untreated pain is reported to be associated with behavioural and psychological symptoms of dementia (BPSD), such as agitation, depression and anxiety. Moreover, pain is also related to poor sleep and reduced physical activity, leading to a lower quality of life in people with dementia. Social robots, such as the robotic seal PARO, are promising psychosocial interventions to improve mood and manage behaviours in people with dementia, and the results from feasibility studies also indicate the potential effect of PARO to reduce pain in people with dementia. However, no randomised controlled trials (RCT) have been conducted to explore the effect of PARO on chronic pain in people with dementia living in RACFs. Objectives: This PhD study had four main aims: (1) to obtain the feasibility of a pilot RCT of a PARO intervention on observational pain levels in people with dementia living in RACFs; (2) to explore the effect of the PARO intervention on pain, agitation, depression, anxiety and quantified dosage of medication use in people with dementia living in RACFs; (3) to explore the effect of the PARO intervention on physiological responses (i.e., sleep and motor activity, salivary cortisol) in people with dementia; and (4) to explore experiences and perceptions of people with dementia towards the PARO intervention. Methods: A pilot RCT followed by semi-structured interviews was conducted with residents aged ≥ 65 years with dementia and chronic pain living in RACFs in Southeast Queensland, Australia. Participants were randomised into either a PARO intervention group (individual, non-facilitated, 30-minute sessions, 5 days per week for 6 weeks) or a usual care group (music, church, singing, story listening, etc.) using a computer-generated random number list. Feasibility of this pilot study included recruitment, eligibility, attrition, protocol adherence, data collection and safety issues. The primary outcome was the effect size of the change in the mean difference of researcher-observed pain level measured by the Pain Assessment in Advanced Dementia Scale (PAINAD) between the two groups. Secondary outcomes included staff-rated pain, agitation, depression, anxiety, quantified dosage of regular and pro re nata (PRN) medications, sleep and motor activity (i.e., step counts, physical activity and energy expenditure) measured by actigraphy, as well as stress level measured by salivary cortisol. Quantitative analyses followed the intention-to-treat approach. Differences in outcomes between two groups were examined using the generalised estimating equation model. Covariate-adjusted mean differences with 95% confidence intervals accounted for the potential confounding factors of age, gender, cognitive status and medications at baseline. Cohen’s d for effect size was calculated, and statistical significance was set at p < .05. Participants who were capable of verbal communication and comprehension were interviewed about their experiences and perceptions of the PARO intervention. Qualitative data were analysed using inductive thematic analysis. Results: Feasibility of the pilot RCT was established. Forty-three participants with dementia and chronic pain living in three RACFs participated in the study. The recruitment rate for the eligible residents was 60.6% (43/71) after a strict screening process. The attrition rate of the participants was low, with three out of 43 participants (7.0%) dropping out during the intervention process. The average attended sessions among participants was 23.3 (±7.3) and the average duration of each session was 16.36 (±8.13) minutes. A total of 2,470 out of 2,520 (98.02%) observational pain assessments were completed. No adverse events were reported during the study. Compared to participants in the usual care group, participants in the PARO group had a significantly lowered level of observed pain (-0.514, 95% confidence interval [CI] -0.774 to -0.254, p < .001, Cohen’s d = -0.765) after receiving the PARO intervention and used fewer prescribed PRN medications (-1.175, 95% CI -2.205 to -0.145, p = .025, Cohen’s d = 0.690) during the 6-week PARO intervention, which were adjusted for age, sex, Mini-Mental Status Examination (MMSE) and medication at baseline. No significant results have been found on staff-rated pain, agitation, depression, anxiety and regularly scheduled medications after the 6-week PARO intervention. At the end of the 6-week PARO intervention, compared to the usual care group, participants in the PARO group showed a greater increase in the duration (hours) of daytime wakefulness (1.91, 95% CI: 0.09 to 3.73, p = .042, Cohen’s d = 0.655) and a greater reduction in the duration (hours) of daytime sleep (-1.35, 95% CI: -2.65 to -0.05, p = .040, Cohen’s d = 0.664). After one session of PARO intervention, the increase in the duration (hours) of night sleep was significantly higher in the PARO group (1.81, 95% CI: 0.22 to 3.84, p = .030, Cohen’s d = 0.570). No significant results were found for motor activity. Several difficulties in the collection and analysis of salivary cortisol were encountered, including cognitive impairment of participants and inadequate saliva volume for assay. Four themes emerged from qualitative interviews of 11 participants with mild to moderate dementia: (1) perceptions of PARO, (2) therapeutic effects of PARO, (3) limitations of PARO, and (4) program improvement. Residents with dementia expressed positive attitudes towards the use of PARO and acknowledged the therapeutic benefits of PARO on mood improvement and relaxation for pain relief, but also mentioned the limitations of its weight, voice and characteristics. Residents’ responses to the PARO intervention could fluctuate during the intervention process. Conclusions: Results from this study indicate that the PARO intervention may be incorporated into daily practice as a psychosocial intervention to manage pain in people with dementia. It also provides subsequent benefits on sleep and promotes positive mood for participants. However, the effect of the PARO intervention on BPSD (i.e., agitation, depression and anxiety), motor activity and salivary cortisol level needs further exploration. In addition, considering the challenges of obtaining valid saliva samples, salivary cortisol may not be a feasible biomarker of physiological stress in people with dementia and chronic pain. Larger randomised controlled trials with longer time frames are needed to evaluate the use of PARO for people with dementia living in long-term care settings. Moreover, individual preferences need to be considered before the use of PARO intervention. This thesis consists of nine chapters. Notably, Chapter 2, the literature review, presents two published systematic reviews, and Chapters 5 - 8 present four published/submitted research articles reporting the effects of PARO from the pilot RCT and findings from interviews. This dissertation does not include a traditional discussion chapter as each research article details the major findings of the study and a discussion of the results. The final chapter gives a summary of the main findings, methodological limitations as well as implications for future research, nursing practice and healthcare education.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Nursing & Midwifery
Griffith Health
Full Text

Aim: To investigate trends in the use of psychotropic medication in residential aged care facilities prior to and after the advent of an accredited pharmacist conducted medication review service (PCMRS). Objectives: 1. To compare the mean number of psychotropic medications in the treatment group and comparison group prior to and after the implementation of a pharmacist conducted medication review service. 2. To compare the distribution of classes of psychotropic drugs between the treatment and comparison groups prior to and after a PCMRS 3. To evaluate the appropriateness of psychotropic medication in terms of dose, dosing intervals, dose administration and dosing regimens of benzodiazepines. Study Design: A comparative design with repeated measures was used with residents in the treatment group exposed to a pharmacist conducted medication review service. For the treatment group data were collected prior to and after the implementation of this service. For the comparison group data were collected over corresponding time periods. Setting: A convenience sample of 14 residential aged care facilities in the Sydney metropolitan area was recruited. The treatment group consisted of 128 residents randomly selected from 12 residential aged care facilities serviced by accredited pharmacists. The comparison sample consisted of all the 121 residents from 2 residential aged care facilities. Results: There was a significant downward trend in psychotropic drug use in the treatment group. While in the comparison group there was an increase in psychotropic drug use between the two time periods (p <0.001). There were no differences in the distribution of psychotropic drug classes between the treatment and comparison groups overtime. A trend towards improvement in the overall appropriateness of a resident's psychotropic medication regimen in the treatment group was also observed overtime (p= 0.13). Fifty percent of the pharmacist's recommendations in the treatment group adopted by the general practitioner related to achieving a more appropriate use of the medication and 40% to ceasing a drug. Conclusion: This research provides preliminary evidence of a reduction of psychotropic drug use in residential aged care facilities following a pharmacist conducted medication review service. The concomitant improvement in the overall appropriateness of use adds credence to a positive contribution of the pharmacist to the quality use of psychotropic medication.

This thesis evaluated the effectiveness and cost-saving potential of a health service delivery model in Queensland Australia, the Hospital in the Nursing Home program. The research adopted a before-after controlled study design, comparing the outcomes between an intervention hospital and a control hospital during the pre- and post-intervention periods. Findings from the research supported that the intervention was preferred over the current practice, which reduced the attendances to emergency departments (EDs) and inpatient hospitals from patients in residential aged care facilities, shortened their length of ED stay, and saved the overall costs.

There is an increasing body of research evidence to support the use of music as a therapeutic modality in reducing the agitated behaviour frequently associated with late-stage dementia. Although much of this evidence suggests that music interventions are most effective when they are “individualized”, this type of intervention is often difficult to implement in large, busy, aged care facilities where residents may be located together in communal areas during the day. The challenge therefore is to try and identify a particular musical genre which, when played as “ambient” or “background” music, demonstrates a consistent capacity to reduce agitated behaviour in late-stage dementia across resident populations in multiple facilities. This study was designed to test the comparative utility of three different types of background music identified in the existing research literature as being of possible benefit in this context. These three types of music were: gentle classical music, familiar music and baroque music. Using a sample of 65 older people with late-stage dementia living in a total of eight residential aged care facilities, this quasi-experimental study used quantitative measures to assess a specific range of agitated behaviours over a one week intervention period. The specific agitated behaviours were documented using the Scale for the Observation of Agitation in Persons with Dementia (SOAP-D) scale (Hurley, Volicer, Camberg, Ashley, Woods, Odenheimer, Ooi, McIntyre, & Mahoney, 1999). In addition, the Quality of Life in Alzheimer’s Disease (QoL-AD) tool (Logsdon, 1999) was used to collect collateral information from family members or experienced care staff at each of the participating facilities about whether they perceived that the playing of music exerted any influence on the quality of life of participants. Participants were randomly assigned to one of five experimental subgroups of equal size. Participants in three of the five groups received exposure to audio recordings of music. Participants in one of the two remaining sub-groups were exposed to a non-musical intervention (audio recordings of storybooks) at the same time of day as the participants in the three music groups. Data relating to behaviour and perceived quality of life were recorded in the same manner for this group. The final group of participants acted as the control group for the study. Quantitative data were collected in the same manner for this group: however, they were exposed to no intervention. In addition, a series of structured interviews was undertaken with experienced care providers at each of the participating residential aged care facilities. The purpose of this procedure was to determine whether the experiences and subjective opinions of staff regarding the utility of music as an intervention to settle agitated behaviour in late-stage dementia and improve quality of life were consistent with the observational data recorded using the SOAP-D scale in conjunction with the proxy-rated QoL-AD scale. Results of the study indicated that overall levels of agitated behaviour were less within the three groups exposed to music compared with the nonmusic intervention group and the control. However, perceived quality of life was not measurably improved in any of the three music intervention groups. This study supports the continued use of music as a therapeutic intervention in the management of maladaptive behaviour associated with late-stage dementia, although the results do not support the preferential use of any of the three selected music forms.

碩士
國立宜蘭大學
建築與永續規劃研究所碩士班
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This paper reports on two study aims: (1) to explore the process of adapting the English version of the Environmental Audit Tool (EAT) developed in Australian into Chinese questionnaire survey that can be used to investigate RACFs in Taiwan; (2) to compare EAT scores of a sample of RACFs in Taiwan with the mean and standard deviation (SD) of EAT scores across a variety (N=56) of RACFs in Australian where some (N=24) were purpose-built for people with dementia while others (N=32) were non- purpose-built.

There has been a significant increase in age-related diseases, particularly dementia. By necessity, people with dementia spend most of their time in one setting, typically a Residential Aged Care Facility (RACF), as the requirements of care exceed the resources of most families. With increased environmental sensitivities and dependence on the environment to support their diminished cognition appropriate design of RACFs becomes a critical factor in promoting well-being. The developing body of research on the design of environments for people with dementia is largely empirical, focused on mid-stage dementia, and on managing behavioural and clinical issues with minimal direct input from the perspective of people with dementia. Framed by hermeneutic phenomenology, this study explores the influence of the design of RACF built environments for people living with late stage dementia. Through collaboratively interpreted stories in an immersive case study setting, it interrogates the lived experiences of people with dementia, their families, and staff. These stories reveal the complex and at times, paradoxical construction of RACFs as both hospital and home, in addition to their unspoken and often unacknowledged role as places to die. I argue that rather than ‘homes’, RACFs need to be reconceptualised as hybrid places for the living and dying that anticipate and support the lived experiences of all those in the care triad. This requires the development of a new typology situated between the hospital, home and hospice and a paradigm shift in design thinking, practice, and policy aligned with the shifting landscape towards reciprocal models of care. Central to this transformation is recognition of the rights, value, and capacity of people with late-stage dementia to provide insights into their experiences of the world-of-being-inaged-care. The sensitively designed, collaborative, and inclusive approach in this study goes some way to identifying processes and procedures to enable their meaningful participation in future research and design projects.

Research Doctorate - Doctor of Philosophy (PhD)
The world’s ageing population means that many older people in developed countries now live out the latter parts of their lives in Long-Term Care (LTC) settings such as Residential Aged Care Facilities (RACFs). The majority of the older people in LTC settings have problems with cognition and a range of debilitating chronic conditions associated with frailty which means they are dependent on others for the needs of everyday living. South Korea has one of the world’s fastest growing ageing populations. The catalyst for this study was the instigation of a national government LTC insurance system in South Korea in 2008 and issues and concerns about the Quality of Care (QOC) in RACFs. The introduction of the LTC system highlighted the absence of care standards for care provision in RACFs in South Korea. The research study reported in this thesis used modified Delphi methodology for the development of care standards for RACFs in South Korea. Methods included; 1) Document analysis of international care standards from Australia, the United Kingdom and the United States, 2) qualitative descriptive analysis of the transcriptions of focus group meetings held with residents, their families and older people within the community, and 3) Analysis of the assessment data relating to the health and functional status of Korean residents. A pilot study was conducted of the Delphi method which was followed by three rounds of Delphi to complete the data collection, analysis and development of standards. Donabedian’s framework was used to inform the quality care elements of the care standards. A suite of standards for care in RACFs, underpinned by international principles of care for older people, comprising 15 statements of standards and 155 criteria, were developed. International, cultural, social and individual requirements for care are reflected in the standards. Of importance is that the care standards may assist the South Korean Government’s National Health Insurance Service (NHIS) policy makers to ensure the provision of culturally appropriate care in RACFs. In addition, they may guide Quality Assurance (QA) activities for private and public service providers. Finally, the findings from this research provide nurses with an opportunity to play a central role in the emergence of the gerontological nursing specialty in South Korea. It also serves as a reference point for nurses from other countries in the Asia Pacific that are also facing rapidly ageing populations.

The major psychotropic drug classes are antipsychotics, antidepressants and anxiolytic/hypnotics. Professional guidelines advise that these agents should only be prescribed to manage behavioural and psychological symptoms of dementia (BPSD), anxiety and insomnia in older people after non-drug measures have proved ineffective. Psychotropic medications, particularly antipsychotics and benzodiazepines, are associated with significant risks, yet they only offer modest benefits to treat these conditions. Consequently, these medications should be initiated at the lowest effective dose, monitored regularly and administered for time-limited periods. Despite this advice, many researchers have reported high rates of psychotropic drug use in Residential Aged Care Facilities (RACFs) both in Australia and internationally over the last three decades. Moreover, rates of psychotropic use in RACFs appear to be increasing, a trend which most likely reflects the growing proportion of residents with mental health conditions. The main focus of this thesis was on antipsychotic and benzodiazepine use as the prescribing of these particular psychotropic agents is widespread, there are doubts over their effectiveness and they are strongly associated with significant risks in older people. There has also been considerable attention from both professional and regulatory authorities directed at rationalising the use of these medications. Although antidepressants are also associated with risks, there is strong evidence for their effectiveness in this population and many experts in the psychogeriatric field feel they are underutilised in the RACF setting. For this reason, the research was targeted at promoting guideline-based use of antipsychotics and benzodiazepines. Aside from their traditional supply role, pharmacists are increasingly becoming involved in promoting Quality Use of Medicines or ‘QUM’. In Australia, at the time of this research, community pharmacies were funded to provide Residential Medication Management Reviews (RMMRs) and associated QUM strategies to each facility, such as medication audit, formulary development and nurse education. Although RMMRs were shown to improve medication use in one large controlled trial, the effect of pharmacist-led QUM strategies on RACF psychotropic prescribing has not been evaluated. Therefore, the key objective of this thesis was to assess if pharmacists could positively influence RACF psychotropic utilisation through the use of a series of facility-focused QUM strategies delivered in a dedicated intervention project. However, before the intervention project could be developed, some vital background research was required. This is why the research for this thesis was conducted in three chronological stages. An evaluation of current psychotropic usage was initially needed to identify the main areas of concern and gauge the overall pattern of prescribing; thus, the first stage involved a retrospective cross-sectional study of prescribing data in a large representative sample of 40 RACFs throughout Tasmania. As professional guidelines recommend that psychotropic medications are reviewed on a regular basis and dose reductions attempted routinely, the cross-sectional measure was repeated 12 months later to evaluate the extent of review in the RACFs. Previous studies had shown a high rate of psychotropic use in Tasmanian RACFs. This trend was also evident in this study, with an average of 42% of residents taking regular doses of benzodiazepines and 20% of residents taking antipsychotics during 2006. Although the rate of antipsychotic prescribing was similar to rates reported in Sydney and New Zealand in the same time frame, the rate of benzodiazepine use in Tasmania was three times that reported in these other studies. Further, when the RACFs were re-audited a year later, over 60% of antipsychotic and benzodiazepine medications and doses were unchanged; a finding which strongly implies a lack of review of these psychotropic agents, contrary to current professional guidance. After obtaining an overall picture of prevalence, inappropriateness and the extent of review of antipsychotics and benzodiazepines, the second stage of this research thesis sought to gain a greater understanding of the determinants underlying their use in RACFs. A qualitative approach involving thematic analysis of semi-structured interviews with health professionals and relatives was chosen to answer the key research questions of this second stage, including why these medications are used and who is influencing their initiation and review? As there is a paucity of qualitative research related to psychotropic use in the residential aged care setting, this study not only provided valuable insight but also strongly informed the methodology of the subsequent intervention project. It became evident that many health professionals had limited knowledge about the risks associated with psychotropic use in older people, and that reviews were conducted infrequently, if at all. Of all health professionals, nursing staff were the most influential when psychotropic medications were initiated and utilised. As a consequence of this qualitative research, the key strategies of the intervention project were primarily targeted at nursing staff and designed to offer feedback on psychotropic use to individual RACFs, provide education about the risks associated with these agents, promote professional guidelines and encourage regular review and dose reduction. The main objective of the thesis was to design, conduct and evaluate an intervention project, trialling QUM strategies provided by community pharmacists, to facilitate the quality use of antipsychotic and benzodiazepine medications in RACFs. This third and final stage involved a large controlled trial run in 25 RACFs in the two major cities of Tasmania and was termed the ‘Reducing Use of Sedatives’ (RedUSe) project. Thirteen Hobart RACFs were recruited as the intervention group, with 12 Launceston RACFs acting as the control group. The RedUSe intervention was run over six months during 2008 to 2009. A series of QUM strategies were offered in the intervention RACFs, including two dedicated psychotropic medication audits, nurse education and feedback, and an interdisciplinary sedative review process. At the conclusion of the project, the prevalence of benzodiazepines was significantly reduced in intervention facilities (31.8% to 26.9%, p < 0.005), whereas a small non-significant increase in use was found in control homes. Likewise, antipsychotic use was significantly reduced in intervention facilities when compared to control facilities, although to a lesser extent than benzodiazepines (20.3% to 18.6%, p < 0.05). Over the six months of the intervention project, the proportion of dose reductions of both benzodiazepines and antipsychotics in intervention facilities was almost double the proportion recorded in control facilities. Although several intervention projects aimed at improving RACF psychotropic use have been published, few research teams have reported cost effectiveness data, clinical outcomes for residents or evaluated the sustainability of the intervention project over the long term. Consequently, various post-analyses of intervention data were conducted to evaluate the clinical impact of the project on residents in terms of falls and behaviour, and assess cost effectiveness. In order to determine the sustainability of the intervention, a final follow-up audit measure was performed 12 months after the project was completed. The post analyses indicated that the reduction in sedative use had limited impact on falls; however, there was a significant decrease in challenging behaviours in those facilities recording a significant reduction in antipsychotic use. Some cost savings were achieved resulting from the reduction in benzodiazepine prescribing, but savings were not observed in antipsychotic costing. Finally, the repeat 12- month audit measure demonstrated that the reduction in benzodiazepine use in the intervention RACFs was sustained, with the mean daily dose of benzodiazepines continuing to reduce even further. In contrast, RACF antipsychotic use returned to pre-trial levels and doses remained static. The RedUSe intervention led to a statistically significant reduction in the proportion of residents in RACFs receiving benzodiazepines and antipsychotics, and the number of dosage reductions of these agents in intervention facilities was double that reported in the control facilities. These findings suggest that QUM strategies coordinated through community pharmacies, and incorporating the dissemination of local data on medication use, offer an effective approach to reduce antipsychotic and benzodiazepine use in RACFs.

Research Doctorate - Doctor of Philosophy (PhD)
The population in Australia and much of the developed world is ageing and increasing the demand on residential aged care (RAC) which is costly to establish and operate thereby imposing an economic burden on society and impacting upon social sustainability. Quality of life (QoL) for residents is a primary condition of RAC. Quality of care is a significant factor of QoL and is provided by the care team however, it can be affected by work stress/satisfaction. RAC facilities are work places for the care team and studies within the field of environmental psychology indicate that the work place environments can affect work stress/satisfaction impacting upon work outputs. This research investigates the potential for the RAC built environment to influence the work stress/satisfaction of the care team thereby impacting quality of care, affecting QoL and addressing concerns for the future on a number of levels. The research identifies a number of design influences (DI) and then, over two stages studies the DI within the context of work stress/satisfaction to identify the care team’s perception of the identified DI, their control over them (Stage 1) and the level of consideration facility managers and designers gave to the impact on care team work stress/satisfaction during the design process (Stage 2). Stage 1 comprises qualitative interviews with members of care teams where Stage 2 involves three case studies with qualitative interviews of three cohorts (care team, managers and designers) along with observations on site and desktop audits of documentation to corroborate comments made in interviews. The significance of this research is threefold: i) investigating the relationships of the identified DI, ii) identifying factors that affect the inclusion of DI in the design process, and iii) identifying a process to enable the DI to be appropriately incorporated into the RAC built environment in order to provide an optimal impact on the work stress/satisfaction of the Care Team.

Aim: The thesis reports the outcomes of a systematic review conducted to identify the risk factors associated with antimicrobial resistant organism (ARO) carriage in residents of residential aged care facilities (RACF). Background: The World Health Organization (WHO) recognises antimicrobial resistance as a critical world health issue and acknowledges that with the reduction in the development of new antibiotics there is an urgent need to take action to slow the spread of antimicrobial resistant organisms (AROs). Residential Aged Care Facilities (RACFs) aim to provide nursing and personal care to the elderly who can no longer remain in their own home; in an environment that is safe and home-like. AROs are commonly found in aged care settings. A resident who is infected or colonised with an ARO may be a temporary or longer-term carrier of an ARO, and may act as a reservoir for the organism and a potential source of transmission to others. A risk-management approach is required in order to implement effective infection prevention strategies for dealing with residents with AROs. All facilities need to be able to identify the risks in their own context and select the appropriate course of action; however, little is known about the risk factors for ARO acquisition in this population. Method: A comprehensive literature search was conducted of Medline, Cumulative Index to Nursing and Allied Health Literature (CINHAL), Embase and Cochrane databases for quantitative studies that examined the risk factors for carriage of AROs in residents of RACFs. All risk factors associated with carriage of any antibiotic resistant organism in the target population were considered in this review. The review followed the Johanna Briggs Institute (JBI) methodology for conducting systematic reviews of quantitative studies. Results: This review considered 32 quantitative studies that met the inclusion criteria and identified risk factors associated with ARO carriage in residents of residential aged care facilities. In all, over seventy potential risk factors were examined in the included studies. Data extracted from these studies were analysed with Comprehensive Meta Analysis (CMA) software. As a result of the meta-analysis a total of 10 statistically significant risk factors that influence the colonisation or infection of residents of RACFs with AROs were identified; • Comorbidities • Immobility • Dependency • Wounds • Incontinence • History of an ARO • Male Sex • Invasive devices • Previous antibiotic therapy • Hospitalisation The results will be presented in detail in the thesis. Conclusions: Of the 10 risk factors identified not all were generalisable to the population as a whole; however some were, and this generalisability will be discussed further in the thesis. This information will inform risk identification and mitigation protocols for use in this setting. It may potentially lead to the development of a reliable risk assessment tool that staff can use to identify those residents most at risk. This review has provided an evidence base on which to build a planned approach to risk management and the implementation of transmission prevention strategies to prevent AROs in residents of RACFs.
Thesis (M.Clin.Sc.) -- University of Adelaide, School of Translational Health Science, 2015.

This Doctoral study explored the impact of structured clinical leadership training on registered nurses who hold positions as clinical leaders and managers in Residential Aged Care Facilities (formally Nursing Homes) in Australia. The aim of the study was to empower nursing workforce in Australian aged care settings through a formal clinical leadership and leadership training program that represented an intervention designed to empower participants to become care team leaders. The study followed a sequential mixed-methods design and included a pre and post-intervention survey completed by the 150 members of the intervention/study and the 150 members of the control group. The intervention group engaged in a structured 5-module training course in clinical leadership undertaken over a period of 5 months. This group was then involved in a qualitative interview and a process of thematic analysis was used to analyse transcripts of these sessions to enhance the findings of the quantitative survey results. The results from both the quantitative and qualitative inquiry were then synthesised through integrative analysis. The findings from this study suggest that nurses are well suited to being transformational leaders in aged care and that clinical leadership training has the capacity to empower registered nurses to become care team leaders in managing the multidisciplinary team. Clinical Leadership training gave clarity to the position of RN Team Leader and provided skills in leading the team to improved outcomes for all stakeholders. The role of the RN in aged care is a specialised one and as such requires contextualised clinical leadership training that empowers the nurse to transact with the team and transform the care. The study findings also suggest that, if organisations respect the value of a nurse’s autonomy and skills to practice, along with the valued role of the RN as the Clinical leader, then improved recruitment and retention of nurses in aged care will be achieved. Society is changing and so too are the demands on healthcare. As the population of the world ages, there will be a fundamental shift in how we provide care and support to an increasing number of frailing individuals and their circles of influence. Nurses are instrumental for leading change and, once trained in clinical leadership, become empowered and positively disposed towards what is usually a complex and diverse care setting. Nurses and nursing care continues to hold the high ground on the values and principles of society that reflect the expectation of the profession in supporting their needs. The true value will be realised when we empower the nurses to be the change champions in clinical leadership in aged care.
Thesis (Ph.D.) -- University of Adelaide, School of Translational Health Science, 2015.

Research Doctorate - Doctor of Philosophy (PhD)
People living in Residential Aged Care Facilities (RACFs) in Australia are old, vulnerable, frail and have complex health care needs. This population commonly experiences acute deterioration resulting in transfer to the Emergency Department (ED) where they have longer ED and hospital stays and higher hospital mortality than the broader population. RACF residents also experience increased rates of hospital acquired complications including falls, pressure injuries and delirium, and high rates of invasive intervention. Given the risks associated with hospitalisation for this cohort, it is important that the reasons and benefits of ED transfer are clearly defined. There is a need to establish models of care that continue to ensure access to the ED for older people in RACFs while mitigating the avoidable risks. This thesis by publication traces the evolution of a model of care to support the care of acutely unwell older people living in RACFs in the Hunter New England region of New South Wales, Australia from 2011 to 2020. The model of care focuses on avoiding hospitalisation, whilst delivering clinically appropriate care, in line with the goals of older persons, their carers and families. A research paradigm that supports pragmatic real-world interventions underpins the study. The Sax Institute Translational Research Framework has been used to frame the body of work. Publications about the model of care align to the Translational Research Framework elements from idea generation through to scalability. Consistent with a pragmatic approach, multiple research methods were used to guide the development of and test the model of care. These included focus groups, analyses of pre and post outcomes to pilot the model of care and use of video-telehealth within the model, as well as a cost analysis and a large stepped wedge evaluation. The program of research demonstrated that the model of care was able to reduce ED presentations and hospital admissions thereby generating cost savings. It also demonstrated that an assistant workforce in the ED could undertake screening and provide supportive care. The use of video-telehealth did not demonstrate a significant change in ED presentations or hospital admissions when compared to telephone consultation. The research highlighted the mechanism of the Community of Practice in facilitating clinicians and managers from multiple agencies to work interprofessionally to support research and ongoing development of the ACE program as evidence into practice. It highlighted the need for an integrated health and aged care system, the importance of person-centred care and the need for ED avoidance strategies to ensure alternative access to clinical care for older people who are acutely unwell.

Research Doctorate - Doctor of Philosophy (PhD)
Dental hygienists are preventive focused oral health professionals with the skills, knowledge and expertise to provide preventive oral health care. To contribute to the development of these attributes in their students the Faculty of Health and Medicine at the University of Newcastle implemented a novel student placement program in Residential Aged Care Facilities (RACF) on the NSW Central Coast, Australia. As with any educational innovation it was imperative to monitor whether the intervention had been positive and if improvements were required. The program was assessed using both qualitative and quantitative methodology to explore issues that students documented and reported with reference to their placement experiences. After analysing the students’ feedback from questionnaires, reflective folios and focus groups the placement proved to provide considerable benefits. Students reported an improvement in their knowledge of the oral health needs of residents; an improvement in their knowledge and ability to assess the oral health needs of residents with Dementia and Alzheimer’s disease, improved knowledge relating to medical and dental conditions of older people; increased confidence working with other health professionals and an increased knowledge of the RACF environment. Early results and feedback showed that there was a need for the development of a more comprehensive ‘real life’ orientation that depicted the student journey and experience during the RACF placement. Students reported feeling anxious and nervous in the early stages of the placement, and felt the pre-placement orientation did not prepare them for the challenges of dealing with cognitively impaired residents nor did it prepare them for interacting with staff in the RACFs. As a result student learning in the initial stages of the placement was hindered until they became acclimatised to the RACF environment and its challenges. The results from phases one to five of this research enabled a DVD to be produced depicting the RACF placement program using recent graduates who had previously completed a RACF placement during their own undergraduate degree. The DVD provides a comprehensive representation of the RACF environment and its daily routines and includes a series of scenarios that show students dealing with the challenges of providing oral hygiene care to residents with Dementia and Alzheimer’s disease. The DVD has been used to provide undergraduate dental hygiene students with a more realistic orientation to the aged care placement enabling them to transition from the classroom to the ‘real life’ experience that is residential aged care in a more positive and timely manner. The impact of the DVD on the student experience was measured by a two-group qualitative study. The findings and tools developed from this research have been implemented in the Bachelor of Oral Health degree program at the University of Newcastle, Australia. There has also been international, national and local interest in the research and its findings with funded research development utilising dental hygienists in residential aged care facilities on a permanent basis currently underway.