The morning was spent learning about the beautiful UNESCO World Heritage Site of the Old-City of Torun where the conference was held, including its historical buildings, legends and claim to fame as birthplace of Copernicus. The link to the renaissance father of Heliocentric theory was a wonderful reminder to never assume that the way we do or think about processes cannot change. In a world with an ageing population simply trying to improve or ‘add on’ to the existing way we care for our elders may not be enough, and a re-ordering of our social universe may be needed just as much.
With these thoughts having been brought to mind, a tour of a factory just outside of Torun provided excellent insight into the production and supply chain of incontinence products for older adults and sterile hospital equipment. Caring for older people, we should be careful to not simply advise that one thing or another is best just because it claims to be. Having a knowledge of the products that they may need day in, day out can make all the difference to their welfare.
We all know how a piece of ill-fitting clothing can irritate or niggle after just a few hours of wear, and spend hours shopping for just the right fit, or spend the time to have it altered to be comfortable. Yet with incontinence being a part of ageing that as a population we generally don’t like to discuss we tend to rush these purchases, and not look into it too much. I ask why? When these will be worn against the skin potentially 24/7 and the need for correct fit and type is even more important.
The day was rounded off with the Opening Ceremony of the Long-Term Care Conference. With representatives attending from around the world I was excited about this opportunity to learn how other countries approach, deal with and manage Long-Term Care. Would there be trends, or vast differences to learn from? The Ceremony was opened with an initial lecture on “Long-Term Care, is there one way to develop?” Focussing on the approach of our Host Country, Poland to Long-Term Care. Another lecture regarding overcoming trauma and Epigenetics examined the issues of inherited trauma through generations and the fascinating results of recent studies providing more and more overwhelming evidence on the effectiveness of Epigenetics in humans from the initial Pavlovian experiments some time ago. This in itself really pushed the point, at least to me, of how important it is to look after our elders for the sake of our children.
The full day of Lectures opened at 9am for the first session, addressing “Individual needs and standardisation of Services”. Headed off by the eximious Dan Levitt from Canada, speaking on the subject of ‘A new approach to ageing: it is not a traditional nursing home for grandma’ He initially examined the discrepancy our society has in the services it provides to those with extra needs at both ends of the age range. Children with extra needs have many extra facilities and additional support available at schools whilst integrated with their peers, and paediatrics is a popular profession, whilst our older generation tend to be shut away when their needs become too great, and suffer from uncoordinated geriatric approaches with understaffing. He queried why this is the case with an ageing population, as surely our services for the larger and increasing demographic should be priotitised. Mr Levitt pointed to an insidious ageist attitude in our society, perpetuated by media and language which must be overturned to re-think how we approach geriatric care.
The other main concern he voiced was how care for our elderly is still often done in sweeping generalisations, for example services such as changing of incontinence pads still done to a ‘rota’ for staff ease, rather than when needed by the individual. He also highlighted issues such as coddling of the elderly, for fear of lawsuits which results in a far more detrimental lack of choice and interest to keep the brain active and life worth living.
This is something he found compounded even more by overmedication in Canada, pointing to an experiment where an individual attempted to get music to all elderly residents of homes in a certain area for music therapy and could not. He could, however, get every one of them medications to be prescribed. It is easier for overworked staff to say ‘this will keep them level and safe’ than ‘what does this specific person need to get as much out of life as they can?’
Mr Levitt’s conclusion was that the ‘Village movement’ should be the key move forward, reintegrating the elderly back into society rather than segregating them. Two key factors that are detrimental to our health are loneliness – and we separate out our older generation – and human interaction, especially touch, which nothing can replace – which we reduce and ban on an increasing level by the day. These two things may make our elderly more ‘safe’, but they do not help their mental health or quality of life.
Our very own Jo Croft represented the UK at the conference, speaking on ‘Promoting independence with the use of the Structure of Positive Risk’. Ms Croft very clearly identified that currently what is held as a ‘high quality of care’ is not the same as a ‘high quality of life’. She echoed the same feelings of Mr Levitt that it is our society’s fear of legal action and repercussions, whether from families or governing bodies that prevents carers from allowing older clients to continue with activities which make them who they are, intrinsic to their personal identities and mental health.
She pointed out the tension between ensuring a duty of care and allowing a client to live a fulfilling life, giving the hypothetical example of poor ‘George’, wrapped in bubble wrap by his carers to keep him safe from the world and suffocating inside his protection. Carers are often afraid to potentially cause or allow harm to come to patients for fear of getting it wrong, and as a result just see the condition the person has, and stop seeing the person themselves and what they might need to make their life worth living.
However, Ms Croft gave a wonderful example of the ‘Positive Risk Framework’; a tool enabling carers to carry out risk assessments of various situations taking both the potential risk and the benefit to that individual into account, then balancing the two. This tool enables carers to really show due diligence in having taken all reasonable steps to ensure an individuals’ safety who is in their care, but give more of an opportunity for people to continue doing what they love rather than just saying ‘no, it’s not safe’.
Of course, the tool is adaptable to individual circumstances which makes it flexible and useable to a wide variety of care providers in theory, however, I find myself considering as with many of the elements of care we have now a) which care providers have the time to dedicate to this paperwork, when we are already understaffed in care just to provide the bare minimum required by our older generation and b) who would pay for it, would the NHS actually fund these extra admin hours to improve the quality of care? I think it should, but I’m not holding my breath. It would therefore become an extra private cost for families, increasing the divide of ‘good’ or ‘poor’ care between the have’s and the have not’s.
The first session was rounded off by Dr Bugajska from Poland, who discussed the issue of ‘Securing the diverse needs of older people’ focussing on solutions implemented in Szczecin. Dr Bugaiska identified that in this scenario, impressive as it was, technology improvements and implementations were at the forefront. Again, the opinion was put forward that although these advances can be utilised to great effect they should not be relied upon instead of human touch and compassion, as these simply cannot be replaced.
The talk discussed the specific legislation changes which affected this area, but was once again relevant to care in the UK by highlighting how understaffing and an ageing population is becoming more of an issue on a global scale, and still needs much work to go to cope with. The feeling again of reintegrating our elderly in the community was voiced, both for their benefit and for resource management, with yet another vote for building and converting more assisted living complexes than new nursing homes.
The second session of the day dealt with ‘The image of long-term care institutions’ and was opened by Magdelena Jaworska-Niziol who’s topic was ‘Harnessing the fourth power’. She spoke on the power of the press in relation to improving the image and attitude to long-term care in society and how care providers can use the media to their advantage in modern social media to try to spread information, improve image and help people accept geriatric care as less of a taboo. Ms Jaworska-Niziol gave a charming example of a video created by a superfluity of nuns doing a penguin walk on international penguin day. Of course, the video went viral and although in itself was not informative, it brought attention to the convent and gave them a platform to then tell a wider audience about the care work they were doing and the help they needed.
Jeroen Van Den Oever from the Netherlands then spoke on the ‘Confusing image of Nursing Homes’, approaching the subject from varying perspectives. Initially he demonstrated that from the perspective of clients and their families it was still not a positive experience on the whole. It is a service largely not wanted, with feelings of guilt and an image of deprivation in the families causing tension and seeing it as the last stage of life giving a finality that is not welcome.
This naturally makes clients and families overly critical of services and standards expected, to improve this he suggested making a much earlier connection with people, long before services are required. This building of relationships with future clients and including families in the organisation of care greatly improves the transition into care when it’s required and reduces the stigma surrounding it. Mr Van Den Oever also emphasised the importance of making care more homely and less institutionalised, with small changes such as staff not wearing uniforms, being helpers rather than governors of patients’ lives, and ensuring family participation in care even to the extent of family owned care homes to ensure client welfare.
As far as care is seen from a market perspective, there is a wide variation in size and quality. Affordable accommodation is an issue, and in the Dutch market means there is now more competition than ever for nursing homes and assisted living homes with dedicated comparison websites. The main issue being faced in the Netherlands reiterated once more that we are not alone – the shortcoming in the labour market and understaffing in the care sector is a problem being faced globally.
Society as a whole in the Netherlands was shown to be divided on its view of care homes, ostensibly represented by the government as public possessions they are in reality private ventures. It is very easy for journalists to jump on issues that arise, making management of the homes difficult as managers ‘can’t do anything right’ and are in a vulnerable position. This echoed earlier sentiments from the first session that care provision is often stifled by providers’ fear of condemnation or prosecution if something goes wrong.
The talk concluded with the opinion that a better welfare system for the elderly was required in the Netherlands, but with little hope of this happening any time soon. An expectation for care to be more and more in the private sector was voiced, but that along with this the need for the quality to improve and families to be involved more in the care process. Finally, a need for greater training for staff in relation to hospitality and empathy was emphasised, with attitude being far more important than simply the amount of money spent on a home.
The second session ended with a talk on ‘Relational Marketing in Long Term care’ by Professor Pawel Dobski. Prof. Dobski identified how today’s medicine treats individual symptoms, not the person as a whole and how conditions and symptoms are often complex and perplexing, making marketing vital to build relationships between doctors and care providers and the service users and wider public.
Just because someone doesn’t understand a topic does not stop them forming an opinion on it, and with the internet and social media the modern age has not made word of mouth obsolete, it has simply given many more avenues for those words to be passed through. He identified how studies have shown that even with something as crucial to someone’s life as care, where you might assume deliberation and careful consideration has gone into any decision made research is typically not in depth with opinions formed from skimming initial information in less than one hour.
This shows how integral a good marketing strategy is to care providers to ensure that their potential service users get the information they need and want quickly. However, Prof. Dobski focussed his talk on the importance of ensuring that care providers do not market what they cannot deliver. For marketing to focus on quality, the quality must exist in thorough procedures, standards, documentation and training. To market good care, you must provide good care, and this must be in all aspects of the company. When going out for a meal you do not just judge the quality just by the food on your plate, you judge the surrounding fittings, atmosphere and service to say whether the experience as a whole was of ‘good quality’. He identified that care providers often forget this and focus on simply the personal care activities provided to someone, when they should also ensure that the surroundings, punctuality, attitude and professionalism of their care environment are kept to a high standard to really be able to say that they provide ‘quality care’. If not, they leave themselves open to dissatisfied clients who feel they were promised more than they received, and the higher someone’s hopes were that were disappointed, the more people they will tell about how ‘bad’ it was.
The conclusion of the talk held a small gem of wisdom which I feel is important for all care providers to remember, and that is when a care provider is initially contacted by a new potential client, or are trying to market themselves towards new clients, people who are just beginning to need care services have often just received a diagnosis of a degenerative or terminal illness. In communication we must remember that this type of news is almost always dealt with in the same way as dealing with a loss and to address ourselves to someone who may be going through the 5 stages of grief and so denial, anger, bargaining and/or depression are to be expected before acceptance of their situation. If we always remember this, we can communicate more effectively to the benefit of both care provider and service user.
The final session of the day addressed ‘Long-term care management in conditions of staff shortage’ and was opened by Volker Rosche from Germany. He reiterated that personnel staffing in care was a global issue, and that there was a need to retain loyal employees. He examined how although staff leave for many reasons it is often that superiors have a tendancy to not appreciate good employees whilst not dealing with bad ones. More than ½ of all leavers give a reason of not getting along with their direct manager, so employers need to show commitment and lead by example or else why should their employees bother? Another reason given was that people not necessarily deserving of promotion are advanced when they shouldn’t be, leaving other employees frustrated. Also listed was a lack of intellectual stimulus, lack of growth and lack of development opportunities.
Mr Rosche raised that there are many different management styles and often managers utilise the wrong one, for example trying to manage a small business like a corporation. Although there are many established management techniques, Mr Rosche listed two new ones he had encountered over the years, more common that should be expected and detrimental to companies. These were ‘Management by Helicopter’ where a manager rushes in, creates lots of dust then flies off, after which nothing has really changed. The other was similar being ‘Management by Submarine’ where a manager surfaces, makes waves then disappears and you would never have known they were there afterwards.
Instead he was a proponent of Transformational leadership, where a manager conveys a vision but goes on the journey together with the employees. This ‘all in it together’ approach is far more successful at inspiring motivated and loyal employees. The importance of separate teams to focus on separate tasks was emphasised to create boundaries, responsibility and accountability, but with the need for close communication between teams to ensure everyone knows the overall objective and progress. Mr Rosche also emphasised the importance of seeing what you are asking from the employee’s perspective, and how you would feel if you were asked to do that, and in that way. He spoke on how management was about maintaining the balance of employee’s motivation and competency, with motivation higher at the start of new projects but competency lower while learning, with competency increasing over time but motivation decreasing in line with monotony. He divided this process into four stages; 1) Feed information with no need for motivation 2) Motivation of employees 3) More need to control employees 4) Employees self-manage, leave them to work but ensure they have support and get neither lonely nor self-important and forget about the rest of the team.
The issue of staff retention was then followed up with the issue of staff recruitment. It is all well and good trying to improve the quality of your staff, but what do you do when you have such a limited applicant base? Many care providers are happy just to manage to recruit any staff let alone pick and choose based on skills and qualifications.
More care in Poland is being delivered in the home, but they suffer from the issue that these carers are not trained in reconciling professionalism and care giving and often cannot cope in an emergency. It was raised how the media makes a big difference regularly publishing about staff shortages, potentially perpetuating the problem as fewer people want to train to work in such a short-staffed environment as it would mean more strain on them. Globally everyone knows that staff shortage in care is an issue, however no one has yet come up with how to solve it.
The mean age of nurses, geriatric doctors and carers is increasing, with fewer qualifying each year. A lack of people in general is not the issue, in Poland the unemployment rate is almost 0%, yet there are still issues with staff shortages in the care sector. Low wages are often pointed to as an issue, and staff turnover there has now raised to 40% p.a. for carers and 25% p.a. for nurses. This puts even more of a strain on the care industry, increasing staffing costs and reducing quality of care.
The day was closed with a talk from Dr Beata Bugajska speaking on Stress Management. The median age across Europe is projected to be 40-50, and so with an ageing population maintaining dignity is key. She pointed to how society has lost the long-held perspective of respecting elders and their wisdom, and how the standard family support system in place for centuries has collapsed with no proper replacement in care. Reminded of how recent this change to institutional care as a concept is, she continued to highlight some small but useful ways to help lower client stress and maintain dignity.
The ‘Faces of the Century’ project and ‘It’s still me’ photo project are used to remind both service users and carers alike of what the individual was like as a young person, and serve as a useful tool to identify what in our lives has remained constant and what has changed. This applies not just to physicality but likes and dislikes, mentality and world view. Games such as ‘Idetic’ where one individual draws an image and then must describe it to others, to see who can draw an image as similar as possible also helps adults of all ages to see how others view the world differently and react to their communication, increasing self-awareness and consciousness of social interactions.
Dr Bugajska raised how products aimed specifically at older people are an issue primarily as what does each person consider as old? When would you consider yourself old? Mentally we try to delay this change as long as possible and so resist products that could help as we do not wish to be associated with requiring them. Another issue is that they are often marketed in a similar way as children’s products which as adults make us naturally resistant. She emphasised how if we delay treating someone as dependent, the longer it delays them becoming dependent, whereas if we continue to encourage independence it infers to the person that they are, and they continue to act in an independent manner.
Of course, this does not mean that older people do not need the products that are made for them, but small changes in perspective can make significant mental differences. Giving incontinence as an example, this is something many people do not wish to accept they have got to the age of requiring help for, and often see adult incontinence products as children’s nappies. A simple but effective way of combatting this, Dr Bugajska suggested, is simply to store someone’s incontinence products in their drawers along with ‘the rest of their underwear’ so it is seen more as an extra layer of garment and normalises the need.
The conference ended, an integration event in the evening allowed representatives from all over the world to compare issues and ideas when it comes to long term care, highlighting many common themes but allowing for an interesting interchange of approaches and ideas.
We attended a training session on specialist adult incontinence products, which provided exceptionally useful information on the make-up, how different types of products are better suited to different needs of patients, and common errors in their use which increase cost and reduce their efficacy. This training was exceptionally interesting and meant that we have come away better able to advise clients on what may be best suited for them. Being able to give more proactive advice in an area that often many people remain ignorant on, as they are either embarrassed to ask or simply do not know that there is such a range out there that means they could find something that could better suit their individual circumstances and needs means we can better serve our clients interests.
Overall the trip has provided food for thought. It is comforting in one way to know that much as we struggle in the care industry in the UK, we are not alone. At the same time it is worrying to know how widespread the issue is of lack of proper long-term care for our older generations. Something definitely needs to change, and fast, and we have heard some excellent suggestions from around the globe on how to potentially combat one issue or another. Largely though, there is not a ‘one size fits all’ solution and everyone will have their own unique problems to overcome.
However, we now have many more ideas to work from, and if one isn’t right for us, we move on to the next until we have found a solution.