WA’s Brightwater Care Group has designed and implemented a workplace innovation, incorporating well-being mapping, which has shown tangible benefits in terms of the job quality of care workers and the quality of care. Wendy Hudson and Sue Jarrad report
Direct care workers form the majority of the aged care workforce and are critical to the future of the aged care sector. The Quality Jobs Quality Care Project, based at the University of South Australia* was a partnership between the university, a union and three aged care providers that aimed to investigate job quality for this group**.
Using a collaborative action approach (Bailyn & Fletcher 2007), the three providers were supported in the design, implementation and evaluation of a number of workplace innovations in a residential or community care service over a six-month period in 2015 and 2016. Each innovation focused on the job quality of care workers and on connections with care quality, recognising that workers in good quality jobs are assisted to deliver high-quality care (Baines & Armstrong 2015). The first three innovations were completed in 2015, another two commenced in late 2015 and the final one, described in this article, began in December 2015 and was completed in June 2016.
What is job quality?
There are many different ways of looking at job quality: from the perspective of the individual performing the job, the
workplace where the job is placed and the organisation’s workplace policies and culture.
At an organisational level, a good quality job is considered to be one that is well-designed with employment conditions that foster the well-being of the worker (Green 2006). There are two key elements of job quality – the employment conditions and the job organisation and design. The first includes aspects such as the level of pay, the security of the job, hours worked (and when), access to education and training, relations with management, and the workplace culture and safety.
The second aspect, job design, relates to how the work tasks are organised, the extent to which the individual is equipped with the relevant skills and the opportunities to use their skills, the level of autonomy experienced in the job, the work demands of the job and the level of support from managers and co-workers.
High job quality in care work results in benefits for the worker such as enhanced mental and physical health, a good work-life balance and job satisfaction (Castle et al 2007; Clarke & Hill 2012; Liang et al 2013; Schmidt & Diestel 2013). High job quality also has benefits for the organisation, such as improved recruitment, reduced turnover, increased staff effectiveness and safety, and also provides benefit to clients (see Diagram 1) (Parker 2014; West et al 2014).
How does a quality job affect care quality?
Job quality has a direct impact on care quality. For instance, aged care literature shows that workers who feel supported and encouraged through the experience of a quality job report higher well-being, and these benefits then flow on to the client through the care relationship (Kitwood 1997). Where care workers are satisfied with their job, clients also report high satisfaction with the quality of care (Chou et al 2003; conversely, low job satisfaction is also related to low client satisfaction (Pol-Grevelink et al 2012). Care workers report greater job satisfaction when they have a sense of autonomy, of being valued and of being able to use their skills in the job (Radford et al 2015).
Another aspect connected to quality care is that of work practices. For instance, where job design supports good team communication and problem-solving, care workers and their co-workers are able to be more responsive to the needs of their clients in a timely manner, which enhances client quality of life and maintains their good clinical care (Toles & Anderson 2011). If the job design is such that the worker is under constant pressure to complete tasks, client needs can be missed and the care relationship is diminished (Gittell et al 2008).
A third aspect is the impact of staff turnover on care quality. High job satisfaction underpins staff retention. A stable workforce results in more effective team work, and provides continuity of knowledge of the client’s needs and preferences, both of which enhance the quality of care provided (Clarke & Hill 2012; Rosati et al 2009; West et al 2014).
Care workers are also more likely to stay in an organisation which has a supportive culture and values their contribution (Radford et al 2015; West et al 2014). Conversely, stresses from high work pressure, the inability to have sufficient time to provide quality care, the lack of autonomy and flexibility, and unsupportive supervisors, can lead to care workers leaving their jobs (Vernooij-Dasssen et al 2009; Mittal et al 2009).
Well-being mapping: a case study
As part of the Quality Jobs Quality Care Project, Brightwater Care Group Ltd, a not-for-profit aged care and disability support organisation in Western Australia, designed and implemented a workplace innovation that incorporated a person-centred and team approach to support and care planning. This innovation addressed the job quality issues of effective team work and team cohesion in one of its aged care facilities, along with a focus on care quality.
Wendy Hudson, Brightwater Care Group Well-being and Dementia Support Coordinator, describes the approach and the benefits that ensued for care workers and clients.
Over the past few years, as a result of the transition to ageing-in-place from hostel type accommodation, one of Brightwater’s small aged care residences was experiencing an increase in the frailty and complexity of care needs of people living there, with 45% of residents having a diagnosis of cognitive impairment. This consequently meant a greater focus on clinical care, leading to increased staffing hours in nursing, allied health and therapy. This was a significant change from the previous staffing model of care workers and a part-time enrolled nurse.
With these staff changes came concerns about the impact of ageing-in-place on the care worker role. Care workers’ responsibilities changed with the move from a social model of care to a more clinical model. They were less autonomous and less involved in direct contact with residents’ families and doctor regarding care. The service manager perceived that care workers were consequently feeling disempowered and less valued, which had affected morale, team cohesion and communication, and key elements of job quality.
The low morale was also affecting the social environment, with the potential to impact on quality of care. Hence, Brightwater’s partnership with the University of South Australia’s (UniSA) Quality Jobs Quality Care Project was timely.
The first stage of the project involved deciding upon an innovation to improve care worker job quality and resident care quality. The service manager had previously led an initiative at another Brightwater aged care residence using well-being mapping to translate a person-centred approach into practice, based upon a shared knowledge of each resident as an unique individual. This had been driven by the service manager’s concern that “far too often we learn more about a person from the eulogy at their funeral than during their time in aged care”.
An unexpected positive outcome from this previous initiative was a demonstrated increase in communication, collaboration and teamwork across the site by all staff. The service manager believed that well-being mapping could achieve similar outcomes for job quality in the current situation, particularly as the approach ensured care workers were integral to the process.
Focus groups conducted by UniSA with staff indicated staff support for using well-being mapping as an innovation to improve care worker job quality and resident care quality. A worksheet with an implementation plan, timeline for a six-month pilot and evaluation was completed. Nineteen staff attended toolbox training in ‘Enabling Well-being’. The training included personal reflection on the meaning of well-being, the components of well-being and how to measure, map and enable well-being in aged care.
What is well-being mapping?
Well-being mapping is a person-centred team approach to support and care planning that places the person (resident/client) at the centre of the process (see Diagram 2) and recognises and enables care workers, residents and family members as partners in care. The approach ensures skilled and informed staff able to provide individualised care and support based on the knowledge of each individual’s strengths and abilities.
Brightwater’s well-being mapping approach uses the concept mapping model (Aberdeen & Byrne 2016) with Alzheimer’s Australia Vic’s CAUSEd problem solving acronym (Communication, Activity, Unwell, Story, Environment, dementia) (see http://dementialearning.org.au/course-modules) to identify key concepts as a prompt for team discussion. Together these provide a visual schematic for staff and families that enhances understanding of the person and their ‘story’, as well as facilitating problem-solving and goal setting with and for that person. Mapping importantly highlights a person’s strengths, abilities, routines and preferences within the context of their diagnosis, current health status and physical and social environment (Aberdeen 2015).
The well-being mapping process starts with a one-hour facilitated session on site, held in a suitable private space in the residence, and at a time that enables as many staff who know the person from their perspective of practice to come together with the family and the person. The participation of care workers is central to the approach and, where practicable, at least one care worker from the morning and from the afternoon shifts is invited to participate.
The person (resident/client) is at the centre of the conversation. The emphasis in the session is on dialogue and relationships, rather than a one-way assessment process.
Seven well-being mapping sessions were completed during the pilot at the Brightwater residence. In a staff group of 18 care workers, 11 care workers participated in the sessions overall, including three night shift care workers who came in on their day off. The part-time occupational therapist facilitated the well-being mapping sessions and coordinated the process and communication with resident, family and staff. A number of communication tools were developed to ensure all staff were aware of the session outcomes.
This included the well-being profile (‘This is Me’) – a person-centred thinking tool describing what is important to the individual and how best to support them to promote an individualised approach to their care (see example profile).
The involvement of UniSA enabled a participatory action research approach which provided feedback for the team and service manager to reflect upon and improve practices, particularly communication strategies that could support shared knowledge and understanding.
Doreen was suggested by care workers as someone who would benefit from taking part in a well-being mapping session. She and her daughter were invited and agreed to participate. Doreen has been a Brightwater resident for four years, and since arrival has frequently called out at night.
When asked at the time why, Doreen would just laugh or say she didn’t know she was calling out. Care workers were concerned that Doreen was in pain and requested pain relief. Until the care workers recommended Doreen for a mapping session, the service manager and clinical staff had not been aware of the frequency or extent of Doreen’s calling out, which was increasingly disturbing for other residents.
The mapping session provided a valuable history of Doreen’s life and her current preferences. During the mapping session, Doreen’s daughter advised that Doreen had been calling out at night for at least 15 years prior, and other family members had been significantly impacted by this. She reported that Doreen had experienced significant trauma in the past, not all of which she knew, only that her mother had been threatened by someone with a knife, and that she had not received any support or counselling in this regard. This information indicated that Doreen’s calling out at night was not due to pain, but because she was fearful of being on her own.
The knowledge that calling out was Doreen’s personal expression of fear at being on her own at night enabled a more consistent and compassionate response by all staff. While some care workers had been responding by spending time, offering emotional reassurance and a cup of tea, this knowledge gave all staff a greater understanding of Doreen’s needs. Her actions were no longer perceived as behaviours or ‘symptoms’ of dementia but as signs of distress (Bryden 2016).
Observing the interaction between Doreen and her daughter provided staff with a deeper insight into their relationship. Staff realised what they had perceived as detachment on the daughter’s part towards her mother was actually anticipatory grief and fear of losing her. Doreen’s daughter’s love for her mother was evident. It also gave Doreen and her daughter an opportunity to recollect and share memorable moments together and with staff. Although Doreen had shared some stories from her past, this conversation triggered more memories that staff could use as prompts for reminiscence in the future.
Doreen tired towards the end of the session and left to have a cup of tea. It was an opportunity for Doreen’s daughter to share her concerns, especially the anticipated loss of her mother and provided staff with a better understanding and insight into her needs.
It gave an opening for discussion about end-of-life issues and enabled a clinical staff member to arrange another meeting with Doreen’s daughter to explore these issues further.
The shared understanding of Doreen’s history and current needs resulted in improved collaboration across the whole team to support and maintain Doreen’s well-being.
Key outcomes: job and care quality
The workplace innovation resulted in a number of tangible benefits in relation to job quality. The staff team has remained stable with no turnover since the pilot, and there was a reduction in single days off by care workers. Staff perception of the level of organisational support, measured by the Person-Centred Care Assessment Tool (Edvardsson et al 2010), increased by 39%.
The service manager reported that “constant grumbles and complaints about lack of time, and this or that not being done by other staff” had ceased.
Feedback from the focus groups demonstrated an increase in team communication and cohesion, and an increase in respect by clinical staff for care workers’ knowledge about residents.
Benefits were also apparent in care quality, with an increase in rapport and conversations by staff with residents on topics meaningful to them. Medication variation incidents were also reduced.
Care workers and clinical staff both reported benefits from well-being mapping, gaining a greater understanding of each individual resident’s life and what was important to them. This was supported by objective data, with a 50% reduction in staff recording actions by residents as ‘behaviours’.
Care workers also reported a reduction in stress: with the increased understanding of an individual’s personal preferences they could tailor their care and support accordingly.
Care worker feedback included:
- “Feeling part of a team, feeling valued.”
- “If I had known what we know now, it would have made it so much easier…”
- “… did not alter the tasks to be done, but the new knowledge assisted to ‘cope easier’”.
- “I feel that when we have a better understanding of a resident’s needs, that we can have an even better resident-centred approach, custom made for each resident.”
- “With gaining more information on the resident’s life it allows you to open conversation on discussions that he likes to talk about. What’s important to maintain quality of life for him to the smallest thing.”
Family members involved in the mapping reported satisfaction in the understanding staff had about their relative, and there was a 100% reduction in family complaints related to care. Feedback from family members who attended a well-being mapping session demonstrated benefits in family member knowledge about the care provided:
- “Well-being mapping shows that Brightwater management have my father’s best interests at heart.”
- “It is important that Mum is cared for to the best possible level. I’m convinced that is occurring. Staff seem to have it all under control and know Mum well.”
Due to the small sample size, quantitative results from the evaluation need to be interpreted with care and considered indicative of possible trends or changes.
However the qualitative data was consistent with trends observed in survey results, providing additional evidence that the well-being mapping process had a positive impact on job and care quality.
There was a range of well-being outcomes from this project:
- Through their participation in the well-being mapping process, care workers reported a sense of being valued and were empowered by their increased knowledge and understanding, and enabled to be more responsive to the unique needs of each individual.
- Residents were known and respected as individuals, and more meaningfully engaged in interactions with all staff care workers.
- Family members were reassured and confident about care, with enhanced staff-family-resident interactions and relationships.
- For all staff there was an increase in mutual respect and understanding about respective work roles, and more effective communication and teamwork.
The focus on job quality and its relationship to care quality demonstrates a range of benefits to clients, staff and the organisation. Integrating the well-being mapping processes into standard practice will involve taking into account organisational policies and processes, resourcing of roles and training and the importance of leadership in creating and maintaining a positive work culture where the value of working together as a team is promoted and well-being is the focus.
A toolkit for industry
From the workplace innovations in the Quality Jobs Quality Care project, a toolkit has been developed to assist aged care organisations to facilitate similar small-scale workplace innovations to enhance job quality and care quality.
The toolkit, to be launched early in 2017, will provide a range of resources, such as methods to assess an organisation’s job quality, tools to measure client views on quality care, and worksheets to assist in implementation and evaluation of workplace innovations.
The toolkit will be available at http://www.qualityjobsqualitycare.com.au/
The Quality Jobs Quality Care Project was funded by the Australian Government Department of Health under the Aged Care Service Improvement and Healthy Ageing Grants Fund. Details: http://www.qualityjobsqualitycare.com.au/
*Chief Investigators: Professor Sara Charlesworth, RMIT; Professor Debra King, Flinders University; Research team University of South Australia: Dr Natalie Skinner, Dr Sue Jarrad, Jacquie Smith (Project Coordinator).
** Project partners: Brightwater Care Group Ltd (WA), HammondCare (NSW), Helping Hand (SA); United Voice.
Wendy Hudson is Well-being and Dementia Support Coordinator Brightwater Care Group. Contact her at: email@example.com; Dr Sue Jarrad is Research Fellow, Centre for Workplace Excellence, University of South Australia and a member of the Quality Jobs Quality Care Project team. Contact her at Sue.Jarrad@unisa.edu.au
Aberdeen SM, Byrne G (2016) Concept mapping to improve team work, team learning and care of the person with dementia and behavioural and psychological symptoms. Dementia doi:10.1177/1471301216641785.
Aberdeen S (2015) Concept mappping: a tool for team learning, collaboration and quality care. Nursing Standard 29 (48) 49-58.
Baines D, Armstrong P (Eds) (2015) Promising practices in long term care. Ottawa: Canadian Centre for Policy Alternatives.
Bailyn L, Fletcher JK (2007) Collaborative interaction action research. Sloan Network Encyclopaedia. Available at: http://workfamily.sas.upenn.edu/wfrn-repo/object/cr5vp8go5ji2xp2s. (Accessed 28/11/2016).
Bryden C (2016) BPSD: alternative understanding of a well-accepted term. Australian Journal of Dementia Care 5(5) 20-22.
Chou S-C, Boldy DP, Lee AH (2003) Factors influencing residents’ satisfaction in residential aged care. The Gerontologist 43(4) 459-472.
Clarke MA, Hill SR (2012) Promoting employee well-being and quality service outcomes: the role of HRM practices. Journal of Management & Organisation 18(05) 702-713.
Edvardsson D, Fetherstonhaugh D, Gibson S, Nay R (2010) Development and initial testing of the Person-centred care Assessment tool (P-CAT) International Psychogeriatrics 22 101-108.
Gittell JH, Weinberg D, Pfefferle S, Bishop C (2008) Impact of relational coordination on job satisfaction and quality outcomes: a study of nursing homes. Human Resource Management Journal 18(2) 154-170.
Green F (2006) Demanding work: the paradox of job quality in the affluent economy. Princeton University Press.
Kitwood T (1997) The experience of dementia. Aging and Mental Health 1(1) 13-22.
Liang Y-W, Hsieh Y, Lin Y-H, Chen W-Y (2013) The impact of job stressors on health related quality of life of nursing assistants in long-term care settings. Geriatric Nursing(0). doi: http://dx.doi.org/10.1016/j.gerinurse.2013.11.001.
Mittal V, Rosen J, Leana C (2009) A dual-driver model of retention and turnover in the direct care workforce. The Gerontologist 49(5) 623-634.
Parker SK (2014) Beyond motivation: job and work design for development, health, ambidexterity, and more. Annual Review of Psychology 65(1) 661-691.
Pol-Grevelink A, Jukema JS, Smits CHM (2012) Person-centred care and job satisfaction of caregivers in nursing homes: a systematic review of the impact of different forms of person-centred care on various dimensions of job satisfaction. International Journal of Geriatric Psychiatry 27(3) 219-229 doi: 10.1002/gps.2719.
Radford K, Shacklock K, Bradley G (2015) Personal care workers in Australian aged care: retention and turnover intentions. Journal of Nursing Management 23(5) 557-566.
Rosati RJ, Marren JM, Davin DM, Morgan CJ (2009) The linkage between employee and patient satisfaction in home healthcare. Journal For Healthcare Quality: Official Publication Of The National Association for Healthcare Quality 31(2) 44-53.
Toles M, Anderson RA (2011) State of the science: relationship-oriented management practices in nursing homes. Nursing Outlook 59(4) 221-227.
Vernooij-Dasssen MJ, Faber MJ, Olde Rikkert MG, Koopmans RT, van Achterberg T, Braat DD, Wollersheim H (2009) Dementia care and labour market: the role of job satisfaction. Aging and Mental Health 13(3) 383-390.
West MA, Topakas A, Dawson JF (2014) Climate and culture for health care. In: Schneider B, Barbera K (Eds) The Oxford Handbook of Organisational Climate and Culture 335-359. Oxford: Oxford University Press.