Wicking teaching aged care facilities program: Innovative Practice

Aims

A program auspiced through the Wicking Dementia Research and Education Centre was instituted to prototype teaching aged care facilities in Australia. Implementing the prototype centred on establishing large-scale quality inter-professional clinical placements in two Tasmanian residential aged care facilities, within a ‘whole-of-organisation’ change process designed to build organisational capacity to drive high performance. The intent was to develop a nexus between teaching, research and practice to facilitate innovation and an environment that would attract a new generation of health professionals and drive evidence-based practice.

Program design

The six-stage program design (Figure 1) is underpinned by an action learning/action research method informed by evidence accrued in our team’s research undertaken between 2001 and 2011 (e.g. Andrews et al., 2012; Robinson et al., 2008). Action research aims to build a sense of shared ownership of the research process (Kemmis & McTaggart, 1986). In this program, this involves collaborating with aged care staff to identify organisational problems which might undermine effective learning and teaching, then taking action aimed at improvement (Kemmis & McTaggart, 1986). The Wicking program involves a whole-of-organisation change process that includes implementing two concurrent, inter-related, intervention streams:

Clinical stream – large scale, mentor-based inter-professional clinical placement program adaptable to health student needs, informed by the evidence-based best practice model of quality clinical aged care placements (Robinson et al., 2008).

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Figure 1.

Six stages of the Wicking Teaching Aged Care Facilities Program.

Within the Clinical stream, the action research method is utilised to engage aged care staff in the development of quality inter-professional aged care clinical placements. In each facility, staff members volunteer to establish a mentor group. As members of the mentor group, staff work through a series of action research spirals comprising preliminary investigation, problem identification, action planning, taking action, data collection (involving mixed methods) and analysis and reflection leading to a re-plan (Kemmis & McTaggart, 1986). In response to evidence indicating many aged care facility staff have limited professional engagement (Andrews et al., 2012), the program initiates a range of capacity building and clinical leadership development activities. These are designed to enhance their capability as student mentors to configure their practice in ways that facilitate quality aged care placements. Given the increasing incidence of residents with dementia in aged care facilities, dementia provides a key clinical focus for placement learning and teaching.

Concurrently, the program’s organisational stream engages facility leaders within an action learning framework to facilitate the development of organisational leadership capability. Action learning involves participants taking action to address real problems in real time, while learning through critical questioning and personal reflection on their practice (Marquardt, 2000). The intent is to foster real behaviour change and strengthen individual and organisational capability, thereby supporting the establishment of a teaching aged care facility.

In Stage 1 (see Figure 1), residential aged care facility partners are recruited and their capacity and capability to support large-scale inter-professional student placements is developed, partly through the formation of mentor groups. To implement this stage, two facilities partnered with the Wicking Centre and Schools within the University of Tasmania’s Faculty of Health. University-based academic liaison staff members were identified to facilitate communication and placement co-ordination between schools and facilities. This is critical when the involved disciplines have limited or no prior engagement with the residential aged care sector. Ethical clearance was obtained during this stage (Human Research Ethics Committee (Tasmania) Network (No.H11576)), with informed consent acquired from all project participants.

A mentor group was established in each facility, comprising registered and enrolled nurses, and care workers who had volunteered to mentor students on placement. A mentor leader (funded part-time) assumed responsibility for liaison with students, university and project team staff. Mentor group members participated in 10 preparatory meetings designed to build their capacity to facilitate evidence-based learning and teaching.

Concurrently, the Discovery organisational review, led by an organisational consultant (CS), identified organisational imperatives to support the successful implementation of the mentor-based facility clinical placement program, and ultimately the organisational design considerations necessary to support formation of a teaching aged care facility. An action plan was established to address issues such as development of leadership, change and communication strategies. Bi-monthly facility visits by the organisational consultant facilitated ongoing engagement with organisational leaders.

The Stage 2 ‘Run-in’ involves the mentor group implementing the action plans developed in Stage 1 with the first student cohort. Organisationally, this stage includes regular coaching of the mentor group and key leaders to maintain momentum during the placement. Implementation of the ‘Run-in’ stage gave mentors a chance to put their new mentoring-related learnings into practice. It also provided an opportunity for mentors to engage with the action research process in developing evidence-based practice and identify key barriers to successful implementation. This was particularly important given the large-scale placements of over 40 students per facility; an increase from the two nursing students who would historically participate in a placement. Involved cohorts included first and second year nursing students and final year paramedic and medical students, in placements ranging from one to three weeks. Where practical, placements overlapped to facilitate inter-professional learning.

Within the broad evidence-based model of quality clinical aged care placements, placement curricula were designed for each group of students to suit course requirements and support a dementia practice focus. As this was the first time paramedic and medical students had participated in an aged care clinical placement, working groups were established in collaboration with both schools to facilitate development of aged care specific curricula. A highly structured program was designed for medical students by the university’s medical academic liaison staff, in co-operation with general practitioner and pharmacist academic tutors.

Consistent with the evidence-based model, implementation of on-site student support included a pre-placement site visit (where possible) to provide an opportunity to discuss expectations and orientate students to the context. In the first placement week, students participated in a dementia workshop or, alternatively, accessed this material on-line or via general practitioner tutors. The medical students’ program included a clinical audit, skills-building in dementia assessment, and up to three hours daily clinical contact with a general practitioner tutor. Placement activities were implemented through site-specific action plans developed by the mentor group or, for medical students, the general practitioner tutors, which took into account local arrangements. Student and mentor participation in separate parallel meetings, with a facilitated feedback loop between the groups, supported the ongoing iterative development of the placement program.

Stage 3 Review and Strategy Design is a critical element of the action research/action learning method that underpins the Wicking Teaching Aged Care Facility model. It provides facility and university stakeholders with access to the mixed methods evaluation findings from Stage 2 (see Program Evaluation), and engages stakeholders, including the mentor group, in a process of developing strategies to consolidate gains and address issues of concern prior to the arrival of the second student cohorts.

In the Stage 4 Trial/Prototype Phase, mentor group members in each facility implement locally-specific action plans informed by Stage 2 evaluations, with a second cohort of students. Implementing this stage involved over 30 second year nursing and final year medical students on placement in each facility. Concurrently the organisational consultant continued to work with facility leaders to re-confirm strategic organisational priorities for change during this next stage of the program.

Stage 5 is a second period of analysis, review and strategy redesign. In implementing Stage 4, evaluation data were analysed and presented to the respective facility and university school staff to further refine the placement program, as per Stage 3. These presentations included a Stage 2–4 cohort comparison. Senior project staff met with facility and university stakeholders to communicate evaluation findings and begin the process of designing a teaching aged care facility framework to embed in partner facilities. The respective groups then took action to address issues and concerns identified and consolidate gains made in Stage 4.

The Stage 6 consolidation period enables university and facility partners to consider the gains made and effort needed to support the establishment of a Teaching Aged Care Facility in a sustainable manner. Implementation will involve replication of Stages 2–5 with additional student cohorts, including psychology and pharmacy students. Ongoing consolidation is central to a sustainable and dynamic Teaching Aged Care Facility model.

Program evaluation

As part of the Program Design, evaluation of the program is important to test the effectiveness of the model, as well as to provide feedback to key stakeholders to allow placement programs to be improved. Evaluation of the Clinical Stream involves a combination of qualitative and quantitative data collection strategies. Qualitative data are derived from weekly-fortnightly mentor group action research meetings held before, during and following student placements, which are facilitated by a project officer. These provide a crucial source of data on the development of, and ongoing changes in, mentors’ understandings and practices. Weekly meetings with students during placement provide data on their placement experiences. Meetings are audio-taped, transcribed and analysed for key emerging themes/issues related to mentor and student experiences. Case notes (meeting summaries) of mentor meetings are returned to participants prior to each successive meeting, to facilitate critical reflection on issues raised (Andrews et al., 2012) and member checking. A range of questionnaire-based evaluation tools are also used to survey students and mentors on issues such as dementia knowledge (Toye et al., 2014), assessment of teaching and learning (Robinson, Andrews-Hall, & Fassett, 2007) and attitudes towards aged care (Robinson et al., 2007). These quantitative data are collected within a pre-post-test design and managed by IBM SPSS Statistics (vsn 20.0).

Evaluation of the Organisational Stream involves a range of qualitative strategies. The process commences with an organisational review (Discovery, see Figure 1). Evaluation at this stage includes reviews of organisational documents, analysis of current business processes and activities, and interviews/focus groups with facility leaders. These evaluation data inform the development of an organisational action plan. Subsequently, meetings are held across all program stages with organisational leaders (executive, clinical and mentor leaders), with each site evaluating progress against action plans (Figure 1). Meeting notes facilitate evaluation of key organisational issues.