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It seems a lifetime ago when we worked together at Arcare Aged Care to co-imagine a shared vision for the future. This vision was distilled from resident, staff and family member stories about what mattered most to them. Although each person’s story was unique, the common thread was the pivotal role of relationships characterised by trust, respect and reciprocity. A recognition of the centrality of relationships in the lives of everyone became the starting point for all future policies, programs and quality improvement endeavours.

To operationalise this renewed commitment to relationships, the focus immediately turned to staffing models. This led to a 12-month pilot of a strict consistent staff assignment model – which Arcare called Dedicated Staff Assignment – in one of their dementia specific residential communities. Dedicated Staff Assignment was then successfully rolled out across the entire organisation as the primary operational feature of their relationship-first approach.

 

What is consistent staff assignment?

The primary purpose of consistent staff assignment is to ensure that residents have the same staff supporting them with personal care. The more you know someone, the more you will understand their expressions of preference, pain, joy, humiliation, connection, self-assertion and personality.  This familiarity is particularly vital when working with residents who express themselves non-verbally (through body language, emotion, protest, facial expression, action and reaction).

Importantly, when implementing consistent staff assignment, residents have a say in choosing their consistent carers and they provide regular feedback on them when their care plans are reviewed.  It means that staff training can be tailored to meet the needs and preferences of each resident they support and that individual staff duties lists shift in response to resident’s changing preferences. These benefits are among the key reasons that the model needs to be strictly implemented – having a regular team or just some of that team consistently working in the same area is not a strict consistent staff assignment model. The below table is an example of a weekly consistent staff assignment schedule for a resident, Dulcie, that repeats each week.

 

Dulcie’s carers  

The table highlights the unique accountability the model offers. For example, if issues emerge related to Dulcie there is a clear line of accountability in terms of the staff members involved. The model also ensures that nursing, environmental, lifestyle and catering staff work consistently in the same area (or house or unit). It is not difficult to imagine the benefits this level of accountability affords, including improved trust and understanding between residents, staff and family.

I am often asked what I would look for if I were assisting a family member to choose a residential aged care home. My response is always the same, if the organisation cannot provide you with a one-page table such as the one above, then don’t move in, regardless of the beautiful building or promise of individualised care or their stated focus on relationships.  Organisations with consistent assignment strictly in place will absolutely be able to provide residents and family with a similar table as the one above. I have seen residents enlarge this table to A3 size and place it on the wall of their room so they will know as soon as they wake up exactly who will be knocking on their door to help them with the most intimate parts of their personal care.

 

My experience implementing consistent assignment internationally

For the last three years I have been working as a consultant internationally in a range of senior care contexts. This work has included supporting organisations in implementing consistent staff assignment. Needless to say, the failures and insurmountable challenges have provided the most powerful learnings. Some of these practical learnings and recommendations can be found here (for example in relation to leave management, workload balance, teamwork and supporting staff, etc.).

One common theme I have encountered – regardless of the build or model of care – is that residents routinely have to endure between 28-48 different care staff per month assisting them with the most intimate parts of their personal care. As shown in the table above, a strict consistent assignment model reduces this to around 6-8 people per month. With a heightened focus on infection control in aged care, a strict consistent assignment model ensures that staff work not only in the same site (as has been recommended by the Department of Health), or even on the same floor or unit, it sees them working with exactly the same small group of residents every time they come to work.

Beyond the practical learnings outlined above, many of the challenges and roadblocks I experienced were part of something much larger, where the pros and cons of consistent assignment were debated almost exclusively from an institutional perspective – a perspective based on highly paternalistic assumptions and neoliberal social values.

 

Moving to a human rights approach

There is wide consensus that a human rights framework is needed in aged care in Australia, including recommendations for a new Act based on human rights principles.  This represents a complete paradigm shift away from the current highly paternalistic and deficit-based domains of medicine and charity. The shift also recognises the ways that consumerist notions of choice, and the stated benefits of market competition, have failed to secure the rights of the most vulnerable citizen residents.

To be clear, this does not translate to a reduced quality of clinical care – excellent clinical care where this is needed is fundamental to a human rights approach. It is about ensuring that everyday decisions, preferences, tasks and expressions in residential aged care – that are central to human rights and citizenship – are not be subject to clinical sanction, the desires of others, or to institutional efficiencies and imperatives.

Putting human rights at the centre of care and care practices calls for government and organisations to recognise their reasonable accommodation obligations in relation to actualising the experience of rights for all residents – not just the ones who are able to verbally express their preferences and complaints.

Within a rights-based framework, operational shifts such as consistent staff assignment – a measure required to practically support dignity, self-determination, decision-making and health – become obligations in terms of reasonable accommodations to support rights. Through the lens of human rights, a failure to provide reasonable accommodations – such as consistency in staffing – is discrimination and a violation of fundamental rights. This highlights the corresponding obligation of government to monitor that reasonable accommodations have been put in place to support dignity and the unique needs and preferences of individual residents.

 

Consistency is not enough

Realising human rights for vulnerable residents requires staff who not only know them well and who are responsive to their needs and preferences, it requires a commitment to call out deeply embedded and resilient paternalistic assumptions that construct residents as child-patients rather than as adult rights-bearing citizens. It demands a new vigilance in eradicating harmful training and frameworks which deem many of the intentional acts of communication and self-assertion of residents as pathological behaviours that need managing whether by chemical or other forms of restraint as outlined in the Royal Commission into Aged Care Quality and Safety (2019).

A human rights framework requires a conscious focus on the largely ‘invisibilised’ micro geographies of care – the tiny day-to-day spaces where injustice and exclusions may routinely occur or, where justice and inclusion might be promoted and facilitated.  Consistent assignment is the first step in turning everyone’s attention to these traditionally hidden spaces and to the forces that shape them. It is within the context of these relationships that staff are able to recognise residents’ assertions of self-determination leading to the reduction of power imbalances and deeper and more satisfying relations for everyone.

(A comprehensive presentation outlining a human rights framework for residential aged care operations and practices can be found here)

Daniella Greenwood, BA (Hons 1), B Hlth Sc (Leisure and Health), Dip Diversional Therapy, Cert IV Leisure & Health. 
International consultant, keynote speaker and published author specialising in human rights policy and practice in long-term care.
Daniella can be contacted on:
daniellagreenwood@mac.com

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