Survey of facility staff
Respondents were largely personal carers or nursing staff (152 [43%] carers, 40 [11%] registered nurses and 17 [5%] enrolled nurses). Allied health and therapy assistant staff (n
26; 8%), support staff (cleaning, catering, laundry and maintenance n
42; 12%), administrative and management (n
53; 15%) and other staff (n
20; 6%) also responded. Few staff were young (19 [5%] ≤25 years, 33 [9%] 26–35 years, 69 [19%] 36–45 years, 112 [31%] were aged 46–55 years, 74 [21%] 56–65 years, 10 [3%] ≥65 years, 39 [11%] missing). The median length of service was 2.8 (IQR 1.3, 5.8) years.
Staff reported positive relationships and communication at their facility (; median Shortell scale score 3.8, IQR 3.5, 4.2). Team work and leadership were also rated positively (median scale score 3.7, IQR 3.3, 4.1). The median total Shortell scale score was 3.8 (IQR 3.5, 4.1). Reported engagement/empowerment (median HTVI scale score 3.7; IQR 3.0–4.0) and communication (median 4.0, IQR 4.0, 4.5) were also positively assessed using the Healthcare Team Vitality Index.
Some qualitative feedback from staff emphasised negative perceptions of aspects of communication, leadership and teamwork. Teamwork was sought and valued, but sometimes perceived to be lacking. Communication was perceived as challenging at times, with some attempts at communication ineffective:
‘Staff meetings are intimidating and methods of communication “tell us what you think” forms are ridiculed’
Staff levels were perceived as a dominant challenge, threatening care quality:
‘As usual, the main complaint appears (in my opinion) to be poor staffing in patient/carer ratios. Although staff are concerned and caring, pressure of work results in cut back to care time available’
The importance of leaders establishing and maintaining the culture of an organisation was emphasised. Leadership was perceived to have concrete influences on organisations in areas such as staff retention.
‘This facility is poorly managed in every area….32 staff members have resigned in the last 6 weeks’
Despite these difficulties and challenges, resilient personal values were emphasised:
‘I am proud to work at <organisation name>, dedication, honesty, trust’
Survey of family involvement in care
Responses were received from 331 family members, who reported that their relative had lived in the facility 1.7 (0.8, 3.1) years. () Total F-involve scores were 46.1±11.9. The scaled (i.e. corrected for missing items, and answers of “not applicable” or “ unsure”) scores were 55.3±11.4.
Respondents were concerned that facilities did not necessarily act on information provided, and suggested solutions to facilitate communication, such as providing family members of new residents with a list of facility contacts.
‘As my mother has been in aged care for over 5 years, at some point in that time some of the information has been supplied. Is it just filed away?’
Like facility staff, family respondents focused on staff mix, turnover and workloads as major challenges impacting communication and care.
‘a lot of staff changes at <facility name> which has confused me let alone my mother who is confused some of the time’
‘I find staff are too busy to talk about family members and that I am a nuisance.’
Family respondents also identified potential to strengthen teamwork.
‘a major problem also appears to be barriers to effective communication and action between different staff categories e.g. nursing, carers, cleaning, kitchen, with each seeming to operate within their own cells most of the time rather than more effectively as a team’
Respondents did emphasise quality aspects of care they observed.
‘The critical aspect of care from my perspective is the quality of affection, respect shown to my mother. It's not so evident in the formal structures but in the minor day-to-day attentions she receives’
Being welcome to visit the facility and participate in the community there was highly valued.
‘Something I appreciate very much is that I feel welcome arriving there at any time and being able to take part in whatever is going on at the time, and, that all the staff are really friendly and willing to assist with any enquiry’
Observation at facilities
The mean score for the OIQ in the 21 facilities was 124.5±8.7. One facility scored below 104 (suggesting quality issues), and 8 scored above 127 (suggesting a quality nursing home). The remaining 12 scored in the typical range.
Field notes emphasised variability within and between facilities.
‘Resident staff interaction was really variable across the facility. Where staff responded well to residents their engagement and communication was caring and appropriate…… while in High Care there was almost no engagement with residents. Staff fed in silence and did not engage with the resident at all’
The physical environment and design was a frequent theme, perceived to have some potential to influence staff work and interactions, as well as resident care. However there was not necessarily correlation between the physical environment and the interactions observed between staff and other staff or residents, or the wellbeing of residents. For example, physical spaces (such as gardens and outdoor areas) were not necessarily accessible or used by residents. Instead, relationships and community were emphasised as having the potential to impact resident wellbeing regardless of the physical environment:
‘Physically lovely facility but quite unfriendly, no obvious evidence of resident engagement in facility’
Communal dining experiences were recognised as often being indicative of the broader impression of community at the facility. Management and leadership was also an important theme in the observers’ field notes, including the influence of visible leadership on the facility. Generally, there was thought to be correlation between the leadership style and the interactions observed in the facility.
‘Calm, serene manager. Calm, serene facility’
Acceptability of measurement tools in this Australian context
Facility staff reported that the survey took a median of 9 (IQR 5, 10; minimum 1, maximum 30) minutes. () Internal reliability of the scales was generally acceptable: Cronbach's alpha was 0.96 for the Shortell Scale, 0.85 for the HTVI-EE, 0.524 for the HTVI-TC and 0.825 for the HTVI items. Shortell scales scores correlated significantly with HTVI-EE (r
0.89, p<0.001) and HTVI-Comm (r
0.72, p<0.001). Staff rated communication was weakly positively associated with the observed care quality (r2
0.097 for the Shortell total scales score; 0.056 for the HTVI-EE and 0.028 for the HTVI-Communication)
Respondents perceived greater relevance of the survey in high level care facilities. Similarly there was concern that the questions may have limited relevant to some groups of staff (such as non-care staff). Some respondents felt that the questions did not allow them to indicate the variability present in their facility.
Family respondents reported that the F-involve survey took a median of 5.5 minutes (IQR 5, 10; minimum 1, maximum 60). Some family respondents contended that “not applicable” should be provided for all questions, feeling that the survey remained too dementia specific. Several respondents felt questions could be answered with yes/no responses.
Research staff using the OIQ questioned the usefulness of the tool. They felt that the tool did not facilitate adequate assessment of the physical environment or communication. Measures of physical spaces (such as gardens and outdoor areas) were difficult to rate and differentiate and the relationship to level of care and resident engagement was difficult to determine. There was great variation in design as well as environment across facilities and this was difficult to assess. The OIQ was not perceived effective in measuring leadership, even though there appeared to be a correlation between the leadership style and the interactions observed in the facility. The influence of visible leadership on staff and residents was described as ‘palpable’ but impossible to score. Research staff felt that the specific staff rostered at the time of observation may influence results, as did the unit type observed at mealtime (eg. high care or low care unit). Applicability of some items in the tool in low level care environments was particularly uncertain.