Royal Commission Submission
The following submission was lodged with the Royal Commission into Aged Care Quality and Safety to explain the explore the issue of volunteering with respect to the Commission's terms of reference.
The submission was written by Sam Bookatz, on behalf of Aged Care Volunteering Australia.
Aged Care Volunteering Australia is a not for profit organisation established to promote the benefits of volunteering programs at aged care homes and to facilitate research into advancements in aged care volunteering. We believe that volunteering programs are an untapped, yet highly valuable resource in achieving the desired improvements to Australia’s aged care system.
There has been much discussion about the role that the public and private sector can play in improving the lives of aged care residents, but we believe that it is vital that the “third sector”, the volunteers at aged care facilities, be given greater voice in the conversation (Lohmann, 2013). There are currently 366,000 paid workers in aged care and 68,000 volunteers, but we believe this number could be much higher in the future with proper investment in promoting and improving volunteering programs (Aged Care Financing Authority, 2019). It is our view that aged care residents, aged care service providers and the Australian taxpayer are currently largely missing out on the benefits that volunteers can provide to a range of outcomes because of a lack of investment by providers in quality volunteering programs and a lack of research into volunteering in the aged care sector.
Investing in practical measures to promote volunteering in aged care, including supporting research programs, can yield high value outcomes, especially in comparison with the small initial and ongoing financial investment required. Volunteering programs can provide significant support to the existing aged care staff, and potentially encourage more people to consider a carer’s career. It provides much needed links into broader communities enabling aged care residents to remain connected, with practical and mental health benefits, particularly with respect to making aged care more person-centred, as well as enhancing the volunteers’ sense of purpose and connection to community. There is also the potential for a standardised approach nationally encouraging a greater uptake of volunteering programs to complement existing measures.
This submission will address the following Terms of Reference with respect to the potential benefits from enhancements in aged care volunteering programs:
a) The quality of aged care services
b) Future challenges and opportunities for delivering accessible, affordable and high-quality aged care
c) How best to deliver aged care services to Australians living with dementia
d) What the Australian Government, aged care industry, Australian families and the wider community can do to strengthen the aged care system
e) How to ensure that aged care services are person-centred
f) How best to deliver aged care services in a sustainable way
A) The quality of aged care services
Volunteers can immensely improve the non-clinical aspects of the quality of aged care, particularly with respect to improving residents’ sense of self and community, mental heath and preventing social isolation, neglect and abuse.
Over the past decades there has been a significant shift in thinking about what care means from a physician-centred, clinical approach towards a patient-centred approach and more recently to a person centred approach. This is in line with the biopsychosocial model of health which views social and psychological factors as being just as important as biological factors in assessing the quality of care (WHO, 2013). While failures of aged care services to properly look after the physical health of residents are certainly shocking, perhaps even more regrettable is the prevalence of mental health conditions among residents. A 2013 Australian Institute of Health and Welfare (AIHW) study found that 52% of all permanent aged care residents had mild, moderate or major symptoms of depression when they were last appraised (AIHW, 2013), whereas it is estimated that only 10-15% of older Australians still living in the wider community experience depression or anxiety (Haralambous et al. 2009). This fivefold increase can be explained according to many factors that change when an older person moves from their home into aged care, including loss of control over routine and diet, becoming physically separated from the wider community and the stress of adjusting to an unfamiliar, busy and often clinical-seeming living environment with little focus on individualised care (Moyle et al. 2008). These factors are often confounded by grief following the death of a spouse, financial stress from the loss of employment income and the loss of independence following the deterioration of mental and physical faculties (WHO, 2013).
While it is true that volunteers cannot take the place of qualified nursing and medical staff in administering clinical care, volunteers can make a significant contribution to improving the psychological and social health of aged care residents. One of the only studies into the impact of volunteering programs in Australian aged care homes to date was conducted by the University of Western Sydney in conjunction with Catholic Healthcare in 2017. The study, although limited by its small sample size, proved that the involvement of volunteers was instrumental in assisting with the multifaceted mental health challenges faced by residents, with the volunteers providing many residents’ only source of regular connection and contact with the outside world. Additionally, the study demonstrated the effectiveness of a properly designed and resourced volunteer program in assisting aged care residents to recover their sense of self, identity and dignity (Narchal et al. 2017). When residents are matched with the right volunteer, volunteers are properly trained to provide support and there is regular interaction over a substantial length of time between the same volunteer and resident, then the connection between volunteer and resident can facilitate a process of ‘re-living’, helping the resident to achieve a new sense of belonging and affirming the resident’s enduring sense of place in the world, validating their worth as human beings.
Volunteers can additionally play a vital role in addressing the mistreatment and abuse of residents, a theme specifically highlighted in the Commission’s Terms of Reference. Volunteers are able to fulfil the function of check-in point and advocate for aged care residents who do not have regular visitors. Studies have shown that volunteers at aged care homes tend to approach their role with passion and conscientiousness, and when paired with one resident over a longer duration tend to form a close bond (Narchal et al. 2017). These volunteers also tend to take a very proactive approach to monitoring the health and wellbeing of the residents they are assigned to, which as well as resulting in the more expedient addressing of physical health issues through volunteers raising concerns with clinical staff, can also bring about the identification and escalating of concerns the volunteers may have about the clinical care itself, including abuse and neglect. Volunteers can often raise the concerns of residents, and make sure concerns are acted on, in a way that the residents themselves are unable to.
B) Future challenges and opportunities for delivering accessible, affordable and high-quality aged care
Volunteering is a low-cost option for improving a range of outcomes in aged care, with properly trained volunteers able to take significant pressure off paid staff.
The key challenge facing the delivery of aged care is the economic cost of meeting exponentially growing demand while lifting the quality of service. Because of Australia’s aging population, it is expected that by 2039 demand for residential care places will double from the current level of around 180,000 to 360,000 (Aged Care Financing Authority, 2019). One of the factors that has been consistently identified in the research over the past thirty years into the ways in which aged care services have been failing residents has been a shortage of staff and resourcing (Woodley, 2019). Introducing volunteer programs and enhancing existing programs at aged care homes is a low-cost model to achieve the dual objectives of improving the quality of residents of nursing homes without taking on additional staff, as well as increasing capacity overall, with volunteers able to share some of the load of non-clinical aspects of providing care, specifically with respect to providing regular human contact, emotional support and providing a point of contact for the residents’ cares and concerns (Narchal et al. 2017).
It is our view that volunteering is a potentially enormously valuable and currently largely untapped resource in increasing Australia’s capacity to deliver affordable and high-quality aged care moving forward. While there are currently 68,000 volunteers in aged care nationally, our experience has been that established volunteering programs are confined mostly to private homes with a religious affiliation and those in suburbs with a higher socio-economic demographic (Aged Care Financing Authority, 2019). Yet, even these established programs are often hindered by a lack of investment in training volunteers or having effective support structures in place, with volunteers feeling they could be better utilised if they had more direction and support (Narchal et al. 2017). For the vast majority of homes which do not have volunteering programs, we believe the reason is not that there is a lack of individuals who are willing to volunteer at a local aged care home in the relevant community. The main issue we have found is that too many homes, particularly new homes run by large corporate entities, are unwilling to establish and invest in volunteering programs because they are unaware or sceptical of the immense benefits that both they and their residents could reap from volunteers. For example, we have visited new and otherwise very impressive facilities that are not even built with any activity or meeting rooms where volunteering programs could take place.
As such, a comprehensive study into the benefits of volunteering programs could result in wholescale positive change in the aged care industry by conclusively demonstrating the ways in which well structured programs improve outcomes for residents, paid workers and management alike. Our experience is generally that once the facilities and structures for a volunteering program exist, finding volunteers is relatively easy, and can be as simple as putting up notices in local community centres and houses of worship. But the process needs to start with the homes themselves seeing the need for volunteers, and thus the funding of research and other measures by the Royal Commission to encourage homes to establish and invest in volunteering programs has the potential to dramatically increase the numbers of volunteers at aged care homes nationally, and result in significant improvement to health and wellbeing outcomes from a relatively small financial outlay, both from in public funding and from the care providers.
C) How best to deliver aged care services to Australians living with dementia
Studies have proven that volunteers assisting older Australians with dementia can improve a range of aspects of the residents’ care.
Aged care residents living with dementia are just as able to have their quality of care markedly improved by the involvement of volunteers, except with the requirement for volunteers to be properly trained being even more important. A 2016 study by Rural and Remote Health (RRH) found that after establishing a relatively inexpensive training program, volunteers were able to substantially improve a range of outcomes for patients with dementia at rural hospitals. These included reducing the patients’ length of stay, increasing the awareness of pain that was being untreated, and also likely reducing the incidence of falls. In addition to the benefits experienced by patients, the study reported that 100% of the volunteers found the experience of volunteering over six months positive and meaningful. (Bateman et al. 2016). Crucial to the success of such volunteering programs is the resources being made available to train volunteers in how to provide support to someone who is suffering from dementia. The findings of the RRH study suggest that similar positive outcomes could be experienced by patients in aged care facilities, but to confirm this a specific research study into volunteers assisting residents of aged care homes with dementia would need to be carried out. Such a study could have a significant effect in encouraging aged care homes to expand their volunteer programs to include dementia wards, which currently mostly lack the involvement of volunteers.
D) What the Australian Government, aged care industry, Australian families and the wider community can do to strengthen the aged care system
Enhancing volunteer programs will require a collaborative effort, with the government funding studies into improving volunteering programs, the aged care industry establishing and resourcing programs at homes, and the wider community putting their hands up to volunteer.
Aside from the economic advantages, one of the key appeals of investing in volunteer programs as opposed to merely increasing staff numbers is that volunteering programs directly involve the wider Australian community in caring for the older members of our community, which is ultimately a burden that we should share collectively as a nation. Research into the experience of volunteers at aged care homes can show that it can benefit the volunteers as much as the residents in providing an enhanced sense of purpose, connection and community (Bateman et. al, 2016). Often volunteers are motivated by having an elderly parent or grandparent in a home and a want to contribute to the system that is supporting them, or have found themselves in a situation where they have extra time and resources on their hands (such as stay-at-home parents after their children have left the house) and are looking to ‘give back’, or are themselves part of a group that is at increased risk of isolation, with volunteering providing them a meaningful way to reconnect. Volunteering in aged care is attractive to a wide section of the population because ultimately all Australians will at some point in their life reach a point when they will require care and support, thus the value of assisting a vulnerable older Australian who is without other support is not difficult to appreciate for most people. However, in order for more members of the wider Australian community to play a direct role in supporting aged care workers and strengthening the aged care system, there needs to be greater adoption of volunteering programs across a border range of homes and there needs to be investment in appropriately training and supporting volunteers, so that each volunteer can make the greatest impact.
Expanding the role of volunteers in the aged care sectors is an objective in which the government, the aged care industry and the wider community all have a role to play. The process needs to start with the public sector, including through this Royal Commission, releasing recommendations in favour of the uptake and enhancement of volunteering programs (and guidelines with respect to best practice for volunteering programs), and also providing funding for pilot studies into the benefits of volunteering programs at aged care homes as well as a cross-comparative study of the different models of volunteering. We have approached several academic and research institutions to encourage them to conduct further research into volunteering in aged care. While the responses have been very enthusiastic and supportive of the notion that volunteers are capable of performing a larger role than at present, the institutions have noted that they are waiting for the Royal Commission to release its findings and recommendations before making any significant new investment in research. The Commission’s report, and any funding it may decide to allocate to researching volunteering, could thus instigate the conducting of research that could be used to encourage aged care providers to set up, expand and enhance volunteering programs. Once the aged care homes have responded by implementing such programs, it will then be up to the wider community to increase participation by signing up to volunteer, which we are confident will occur once the infrastructure is in place. Increasing and improving volunteering in aged care will thus involve a true collaboration across the various levels of Australian society, yielding tremendous benefits for all.
E) How to ensure that aged care services are person-centred
Properly trained and resourced volunteers can significantly shift the focus of care to becoming more person-centred, with volunteers having a genuine interest in the wellbeing and needs of the individual residents they assist, becoming a friend, advocate and check-in point.
Implementing a well-structured and well-resourced volunteering program where properly supported volunteers are assigned to a patient over a substantial duration of time is perhaps the single most significant step an aged care facility can take in ensuring its services are person-centred. The fundamental characteristics of person-centred care are understanding the patient as a unique human being rather than just part of a system, looking at each patient’s wellbeing as a whole rather than focusing just on medical conditions, and taking into account each individual’s beliefs, preferences, background and communication style (Santana et. al. 2017). Studies into the success of healthcare systems in moving towards a person-centred model have identified a shortage of staff as the single most significant obstacle, with a lack of training also limiting progress (Pelzang, 2010). The reason why volunteers are in many ways better placed to provide a person-centred approach to care stems from the way their motivation differs from that of clinical staff. The primary motivation of clinical staff is to fulfil the requirements of their job to a satisfactory standard, which is often measured in clinical and quantifiable terms. Conversely, volunteers are motivated by a desire to improve someone’s quality of life, make a meaningful contribution to a cause and to establish a genuine human connection. That volunteers are naturally geared towards providing person-centred care is reflected by the experience of one volunteer in the 2016 RRH study:
The benefits I experienced working with the patients [included seeing] the change they go through. Some patients on the program, when first admitted are anxious, insecure, suspicious and lacking of trust. After a period of time with them, one sees the unfolding of trust, love, respect and cooperation. Very rewarding (Bateman et al. 2016)
The ability of a volunteer, as part of the network of individuals involved in the care of an aged care resident, to ensure that the care being received by the resident is person-centred is dependent on that volunteer being properly trained, paired with a resident who is a good personality fit, having regular contact with the resident over a sustained period of time and having a line of communication with the clinical staff who are involved with that patient’s care. When these conditions are met volunteers can establish a relationship of mutual understanding, empathy and support with aged care residents, allowing them to better understand and advocate for the resident’s needs as well as making the resident feel validated as an autonomous human, and not just part of a system. The involvement of volunteers is also conducive to shifting towards person-centred care because volunteers can be paired with individual residents in such a way that ensures that the individual resident is the only focus of the volunteer’s concern, preventing patients slipping through the cracks of the system. This is impossible with paid staff who invariably have to be responsible for a large number of residents and have their attention pulled in different directions. Person-centred care is thus an area of concern where the implementation of properly resourced and structured volunteer programs is uniquely placed to advance the goals of the Royal Commission.
F) How best to deliver aged care services in a sustainable way, including through innovative models of care, increased use of technology, and investment in the aged care workforce and capital infrastructure
Volunteering programs are a sustainable and affordable way to improve the quality of aged care services, and require a much smaller outlay than taking on large numbers of additional staff or widespread deployment of new technologies.
The ratio between the financial investment that would be needed to implement, expand and improve volunteering programs and the benefits that such expansion could yield for the outcomes outlined in the Royal Commission’s terms of reference make it a compelling proposition. Additionally, the relatively low cost to aged care providers of implementing and supporting volunteer programs compared with the potential for reducing the burden on paid workers make it a highly sustainable way to bring about long term improvements to care. We have no doubt that new technology and investment in other forms of capital have great potential to improve the lives of aged care residents in various ways, and to assist in the clinical treatment of aged care residents. However, these will require a much more significant financial investment than the relatively low cost of a comprehensive research program designed to encourage the uptake of volunteer programs, and ultimately technology is not a substitute for the human involvement required to achieve the goals of reducing social isolation, improving patients’ mental health, making care more person-centred and preventing neglect and incidents of aged care residents slipping through the cracks of the system. A larger population of better trained and supported volunteers could become an increasingly valuable component of the overall ‘capital’ of the aged care system moving forward.
A stronger partnership between the government, aged care providers and the third sector of volunteers could yield substantial and long-term benefits for a range of outcomes identified in the Royal Commission’s terms of reference, including improving the quality of aged care services, making aged care affordable and accessible, making aged care more person-centred, involving the wider community and investing for the future of aged care in a sustainable way. At present, the limited extent and effectiveness of volunteer programs at aged care homes in Australia is not due to a shortage of members of the public who are willing and able to volunteer, but more because too few homes have invested in volunteer programs and those programs that do exist are often poorly thought out or under resourced, with volunteers lacking the training and support to provide the person-centred ongoing care to individual residents which the volunteers are willing and able to provide in the right conditions. The research that has been conducted to date shows overwhelmingly that volunteering in aged care homes has a profound and meaningful benefit for both the volunteers and the residents. However, this research has been limited in its scope, and in order for more aged care providers to be encouraged to invest in volunteering programs, there is an urgent need for further research to be undertaken.
Research institutions are waiting for the findings and recommendations of the Royal Commission before considering undertaking such an investigation. As such, we would strongly encourage the Royal Commission to support funding for pilot research programs into volunteering in aged care homes, and as part of its report to take a comprehensive look at the topic of the third sector, producing appropriate guidelines and recommendations with respect to aged care volunteers. The government, aged care providers, aged care residents, future volunteers and the wider community have so much to benefit if we can work together to expand and enhance the involvement of the third sector in aged care.
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