Leadership in Aged Care

It will require good leadership for Australia to become a successfully ageing society. Over the next twenty years, due to the baby-boomer generation, the number of Australians aged 65 years and over is projected to nearly double from around 3.2 million to approximately 6.2 million people.

This is testament to increased life expectancy from the good nutrition, living conditions, social stability and health care in Australia; but there will also be the accompanying age-related chronic health conditions, including dementia and other degenerative disorders such as macular degeneration, Parkinson's disease and osteoarthritis.

According to Access Economics, the number of people with dementia is expected to more than double from around a quarter of a million Australians in 2010 to over 590,000 by 2030.

The impact of this demographic change upon the community and residential aged care system will be immense, as indicated in the recent Productivity Commission Inquiry Report, 'Caring for Older Australians'. Similar challenges will be experienced in hospitals that are already having difficulties treating older people with dementia and other causes of confusion.

To meet these challenges effectively will require leadership at many levels within the system – from those responsible for ensuring that system capacity is able to keep up with the demands of the expanding ageing population; executive level management responsible for putting organisational leadership to ensure strong workforce is in place for quality and safe care; and to middle managers responsible for ensuring that their individual units are functioning efficiently, effectively, and utilising 'best practice'.

There are already concerns that leaders in Australia are not adequately addressing aged care issues. Although we await the Government's response to the Productivity Commission Inquiry, concerns about the organisation and co-ordination of the aged care system have been repeatedly expressed in various reports over the last decade, such as the 2004 Hogan review, without significant change being enacted. Certainly there are enlightened leaders within aged care, but the concern is that aged care issues are not being adequately addressed by leaders within the mainstream.

Poor workforce planning is also an issue. Aged care is heavily reliant on adequate numbers of well-trained staff for optimal performance in the health, community, and residential sectors. There are, however, already well-documented deficiencies in the aged care workforce and it is not just numbers; it is also skills within the workforce and the fact that the workforce itself is an ageing one. The issue is certainly not being ignored by leaders, but the response to date has been piecemeal and inadequate to address not only the current deficiencies but also the projected increased demands over the next 20 years.

It is not clear whether mainstream leaders understand that the business model of obtaining efficiencies in an industry by staff reductions compensated for by technological improvements does not work in aged care.

For the foreseeable future, new technology is not going to replace the interpersonal skills of dedicated professional health, welfare and other community workers. Instead, new technology such as the robot seal Millie used in dementia care will assist staff in providing higher quality care.

So if the ageing population is going to double in the next 20 years, the workforce will need to double just to remain on par with the current struggling situation.

There is also a lack of adequate mainstream appreciation that aged care environments need to be better designed for an ageing population. Even the places that you might think would be most likely to be user friendly for older people are deficient.

Hospitals are poorly designed for older people despite around 50% of patients being over 65 years of age. Many hospital environments have long been known to increase confusion in patients, particularly those with dementia and sensory deficits, and yet very little has been done to systemically improve hospital design. Indeed it was only earlier this year that the world's first 'elder-friendly' acute hospital, the Royal Jubilee Patient Care Centre, was opened on Vancouver Island.

Similarly in the residential aged care sector where the majority of residents have dementia, many new facilities do not adhere to the well-established design principles for people with dementia. Interestingly, this research found that active involvement of aged care nurse managers in the design process was associated with better design outcomes. A barrier for leaders in both sectors is the increased cost of appropriate design, but such design is associated with better outcomes and may reduce the risk of acute confusion, falls, and injuries such as hip fractures. It needs leaders with the right vision to ensure that such designs are regarded as being mainstream.

Another feature of leadership in the aged care workforce is the importance of middle management in hospitals, residential aged care facilities and community aged care programs. In each of these settings middle managers are responsible for the organisation of the care of 30 or more older people and a similar number of staff. Effective middle managers need to have mastered a complex mix of knowledge and skills related to ageing, dementia and other aspects of aged care, and general management as well as having the right attitudes towards older people and staff.

A recent review of aged care middle management leadership found that strong, effective leadership is critical in improving job satisfaction, workforce retention, care quality, patient outcomes, and reducing the associated costs. The review noted that, "the essential attributes of good leadership for aged care middle management are a hands-on accessibility and professional expertise in nurturing respect, recognition and team building, along with effective communication and flexibility." But it was noted that this couldn't develop effectively in isolation as "successful leadership and management outcomes depend on coherent and good organisational leadership."

However, there is inadequate preparation for middle management leadership roles in the aged care sector and a lack of clear guidelines and key performance indicators to assess leadership and management skills. It is a challenge for employers to find staff with adequate knowledge, skills and experience. Too often a person without adequate aged care or managerial experience is appointed due to the lack of better alternatives. Aged care is not as popular as working in other health and welfare sectors and so it suffers from lack of competition in job applications.

The way forward is to systematically develop middle management leadership skills in aged care. In the context of a research project funded by the Australian Research Council and led by Associate Professor Jeon from the University of Sydney, an Aged Care Clinical Leaderships Quality Framework was developed and validated using a Delphi survey and consultations from a National Aged Care Clinical Leadership Consortium comprising of representatives from key government and non government organisations, aged and community care, industry and consumer and professional bodies.

The framework comprises eight key components, which have subsequently been used to guide the development of the Clinical Leadership in Aged Care program. Working in partnership with Baptist Community Services NSW and ACT, the program is well underway and its results are yet to be reported.

There are many challenges ahead for Australian aged care leaders but perhaps most importantly it is the mainstream political, public service and business leaders that need to get a better understanding of what needs to be done and to ensure that it happens properly and with some urgency.