FIONA CASSIE caught up with some nursing leaders as facilities headed down the home straight in a race to meet the deadline to train nurses in an already time and resource-stretched sector.
Getting enough nurses to be proficient with the new electronic interRAI tool by the Government’s 1 July deadline was a tight race.
Some facilities crossed the finish line early; others made it after hard slog; some got there only after considerable panic, with nurse turnover undermining their best efforts to be prepared.
Training courses were run right up to 1 July and will continue for some time to ensure nurses are competent in the clinical assessment tool – a 53-hour process that is costly both in time and resources. Concerns about lack of government support for its own project prompted a backlash from the aged care sector during contract talks last year, leading to a post-budget, pre-election funding boost for ongoing interRAI support, which started from 1 July this year (see timeline sidebar for details of interRAI funding).
The Ministry of Health reported that 2,302 registered nurses had reached interRAI competency as at 21 May and it expected to exceed the project target of 2,370 and have 2,500 RNs trained by July. It appears the problem a number of facilities face is not getting nurses interRAI trained, but retaining them, said aged care nurse practitioner Dr Michal Boyd.
Boyd was the lead researcher for an initial demonstration trial of interRAI in residential aged care in Waitemata and Bay of Plenty DHBs back in 2008. She has always believed the standardised interRAI assessment tool could bring rewards, as long as effort was put in to making the electronic tool user-friendly for time-pressured nurses. “They have succeeded in training staff in residential aged care for interRAI, that is true,” said Boyd. “And they have succeeded in people doing interRAI in residential aged care, but at different levels depending on the facility and how up to speed they are.”
She said a major dilemma for facilities with interRAI is the huge turnover of nursing staff. “I was talking to one facility manager who said she has trained five nurses in interRAI and only one of them still remains at the facility.” Boyd said high turnover is now an ongoing issue as residential aged care is a relatively low-paid sector and if nurses get an opportunity for higher pay or better shifts they will take it.
Staff turnover of interRAI-trained nurses has hit Metlifecare’s eight facilities hard, said Amanda Iavarone, an experienced aged care nurse who is Metlifecare’s clinical quality and risk manager.
She said all of its facilities have lost interRAI-trained staff and had to start over and train more, with the result being in early June they had 14 of the 35 interRAI-competent RNs that they required.
Iavarone said Metlifecare was one of the first providers to get on board with interRAI and the initial response had been positive. “This has changed now…”
Hilda Johnson-Bogaerts, an experienced aged care sector who is general manager of residential and community care for the Selwyn Foundation’s 10 facilities, said it also had had to train”a few more nurses than initially envisaged” because of staff turnover.
However, it had also been able to recruit some trained interRAI nurses and had been able to meet the ratio of interRAI-competent RNs set by the DHB, “which I’m confident will be sufficient”. She said it had initially thought that all its primary nurses with a care-planning caseload needed to be interRAI proficient, but after gaining more experience with interRAI, that was no longer the goal.
“We may have interRAI-trained nurses preparing the assessments for the primary nurses, who can then use the information to further work on their residents’ care plans.”
Sylvia Meijer, an older adult nurse practitioner, said most of the facilities she worked with in Horowhenua had the majority of RNs trained and appeared to have systems in place to ensure they met the deadline.
Audit and hardware
Early in the interRAI journey much of the frustrations were IT-based in a largely low-tech health sector – and the length of time interRAI assessments take.
Boyd said an ongoing struggle has been integrating the electronic interRAI tool with facilities’ existing IT systems or, in some cases, facilities that still largely operate a paper-based system. She said another conundrum for facilities has been that, prior to interRAI becoming mandatory, auditors have not recognised interRAI data for certification and spot audit purposes, so facilities already using interRAI have had to double-up and continue with traditional assessment reporting, as well as interRAI.
Johnson-Bogaerts said all Selwyn facilities now have Wi-Fi internet access and at least one COW (computer on wheels) but government funding had not been enough to cover the hardware or the backfill cost to cover training and ongoing increased demand on staff time.
Iavarone said Metlifecare facilities are using desktop PCs to carry out interRAI and thinks the government investment in hardware was “enough”. But she said a lot of the RNs “aren’t very computer savvy”, seeing hands-on care as their priority, and find interRAI assessments take a very long time.
Meijer said there was initial reluctance by some nurses because of the IT requirements of interRAI and she still hears occasional comments by nurses about the time interRAI assessments take. Nurses also talk about finding it hard to concentrate on completing assessments, she said, because facility computers are often in a busy office, leading to many interruptions.
Boyd said another conundrum for facilities has been that auditors have not recognised interRAI data for certification and spot audit purposes; so facilities already using interRAI have had to double-up and continue with traditional assessment reporting as well as interRAI. Auditors are now officially considering how facilities are using interRAI assessments to inform care planning.
Meijer agreed, saying most facilities she deals with still have separate care plans and IT compatibility with organisational policy sees some facilities continue to simultaneously operate an electronic and paper system.
Next step: using interRAI for care planning
Boyd said the next step, now that interRAI training has been established, is to really focus on using interRAI assessment findings to inform care planning.
Currently, nursing staff often view interRAI as too time-consuming and tedious, said Iavarone, and don’t always see the big picture of what interRAI can offer.
“In theory, interRAI is excellent, and of course in time when everyone is trained and faster at doing the assessments then things will run more smoothly,” she said.
“In reality, there are many RNs who are struggling with this, those older RNs who aren’t tech savvy, or those with English as a second language – often both. So far there isn’t a great benefit for our residents that we have found.”
Meijer said interRAI is helpful in her NP role as it provides more detailed information on residents that is used as a basis to discuss care with the client and/or staff. She has noticed some variability in interRAI skills among nursing staff, with some RNs more “confident and competent” to do assessments and others needing additional teaching.
“Assessments in general should be person-focused, but as a starting point, interRAI is helpful to have a level of consistency and rigour throughout the country,” she said, about the now-mandatory tool.
Johnson-Bogaerts said Selwyn nurses also initially felt that the increased time spent on interRAI assessment was taking them away from actual ‘hands-on’ caring for residents.
“Now that they have more experience in using the tool, there is greater understanding of how the evidence-based interRAI assessments contribute to improved care planning and, ultimately, to improved care,” said Johnson-Bogaerts.
“InterRAI enables nurses to quickly focus on health issues and plan care interventions to improve or prevent the issue from getting worse.”
Nonetheless, she expected there to be increased pressure on nurses’ time for a period post-1 July as they work to ensure all existing long-term residents have an interRAI assessment.
With the finishing line having finally being crossed, it may still be some time before the country’s residential aged care facilities can catch their collective breath and decide whether they’ve won the race.