CHCAC318A Work Effectively With Older People WBK

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Document Name: CHCAC318A Work effectively with older people WBK Created Date: 10 Dec 2008
Document No: Version No: V1 Last Modified Date: 30 Jan 2009
John Bailey 2008 Page Sequence: Page 2 of 215

CHCAC318A.
Work effectively with older people
Author
John Bailey
Copyright

Text copyright 2009 by John N. Bailey.
Illustration, layout and design copyright 2009 by John N. Bailey.

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CHCAC318A. Work effectively with
older people
CONTENTS

Description: .................................................................................................................................................... 8
ABOUT THIS UNIT OF STUDY INTRODUCTION. .................................................................................................................... 8
THIS LEARNING GUIDE COVERS: .................................................................................................................................... 8
LEARNING PROGRAM: .................................................................................................................................................. 8
Additional Learning Support .......................................................................................................................... 9
Facilitation ..................................................................................................................................................... 9
Flexible Learning .......................................................................................................................................... 10
Space ............................................................................................................................................................ 10
Study Resources ........................................................................................................................................... 10
Time ............................................................................................................................................................. 10
Study Strategies ........................................................................................................................................... 11
Using This Learning Guide. ........................................................................................................................... 11
THE ICON KEY ................................................................................................................................................ 12
THE SUPPLEMENTARY ICONS ......................................................................................................................... 13
How to Get the Most out of Your Learning Guide: ....................................................................................... 14
ADDITIONAL RESEARCH, READING AND NOTE TAKING....................................................................................................... 14
EMPLOYABILITY SKILLS ................................................................................................................................ 15
PERFORMANCE CRITERIA ............................................................................................................................... 19
SKILLS AND KNOWLEDGE ............................................................................................................................... 22
Required Knowledge .................................................................................................................................... 22
Required Skills .............................................................................................................................................. 23
RANGE STATEMENT. ...................................................................................................................................... 24
EVIDENCE GUIDE ............................................................................................................................................ 26
1. APPLY UNDERSTANDING OF THE STRUCTURE AND PROFILE OF THE RESIDENTIAL AGED CARE
SECTOR .......................................................................................................................................................... 28
INTRODUCTION. ........................................................................................................................................................ 28
Working Definitions ..................................................................................................................................... 28
1.1 CONDUCT WORK THAT REFLECTS AN UNDERSTANDING OF THE KEY ISSUES FACING OLDER PEOPLE AND THEIR
CARER/S 29
Who are the primary carers? ....................................................................................................................... 31
Demands and consequences of caring work ................................................................................................ 31
Implications for policy and practice ............................................................................................................. 33
Carer health and well-being survey 2007..................................................................................................... 33
1.2 CONDUCT WORK THAT REFLECTS AN UNDERSTANDING OF THE CURRENT PHILOSOPHIES OF SERVICE DELIVERY IN THE
SECTOR 34
1.3 RECOGNISE THE IMPACT OF AGEING DEMOGRAPHICS ON FUNDING AND SERVICE DELIVERY MODELS. .............................. 39
Ageing .......................................................................................................................................................... 39
Demography of Ageing ................................................................................................................................ 40
Global Ageing ............................................................................................................................................... 40
Life Expectancy ............................................................................................................................................. 40
Figure 1a: Life Expectancy for Women* ....................................................................................................... 41
Figure 1b: Life Expectancy for Men* ............................................................................................................ 42


Biology of Ageing ......................................................................................................................................... 42
Table 2: Some theories of Ageing ................................................................................................................ 44
1.4 CONDUCT WORK THAT REFLECTS AN UNDERSTANDING OF CURRENT LEGISLATION....................................................... 44
Table 3: Employee and employer responsibilities ........................................................................................ 45
The Workers Common Law Obligations ...................................................................................................... 45
The Employers Common Law and Statutory Obligations ............................................................................ 45
Statutory framework within which work takes place .................................................................................. 46
Residential aged care service standards ...................................................................................................... 48
Home and Community Care National Service Standards ............................................................................. 49
Residents' rights ........................................................................................................................................... 49
Activity 1: ..................................................................................................................................................... 52
Activity 2: ..................................................................................................................................................... 54
Activity 3: ..................................................................................................................................................... 55
Activity 4: ..................................................................................................................................................... 56
2. APPLY UNDERSTANDING OF THE HOME AND COMMUNITY CARE SECTOR ............................................ 57
2.1 DEMONSTRATE BROAD KNOWLEDGE OF POLICY AND PROGRAMS SUCH AS HACC, DVA AND GOVERNMENT
COMMUNITY CARE DIRECTIONS ..................................................................................................................................... 57
Delivery of Aged Care ................................................................................................................................... 59
Figure 3: Australias Aged care framework. ................................................................................................. 59
Residential aged care ................................................................................................................................... 60
Community based care ................................................................................................................................ 60
Key points of an Aged Care Profile of Australia ........................................................................................... 60
Aged care represents a social product system ........................................................................................... 61
A profile of older Australians requiring care ................................................................................................ 62
Need for care................................................................................................................................................ 62
Figure 4: Need for assistance and living arrangements of older persons .................................................... 63
Figure 5: Need for assistance by age of older persons, 2003 ....................................................................... 64
Data source: ABS (Survey of Disability, Ageing and Carers: Summary of Findings, Cat. no. 4430.0). .......... 64
Income and wealth....................................................................................................................................... 64
Accommodation arrangements ................................................................................................................... 65
Types of care ................................................................................................................................................ 65
Community care ........................................................................................................................................... 65
Table 3: Profile of main community care programs ..................................................................................... 66
Residential care ............................................................................................................................................ 67
Table 4: Characteristics of permanent residential care clients .................................................................... 68
The role of government in aged care ........................................................................................................... 69
Current policy and legislative framework .................................................................................................... 69
The main areas of regulatory control .......................................................................................................... 71
Funding services ........................................................................................................................................... 72
Table 5: Recurrent government expenditure on aged care programs in Australia, 2006-07 ....................... 73
Setting prices ................................................................................................................................................ 75
Regulating quality ........................................................................................................................................ 76
Table 6: ........................................................................................................................................................ 77
Recent trends in aged care ........................................................................................................................... 77
Increasing numbers of older Australians requiring care .............................................................................. 77
Figure 6: Numbers of older Australians, 1996-2007 .................................................................................... 78
Figure 7: Government real expenditure on selected social services ............................................................. 79
Greater reliance on user contributions ........................................................................................................ 79
Increasing emphasis on community care ..................................................................................................... 80
Figure 8: Aged care places and packages .................................................................................................... 80
Increasing support for carers ....................................................................................................................... 81
Greater proportion of residents in high level care ....................................................................................... 81
Decreasing number of small facilities .......................................................................................................... 81
Table 8: Number and size of residential aged care facilities, 1998 and 2007 .......................................... 82
Increasing investment by private for-profit providers.................................................................................. 82
Table 9.......................................................................................................................................................... 84


2.2 COMPLY WITH DUTY OF CARE IMPLEMENTATION IN HOME AND COMMUNITY SETTINGS AND WORKER ROLES ................... 87
Duty of Care ................................................................................................................................................. 87
Standard of Care .......................................................................................................................................... 87
Duty of Care and Negligence ....................................................................................................................... 88
Breach of Duty of Care ................................................................................................................................. 89
Duty of Care Dilemmas ................................................................................................................................ 89
Access and equity in aged care .................................................................................................................... 89
Anti-discrimination in aged care .................................................................................................................. 90
Complaints mechanisms .............................................................................................................................. 90
Figure 9: Sample complaints/suggestions form ........................................................................................... 91
2.3 DEMONSTRATE BROAD KNOWLEDGE OF AGEING IN PLACE .................................................................................. 93
Challenging personal values and attitudes .................................................................................................. 93
Table 10: Myths about Ageing ..................................................................................................................... 94
Stereotypes .................................................................................................................................................. 94
Media ........................................................................................................................................................... 95
Language of ageing ..................................................................................................................................... 96
Perceptions of aged people among health professionals ............................................................................ 96
Ageing as an individual process-coming to terms with the ageing process ................................................. 97
The Care Plan ............................................................................................................................................... 99
The Planning Process ................................................................................................................................... 99
Figure 10: Sample Care Plan. ..................................................................................................................... 100
AIDS ..................................................................................................................................................................... 101
Other .......................................................................................................................................................... 105
Monitoring ................................................................................................................................................. 107
Progress Notes ........................................................................................................................................... 107
3. DEMONSTRATE COMMITMENT TO THE PHILOSOPHY OF POSITIVE AGEING ...................................... 108
INTRODUCTION ....................................................................................................................................................... 108
Table 11: Ten Principles of a Positive Ageing Strategy .............................................................................. 109
Table 12: Ten Priority Goals of a Positive Ageing Strategy ........................................................................ 110
3.1 TAKE INTO ACCOUNT PERSONAL VALUES AND ATTITUDES WHEN PLANNING AND IMPLEMENTING WORK ACTIVITIES ......... 111
Fundamental Principles for Caregiver Assessment .................................................................................... 112
Guidelines for Practice ............................................................................................................................... 112
Table 13: Recommended Domains and Constructs .................................................................................... 114
3.2 RECOGNISE AND MANAGE AGEIST ATTITUDES THROUGH THE SUPPORT OF THE APPROPRIATE PERSON........................... 118
Activity ???? ............................................................................................................................................... 118
Our Attitudes .............................................................................................................................................. 119
Table 13: Cultural Awareness .................................................................................................................... 120
Table 14: Critical Thinking .......................................................................................................................... 120
Gerontophobia ........................................................................................................................................... 121
Table 15 Ageing: Myth Versus Fact ............................................................................................................ 121
Ageism ....................................................................................................................................................... 122
3.3 RECOGNISE THE IMPACT OF CONSUMERISM ON SERVICE DELIVERY ........................................................................ 123
Table 16: Critical Thinking .......................................................................................................................... 124
Advance Directives ..................................................................................................................................... 124
What does aged care cost? ........................................................................................................................ 125
High-level care ........................................................................................................................................... 125
Low-level care ............................................................................................................................................ 127
3.4 CONDUCT WORK THAT REFLECTS AN UNDERSTANDING OF THE INDIVIDUALITY OF AGEING. ......................................... 128
What makes us age? .................................................................................................................................. 128
The individuality of ageing ......................................................................................................................... 129
Healthier ageing on the horizon ................................................................................................................ 130
3.5 CONDUCT WORK THAT MINIMISES THE EFFECTS OF STEREOTYPICAL ATTITUDES AND MYTHS ON THE OLDER PERSON ........ 131
Understanding Ageing and its Biological and Social Processes ................................................................. 132
Activity xx. .................................................................................................................................................. 135
Activity 11: ................................................................................................................................................. 137
Activity 12: ................................................................................................................................................. 138


4. APPLY UNDERSTANDING OF THE PHYSICAL ......................................................................................... 140
4.1 OUTLINE STRATEGIES THAT THE OLDER PERSON MAY ADOPT TO PROMOTE HEALTHY LIFESTYLE PRACTICES ..................... 140
Figure 10 Persons working in long-term care facilities must have excellent communication skills, .......... 141
Effects Of Ageing ........................................................................................................................................ 141
4.2 TAKE INTO ACCOUNT PHYSICAL CHANGES ASSOCIATED WITH AGEING WHEN DELIVERING SERVICES .................................... 142
Physical Changes in Ageing ........................................................................................................................ 142
Emotional Adjustments to Ageing ............................................................................................................. 142
Table 17 Physical Changes Of Aging .......................................................................................................... 143
Specific Emotional Responses. ................................................................................................................... 145
Figure 10: Residents may exhibit feelings of frustration and anger. ......................................................... 146
Nutritional Needs ....................................................................................................................................... 147
Figure 11 .................................................................................................................................................... 148
Preventing Infections In Residents ............................................................................................................. 148
Figure 12: Encourage fluid intake. ............................................................................................................. 149
Keeping Residents Safe .............................................................................................................................. 151
Other Safety Concerns................................................................................................................................ 152
4.3 RECOGNISE AND ACCOMMODATE THE OLDER PERSONS INTERESTS AND LIFE ACTIVITIES WHEN DELIVERING
SERVICES. 153
Exercise And Recreational Needs ............................................................................................................... 153
Recreation .................................................................................................................................................. 153
Figure 14: There are many exercises that people in wheelchairs can do. ................................................ 154
General Hygiene ......................................................................................................................................... 154
Partial Baths ............................................................................................................................................... 154
Total Baths ................................................................................................................................................. 154
Hand and Foot Care ................................................................................................................................... 154
Guidelines For bathing The Elderly ............................................................................................................. 155
Figure 15: Check Shower Seats and Hydraulic Tub Lifts Before Using Them.............................................. 156
Figure 16: Foot Care Is An Important Part Of Daily Hygiene. ..................................................................... 156
Hair Care .................................................................................................................................................... 157
Facial Hair .................................................................................................................................................. 157
Mouth Care ................................................................................................................................................ 158
Eyes, Ears, and Nose .................................................................................................................................. 158
Mental Changes ......................................................................................................................................... 158
4.4 ASSIST THE OLDER PERSON TO RECOGNISE THE IMPACT PHYSICAL CHANGES ASSOCIATED WITH AGEING MAY HAVE
ON THEIR ACTIVITIES OF AGEING .................................................................................................................................. 159
Caring is about empathy. ........................................................................................................................... 159
Growing old presents a variety of threats to independence ...................................................................... 160
Activity 6 .................................................................................................................................................... 162
5. APPLY UNDERSTANDING OF CHANGES ASSOCIATED WITH AGEING .................................................... 164
5.1 OUTLINE STRATEGIES THAT THE OLDER PERSON MAY ADOPT TO PROMOTE HEALTHY LIFESTYLE PRACTICES ..................... 164
5.2 TAKE INTO ACCOUNT PHYSICAL CHANGES ASSOCIATED WITH AGEING WHEN DELIVERING SERVICES. .............................. 167
Activity 9 .................................................................................................................................................... 168
5.3 UTILISE KNOWLEDGE OF COMMON PROBLEMS ASSOCIATED WITH AGEING WHEN DELIVERING SERVICES. ....................... 168
Osteoporosis .............................................................................................................................................. 169
Arthritis ...................................................................................................................................................... 169
Bladder and bowel ..................................................................................................................................... 171
Breast Cancer ............................................................................................................................................. 172
Figure 17: Diagram of breast ..................................................................................................................... 172
Cholesterol ................................................................................................................................................. 173
Incontinence ............................................................................................................................................... 175
Diabetes ..................................................................................................................................................... 176
Heart Disease ............................................................................................................................................. 179
Irritable bowel syndrome (IBS) ................................................................................................................... 182
Activity 10 .................................................................................................................................................. 184


5.4 ASSIST THE OLDER PERSON TO RECOGNISE THE IMPACT THAT CHANGES ASSOCIATED WITH AGEING MAY HAVE ON
THEIR ACTIVITIES OF LIVING ........................................................................................................................................ 184
Prevention. ................................................................................................................................................. 184
Chronic care. .............................................................................................................................................. 185
Comorbidity. ............................................................................................................................................... 185
Long-term care. .......................................................................................................................................... 185
Best practices across settings of care. ....................................................................................................... 185
Client decision making. .............................................................................................................................. 185
Enhancing Client safety. ............................................................................................................................. 186
5.5 COMMUNICATE SITUATIONS OF RISK OR POTENTIAL RISK ASSOCIATED WITH AGEING TO THE OLDER PERSON. ................. 186
Ask Yourself ................................................................................................................................................ 187
Older people and risk ................................................................................................................................. 187
Confidentiality ............................................................................................................................................ 188
6. SUPPORT THE RIGHTS AND INTERESTS OF OLDER PERSON .................................................................. 189
6.1 ENCOURAGE AND SUPPORT THE OLDER PERSON AND/OR THEIR ADVOCATE/S TO BE AWARE OF THEIR RIGHTS AND
RESPONSIBILITIES ..................................................................................................................................................... 189
Traditional meaning ................................................................................................................................... 189
How is advocacy undertaken? ................................................................................................................... 190
6.2 CONDUCT WORK THAT DEMONSTRATES A COMMITMENT TO ACCESS AND EQUITY PRINCIPLES ..................................... 191
An ethical framework for advocacy ........................................................................................................... 191
Social justice ............................................................................................................................................... 192
Confidentiality ............................................................................................................................................ 193
6.3 ADOPT STRATEGIES TO EMPOWER THE OLDER PERSON AND/OR THEIR ADVOCATE/S IN REGARD TO THEIR SERVICE
REQUIREMENTS ....................................................................................................................................................... 194
The 'professional' consumer/carer ............................................................................................................. 194
Accountability and responsibility ............................................................................................................... 196
Being Prepared ........................................................................................................................................... 197
6.4 PROVIDE INFORMATION TO THE OLDER PERSON AND/OR THEIR ADVOCATE/S TO FACILITATE CHOICE IN THEIR
DECISION MAKING. ................................................................................................................................................... 197
Being valued ............................................................................................................................................... 197
Burden of Responsibility ............................................................................................................................. 198
Problem solving .......................................................................................................................................... 199
Types of problems ...................................................................................................................................... 199
6.5 RECOGNISE AND REPORT TO AN APPROPRIATE PERSON WHEN AN OLDER PERSONS RIGHTS ARE NOT BEING UPHELD. ....... 200
6.6 PROVIDE SERVICES REGARDLESS OF DIVERSITY OF RACE OR CULTURAL, SPIRITUAL, OR SEXUAL PREFERENCES. ................. 201
Dealing with organisational culture ........................................................................................................... 201
6.7 PROVIDE INFORMATION TO THE OLDER PERSON AND/OR THEIR ADVOCATE/S REGARDING MECHANISMS FOR
LODGING COMPLAINTS .............................................................................................................................................. 202
NACAP ........................................................................................................................................................ 203
Aged Care Complaints Investigation Scheme ............................................................................................. 203
Activity 11: ................................................................................................................................................. 210
Activity 12: ................................................................................................................................................. 211
Activity 13: ................................................................................................................................................. 212
Activity 14: ................................................................................................................................................. 213
Activity 15: ................................................................................................................................................. 214


Work effectively with older people -
CHCAC318A.

Description:
This unit describes the skills and knowledge required by the worker to
perform work that reflects understanding of the structure and profile of the
residential aged care sector, the home and community sector and key
issues facing older people in the community

About this Unit of Study Introduction.
As a worker, a trainee, or a future worker you want to enjoy your work and
become known as a valuable team member. This unit of competency will help
you acquire the knowledge and skills to work effectively as an individual and in
groups. It will give you the basis to contribute to the goals of the organisation
which employs you.
It is essential that you begin your training by becoming familiar with the
industry standards to which organisations must conform.
This unit of competency introduces you to some of the key issues and
responsibilities of workers and organisations in this area. The unit also
provides you with opportunities to develop the competencies necessary for
employees to operate as team members.

This Learning Guide Covers:
Apply understanding of the structure and profile of the residential aged
care sector
Apply understanding of the home and community care sector
Demonstrate commitment to the philosophy of positive ageing
Apply understanding of the physical and psychosocial aspects of ageing
Apply understanding of changes associated with ageing
Support the rights and interests of older person

Learning Program:
As you progress through this unit of study you will develop skills in locating
and understanding an organisations policies and procedures. You will build
up a sound knowledge of the industry standards within which organisations
must operate. You will become more aware of the effect that your own skills
in dealing with people has on your success or otherwise in the workplace.
Knowledge of your skills and capabilities will help you make informed choices
about your further study and career options.


Additional Learning Support

To obtain additional support you may:
search for other resources in the Learning Resource Centre (LRC) of
your learning institution. You may find books, journals, videos and other
materials which provide additional information about topics in this unit.
search for other resources in your local library. Most libraries keep
information about government departments and other organisations,
services and programs. The librarian should be able to help you locate
such resources.
contact information services such as Infolink, Equal Opportunity
Commission, Commissioner of Workplace Agreements, Union
organisations, and public relations and information services provided by
various government departments. Many of these services are listed in
the telephone directory.
contact your local shire or council office. Many councils have a
community development or welfare officer as well as an information and
referral service.
contact the relevant facilitator by telephone, mail or facsimile.

Facilitation

Your training organisation will provide you with a flexible learning facilitator.
Your facilitator will play an active role in supporting your learning. Your
facilitator will make regular contact with you and, if you have face to-face
access, should arrange to see you at least once. Your facilitator will contact
you by telephone or letter as soon as possible after you have enrolled to let
you know:
how and when to make contact,
what you need to do to complete this unit of study, and
what support will be provided.

Here are some of the things your facilitator can do to make your study easier:
Give you a clear visual timetable of events for the semester or term in
which you are enrolled, including any deadlines for assessments.
Check that you know how to access library facilities and services.
Conduct small 'interest groups' for some of the topics
Use 'action sheets' to remind you about tasks you need to complete, and
updates on websites.
Set up a 'chat line'. If you have access to telephone conferencing or
video conferencing, your facilitator can use these for specific topics or
discussion sessions.
Circulate a newsletter to keep you informed of events, topics and
resources of interest to you.


Keep in touch with you by telephone or e-mail during your studies.

Flexible Learning
Studying to become a competent worker is an interesting and exciting thing to
do. You will learn about current issues in this area. You will establish
relationships with other candidates, fellow workers, and clients. You will learn
about your own ideas, attitudes and values. You will also have fun. (Most of
the time!)
At other times, study can seem overwhelming and impossibly demanding,
particularly when you have an assignment to do and you aren't sure how to
tackle it ... and your family and friends want you to spend time with them...and
a movie you want to see is on television...
Sometimes being a candidate can be hard.

Here are some ideas to help you through the hard times. To study effectively,
you need space, resources and time.

Space
Try to set up a place at home or at work where:
you can keep your study materials,
you can be reasonably quiet and free from interruptions, and
you can be reasonably comfortable, with good lighting, seating and
a flat surface for writing.
If it is impossible for you to set up a study space, perhaps you could use your
local library. You will not be able to store your study materials there, but you
will have quiet, a desk and chair, and easy access to the other facilities.

Study Resources
The most basic resources you will need are:
a chair
a desk or table
a reading lamp or good light
a folder or file to keep your notes and study materials together
materials to record information (pen and paper or notebooks, or a
computer and printer)
reference materials, including a dictionary.
Do not forget that other people can be valuable study resources. Your fellow
workers, work supervisor, other candidates, your flexible learning facilitator,
your local librarian, and workers in this area can also help you.

Time
It is important to plan your study time. Work out a time that suits you and plan
around it. Most people find that studying in short, concentrated blocks of time
(an hour or two) at regular intervals (daily, every second day, once a week) is


more effective than trying to cram a lot of learning into a whole day. You need
time to 'digest' the information in one section before you move on to the next,
and everyone needs regular breaks from study to avoid overload. Be realistic
in allocating time for study. Look at what is required for the unit and look at
your other commitments.
Make up a study timetable and stick to it. Build in 'deadlines' and set yourself
goals for completing study tasks. Allow time for reading and completing
activities. Remember that it is the quality of the time you spend studying
rather than the quantity that is important.

Study Strategies
Different people have different learning 'styles'. Some people learn best by
listening or repeating things out loud. Some learn best by 'doing', some by
reading and making notes. Assess your own learning style, and try to identify
any barriers to learning which might affect you. Are you easily distracted? Are
you afraid you will fail? Are you taking study too seriously? Not seriously
enough? Do you have supportive friends and family? Here are some ideas for
effective study strategies:
Make notes. This often helps you to remember new or unfamiliar information.
Do not worry about spelling or neatness, as long as you can read your own
notes. Keep your notes with the rest of your study materials and add to them
as you go. Use pictures and diagrams if this helps.
Underline key words when you are reading the materials in this learning
guide. (Do not underline things in other people's books.) This also helps you
to remember important points.
Talk to other people (fellow workers, fellow candidates, friends, family, your
facilitator) about what you are learning. As well as helping you to clarify and
understand new ideas, talking also gives you a chance to find out extra
information and to get fresh ideas and different points of view.

Using This Learning Guide.
A learning guide is just that, a guide to help you learn. A learning guide is not
a text book. Your learning guide will:
describe the skills you need to demonstrate to achieve competency for
this unit;
provide information and knowledge to help you develop your skills;
provide you with structured learning activities to help you absorb
knowledge and information and practice your skills;
direct you to other sources of additional knowledge and information about
topics for this unit.


The Icon Key

Key Points
Explains the actions taken by a competent person.

Example
Illustrates the concept or competency by providing examples.

Activity
Provides activities to reinforce understanding of the action.

Chart
Provides images that represent data symbolically. They are
used to present complex information and numerical data in a
simple, compact format.

Intended Outcomes or Objectives
Statements of intended outcomes or objectives are
descriptions of the work that will be done.

Assessment
Strategies with which information will be collected in order to
validate each intended outcome or objective.


The Supplementary Icons

PowerPoint
Any PowerPoint associated with a unit will have this icon next
to them
Forms and Care Plans
If there is a form or care plan associated with a unit there will
be an icon like this with the relevant number of the form or
care plan in the format FFACF-015
Employability Skills
Where the employability skills are shown to be embedded in
the unit and relates to the table in the front of each unit eg: T1,
S1, E1.

Readings
Provides backup and reasoning to the underpinning
knowledge and skills

Primary Skills Assessments
Where the Primary Skills Assessments are applicable there
will be an icon in the format PSA - XX

World Wide Web
Where the world wide web is used for an activity in the unit
you will find this icon.
Resource Document
Where the Resource documents are applicable there will be
an icon in the format RDN - XX


How to Get the Most out of Your Learning Guide:
1. Read through the information in the learning guide carefully. Make
sure you understand the material.
Some sections are quite long and cover complex ideas and information.
If you come across anything you do not understand:
talk to your facilitator;
research the area using the books and materials listed under
Resources;
discuss the issue with other people (your workplace supervisor,
fellow workers, fellow candidates);
try to relate the information presented in this learning guide to your
own experience and to what you already know.
Ask yourself questions as you go. For example 'Have I seen this
happening anywhere?' 'Could this apply to me?' 'What if....'. This will
help you to 'make sense' of new material, and to build on your existing
knowledge.
2. Talk to people about your study.
Talking is a great way to reinforce what you are learning.
3. Make notes.
4. Work through the activities.
Even if you are tempted to skip some activities, do them anyway. They are
there for a reason, and even if you already have the knowledge or skills
relating to a particular activity, doing them will help to reinforce what you
already know. If you do not understand an activity, think carefully about the
way the questions or instructions are phrased. Read the section again to
see if you can make sense of it. If you are still confused, contact your
facilitator or discuss the activity with other candidates, fellow workers or
with your workplace supervisor.
Additional Research, Reading and Note Taking
If you are using the additional references and resources suggested in the
learning guide to take your knowledge a step further, there are a few simple
things to keep in mind to make this kind of research easier.
Always make a note of the author's name, the title of the book or article, the
edition, when it was published, where it was published, and the name of the
publisher. If you are taking notes about specific ideas or information, you will
need to put the page number as well. This is called the reference information.
You will need this for some assessment tasks, and it will help you to find the
book again if you need to.
Keep your notes short and to the point. Relate your notes to the material in
your learning guide. Put things into your own words. This will give you a better
understanding of the material.
Start off with a question you want answered when you are exploring
additional resource materials. This will structure your reading and save you
time.


Employability Skills
Certificate III in Aged Care
EMPLOYABILITY
SKILLS
FACETS ADDRESSED: Industry/enterprise requirements
for this qualification include the following facets:
Code
Communication
1. Listening to and understanding work instructions,
directions and feedback
C1
2. Speaking clearly/directly to relay information
C2
3. Reading and interpreting workplace related
documentation, such as prescribed programs
C3
4. Writing to address audience needs, such as forms,
case notes and reports
C4
5. Interpreting the needs of internal/ external clients from
clear information and feedback
C5
6. Applying basic numeracy skills to workplace
requirements involving measuring and counting
C6
8. Sharing information (eg. with other staff, working as
part of an allied health team)
C8
9. Negotiating responsively (eg. re own work role and/or
conditions, possibly with clients)
C9
11. Being appropriately assertive (eg. in relation to safe or
ethical work practices and own work role)
C11
12. Empathising (eg. in relation to others)
C12
Teamwork
1. Working as an individual and a team member T1
2. Working with diverse individuals and groups T2
3. Applying knowledge of own role as part of a team T3
4. Applying teamwork skills to a limited range of situations
T4
5. Identifying and utilising the strengths of other team
members
T5
6. Giving feedback T6


EMPLOYABILITY
SKILLS
Code
Problem solving
1. Developing practical solutions to workplace problems
(i.e. within scope of own role)
P1
2. Showing independence and initiative in identifying
problems (i.e. within scope of own role)
P2
3. Solving problems individually or in teams (i.e. within
scope of own role)
P3
5. Using numeracy skills to solve problems (eg. time
management, simple calculations, shift handover)
P5
6. Testing assumptions and taking context into account
(i.e. with an awareness of assumptions made and
work context)
P6
7. Listening to and resolving concerns in relation to
workplace issues
P7
8. Resolving client concerns relative to workplace
responsibilities (i.e. if role has direct client contact)
P8
Initiative and
enterprise
1. Adapting to new situations (i.e. within scope of own
role)
I1
2. Being creative in response to workplace challenges (i.e.
within relevant guidelines and protocols)
I2
3. Identifying opportunities that might not be obvious to
others (i.e. within a team or supervised work context)
I3
5. Translating ideas into action (i.e. within own work role)
I5
6. Developing innovative solutions (i.e. within a team or
supervised work context and within established
guidelines)
I6


EMPLOYABILITY
SKILLS
Code
Planning and
organising
1. Collecting, analysing and organising information (i.e.
within scope of own role)
O1
2. Using basic systems for planning and organising (i.e. if
applicable to own role)
O2
3. Being appropriately resourceful O3
4. Taking limited initiative and making decisions within
workplace role (i.e. within authorised limits)
O4
5. Participating in continuous improvement and planning
processes (i.e. within scope of own role)
O5
6. Working within clear work goals and deliverables O6
7. Determining or applying required resources (i.e. within
scope of own role)
O7
8. Allocating people and other resources to tasks and
workplace requirements (only for team leader or
leading hand roles)
O8
9. Managing time and priorities (i.e. in relation to tasks
required for own role)
O9
10. Adapting resource allocations to cope with
contingencies (i.e. if relevant to own role)
O10
Self management 1. Being self-motivated (i.e. in relation to requirements
of own work role)
S1
2. Articulating own ideas (i.e. within a team or
supervised work context)
S2
3. Balancing own ideas and values with workplace values
and requirements
S3
4. Monitoring and evaluating own performance (i.e. within
a team or supervised work context)
S4
5. Taking responsibility at the appropriate level S5


EMPLOYABILITY
SKILLS
Code
Learning 1. Being open to learning new ideas and techniques) L1
2. Learning in a range of settings including informal
learning
L2
3. Participating in ongoing learning L3
4. Learning in order to accommodate change L4
5. Learning new skills and techniques L5
6. Taking responsibility for own learning (i.e. within scope
of own work role)
L6
7. Contributing to the learning of others (eg. by sharing
information)
L7
8. Applying a range of learning approaches (i.e. as
provided)
L8
10. Participating in developing own learning plans (eg. as
part of performance management)
L10
Technology 1. Using technology and related workplace equipment (i.e.
if within scope of own role)
E1
2. Using basic technology skills to organise data E2
3. Adapting to new technology skill requirements (i.e.
within scope of own role)
E3
4. Applying OHS knowledge when using technology E4


Work effectively with older people CHCAC318A.
Element Performance Criteria
1. Apply understanding of the structure and profile of the
residential aged care sector

1.1
Conduct work that reflects an understanding of the key issues facing
older people and their carer/s
1.2
Conduct work that reflects an understanding of the current
philosophies of service delivery in the sector
1.3
Recognise the impact of ageing demographics on funding and service
delivery models
1.4
Conduct work that reflects an understanding of current legislation
2. Apply understanding of the home and community care
sector

2.1
Demonstrate broad knowledge of policy and programs such as
HACC, DVA and Government community care directions
2.2
Comply with duty of care implementation in home and community
settings and worker roles
2.3 Demonstrate broad knowledge of ageing in place
3. Demonstrate commitment to the philosophy of positive
ageing

3.1
Take into account personal values and attitudes when planning and
implementing work activities
3.2
Recognise and manage ageist attitudes through the support of the
appropriate person
3.3
Recognise the impact of consumerism on service delivery
3.4
Conduct work that reflects an understanding of the individuality of
ageing
3.5
Conduct work that minimises the effects of stereotypical attitudes and
myths on the older person


Element Performance Criteria (contd)
4. Apply understanding of the physical and psychosocial
aspects of ageing

4.1
Outline strategies that the older person may adopt to promote
healthy lifestyle practices
4.2
Take into account physical changes associated with ageing when
delivering services
4.3
Recognise and accommodate the older persons interests and life
activities when delivering services
4.4
Assist the older person to recognise the impact physical changes
associated with ageing may have on their activities of living
5. Apply understanding of changes associated with ageing

5.1
5.2
Take into account physical changes associated with ageing when
delivering services
5.3
Utilise knowledge of common problems associated with ageing
when delivering services
5.4
Assist the older person to recognise the impact that changes
5.5
Communicate situations of risk or potential risk associated with
ageing to the older person
6. Support the rights and interests of older person

6.1
Encourage and support the older person and/or their advocate/s to
be aware of their rights and responsibilities
6.2
Conduct work that demonstrates a commitment to access and equity
principles
6.3
Adopt strategies to empower the older person and/or their
advocate/s in regard to their service requirements


Element Performance Criteria (contd)
6. Support the rights and interests of older person

6.4
Provide information to the older person and/or their advocate/s to
facilitate choice in their decision making
6.5
Recognise and report to an appropriate person when an older
persons rights are not being upheld
6.6
Provide services regardless of diversity of race or cultural, spiritual,
or sexual preferences
6.7
Provide information to the older person and/or their advocate/s
regarding mechanisms for lodging complaints


Skills and Knowledge

Required Knowledge
The candidate must be able to demonstrate essential knowledge
required to effectively perform task skills; task management skills;
contingency management skills and job/role environment skills as
outlined in elements and performance criteria of this unit
These include knowledge of:
Own work role and responsibilities
Principles of access, equity and client rights when working in the aged
care sector
Structure and profile of the aged care sector
Relevant policies, protocols of the organisation in relation to Unit
Descriptor and work role
Relevant legislation in relation to Unit Descriptor and work role
Contemporary issues facing older people in the community
Current service delivery models
Philosophy of various service delivery models
Factors influencing service delivery models in the sector
Ageing demographics
Understanding attitude, stereotypes and false beliefs associated with
ageing
Impact of personal values and attitudes on service delivery
Rights and responsibilities of older people and those working in the aged
care sector
Physical and psychosocial aspects of ageing in supporting older people to
maintain their quality of life
Impact of normal ageing on the older person
Overview of the manifestations and presentation of common problems
associated with ageing
Relevant care needs and strategies related to common problems
Principles of access and equity
Role of carers
Principles of empowerment and disempowerment
Principles and practices of confidentiality and privacy
Strategies for supporting an older person and/or their advocate/s to
exercise their rights
Strategies for manAgeing complaints


Required Skills
It is critical that the candidate demonstrate the ability to:
Follow organisation policies and protocols
Liaise and report to appropriately person/s
Adhere to own work role and responsibilities
Apply the principles of access, equity and client rights when working in the
aged care sector
Adopt a non-ageist and accepting attitude when working with older people

In addition, the candidate must be able to demonstrate relevant task
skills; task management skills; contingency management skills and
job/role environment skills
These include the ability to:
Apply physical and psychosocial aspects of ageing in supporting older
people
Apply reading and writing skills-literacy competence required to fulfil work
role in a safe manner and as specified by the organisation/service
This requires a level of skill that enables the worker to follow work-related
instructions and directions and the ability to seek clarification and
comments from supervisors, clients and colleagues
Industry work roles will require workers to possess a literacy level that will
enable them to interpret international safety signs, read clients service
delivery plans, make notations in client records and complete workplace
forms and records
Apply oral communication skills-language competence required to fulfil
work role in a safe manner and as specified by the organisation
This requires a level of skill that enables the worker to follow work-related
instructions and directions and the ability to seek clarification and
comments from supervisors, clients and colleagues
Industry work roles will require workers to possess oral communication
skills that will enable them to ask questions, clarify understanding,
recognise and interpret non-verbal cues, provide information and express
encouragement
Apply numeracy skills required to fulfil work role in a safe manner and as
specified by the organisation
Industry work roles will require workers to be able to perform basic
mathematical functions, such as addition and subtraction up to three digit
numbers and multiplication and division of single and double-digit
numbers
Apply basic problem solving skills to resolve problems within organisation
protocols
Work effectively with clients, colleagues, supervisors and other
services/agencies


Range Statement.
Older people may
include:
Individuals living in residential aged care
environments
Individuals living in the community
Prospective individuals to the service or services
Contexts may
include:
Older persons own dwelling
Independent living accommodation
Residential aged care facilities
Community centres
Community/government agencies
Issues facing older
people may include:
Changes that ageing may bring to:
- Physical processes
- Cognitive function (including dementia)
- Social interaction
- Role and family relationships
- Living arrangements
- Level of independence (financial, community
access, self-care)
Loss and grief
Family carer issues
Societal attitudes and expectations
Current philosophies
of service delivery
may include:
Changing societal expectations (consumerism)
Changing political context (polices and initiatives)
Changing economic context
Impact of ageing demographics
Rights may include:
Privacy
Confidentiality
Dignity
Freedom of association
Informed choice
To lodge a complaint
Right to express ideas and opinions
To an agreed standard of care


Rights are detailed
in:
Legislation
- Residential Care Manual
- Aged Care Act
Industry and organisation service standards
Industry and organisation codes of practice and
ethics
Accreditation standards
International and national charters
Organisation policy and procedure
Principles of access
and equity may
include:
Creation of a client orientated culture
Non-discriminatory approach to all individuals
using or accessing the service
Respect for individual differences
Appropriate person/s
may include:
Supervisor
Member of senior management
Colleagues
Carers
Health professionals
External agencies (complaints and advocacy
services and professional registering authorities)
Law enforcement officer
Reporting may be: Verbal
- Telephone
- Face to face
Non-verbal (written)
- Progress reports
- Case notes
- Incident reports


Evidence Guide
Critical aspects for
assessment and evidence
required to demonstrate this
competency unit:
The individual being assessed must provide
evidence of specified essential knowledge as
well as skills
This unit will be most appropriately assessed in
the workplace or in a simulated workplace and
under the normal range of workplace conditions
It is recommended that assessment or
information for assessment will be conducted or
gathered over a period of time and cover the
normal range of workplace situations and
settings
Where, for reasons of safety, space, or access to
equipment and resources, assessment takes
place away from the workplace, the assessment
environment should represent workplace
conditions as closely as possible
Access and equity
considerations:
All workers in community services should be
aware of access and equity issues in relation to
their own area of work
All workers should develop their ability to work in
a culturally diverse environment
In recognition of particular issues facing
Aboriginal and Torres Strait Islander
communities, workers should be aware of
cultural, historical and current issues impacting
on Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account
relevant access and equity issues, in particular
relating to factors impacting on Aboriginal and/or
Torres Strait Islander clients and communities
Context of and specific
resources for assessment:
This unit can be assessed independently,
however holistic assessment practice with other
community services units of competency is
encouraged
Resources required for assessment include:
- Access to appropriate workplace where
assessment can take place
- Simulation of realistic workplace setting for
assessment
- Relevant organisation policy, protocols and
procedures


Method of assessment Observation in the work place
Written assignments/projects
Case study and scenario analysis
Questioning
Role play simulation


1. Apply understanding of the
structure and profile of the
residential aged care sector

1.1
Conduct work that reflects an understanding of the key issues
facing older people and their carer/s
1.2
Conduct work that reflects an understanding of the current
1.3
Recognise the impact of ageing demographics on funding and
service delivery models
1.4
Conduct work that reflects an understanding of current
legislation

Introduction.

Working Definitions

Family Caregiver is broadly defined and refers to any relative, partner,
friend, or neighbour who has a significant personal relationship with, and
provides a broad range of assistance for, an older person or an adult with
a chronic or disabling condition. These individuals may be primary or
secondary caregivers and live with, or separately from, the person
receiving care.
Care Recipient refers to an adult with a chronic illness or disabling
condition or an older person who needs ongoing assistance with everyday
tasks to function on a daily basis. These tasks may include manAgeing
medications, transportation, bathing, dressing, and using the toilet. The
person needing assistance may also require primary and acute medical
care or rehabilitation services (occupational, speech, and physical
therapies).
Caregiver Assessment refers to a systematic process of gathering
information that describes a caregiving situation and identifies the
particular problems, needs, resources, and strengths of the family
caregiver. It approaches issues from the caregiver's perspective and
culture, focuses on what assistance the caregiver may need and the
outcomes the family member wants for support, and seeks to maintain the
caregiver's own health and well-being.


A caregiver is a person who provides for the needs of a relative or friend
who is ill or disabled. The person being cared for may need help due to
physical illness or injury, mental illness, memory problems, or some
combination of these. The caregiver is often an adult daughter or daughter-
in-law and may be an older adult herself. Many caregivers are also caring
for young children or grandchildren as well.
A caregiver's job can be very rewarding but may also be frustrating and
stressful. Most caregivers are not specifically prepared or trained for the
role. It is a role some people assume reluctantly because there appears to
be no other choice.

1.1 Conduct work that reflects an understanding of the key issues facing
older people and their carer/s

You must be realistic about what to expect. The following suggestions may
help:
Get information about the person's medical problems. Information can help
you better understand his or her limitations, know what symptoms to
expect, and have an idea of the likely course of the condition.
Often the person being cared for cannot control what he or she says or
does. This is especially true for people who have dementia, head injury, or
a stroke. Reminding yourself that the behaviour is a symptom of the
disease and not in the person's control may help decrease your anger,
frustration, and hurt feelings.
Allow the person to do as much as he or she is able to do. Include them in
decision making whenever possible. Give the person limited choices when
you can. For example, "Do you want your red shirt or the blue one?" The
person may take longer to do things without help but could also find great
satisfaction in taking part in his or her own care. For example, you could
seat the person in front of the sink, set out the toothbrush and toothpaste,
and help only if help is needed. Provide cues and directions in simple
steps. He or she might need assistance performing tasks in the proper
order. For example, you might say "Pick up your coat, put your arms in,
button it up," rather than, "Put on your coat."
Tell the person what to do instead of what he or she should not do.

Its this expectation of what a carers role is that leads to many discussions
both informally and formally. It is also a lack of understanding that leads to
a devaluation of a carers role.

However, relatively little research has
attempted to generate

more meaningful constructions of carers by drawing
these considerations

together.

"Carers face physical and mental challenges every day and should be
more visibly supported and appreciated for the generous and loving
hard work that they do."
1

1
http://www.telegraph.co.uk/health/healthnews/5469023/Carers-reaching-breaking-point.html- 08 Jun 2009


The Survey of Disability, Ageing and Carers (SDAC) was conducted by
the Australian Bureau of Statistics (ABS, 2004) throughout Australia, from
June to November 2003 to collect information about three population
groups:
people with a disability
older people (i.e. those aged 60 years and over)
people who provide assistance to older people and people with
disabilities.
In 2003, there were 2.6 million carers who provided some assistance to
those who needed help because of disability or age. About one fifth of
these (19%) were primary carers, that is, people who provided the majority
of the informal help needed by a person with a disability. Just over half
(54%) of all carers were women. Women were also more likely (71%) to be
primary carers. Of those providing care, 1.0 million (39%) were in the 35-
54 year age range. This age group's caring responsibilities involved
children, partners and/or ageing parents.
Those who provided care to people with a disability were more likely to be
older and/or have a disability than those who did not provide care. Twenty-
four per cent of primary carers were aged 65 years and over, compared to
13% of the total population. Of those living in households, the disability
rates were 40% for primary carers, 35% for all carers and 20% for non-
carers.
2

About one in five carers were identified as primary carers who provided the
majority of informal help to a person with a disability. Most primary carers
(78%) cared for a person living in the same household. The 45-54 years
age group contained the largest number of both male and female primary
carers (32,200 and 83,400 respectively).
In 2003, the percentage of people living in households that were identified
as carers increased gradually with age from 9% of 18-24 year olds to 22%
of 55-64 year olds, and then declined to 18% of those aged 75 years and
over, although this was 5 percentage points higher than the overall rate of
13%.
The proportion of people who were primary carers also increased gradually
with age, from 1% of 18-24 year olds to 5% of 55-64 year olds. Unlike the
overall carer rate though, it did not decrease for the older age groups,
staying at 5%.
Australian Bureau of Statistics (2003) presented results from the Survey of
Disability, Ageing and Carers (SDAC) conducted from June to November
2003
3
The final sample comprised 36,241 people for the household
component and 5,145 people for the cared-accommodation component.
The primary objective of the survey was to collect information about three
population groups: people with a disability; older people (i.e. those aged 60
years and over); people who provide assistance to older people and
people with disabilities.
The SDAC survey was a major achievement for the community care sector
as much of these data have underpinned subsequent analyses of

2
ABS, 2004
3
Disability, Ageing and Carers, Australia: Summary of Findings, Catalogue No. 4430.0.


population need and provided the basis for negotiating agreements
between jurisdictions on program allocations.
In their 2004 report, the Australian Institute of Health and Welfare (AIHW)
present a picture of informal care in contemporary Australia (AIHW 2004)
based on the SDAC data. The report sought answers to the following
questions: who are the primary carers, who do they assist and what does
caring involve? The report also explored the impact of caring work and
patterns of formal service use with informal care.
By revisiting the 1998 ABS data and other key studies, the AIHW report
was able to explore some issues in more detail and report a more complex
profile of carers in Australia. It has built on a growing body of research
that has identified the characteristics of carers and the extent of burden of
their carer role. (p. 2)
4

The main findings from the AIHW 2004 report (pp xii-xvi) were described
under a series of headings covering the characteristics of carers, the
demands on them, the changing context, wider social trends and the
relationship to formal services. These findings are outlined below followed
by observations of their significance for community practice in carer
support, or for a continuing research agenda.

Who are the primary carers?
Caring for a person with a severe or profound core activity restriction in a
community setting is predominantly a female occupation. Men and women
are more equally represented among carers of people with any level of
disability than among primary carers of people with a severe or profound
core activity restriction.
Over half of primary carers cited family responsibility as the reason for
taking on the caring role; other common reasons given by primary carers
were 'could provide better care' and 'emotional obligation'. A similar
proportion of partner and parent carers said that they could offer the best
possible care for their family member.
Overall, 79% of primary carers in 1998 lived with their care recipient; the
rate of co-residency among primary carers of people aged 65 years or over
is somewhat lower (62%).

Demands and consequences of caring work
Primary carers had a lower labour force participation rate (39%) than
people who were not carers (68%). 37% of primary carers spent on
average 40 hours or more per week providing care and 18% spent 20 to
39 hours per week. Over one-half of primary carers spend 20 or more
hours per week in the caring role and over one-third spend 40 or more
hours per week on unpaid caring work.
Three-quarters of primary carers in 1998 had spent at least 5 years in the
caring role and 40% had been caring for at least 10 years. Detailed data
collected by the ABS on co-resident primary carers in 1998 revealed that
60% of care recipients always needed assistance with between one and

4
AIHW 2004 report


four activities of daily living and a further 24% always needed assistance
with between five and nine activities of daily living.
The intensity of a caring role is reflected in substantially lower labour force
participation among working-age carers compared to non-carers of the
same age, with an inverse relationship between primary carer labour force
participation and weekly hours of caring work.
Negative consequences of a primary caring role reported by primary carers
in 1998 include reduced hours of paid employment and resignation from
positions of employment, lower overall life satisfaction and a reduced
feeling of wellbeing, and increased feelings of fatigue and depression.


Implications for policy and practice
Caring as a mainly female occupation has two implications, one being the
need to strengthen older womens networks and improve the capacity of
those networks to offer mutual support and practical assistance, and the
second implication is the necessity to promote more gender equity in the
caring sphere, with attention to promoting mens roles and abilities as
carers.
Growing numbers of frail aged care recipients over the coming decades
highlight the importance of training in manual handling procedures for
carers and access to mobility and bathroom aids. This short list of practical
tools can be extended to include the management of medicines, the
growing number of home health monitoring tools, medical devices, and
tele-health aids, as well as more permanent home modifications.
Beyond strengthening the capacities of carers to cope in the home
environment there is also the need to develop social strategies for greater
workplace assistance for employed carers and easier access to income
support in reinforcing the value of the carer role.

Carer health and well-being survey 2007
Carers Australia contracted with Deakin Universitys Australian Unity Well-
being Index Project to survey approximately 4000 carers, contacted
through the data bases of the state/territory Carers Associations The
survey was used to assess factors concerning their personal well-being,
depression and stress using standardised scales (in particular the
Personal Well-being Index) and additional questions related to their carer
situation.
5

The report on the survey focussed on the subjective wellbeing of family
carers in Australia. The Personal Wellbeing Index score is the average
level of satisfaction across seven aspects of personal life (health, personal
relationships, safety, standard of living, achieving in life, community
connectedness, and future security), and two additional psychological
outcome measures were used and these were the depression and stress
sub-scales from the Depression, Anxiety and Stress Scale.
In summary, carers have the lowest collective wellbeing score of any
group Deakin University has sampled, and have an average rating on the
depression scale that is classified as moderate depression. Female carers
have lower wellbeing than male carers, and the most disadvantaged carer
household group is sole parents.
The report reinforced the known characteristics of the group of self-
identified carers who are connected to Carer Associations. It presented
the results under five headings.
Demographics and employment
The survey reinforces the usefulness of recent initiatives for those carers
who are employed, as over one third of those surveyed has a degree of
worry about losing their job that depresses their wellbeing even further.

5
(Cummins, Hughes and Tomyn et al. 2007).
http://www.deakin.edu.au/research/acqol/index_wellbeing/index.htm


Carer challenges
The wellbeing of carers is more vulnerable to physical pain than is normal,
are more likely to be experiencing chronic pain, to be carrying an injury
and/or a significant medical or psychological condition is associated with
lower wellbeing. Carers are likely to be not receiving treatment for
themselves for a significant medical or psychological condition as they
have no time or cannot afford the treatment.
Carer resources
The wellbeing of carers is less than that of the general population sample
and their satisfaction with their ability to afford the things they would like to
have, and to save money are all severely comprised for carers compared
with a general population sample.
Intensity of the carer role
Wellbeing decreases linearly as the number of hours spent caring
increases and primary carer responsibility for any time each day is
extremely damaging to wellbeing. Female primary carers have lower
wellbeing than male primary carers and caring for adults imposes fewer
burdens than caring for disabled children. The wellbeing of the 3,049
people (83% of the sample) who live with the person requiring care is 58.4
points, the lowest value recorded for large samples.
Satisfaction with caring and leisure
High satisfaction with leisure is more strongly associated with higher carer
wellbeing than satisfaction with caring hours.

1.2 Conduct work that reflects an understanding of the current

The policy changes that led to the growth of home and community based
services have reflected a mixture of social, health and economic goals.
The rationale of most recent policy is to delay or prevent functional
impairment and subsequent nursing home admissions, and behind the
prevention agenda was an important idea promoted through work on what
is known in the literature as the compression of morbidity hypothesis.
6

This theory promoted the value of preventive interventions for older people
and raised the possibility of reducing cumulative lifetime morbidity. Since
chronic illness and disability usually occur in late life, the theory suggested
that cumulative lifetime disability could be reduced if primary prevention
measures postponed the onset of chronic illness, while decreases in health
risks may also increase the average age at death.
The hypothesis predicts that the age at the time of initial disability will
increase more than the gain in longevity, resulting in fewer years of
disability and a lower level of cumulative lifetime disability. There is some
controversy in this hypothesis with some contending that healthier
lifestyles may actually increase morbidity (and health expenditures) late in

6
(Fries 1980)


life by increasing the numbers of years with chronic illness and disability.
7

This change in the morbidity profile has clear implications for there being a
growing need for carers looking after very old people with a range of
degenerative conditions, and is confirmed in the recent publication of the
AIHW on the burden of disease and injury in Australia in 2003, which
stated: The rate of disability will actually decline in most age groups,
except for those 80 years and over, where it is expected to increase and
thereby offset some of the gains for younger age groups. The growing rate
of disability in the oldest age group mostly comes from expected increases
in diabetes and neurological conditions.
8

The most relevant example of the increased burdens of disease from
increased longevity is associated with dementia, as described by AIHW
(2006). Because Australias population is ageing, there has been growing
recognition that dementia represents a significant challenge to health,
aged care and social policy. This report estimates that the number of
people with dementia will grow from over 175,000 in 2003 to almost
465,000 in 2031, assuming the continuation of current dementia age-
specific prevalence rates.
9

In terms of the social impact these changes are likely to make, Access
Economics (2003) for Alzheimers Australia estimated that growth of 6%
per annum in the HACC program would be required to keep up with
increasing demand (even after a 20% top up for current unmet need), plus
additional respite services will be needed to better support informal
caregivers.
10

So the increase in lifespan has not been matched by an extension of
health, and the extra years are spent with disability, disease and dementia,
creating a challenge for social policy in making the end of life worth living
for both carers and their care recipients.
The success of medicine in keeping people alive and the prevalence of
degenerative disease with age have led to an expansion of morbidity, not a
compression. Acute forms of death have been converted to chronic death
or disabilities as heart attacks become heart failure, stroke leads to
vascular dementia and cancers become chronic disabilities
11

The AIHW burden of disease study drew out the obvious implications for
services: Ageing of Australias population will result in increasing numbers
of people with disability from diseases more common in older ages such as
dementia, Parkinsons disease, hearing and vision loss, and osteoarthritis.
This will increase demand for services in the home, community care,
residential aged care and palliative care sectors.
12

There are also expected to be changes to the profile of available carers in
the future. The AIHW published a study on the future supply of informal
care from 2003-2013
13
where they estimated that the informal carer sector
provides the equivalent of one million full time positions, and informal
carers provide 77% of all the care that enables people with disabilities to

7
(Binns 2007)
8
(Begg et al. 2007, p. 8)
9
AIHW (2006).p xii
10
Access Economics (2003) p6
11
(Brown 2007).
12
(Begg et al. 2007, p. 8)
13
(Jenkins et al. 2003)


stay at home. The study points out that structural and numerical ageing of
the population signals higher demand for primary carers and heightens
concern about the circumstances of a growing number of older carers.
Becoming unable to care can cause significant anxiety and practical
difficulties for older carers in particular.
In the AIHW study on The future supply of informal care 2003-2013
14

it was estimated that the informal carer sector provides the equivalent of
one million full time positions, and informal carers provide 77% of all the
care that enables people with disabilities to stay at home. This contribution
of the household sector has an imputed value of approximately $28.8
billion, and $19.3 billion of this is the estimated value of the work of unpaid
carers.
The study points out that structural and numerical ageing of the population
signals higher demand for primary carers and heightens concern about the
circumstances of a growing number of older carers. Becoming unable to
care can cause significant anxiety and practical difficulties for older carers
in particular.
Over 50% of partner and parent carers said that they could offer the best
available care for their family member, confirming the widespread
preference for care in the community. Overall, 79% of primary carers in
1998 lived with their care recipient. The rate of co-residency among
primary carers of people aged 65 years or over is somewhat lower (62%).
Future provision of informal care to people aged 45 to 64 years, in
particular, could prove vulnerable to higher rates of relationship breakdown
than has been evident in previous generations.
The number of people aged 10 years or over in need of ongoing
assistance is projected to increase by approximately 257,100 persons
(22%) between 2003 and 2013. Assuming all other factors are held
constant, in 2013 the ratio of primary carers to the population in need of
assistance from a primary carer will have declined from the ratio observed
in 1998 from 43 primary carers per 100 persons with a severe or profound
restriction to around 40.
This projection is driven by high growth in the age groups from which large
numbers of primary carers are traditionally sourced, counteracting the
effect of a moderate reduction in the proportion of working-age women
who are willing to reduce paid work to care compared to 1998.
Flexible working hours, access to a range of affordable formal support
services and being able to share the load with other family members will
prove to be the key to women continuing in their caring roles and offer
potential for more working men to accept a higher profile in family caring
activity.
A 64% increase in lone person households over the past 12 years, and
predictions that this trend is set to continue, will lead to a shortfall in the
number of primary carers in 2013, relative to 1998. The scenario in the
AIHW (2004) report suggests it may be around 32 primary carers per 100
persons. Access Economics (2005) clearly summarised the findings on the
changing context of informal care in its report on The Economic Value of
Informal Care for Carers Australia (described below), with commentary on
the methods used:

14
(Jenkins et al. 2003)


The AIHW and the National Centre for Social and Economic Modelling at
the University of Canberra
15
have both produced projections of future
demand and supply of informal care by extrapolating out from 1998 SDAC
data and adjusting for possible social trends.
Both the AIHW and NATSEM have recently conducted modelling on
possible future trends in the number of informal carers. Given the
uncertainty about the effect of social trends on peoples need for and
propensity to provide care, these alternative projections are best seen as
possible scenarios, rather than predictions or forecasts about the most
likely outcome.
The AIHW work by Jenkins et al. (2003)
16
used a scenario approach to
estimate the supply of informal carers in the years 2003, 2008 and 2013.
The model took rates of informal care provision for different population
sub-groups, stratified by age, gender, labour force status and living
arrangements, as reported in the 1998 SDAC. In the baseline scenario
these rates or propensities to provide care are held constant for each sub-
group. Allowing for projected changes in Australian demography, labour
force participation and living arrangements over the years 2003 to 2013,
estimates can be generated of the total number of people in each
population sub-group in the future and hence the number of carers.
The AIHW model does not explicitly model the demand for informal care.
By holding rates of informal care provision constant for each cohort, an
implicit assumption of the modelling is that the current amount of informal
care represents equilibrium between supply and demand. This may be
because all demand is met, so that the current balance between formal,
informal and no assistance is optimal. Alternatively, if the supply of care is
always constrained below demand, due to rationing of formal service
places and the choices of informal carers to offer care, supply projections
will also be a proxy for the actual amount of informal care provided.
Scenario analysis was conducted to show how the projected supply of
carers would differ if social change reduced or increased the propensity of
particular groups in society to provide care. Specifically, the scenarios
considered were:
an overall decline in the propensity of people to care, represented by a
20% across-the-board decrease in carer rates;
a decline in the propensity of women to reduce paid employment in
order to provide care, represented by a 20% decrease in the proportion
of women reducing paid employment to care;
an increase in the availability of carers due to converging male and
female life expectancy, represented by a 20% increase in carer rates in
60+ age group or spouse carer populations.
The results of this modelling show that, of these single-effect scenarios,
only an overall decline in propensity to care would have a marked impact
on the number of primary carers in 2013
17
. This indicates the importance of
continuing to develop a range of social programs that aim to support and
sustain the role of carers.

15
(NATSEM, 2004)
16
Jenkins et al. (2003)
17
(Access Economics 2005, pp. 33-34)


In the series of population surveys on ageing disability and carers (SDAC)
by the Australian Bureau of Statistics (2003), the vast majority of people
who reported an ongoing need for assistance received that assistance
from a mixture of unpaid carers and formal services. Most people rely on
family or friends for this sort of assistance.
This is particularly the case for people with higher levels of needs. Based
on the most recent data on the use of care packages, a high percentage of
care recipients under the EACH program did not live alone (76%) and this
reflects the importance of informal care arrangements in supporting a high-
care recipient in their home. Most EACH package recipients (90%)
received assistance from a carer; 74% had a co-resident carer, 16% had a
carer who did not live with the care recipient, and 10% of care recipients
did not have a carer
18
.
A report on The Economic Value of Informal Care by Access Economics
(2005) for Carers Australia used the data from the ABS survey to examine
the amount of informal care being provided in Australia in order to place a
dollar value on the work of informal carers. This was described as the first
step in evaluating whether the current usage of informal and formal care
models is socially optimal, in terms of both efficiency and equity.
The report identified Australias carers, provided a profile of carers and the
care needs of the people they care for, based on the data from the national
Survey of Disability, Ageing and Carers (ABS 2003). It used two measures
of how this time spent by carers could be valued (opportunity cost and
replacement cost). The estimates for the relative value of informal care
were 0.6% of estimated GDP for 2004-2005 by the opportunity cost
method (or $4.876 billion) and 3.5% using replacement cost (or $30.548
billion).
The report went on to quantify where possible, other effects of informal
care that should be included in a full account of the costs and benefits of
alternative care models, examined the level of public (Government)
support for carers relative to other models of care, and outlined the
questions and challenges that face policy makers. A final section provided
a case study of the care needs of people with severe osteoporosis.
The policy challenges included the projected decline in the caretaker
ratio, described as a crude indicator of the number of daughters available
to provide care to her ageing parent(s) currently around 2.5 daughters
per parent. Under current population projections (high, medium and low)
the ratio will start to decline substantially between 2010 and 2025,
continuing to decline to 2050. However the sharpest falls will not occur
until the mid-2020s, so there is little impact by 2013, the latest year of the
AIHW projections.
19

The Taskforce on Care Costs (TOCC) is supported by Australian business
and non-government stakeholders and was established to investigate the
financial cost of care and how it affects workforce participation, and to
promote reforms within a policy framework of financial sustainability, equity
and choice. (http://www.tocc.org.au/) Between 2005 and 2006 TOCC
released reports on public policy reforms to assist working carers to better
balance their work and caring responsibilities, by identifying the direct
relationship between reduced workforce participation and the high cost of

18
(AIHW 2007, p.53)
19
The Economic Value of Informal Care by Access Economics (2005) for Carers Australia (p.35)


care, and proposing financial policy reforms to alleviate this tension. In
November 2007 TOCC released its latest report on the work/care dynamic
for carers. The hidden face of care: Combining work and caring
responsibilities for the aged and people with a disability gives a picture of
the experience of combining work and aged and/or disability care.
20

The methodology for the research behind the report comprised: a literature
review of current financial and policy supports for working carers, both
domestically and internationally; quantitative research, namely a random
sample national survey (conducted by Newspoll) of working age
Australians, and working carers (of the aged and people with a disability),
on the relationship between work and care, and remedial strategies; and
qualitative research with five focus groups with working carers and a
roundtable with experts from peak carer groups on the experience of the
work/care dynamic and options for improvement.
The findings from the research for the hidden face of care are presented in
three sections covering: the policy landscape in Australia; facts and
figures; and the voices of formal and informal carers. Conclusions are
drawn at the end of each section along with recommendations for action.
In summary, there is an unmet need leading to reduced levels of workforce
participation and the high cost of care. One in four carers of the aged
and/or people with a disability have reduced their hours of work because of
the cost of care. The report advocates that Government should provide
additional financial support to relieve the cost of care, and continue to
address the situation where carers currently feel undervalued and
misunderstood by employers and co-workers. 34% of carers surveyed said
that their job/career has suffered because of the competing demands of
their caring responsibilities, and they feel that support services are
inadequate and fractured across Government departments, as well as
Federal and State/Territory Governments. Government financial supports
for carers should not be viewed as welfare, but as a strategy to enable
workforce participation.

1.3 Recognise the impact of ageing demographics on funding and service
delivery models.
Ageing

Ageing is the progressive, universal decline first in functional reserve and
then in function that occurs in organisms over time. Ageing is
heterogeneous. It varies widely in different individuals and in different
organs within a particular individual. Ageing is not a disease; however, the
risk of developing disease is increased, often dramatically, as a function of
age. The biochemical composition of tissues changes with age; physiologic
capacity decreases, the ability to maintain homeostasis in adapting to
stressors declines, and vulnerability to disease processes increases with
age. After maturation, mortality rate increases exponentially with age.

20
(http://www.tocc.org.au/media/Final_TOCC_2007_Report_The_Hidden_Face_of_Care_16_Nov_2007.pdf)


Demography of Ageing

Populations worldwide are ageing. Improvements in environmental (e.g.,
clean water and improved sanitation) and behavioural (nutrition, reduced
risk exposures) factors and the treatment and prevention of infectious
diseases are largely responsible for the 30-year increase in life expectancy
since 1900. In the United States, by 2030, 1 person in 5 will be >65 years.
Old people are not evenly distributed geographically. Half of older people
in the United States live in nine states, led by California, Florida, New York,
and Texas.
21

Global Ageing
Between 2000 and 2030, the number of older adults worldwide is expected
to increase from 420 to 974 million. At present 59% of older adults live in
the developing countries of Africa, Asia, Latin America, the Caribbean, and
Oceania. The developing world has the largest absolute number of older
adults and is experiencing the largest percentage increase.
Only 13% of those 80 years live in the United States; over 40% of those 80
years live in Asia. Embedded within these figures are additional critically
important factors. Women outlive men; only 15% of centenarians are men.
Men also remarry more frequently than do women; consequently, older
women are frequently single and live alone. Women are more likely to
have inadequate financial resources. Women also spend a greater portion
of their surviving years being disabled than do men. In the United States,
rates of disability decreased during the 1980s and 1990s, but the
epidemics of obesity and physical inactivity may reverse these trends. A
further concern for countries that already have high proportions of older
adults (e.g., Japan, Sweden, Greece, and Italy, whose citizens >65 are
1718% of their population) is the ratio of the >65 age group to the 15 - to
64-year age groupthe so-called dependency ratio. This ratio currently
ranges from 22% in Europe to 6% in Africa but is expected to rise to >50%
in Europe by 2050, with all other areas of the world exceeding 25% by
2050, except Africa.
22

Life Expectancy
Often life-extending therapies are not offered to older clients because of an
underestimate of life expectancy. Figures 1a and 1b show average life
expectancy as a function of age together with values for the lowest and
highest quartiles of the population. White women currently have the
highest life expectancy. Black women and white men have nearly identical
life expectancies, and black men have the poorest life expectancy. At age
85 years, racial differences in life expectancy largely disappear. The
average 75-year-old is expected to live to age 86 and the average 85-year-
old to age 91. Furthermore, where the issue has been examined, age is
not a factor in determining the efficacy of a particular intervention. Thus,
age alone generally should not be used to withhold life-extending
interventions.

21
Access Medicine: Chapter 9: Geriatric Medicine accessed 2/7/09 McGraw-Hill
22
Access Medicine ibid


Upper, Middle and Lower quartiles of life expectancy

Figure 1a: Life Expectancy for Women*

* Based on Upper, Middle and lower quartiles of life expectancy for women and men at
selected ages (From LC Walter, KE Covinsky, JAMA 285:2751, 2001)
0
5
10
15
20
25
Top 25th Percenti l e
50th Percenti l e
Lowest 25th percenti l e
Top 25th Percentile 21.3 17 13 9.5 6.8 4.8
50th Percentile 15.7 11.9 8.6 5.9 3.9 2.7
Lowest 25th percentile 9.5 6.8 4.6 2.9 1.8 1.1
70 75 80 85 90 95


0
2
4
6
8
10
12
14
16
18
20
Top 25th Percentile
50th Percentile
Lowest 25th Percentile
Top 25th
Percentile
18 14.2 10.8 7.9 5.8 4.3
50th Percentile 12.4 9.3 6.7 4.7 3.2 2.3
Lowest 25th
Percentile
6.7 4.9 3.3 2.2 1.5 0.8
70 75 80 85 90 95
Figure 1b: Life Expectancy for Men*

* Based on Upper, Middle and lower quartiles of life expectancy for women and men at
selected ages (From LC Walter, KE Covinsky, JAMA 285:2751, 2001)

Biology of Ageing
As we age, we become increasingly unlike one another. For any variable
one can measure, the variation in the distribution of values in a population
increases with age. While the mean value may trend up or down, the age-
related increase in the range of values is striking testimony to the diverse
manifestations of the ageing process. In addition, homeostatic
mechanisms are slower to respond to stressors and take longer to restore
normal function as we age. The ability to maintain stable function in the
face of a change in the environment is called allostasis and it declines with
age.
One problem as we age is nosologic; when is a particular change
considered a normal age-related alteration and when does it become a
disease? Ideas about the range of normal for a particular age continue to
evolve. At one time, a 75-year-old with a blood pressure of 170/90 mmHg
might have been considered to have an age-related increase in systolic
blood pressure that did not require intervention. However, we now know


that such a reading is a reflection of increased vascular stiffness, one of
the most important risk factors for cardiovascular morbidity and mortality.
Similarly, follow-up of individuals with fasting serum glucose levels of 6.1
6.7 mmol/L (110120 mg/dL) have shown them to be at increased risk of
diabetes complications. Accordingly impaired glucose metabolism is now
defined as a fasting glucose level > 6.1 mmol/L (>110 mg/dL). Thus, the
indications for interventions to alter natural history have changed and will
continue to change as we learn more about ageing.
Whether age-related changes that produce an ageing phenotype have a
common origin in a global process that alters cell or organ function or have
heterogeneous contributions in different systems or different individuals is
unclear. Studies of ageing (gerontology) are aimed at understanding the
cellular and molecular basis of age-related changes and have two ultimate
therapeutic goals: preserving function as long as possible and extending
life span. These two goals may not be linked.
The lack of model systems for studying ageing has hampered progress.
For many years, researchers have studied replicative senescence of
normal cells in culture. Why do normal cells have a finite replicative
potential in vitro and why do cells from older individuals undergo fewer
divisions than cells from younger individuals? Many have hoped that
insights from such studies would reveal information about the ageing
process. However, the link between the failure of cells to divide in a
synthetic culture medium and the ageing phenotype of a whole organism is
tenuous, at best. The body tissues with the greatest replicative potential
should identify the organs most susceptible to age-related defective
replication. In humans, these organs are the lining of the small intestine
and the hematopoietic system. In the absence of disease, no age-related
problem is caused by the inability of cells to replicate. Old people do not
run out of absorptive surface in the small intestine or fail to make blood
cells. Better in vitro models of ageing are needed.
Experimental ageing studies rely heavily on manipulation of life span in
intact organisms such as worms, flies, and rodents. Such studies have
revealed important insights. Alteration of genes involved in DNA repair
often leads to premature ageing. Alteration of genes involved in insulin
signalling often leads to life extension. In the worm, life extension can be
accomplished by alteration of gene expression in a single tissue, neurons.
Calorie restriction (at least 30% lower than an ad lib diet) increases both
average and maximal life span in a wide range of species. In several
species, interventions associated with increased life span activate the
expression of one or more of a family of genes, called sirtuins, that function
by silencing the expression of certain other genes. However, these and
other important observations have not yet led to a complete picture of the
molecular basis of ageing. Some ideas are summarized in Table 2.


Table 2: Some theories of Ageing
Hypothesis
How it may work
Genetic Ageing is a genetic program activated in post-
reproductive life when an individuals evolutionary
mission is accomplished
Oxidative stress Accumulation of oxidative damage to DNA,
proteins, and lipids interferes with normal function
and produces a decrease in stress responses
Mitochondrial
dysfunction
A common deletion in mitochondrial DNA with age
compromises function and alters cell metabolic
processes and adaptability to environmental
change
Hormonal changes The decline and loss of circadian rhythm in
secretion of some hormones produces a functional
hormone deficiency state
Telomere shortening Ageing is related to a decline in the ability of cells
to replicate
Defective host
defences
The failure of the immune system to respond to
infectious agents and the overactivity of natural
immunity create vulnerability to environmental
stresses
Accumulation of
senescent cells
Renewing tissues become dysfunctional through
loss of ability to renew

1.4 Conduct work that reflects an understanding of current legislation
All the work you do in your industry is conducted within a legislative,
regulatory and policy framework. Government creates laws and regulations
that industry and organisations must follow. In response, your organisation
develops policies and procedures to ensure they work within the laws and
that the organisation operates smoothly, effectively and safely for
employees and clients. Employers can be prosecuted if they do not ensure
they operate within the law.
Laws, regulations and policies influence your daily activities and place
rules and limits on certain of your duties and responsibilities. It is in your
own interests, as well as those of your employers and clients, that you not
only broadly know the law regarding aged care and where it affects your
work practices, but that you carefully follow the policies and procedures of
your organisation.


Laws relating to health practices in aged care are mainly state/territory
legislation. The most relevant legislation for the health professional is
negligence. You should be aware of the different types of laws and
regulations:
Criminal laws - deal with acts that endanger public welfare or safety
and are enforced by the police service.
Civil laws - deal with rights and duties and other legal relationships
between individuals.
Policies - are the rules and regulations of your organisation, designed
to guide the safe and efficient delivery of services in your organisation.
Practices/procedures - are the ways your organisation works to
implement policies and ensure quality care and services.
Closely related to law is a code of ethics. This is concerned mainly with
reasons behind the way you act. A code of ethics is a system of rules of
good or moral conduct based on what is believed to be right and wrong.
Ethical conduct means selecting the right actions and rejecting the wrong
ones, however, difficulties arise as ethical views do differ between
individuals and between cultures. The nursing code of ethics is provided at
the Australian Nursing Council website: http://agedcare.org.au/index.html
Laws set standards for conduct. Actions outside these standards result in a
punishment set down by courts of law. In health care the law imposes a
duty to act in certain ways. Table 3 shows some responsibilities of workers
and employers under the law.

Table 3: Employee and employer responsibilities

The Workers Common Law
Obligations
The Employers Common Law and
Statutory Obligations
To obey all lawful and reasonable
commands of the employer. The
definition of reasonable depends
on individual cases.
To show care and competence in
the performance of duties.
To disclose information received
that might be relevant to the
employer's business.
To be loyal to the employer's
interests.
To ensure employees possess the
required qualifications and
competence and are registered if
required.
To pay wages and provide other
agreed on conditions of
employment.
Not to discriminate against persons
in employment.
To provide a safe working
environment.

An employer is legally liable for the work practices of employees in the
course of their duty. Although you may work under supervision you are still
personally liable for your actions at work. All workers should refuse to give
care that is:


beyond their role
unable to be performed safely due to lack of adequate training or
practical experience
unclear, unethical, illegal or contrary to policies and procedures of the
organisation.
Policies are requirements of government authorities, health organisations
or professional bodies and relate to particular subjects. They do not have
the force of law; however they are necessary for regulation of practices
and the smooth and safe operation of health services and organisations.
Disciplinary action may be the result of not following workplace policies.

Statutory framework within which work takes place

This concerns the Acts and legal framework that guide you in your
workplace. It is not necessary for you to know every detail of these Acts;
however, you should know the issues which are relevant to you in your
daily work. The main Acts you should be aware of and which can impinge
on your daily activities are as follows.
AGED CARE ACT 1991
All Commonwealth funded aged care services operate under the Aged
Care Act 1977 and providers of aged care (the employer) and their
employees must meet their obligations as set out in the Act. The Act
applies to residential care services, community care services and respite
services. Meeting the Standards for Aged Care is a requirement of the Act.
Some of the main areas covered by the Aged Care Act are:
funding
the range and standard of aged care services to be provided
equal access to aged care services
supporting the rights and choices of the aged person.
FREEDOM OF INFORMATION ACT
Clients under the Freedom of Information Act can now access medical and
health records. Access can be denied if the medical or psychiatric
information is judged to be likely to have an adverse physical or mental
affect on the applicant. There is however also provision for limited access.
Third parties may apply for access to medical records. In general these are
released only with the consent of the client.
ACTS SUPPORTING INDIVIDUAL RIGHTS
Aged care provision must work also within the legislative framework of a
number of Acts designed to protect individual rights and ensure equity of
service. The key Acts here are:
the Racial Discrimination Act 1975
the Sexual Discrimination Act 1984
the Age Discrimination Act 2004.


STATE LAWS
In addition to Commonwealth legislation, a raft of state legislation deals
with aged care together with broader health provision. For example in
Queensland, the legal requirements for nurses in Queensland are included
in the Nursing Act 1992. Nursing legislation confines the practice of nursing
to the branch and level at which the nurse is registered.
Depending on your state of residence, you will need to ensure that you are
acquainted with the relevant legislation affecting aged care provision. As
an Assistant in Nursing, you should approach your supervisor for guidance
on this matter.
Another means of acquainting yourself with this state legislation is to
access the following Internet sites:
Queensland Health www.health.qld.gov.au
New South Wales www.dadhc.nsw.gov.au
Victoria www.dhs.vic.gov.au
Tasmania www.dhhs.tas.gov.au
South Australia www.health.sa.gov.au
Western Australia www.health.wa.gov.au
Northern Territory www.nt.gov.au/health

OCCUPATIONAL HEALTH AND SAFETY ACTS
Occupational health and safety laws promote safe and hygienic working
conditions and practices in health facilities. Occupational health and safety
legislation sets the standards to be maintained for provision of safe and
healthy work systems and procedures, provision of safe storage, and use
of plant equipment and substances. It aims to ensure all in the workplace
are free from the risk of disease or injury that might be created or caused
by the workplace and activities in it.
Accredited aged care organisations will have a Workplace Health and
Safety Committee and a designated workplace officer to support the
adherence to OH&S principles in the workplace. These committees and
officers are useful resources to the carer in sorting out any concerns or
issues associated with occupational health and safety.
POISONS REGULATIONS AND MEDICATION REGULATIONS
An Act of Parliament often does not deal with specific details but
establishes broad principles. The specific details are set out in delegated
legislation in a separate document known as Regulations that give precise
directions that must be followed in order to comply with the particular Act.
Medications and poisons Regulations give precise directions for health
professionals, including nurses, in all aspects of dealing with drugs and
poisons. This legislation permits medical practitioners (and veterinary
surgeons and dentists) to prescribe medications. While nurses may
possess and administer medications as permitted in their level of
registration they are not allowed to prescribe. Such Regulations also set
guidelines for health and safety in administration and storage of drugs and
poisons.


Drugs and poisons are classified by law into Schedules. Each Schedule
describes in general terms the properties of substances that would fall into
its area. The Schedules list the drugs and poisons according to the degree
of control recommended over their availability to the public. Poisons for
therapeutic use (drugs) are in Schedules 2, 3, 4 and 8-the higher number
representing increasingly stricter control.
Health care organisations establish their own policies relating to safe
administration of medications that meet Commonwealth and state
Regulations but are suited to the size of the institution, the services it
provides, the staff it employs and its access or isolation from other
services. These organisational policies are often quite restrictive in order to
provide tight controls to prevent errors in medication. While the nurses are
responsible for following legal provisions they must also strictly follow the
policies set out by their organisations.
It is important to note the distinction in the health network between
'prescribe', 'dispense' and àdminister'. These terms refer in general to:
medical practitioners prescribe
pharmacists dispense
nurses (and other health professionals) administer.
An organisational carer (whether residential or community) may not
administer medications. They may however assist competent elderly
clients in the self administration of their medications. If you have any
doubts about your role regarding medication, always refer the issue to your
supervisor.

Residential aged care service standards

Residential aged care standards are standards set by government for
quality assurance. Their purpose is to ensure that care is of an excellent
quality, in good physical surroundings and the personal rights of clients are
respected.
Standards require that residents are encouraged to live as they wish and
participate in a range of social experiences; accommodation is homelike
with privacy and dignity respected; health is maintained at the optimum
level; and the environment is safe and free from risk of injury and accident.
Standards focus on the end product of the service-the standard of care and
lifestyle for the residents. It is the concern of the providers to meet these
outcomes. Services must document continuous improvement.
The Aged Care Standards and Accreditation Agency assess residential
aged care services for accreditation against these standards. This agency
plays a leading role in ensuring that residential aged care facilities achieve
and maintain high standards of care and accountability. It also ensures
accountability for the billions of dollars of taxpayers' money presently spent
on residential care. The Standards are a structured approach to the
management of quality in the industry.


Home and Community Care National Service Standards
The HACC National Service Standards are the guidelines for service
provision in the community setting. There are seven key areas:
1. access to service
2. information and consultation
3. efficient and effective management
4. reliable service delivery
5. privacy
6. complaints handling
7. advocacy.
These standards should be available to all carers who work in a community
context. Typically they would be introduced and discussed during a carer's
orientation to their work within the organisation. A copy of the HACC
Standards Manual should be available to you through a request placed
with your supervisor.
Residents' rights
It is critical that organisations and individuals involved in care for older
persons understand and demonstrate in their work practices individual
aged care rights. These rights include the principles expressed in:
Charter of Rights
standards documents
general human rights
anti-discrimination laws
freedom of information legislation.
These rights are documented in every organisation. You need to check
these documents for your organisation.
User rights initiatives help to ensure quality of life for residents of aged
care facilities through protection of their rights. This is a practical
application of social justice policy based on the belief that an individual
does not lose his or her rights upon entry to a nursing home or hostel.
While many nursing home residents appear to be reasonably satisfied with
most aspects of their lives the most concern has been expressed about:
isolation and boredom
lack of control over their own lives
lack of information about residential care and the services available to
them
fear of retribution if they complain.
User rights initiatives were introduced to enable residents to gain greater
control over their own lives.


The Charter of Residents' Rights and Responsibilities was developed to
identify:
the sort of services nursing homes and hostels should provide
the rights of residents who use those services
the responsibilities of residents towards themselves and others.
These rights of your clients in residential care are set out in The
Residential Care Manual - The Charter of Resident's Rights and
Responsibilities. The Charter forms part of the formal contract between
every resident and their residential facility. The contract provides details of
services and the conditions that apply. They include:
the right to occupy a bed or room
fees, charges and how they are calculated
services that are included in the basic fee and those that incur extra
cost
conditions under which a resident may be asked to leave
ways in which residents can participate in the running of the facility
ways in which residents can complain or lodge an appeal about actions
in the facility
right to information about the financial position of the facility.
Residents' rights are protected by government bodies and other
organisations, including:
advocacy services
a community visitors scheme
improved complaint handling
greater use of protection from state guardianship legislation
training for staff.
The residents in aged care facilities have a right to considerate and
respectful care. Good care means that every resident should be
encouraged to be as independent as possible and to exercise informed
choice.
Elderly people need to be seen as equal partners in their care, not just as
passive receivers. Carers need to be constantly sensitive to the fact that
there are many ways they can influence the behaviour and attitudes of
their clients. The residential carer in particular needs to remember that the
client is no longer in their home environment surrounded by their usual
friends and securities-they are vulnerable to influence. Carers are now the
primary care giver and their opinions and leadership will be given particular
attention by the resident. It is important therefore to encourage your clients
to maintain their independence and express their choices. This is precisely
what the Aged Care Standards and Charter of Rights strive to achieve.
You should always operate within the Plan of Care; and if situations arise
where you are unsure whether the client's independence or behaviour is
exposing them to an unacceptable risk, immediately check with your
supervisor.


Remember, preventing people doing as they wish requires the appropriate
support in law. Practices found in High Care Dementia Units for example-
such as locking doors, restraining clients or refusing them to go out-
requires the necessary documentation from doctors and family or
guardians.


Activity 1:

1. Attach / Describe a news item from television, radio, newspaper or
magazine. What issue is the focus of the item?

________________________________________________________
________________________________________________________
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2. Present a case study of a client who is affected by this issue
________________________________________________________
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3. How does this case relate to the current legislation in your state?
________________________________________________________
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Activity 2:
Identify three principles which support the current philosophies
Give examples of how they impact on aged care services
1. ________________________________________________________
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2. _______________________________________________________
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3. _______________________________________________________
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Activity 3:
1. Looking at the Demographics of ageing in Australia we need to look
how aged care funding has changed in the past 5 years, give three
examples of these changes.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

2. What has been the impact on the HACC Program?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

3. How has local/regional demographics impacted/changed service
delivery in your workplace?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

4. How have these changes in demographics impacted on your day by
day work?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Activity 4:

You need to consider the impact of legislation in your workplace. How are
your workplace policies and procedures affected by this legislation? Either
consult your supervisor or use the Fitzroy Falls Aged Care Facility
procedures manuals attached to this course.
Choose two examples of a policy/procedures which ensure compliance
with legislation.
How do these two policies/procedures impact on your work?
1. _________________________________________________________
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2. _________________________________________________________
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2. Apply understanding of the home
and community care sector

2.1
Demonstrate broad knowledge of policy and programs such
as HACC, DVA and Government community care directions
2.2
Comply with duty of care implementation in home and
community settings and worker roles
2.3
Demonstrate broad knowledge of ageing in place

2.1 Demonstrate broad knowledge of policy and programs such as HACC,
DVA and Government community care directions

With increasing numbers of older people in the population and increasing
associated health costs, ageing and aged care have gained a significant
national profile. There is now a clearly recognised need for an appropriate
range of choices in residential aged care services as well as community
based care and day care centres. During the 1980s and 1990s there were
a series of Commonwealth Government studies and reports which
established the framework for the funding and provision of aged care in
Australia. Support for our ageing population is now seen to involve:
more consideration of the issues affecting the older person's ability to
be independent
a focus on social and family networks providing increased support
increased assistance for the older person to remain at home, leading
as active a life as possible
increased recognition of the rights of the aged
education of the aged to pursue their rights
free access to mufti-disciplinary health assessment
use of institutional care only as a final resort
varied institutional settings allowing for high level care only when
necessary
emphasis on preventive programs.
One of the most succinct statements outlining our national focus and
framework for aged care support remains that found within the 1999
'National Strategy for an Ageing Australia'. Developed by a Ministerial
Reference Group, the 'National Strategy for an Ageing Australia' aimed to
develop policies and programs to maintain and promote better health,
better retirement incomes and more flexible employment and caring
arrangements for older Australians. Its four broad themes are:


1. Helping Australians to be independent and to provide for their later
years through employment, life-long learning and financial security.
2. Delivering quality health care through new approaches to service
delivery, coordinated care and independent living.
3. Improving attitudes to older people and ageing-including lifestyle issues
such as personal safety, housing, transport, recreation and community
support.
4. Encouraging healthy ageing and the role of general practitioners in
maintaining the well-being of older people.
The above was taken from: `The Government's Vision for Australia's
Health Care System into the New Millennium', Keynote Address to the
Australian Financial Review Health Congress by Minister for Aged Care,
February 1999.
Given that the purpose of government concerning aged care in Australia is
to:
... enhance the quality of life of older Australians through support for active
and healthy ageing and the provision of appropriate high quality and cost-
effective care services for frail older people, people with disabilities and
carer.
23

Commonwealth and state governments cooperate in the funding and
provision of aged care services on a systematic delivery basis.

23
Aged Care in Australia Commonwealth Department of Health and Aged Care, August 1999.


Delivery of Aged Care

Delivery of aged care in Australia is in two main forms, offering a range of
support depending on assessment of needs and circumstances. The
assessment and delivery framework is broadly outlined in Figure 3 below.

Figure 3: Australias Aged care framework.

Consumers

Need for
Service and
care
Aged Care
Assessment
Consumers are
assessed for
entry to
residential care
Accreditation
and Standards
Agency
Accreditation of
residential aged
care
Health and
Community
Services Sector

Hospitals
Primary Health
Care
Population
Health
Housing
Transport

Linkages

Aged Care System

Community Care
Respite Care
Residential Care
Government: the Commonwealth Government provides income support to
individuals and also finances, plans and administers the health and community
services sector, sometimes directly sometimes jointly with state/territory governments

Financial
Contribution
(fee and/or
taxes)


Residential aged care
Residential aged care is mainly funded and regulated by the
Commonwealth, consisting of:
high level or nursing home care
low level or hostel care
facilities offering all levels of care allowing residents to 'age in place'.
There is a broad government commitment to the principle of 'ageing in
place'. This means that the older person is encouraged to remain in
their home for as long as is practicable; and also the older person in an
aged care facility may progress to higher levels of care as they age

Community based care

Community based care is mainly joint funded/administered between
Commonwealth and state/ territory governments, consisting of:
Community Aged Care Package-a community alternative for the frail
elderly who would qualify for low level residential care.
Home and Community Care Program-a home based program for the
frail elderly, those with disabilities and their carers.
Respite Programs which focus on frail aged persons who are cared for
at home by family or other significant persons. Respite is provided to
allow the carer to have a break from their commitment to the aged
person. This can involve a range of options from a few hours to several
weeks in a hostel or nursing home.

Key points of an Aged Care Profile of Australia
Older Australians are an increasingly diverse group in terms of their
backgrounds, care needs, preferences and incomes and wealth.
Aged care services are provided both in the community and in
residential facilities.
Community care is primarily provided by informal carers.
The need for some form of assistance with personal and everyday
activities increases with age. In 2003, 32 per cent of those aged 6574
years needed some form of assistance, compared with around 86 per
cent of those aged 85 or older.
Publicly subsidised aged care services are extensively regulated and
predominantly funded by the Australian Government, although all
levels of government are involved to some extent. Government is
involved in: allocating places to approved providers; assessing client
eligibility for services; funding services; setting prices; and regulating
quality.
The regulated aged care sector has changed significantly over the past
decade or so.


Key trends include:
increasing numbers of older Australians requiring subsidised care
the number of residential and equivalent community care places
increased by nearly 52 per cent between 1998 and 2007.
greater reliance on user contributions their share of total
residential care expenditure increased from 22 to 25 per cent
between 2003-04 and 2005-06.
increasing emphasis on community care its share of subsidised
places under the Aged Care Act 1997 increased from 2 to 20 per
cent between 1995 and 2007.
greater proportion of residents in high level care their share
increased from 58 to 70 per cent between 1998 and 2007.
decreasing numbers of smaller residential facilities the share of
facilities with 40 or fewer beds decreased from 53 to 34 per cent
between 1998 and 2007.
increasing investment by private for-profit providers their share
of residential care beds increased from around 29 per cent in 1998
to 32 per cent by 2007.
Detailed information about the aged care system is available from a variety
of sources notably Australias Welfare (AIHW 2007b), Residential Aged
Care Services in Australia (AIHW 2008d), Aged Care Packages in the
Community (AIHW 2008a) and Report on the Operation of the Aged Care
Act 1997 (DoHA 2007h).
The aged care sector encompasses a broad range of services reflecting
differing client needs and funding arrangements. It is also characterised by
extensive government regulation and high levels of public subsidy. There
are two broad categories of aged care services community (or home
based) care and care provided in residential aged care facilities.
Some older people purchase aged care services that are not funded or
regulated by the Australian Government. However, data on the extent of
these services are not readily available. Thats why we are going to focus
now on the regulated system of aged care service provision in Australia.

Aged care represents a social product system
Aged care is essentially concerned with providing appropriate care for
older Australians as the ageing process impairs their ability to care for
themselves. The provision of aged care can be thought of as a complex
social product system (see, for example, Marceau and Basri 2001 who
examine healthcare in this context).
Features that characterise the social product system for aged care
services include:
the production of bundles of services tailored to the individual needs
of clients, that may include personal care services, other everyday
assistance, accommodation, nursing care and palliative care
a high degree of direct contact between providers and clients rather
than through arms length market transactions


the presence of many different organisations, governance
arrangements, funding instruments and incentive mechanisms
a marked variation in the cost of service provision, with some services
being particularly high cost relative to others
the social value nature of these services justifying a high degree of
government involvement, with regulations determining how, where and
to whom these services are provided and governing what prices are
charged
high, and increasing, community expectations about the provision of
these services (for example, in terms of access, flexibility and
responsiveness).
In common with other complex social product systems, such as the health
and education systems, there are subsystems within aged care (for
example, community care, residential care and respite care) and there are
important interfaces between aged care and other social policy areas, such
as allied health, hospitals, disability and housing services.
Service delivery in each of these areas affects the performance of the
aged care sector. For example, changes in the availability and nature of
care provided by hospitals can affect the demand for community and
residential care.

A profile of older Australians requiring care

The aged are a diverse group, having different preferences, backgrounds,
functional capacities, living arrangements, income and wealth. Reflecting
this diversity, older Australians enter the aged care system at different
points, requiring different levels of care and combinations of services in a
range of different settings. Three important points of diversity that drive
much of the variation in demand for aged care services are differences in
older peoples need for care, their income and wealth and accommodation
arrangements.

Need for care
In 2003, almost half (46.6 per cent) of all Australians aged 65 years or
older reported needing assistance with personal or everyday activities
such as self-care, mobility and communication (Figure 4) As the incidence
of physical and cognitive disability increases with age, so to does the need
for assistance. In 2003, 32 per cent of those aged 6574 years needed
some form of assistance, compared with around 86 per cent of those aged
85 or older (Figure 5)


Aged 65 years or
older
2 497 000
Needs assistance
with personal
activities
a

772 000 (30.9%)
Needs assistance
with other
everyday activities
b

392 000 (15.7%)
Does not need
assistance
1 333 000
(53.4%)
Lives in
private
dwelling

2 219 000 (88.9%)
Lives in
accommodation
for retired & aged

112 000
c
(4.5%)
Lives in
residential
care
d

high care 85 000
low care 48 000
(5.3%)
Lives in hospital

18 000 (0.7%)
Lives elsewhere
self care 8 000
care
d
7 000
(0.6%)
Figure 4: Need for assistance and living arrangements of older persons
Aged 65 years or older, 2003

a. Personal activities comprise self-care, mobility, communication, cognitive
or emotional tasks and health care.
b. Other everyday activities comprise paperwork, transport, housework,
meals and property maintenance.
c. Predominately retirement villages. PC estimate from ABS data allowing for
difference between ABS and AIHW data regarding the number of older
people in residential care.
d. AIHW (2004d).
Data source: ABS (Survey of Disability, Ageing & Carers, 2004, Basic CURF, CD-ROM).


Figure 5: Need for assistance by age of older persons, 2003

P
r
o
p
o
r
t
i
o
n

r
e
q
u
i
r
i
n
g

a
s
s
i
s
t
a
n
c
e

(
%
)

100 'Young old' 'Middle old' 'Old old'
80
60
40
20
0 65-69 70-74 75-79 80-84 85+
Age Groups

Data source: ABS (Survey of Disability, Ageing and Carers: Summary of Findings, Cat.
no. 4430.0).

Income and wealth

The income levels of older Australians play an important part in their use of
care as well as the extent of user contributions for this care. The most
important source of income for a sizeable proportion of the current cohort
of older Australians is the age pension. In June 2007, 66 per cent of
Australians over the current qualifying age (65 years for men; 63.5 years
for women) received the age pension (FaCSIA 2007).
In addition, some in this cohort also received similar means tested income
support from the Department of Veterans Affairs, bringing the total
Australian government age and service pension take-up for this group to
75 per cent.
Of the 1.95 million Australians who received the age pension in 2006-07,
some 60 per cent received a full rate pension and 40 per cent a part rate
(FaCSIA 2007).
During 2005-06, government pensions and allowances accounted for at
least 90 per cent of the income for nearly half (47 per cent) of those
households with at least one member aged 65 years or older (ABS 2007f).
Even so, a significant proportion of households (almost 20 per cent)
received less than 20 per cent of their income from the age pension in
2005-06. Further, there is great variation in wealth among older Australians
whether home ownership is included or excluded.


Accommodation arrangements
The home is an important dimension of community care 89 per cent of
those aged 65 years or older live in a private dwelling with a further 4.5 per
cent living in accommodation for the retired or aged such as retirement
villages (figure 4).
Importantly, the security of accommodation arrangements for the elderly
(that is, stability of tenure) impacts on the scope to provide community care
services. In 2006, 82 per cent of households with at least one member
aged 65 years or older owned their own home, with or without a mortgage,
and 15 per cent rented.
24

Types of care
Older peoples care needs can be thought of as a spectrum, depending on
the degree to which the ageing process has impaired their ability to care
for themselves. Older people will often experience increasing support
needs either gradually or following acute care episodes. Various bundles
of services are available to cater for these needs, ranging from in home
support with some everyday and personal activities, through to full-time
personal and nursing care provided in a residential care facility.

Community care

It is government policy and the wish of most older people to remain in the
community for as long as possible. A wide range of services can assist
older people to live independently: from living and personal care through to
nursing, medical and palliative care. Informal carers (for example, family
and friends) typically supply such services, often in conjunction with one or
more formal community care providers through a range of government
subsidised programs.
The Home and Community Care (HACC) program serves as the mainstay
of community care by providing basic maintenance and support services to
older people (and some younger people) wishing to live independently at
home. HACC providers offer a wide range of services including domestic
assistance, meals, nursing, transport, allied health, home maintenance,
personal care, social support, aids and equipment.
Around 643 000 people aged 70 years or older received HACC services in
2006-07 (table 4). Most HACC clients (90 per cent) received less than two
hours of service each week, although a small proportion (3 per cent)
received more than 4.5 hours each week, some up to 28 hours each week.
Two programs administered by the Department of Veterans Affairs (DVA)
also assist a significant proportion of older people by offering a range of
services similar to that delivered through the HACC program. The
Veterans Home Care (VHC) program provided services to around 72 100
veterans aged 70 years or older in 2006-07 while the DVA Community
nursing program assisted 33 365 veterans of all ages in the same year
(table 4).

24
(ABS unpublished data).


The Australian Government also funds three programs designed for older
people eligible for residential care but who have expressed a preference to
remain in the community:
Community Aged Care Packages (CACPs) provide a bundle of
services averaging 7 hours a week as an alternative to low level
residential care
Extended Aged Care at Home (EACH) programs target older people
eligible for high level residential care by providing an average 23 hours
of packaged care a week
EACH Dementia (EACHD) is designed to provide the highest level of
community care for those with complex cognitive, emotional or
behavioural needs (table 3).
As at 30 June 2007, there were 36 555 older people receiving packaged
care through these programs, the majority receiving CACPs (32 983) with
the balance (3572) receiving EACH and EACHD packages (table 3).
Table 3: Profile of main community care programs
People aged 65 years or older, unless otherwise indicated
a

Program Recipients Service usage
b
Usage of main service
types (% of clients)
Home and
Community Care
c

642 650 in 2006-07 90% use < 2 hours
a week;
97% use < 4.5
hours a week
Domestic 30%
Meals 22%
Nursing 21%
Veterans Home Care 72 100 in 2006-07
d
79% received 1
service
98% received up
to 2 services
Domestic 89%
Home& garden 19%
In-home respite 16%
DVA Community
Nursing
33 365 in 2006-07
e
Bathing 54%
Dressing 45%
Community Aged
Care Packages
32 983 as at June
2007
average 7 hours a
week
50% use 4.59.5
hours a week
May include bathing,
toileting, dressing, meal
preparation, laundry,
home help, gardening
and mobility.
Extended Aged Care
at Home (including
EACH Dementia)
3572 as at June 2007 average 23 hours
a week
50% use 1729
hours a week
As for CACPs, but
may also include
nursing, allied health,
oxygen and enteral
feeding.
National Respite for
Carers Program
42 884 in 2004-05
f
In-home 46%
Commonwealth
residential 21%


a Due to data availability, numbers refer to different time periods.
Some recipients receive services from more than one program.
b Hours standardised to personal care equivalent hours (DoHA
2007g).
c Aged 70 years or older. Usage rates are for 2004-05.
d Estimated number of veterans provided with services who were aged
70 years or older. 96.7 per cent of veterans who were assessed for
services were aged 70 years or older. Veterans approved for VHC
services including domestic assistance, home and garden
maintenance, personal care and respite. The actual number of
recipients will be lower than those approved.
e. Clients of all ages.
f Covers carers looking after people of all ages who received direct
respite care services through Commonwealth Carer Respite Centres.
Sources: AIHW (2007b, 2008b); DoHA (2007g); DVA (2007, 2008);
SCRGSP (2008); PC estimates.

A number of government initiatives provide support to informal carers. The
role of an informal carer is often demanding financially, physically,
socially and emotionally. As such, caring diminishes opportunities to
engage in full-time employment and limits the scope to have a break from
this role.
In recognition of these demands, governments provide assistance to
carers through respite services for the person they are assisting (such as
through the National Respite for Carers Program), as well as through carer
specific payments and allowances (table 3). Such assistance also
influences the ongoing feasibility of providing informal care and thereby
affects the demand for formal modes of care, including residential aged
care services.

Residential care
Aged people with physical, medical, psychological or social care needs
that cannot be practically met in the community are eligible for residential
aged care. There are two main classes of residential care low level care
and high level care. Low level care covers the provision of suitable
accommodation and related living services (such as cleaning, laundry and
meals), as well as personal care services (such as help with dressing,
eating and toileting). High level care covers accommodation and related
living services, personal care, nursing care and palliative care within a
fulltime supervised framework.
At 30 June 2007, there were around 145 000 permanent residential aged
care recipients in Australia aged 65 years or older, with around 70 per cent
receiving high level care (table 4.). Over 50 per cent of recipients were
aged 85 years or older and by far the greatest number were women.


Table 4: Characteristics of permanent residential care clients
30 June 2007.

High Care
a
Low Care
b
Total
Age
64 years & under % 4.6 3.3 4.2
65 74 years % 8.8 7.9 8.5
75 84 years % 33.4 32.6 33.2
85 years & over % 53.3 56.2 54.1

Permanent clients aged 65+
c

Female 000 73.4 31.8 105.2
Male 000 27.9 11.9 39.8
All 000 101.3 43.7 145.0

Average length of stay
d

Less that 1 year % 35.7 44.5 36.9
1 -3 years % 27.8 30.7 28.1
More than 3 years % 36.5 24.8 35.0

a. Residential Classification Scale 14.
b. Residential Classification Scale 58.
c. Data from 0.8 per cent of residents whose dependency levels were
not reported have been allocated proportionally.
d. Level of care for permanent residents at time of separation during
200607.
Sources: AIHW (2008d); PC estimates.


The role of government in aged care
Australias aged care sector is subject to extensive regulation and high
levels of public subsidy. A summary of the current policy and legislative
framework and the main areas of regulatory control follows.

Current policy and legislative framework
National Strategy for an Ageing Australia
The National Strategy for an Ageing Australia (Andrews 2002a) was
introduced to provide a strategic framework for a coordinated national
response to the challenges associated with population ageing. The
strategy is structured around four key elements:
independence and self provision;
attitude, lifestyle and community support;
healthy ageing;
and world class care.
In relation to providing world class care, the national strategy specifies
four goals:
A care system that has an appropriate focus on the health and care
needs of older Australians and adequate infrastructure to meet these
needs
A care system that provides services to older people that are
affordable, accessible, appropriate and of high quality
A care system that provides integrated and coordinated access,
assistance and information for older Australians with multiple,
significant and diverse care needs
A sustainable care system that has a balance between public and
private funding and provides choice of care for older people (Andrews
2002a).

Aged Care Act 1997
The Aged Care Act 1997 is the principal regulatory instrument of the
Australian Government relating to aged care. Section 2-1 of the Act
nominates the Governments objectives in this area, including:
to provide funding that takes account of the quality, type and level of
care
to promote a high quality of care and accommodation and protect the
health and wellbeing of residents
to ensure that care is accessible and affordable for all residents
to plan effectively for the delivery of aged care services and ensure
that aged care services and funding are targeted towards people and
areas with the greatest needs
to provide respite for families and others who care for older people


to encourage services that are diverse, flexible and responsive to
individual needs
to help residents enjoy the same rights as all other people in Australia
to promote ageing in place through the linking of care and support
services to the places where older people prefer to live.

These objectives are elaborated in the Aged Care Principles that
accompany the Act.
The Act also recognises the need to efficiently integrate aged care
planning and service delivery across the related areas of health and
community services.
The Act specifies that in interpreting its objectives, due regard must be
given to: the limited resources available to support services and programs
under the Act; and the need to consider equity and merit in assessing
those resources (s. 2-1(2)).
Thus, although the Act does not explicitly identify sustainability as an
objective, it does recognise that resources are limited. The Act was clearly
framed in the context of meeting the challenges associated with Australias
ageing population. On the introduction of the legislation to the House of
Representatives, the then Minister for Family Services, the Hon. Judi
Moylan, stated:
It is essential we undertake reform now, to meet the challenges of our
ageing population. In little over 30 years, Australias population of over 65s
will increase by more than 50 per cent to 5 million people. This bill provides
the path forward.
25

The Home and Community Care Act 1985
The Home and Community Care Act 1985 provides for the HACC program
to be jointly administered and financed by the Australian, State and
Territory Governments.
The HACC program has a number of principles and goals including several
that encompass notions of equity and efficiency:
to ensure access to HACC among all groups within the target
population, including migrants, Indigenous Australians, persons
suffering from brain failure and financially disadvantaged persons
to ensure that, within available resources, priority is directed to persons
within the target population most in need of HACC
to ensure that, within available resources, HACC services are provided
equitably between regions and are responsive to regional differences
to ensure that HACC services are delivered in a manner that is cost
effective, achieves integration, promotes independence and avoids
duplication

25
(Commonwealth of Australia 1997, p. 3192)


to promote an integrated and coordinated approach between the
delivery of HACC and related health and welfare programs, including
programs providing residential or institutional care (Home and
Community Care Act 1985, s. 5(1)).
26

Charter of Budget Honesty and Intergenerational Reports
Aged care policy, like other areas of government policy, is framed in the
broader context of the Charter of Budget Honesty Act 1998 and the
Intergenerational Reports.
The Charter of Budget Honesty Act 1998 sets out the principles of sound
fiscal management and commits the Government to preparing an
intergenerational report at least every five years. These reports assess the
long-term fiscal sustainability of current government policies (such as aged
care) over the next 40 years, including by taking account of the financial
implications of demographic change.
The first intergenerational report identified seven priorities for ensuring
fiscal sustainability. One of these was to develop an affordable and
effective residential care system that can accommodate the expected high
growth in the number of very old people (people aged 85 years or older)
(Treasury 2002).
The second intergenerational report noted that, looking out over the next
40 years, aged care continues to be one of the main pressures on
government expenditure (Treasury 2007).
State, Territory and Local government regulation
State, Territory and Local government regulation also impacts on the
provision of aged care through regulations covering building planning and
design, occupation health and safety, fire, food and drug
preparation/storage and consumer protection (Hogan Review 2004).
Beyond these measures, Australian, State and Territory governments do
not actively regulate the operation of their aged care sectors, except for the
Northern Territory.
The Northern Territory Government still licenses aged care facilities that
receive Australian Government subsidies and controls their conduct
through annual inspections and powers over licence renewals (Hanks and
De Ferrari 2003). The Territory Government has designed its inspection
and licensing processes to complement those of the Australian
Government (Aagaard 2002).
The main areas of regulatory control
In order to meet the objectives outlined above, governments control key
aspects of aged care by: allocating aged care places to approved
providers, assessing client eligibility, funding services, setting prices and
controlling quality.
Some guidance on the nature of involvement in each area is presented
below.

26
(Home and Community Care Act 1985, s. 5(1)).


Allocating aged care places to approved providers
The Australian Government funds and allocates new aged care places
each year to broadly match growth in the target population those aged
70 years or older plus Indigenous people aged 5069 years. It signals its
long-run intentions through a target provision ratio which provides some
guidance to investment by the private sector.
The Government is currently aiming to achieve a ratio of 113 places per
1000 of the target population by 2011. It comprises 88 residential places
(44 high care and 44 low care) and 25 community care packages (21
CACPs and 4 EACH).
The Government also balances the provision of services between
metropolitan, regional, rural and remote areas, as well as between people
needing differing levels of care. The Secretary of the Department of Health
and Ageing, acting on the advice of the Aged Care Planning Advisory
Committees, allocates places to each Aged Care Planning Region within
each state and territory.
Following the allocation of new places to regions within each state and
territory, the Government conducts an open tender to allocate these places
to approved providers. Because of the time required for building approval
and construction, providers have two years to make residential places
operational. CACP packages and EACH places tend to become
operational sooner after allocation (DoHA 2007h).
The Government also expects service providers to meet regional targets
for places for concessional residents. These targets range from 16 to 40
per cent of places and aim to ensure residents who cannot afford to pay an
accommodation bond (low care) or accommodation charge (high care)
have equal access to care.
Assessing client eligibility
The Australian Government provides grants to State and Territory
Governments to operate Aged Care Assessment Teams (ACATs), or Aged
Care Assessment Services in Victoria, under the Aged Care Assessment
Program. ACATs may include doctors, nurses, social workers and other
health professionals.
Their role is to assess the care needs of frail older people and help them
receive the most appropriate care and support in accordance with the aged
care legislation and Aged Care Assessment Program: Operational
Guidelines (DoHA 2002a). This may involve simply referring clients to
community care providers such as those available under the HACC
program. Alternatively, they may approve their eligibility for residential or
community care services (DoHA 2007h).

Funding services
Aged care in Australia is largely publicly funded. The Australian
Government provides most of the recurrent funding for residential aged
care services, an estimated $5.4 billion to people aged 65 years or older in
2006-07 (table 5.). State and Territory Governments also provide some
funding for these services.


Table 5: Recurrent government expenditure on aged care programs in
Australia, 2006-07
Estimated share for clients aged 65 years or older
Mode of care
Government
expenditure
a

Care mode
expenditure to
total expenditure

$m %
Aged care assessments 58 0.7
Residential aged care
b
5398 62.8
Community care 2117 24.6
HACC
c
1151 13.4
CACP 381 4.4
VHC 93 1.1
Flexible care
d
248 2.9
Respite care
e
191 2.2
Information, support & other community
care
f

53 0.6
Financial support for carers
g
1018 11.9
Total 8591 100.0

a Expenditure estimates are based on the proportions of clients aged 65
years or older. Where applicable, estimates are for total Australian, State
and Territory government expenditure. Components may not add due to
rounding.
b Includes expenditure on residential aged care by the Department of
Veterans' Affairs and State and Territory government funding.
c Estimated aged care share of total government HACC expenditure.
Includes some respite services.
d Includes EACH and EACHD, TCP, MPS and flexible care pilot projects.
e National Respite for Carers Program and Australian Government funded
Day Therapy Centres. Residential respite expenditure estimated as a
share of total residential expenditure on basis of days occupied.
f Includes Commonwealth Carelink Centres, information and assistance
with continence, dementia, housing, Indigenous specific issues and other
care needs.
g Estimated share of total government expenditure on carers payments
and allowances received by those caring for people aged 65 years or
older.
Sources: AIHW (2007b); FaHCSIA (2008 unpublished data); SCRGSP
(2008); PC estimates.


Residents fees and charges provide most of the remaining service
revenue, around $2.1 billion in 2005-06 (AIHW 2007b). Since most user
contributions are financed indirectly from aged pension payments
around 88 per cent of permanent residents receive Centrelink or DVA
pensions (AIHW 2008d) the bulk of the cost of residential care is
effectively sourced from general revenue.
Residents assessed care needs largely determine government funding of
residential aged care. Until recently, the instrument used to classify
residents and determine care subsidies was the eight-level Resident
Classification Scale (RCS).
On 20 March 2008, the Aged Care Funding Instrument (ACFI) replaced the
RCS with a three-year phase-in period. The Australian Government
developed the ACFI in consultation with industry following two reviews
(DoHA 2003a; Hogan Review 2004).
The ACFI calculates basic care subsidies according to each clients level
of need (none, low, medium or high) in three care domains:
activities of daily living (such as nutrition, mobility, personal hygiene,
toileting and continence)
behaviour supplement (cognitive skills, wandering, verbal behaviour,
physical behaviour and depression)
complex health care supplement (DoHA 2007c).
For example, a resident with high care needs in all three care domains
would attract a basic care subsidy of around $138 a day under the new
ACFI (DoHA 2008d).
However, the basic subsidy payable to some residents is reduced by an
income test reflecting their income and the cost of care. Providers can
recover this amount directly from clients through an income tested fee.
Additionally, the Government pays a variety of other subsidies including an
oxygen supplement, enteral feeding supplement, conditional adjustment
payment and a viability supplement that is paid to rural and remote
providers.
The HACC program receives the bulk of community care subsidies
around $1.15 billion in 2006-07 for people aged 65 years or older (table
2.5). The Australian, State and Territory Governments fund the bulk of
HACC services; the shares being approximately 60 and 40 per cent
respectively. In general, the States and Territories allocate HACC funds to
meet regional priorities. Within individual programs and projects, service
providers seek to allocate funds to provide the most benefit to the greatest
number of people.
The Australian Government also contributed around $774 million towards
other community care programs including CACP, EACH, MPS and VHC in
2006-07.
Funding for packages allocated under these programs provide recipients
with a constant level and quality of care. As at 1 July 2008, the basic
subsidies for community care were: CACP ($34.75 a day), EACH ($116.16
a day) and EACH
Dementia ($128.11 a day) (DoHA 2008d). Additional supplements are also
available for oxygen, enteral feeding and remoteness. Many recipients of
community care contribute towards the cost of these services.


Older people and their carers largely fund the provision of their informal
care, although the Australian Government funds a range of carer support
programs. Total funding for the National Respite for Carers Program,
Australian government funded day therapy centres, carer payments and
carer allowances was around $1.2 billion in 2006-07 (table 5)
Setting prices
The Australian Government regulates the amount that aged care clients
pay for subsidised care. For most standard service offerings, charges are
means tested and capped, with concessional rates applying to pensioners.
Additional charges may apply to remote residents.
As of 1 July 2008, the three main daily user fees and charges for new non-
pensioner residents receiving standard care in residential facilities that are
2008 compliant are the:
basic daily care fee, up to $32.05 a day
asset tested accommodation charge, for high care residents with
assets worth more than $34 500, the rate increasing from zero to
$26.88 a day when assets exceed $90 410.40
income tested fee, with residents being charged up to $56.57 a day or
the cost of their care, whichever is the lesser (DoHA 2008e).
An accommodation bond may be required of people entering low care or
extra service residential facilities. The regulations do not cap bond
amounts. However, providers cannot levy a bond that leaves a resident
with assets worth less than a threshold amount $34 500 as at 1 July
2008 (DoHA 2008e). Providers are able to deduct a retention amount over
five years and charge interest on bonds paid periodically, the rate being
11.75 per cent as at 1 July 2008 (DoHA 2008e). The balance of the bond
is refundable on departure. Accommodation charges are levied on
residents in high care, providing their assets exceed a certain amount. The
ACFI classifies a resident as high care if they are in any one of the
following categories:
medium or high care needs in activities of daily living
high behaviour needs
medium or high complex health care needs (DoHA 2008b).
The value of a residents home is counted as an asset for aged care
accommodation payment purposes unless their;
partner or dependent child/student lives in it
carer who is eligible to receive an Australian income support payment
has been living in it for the past two years
close relative who is eligible to receive an Australian income support
payment has been living in it for the past five years (Centrelink 2008).
Further, if a resident is renting out their former home and paying either an
accommodation charge or bond by periodic payments at the same time:
the rental income from the former home is exempt in full for both the
pension income test and aged care fees
the value of the home is exempt from the pension asset test
(Centrelink 2008).


The fees for community care services vary with the type of service and the
clients capacity to pay. State and Territory Governments develop their
own HACC service fee policies and scales, guided by the principles
outlined in the Draft HACC Fees Policy (Commonwealth of Australia 2007).
For those care recipients whose income exceeds the basic rate of pension,
the maximum fee for CACP, EACH or EACH Dementia packages is 17.5
per cent of the persons income to the level of the basic pension, plus up to
50 per cent of their income (minus tax and the Medicare levy) above the
basic pension (DoHA 2008a). However, people assessed for community
care services cannot be refused service on the basis of their inability to
pay (DoHA 2006b).

Regulating quality

Both community and residential aged care services are subject to quality
regulation.
This is justified on the basis that providers and aged care recipients have
unequal access to relevant information and the frailty of residents can
make them vulnerable to exploitation (Hogan Review 2004, p. 273).
Australian government funded residential facilities are subject to a quality
assurance system based on:
legislated responsibilities, which are specified in the Aged Care Act
1997 and in the Aged Care Principles
an accreditation based quality assurance regime, encompassing four
accreditation standards: management systems, staffing and
organisational development; health and personal care; resident
lifestyle; and physical environment and safety systems
a certification process to encourage improvement, particularly of the
physical standard of residential aged care buildings.
The Quality of Care Principles 1997 outline standards that cover the quality
of care and quality of life dimensions of both residential and community
aged care (table 6).
The Aged Care Standards and Accreditation Agency assesses compliance
with the quality standards and the Department of Health and Ageing
monitors compliance with other legislated obligations. Services found to be
noncompliant face sanctions, including suspension of funding and, in the
case of the most serious breaches, revocation of approval.
Since the 2004-05 Budget, Australian Governments have also allocated
funding to the development of a quality assurance and monitoring system
across a number of community care programs (CACP, EACH and NRCP).
This system involves a three step process: self-reporting against uniform
quality standards; departmental monitoring through desk audits; and
validation visits.
The 2007-08 Budget included additional funding to enhance the
community care quality assurance system and provide for the development
of best practice models and benchmarking in key areas of community care.


Table 6:
Part 5: Privacy, dignity, confidentiality and access to personal
information

Principle: The dignity and privacy of each care recipient are to be
respected, and each care recipient (or his or her representative)
will have access to his or her personal information held by the
provider.

Col. 1
Item
Column 2
Matter Indicator
Column 3
Expected Outcome
5.1 Privacy and dignity Each care recipients dignity and
privacy is respected
5.2 Procedures Each care recipient is told of the
service providers privacy and
confidentiality procedures and
his or her rights under the
procedures
5.3 Access to information Each care recipient (or his or her
representative) has access to
personal information about the
care recipient held by the
approved provider

Recent trends in aged care

The aged care sector has changed considerably over the past decade or
so, driven by a combination of demographics, changing care needs,
increased funding for community care and restructuring by service
providers. The most important trends have been:
increasing numbers of older Australians requiring care
greater reliance on user contributions
increasing emphasis on community care
greater proportion of residents in high level care
decreasing numbers of small residential facilities
increasing investment by private for-profit providers.

Increasing numbers of older Australians requiring care
The number of older Australians requiring assistance with day to day
activities has increased over the past decade. As disability rates for those
aged over 65 years have been roughly stable (ABS 1998, 2004b; AIHW
2006a), the main growth driver has been the increase in the numbers of
older Australians. In 1996, there were around 2.2 million people aged 65 or
older. By 2007, this had grown to almost 2.8 million (ABS 1997, 2007a).
Importantly, most of this growth has occurred in the older age groups
(figure 6) the groups that are more likely to require assistance. Indeed,
while the total number of people aged 65 years or older increased by 25.5


per cent between 1996 and 2007, the number of people aged 85 or older
grew by almost 70 per cent.

Figure 6: Numbers of older Australians, 1996-2007
27

Thousands

A
g
e

(
y
e
a
r
s
)

Males Females
85+

80-84

75-79

70-74

65-69

500 400 300 200 100 100 200 300 400 500

2007 0

1996

The growth in older Australians requiring assistance has driven a large
increase in the number of subsidised care places. In 1996, there were
around 141 282 operational residential and equivalent community care
places in Australia. By 2007, the number of these places had grown to 214
250, an average annual growth rate of 3.9 per cent (AIHW 2008d).
The growth in the aged care sector over the past decade has, not
surprisingly, been associated with a large increase in funding for the
sector, from both private and public sources.
Aged care funding by Australian, State and Territory Governments
increased from $4.4 billion in 1995-96 (2006-07 dollars) to $8.6 billion in
2006-07 an average annual real increase of 6.1 per cent in real terms
(figure 7.). This compares with an average annual increase of 6.1 per cent
for health and 5.3 per cent for education.

27
Data sources: ABS (Australian Demographic Statistics, Cat. no. 3101.0); ABS (Population by Age and Sex,
Australian States and Territories, Cat. no. 3201.0).


Figure 7: Government real expenditure on selected social services
28

2006-07 dollars
$

b
i
l
l
i
o
n

70

60

50

40

30

20

10

0

Aged Care Services

Health

Education

Greater reliance on user contributions
The past decade has seen a shift towards greater private funding of aged
care services. As part of the structural reform of the residential aged care
sector in 1997, accommodation payments and income testing of daily care
fees, which previously only applied to low level care, were introduced for
all residential care. The daily care fees paid by residents, plus income
tested fees, as a proportion of the total expenditure on care in residential
aged care facilities increased from 22 per cent in 2003-04 to 25 per cent in
2005-06
29

Additionally, residential care providers have been able to request an
accommodation bond from clients entering low care or making use of extra
service high care facilities since 1997. Providers are able to retain the
interest and deduct a retention amount over five years. Between October
1997 and June 1999, accommodation bonds were held by 63 per cent of
aged care facilities, with the average bond being $58 400. By 2006-07, 78
per cent of facilities held bonds with an average value of $167 450.
30

28
Data sources: ABS (Government Finance Statistics, Australia 1997-98, Cat. no. 5512.0); ABS (Government
Finance Statistics, Education, Australia, 2006-07, Cat. no. 5518.0.55.001); AIHW (2007d); SCRCSSP (1998);
SCRGSP (2008).
29
(AIHW 2007b).
30
(DHAC 1999; DoHA 2007h)
1995-96
2006-07


Increasing emphasis on community care
Government policy, and the choice of most aged people, is to receive
assistance in their own residence when possible. As a result, there has
been a trend away from residential care towards community care in recent
years (figure 8). Indeed, between 1995 and 2007, 54 per cent of the
growth in funded places under the Aged Care Act 1997 has been in
community care.
31

Figure 8: Aged care places and packages
Places and packages per 1000 people aged 70 years or older
a

120

100

80

60

40

20

0

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Residential Aged Care
Community Care

a Community care includes CACP, EACH and EACH Dementia packages and TCP places.
Data source: AIHW (2008d).

In 1995, there were around 2500 subsidised community care places on
offer across Australia, representing less than 2 per cent of total subsidised
care places. By 2007, community care places had grown to around 44 000,
representing around 20 per cent of total places (AIHW 2008d). An
important part of this growth has been the expansion of funding to support
flexible care places (EACH, EACH Dementia and Transition Care
Program). The first of these programs started in 2002-03, and by June
2007 there were almost 6200 such places.
31
The growth of these places
reflects the broadening range of community care services that are provided
to older people. In the past, many of the services that are now provided in
community settings through CACP, EACH and EACH Dementia would only
have been accessed in a residential care setting.

31
(AIHW 2008d).


Increasing support for carers
With greater reliance on community care, there has also been an increase
in funding for carers and for respite services. For example, the combined
payments and allowances for carers (caring for people of all ages)
increased from around $450 million in 1995-96 to almost $2.8 billion in
2006-07, representing an average annual increase of 15 per cent in real
(constant dollar) terms. Similarly, funding for the National Respite for
Carers Program has increased in real terms by an average of 19 per cent
annually since it commenced in 1996-97, to around $170 million in 2006-
07.
32
In addition, the number of occupied place days for respite care within
residential care facilities increased by 7.1 per cent between 1998-99 and
2006-07.
33

Greater proportion of residents in high level care
Older people are more likely to use residential aged care facilities for high
level care than in the past. Between 1998 and 2007, the proportion of all
permanent residents receiving high care increased from 58 to 70 per cent,
an increase of around 32 000.
34
High care residents aged 85 years or older
accounted for most of this growth, increasing by around 31 127 to 56 446.
35
This trend has resulted from ageing in place initiatives and
accompanying changes to the target provision ratio.
Australian Governments have rebalanced the mix of aged care services on
a number of occasions since 1985 by adjusting the target provision ratio.
This has had two effects. First, the proportion of community care places
has increased relative to residential places over the past 20 years
largely by substitution for low level care residential places. Second, the
proportion of high level care residential places has increased relative to
those available for low level care.
Decreasing number of small facilities
Although the number of residential care places has increased in recent
years, the number of aged care facilities has declined by 4.7 per cent, from
3015 in 1998 to 2872 in 2007. The increased average size of residential
aged care facilities reflects this consolidation. For example, around 47 per
cent of facilities offered more than 40 beds in 1998. By 2007, this
proportion had increased to around 66 per cent. In particular, the number
of facilities with more than 100 beds increased by 121 per cent over this
period.

32
(SCARC 2005; SCRGSP 2008)
33
(AIHW 1999, 2008d).
34
(AIHW 1999, 2008d)
35
(AIHW 1999, 2008d).


Table 8: Number and size of residential aged care facilities, 1998 and
2007
36

As at 30 June
1998 2007 Percentage
Change
Facilities Per Cent Facilities Per cent
Size of facilities

(number of places)
1-20 396 13.1 213 7.4 -46.2
21-40 1194 39.6 762 26.5 -36.2
41-60 831 27.6 887 30.9 6.7
61-80 322 10.7 469 16.3 45.7
81-100 141 4.7 252 8.8 78.7
101-120 64 2.1 140 4.9 118.8
121+ 67 2.2 149 5.2 122.4
Total 3015 100.0 2872 100.0 -4.7

Increasing investment by private for-profit providers
Private not-for-profit operators own and operate the bulk of residential
aged care homes and beds. Even so, a number of private for-profit
operators have emerged as important players in the market, such as the
Moran Health Care Group, TriCare and Macquarie Capital Alliance
Group/Retirement Care Australia.
Reflecting this, the share of residential care beds provided by private for-
profit operators has increased, from around 29.5 per cent in 1998 to 32.5
per cent in 2007.
37
These for-profit facilities also tend to be larger, offering
an average of 70 places in 2007, compared with 57 for not-for-profit
facilities and 37 for government facilities.
Aged care in Australia is big business and an important part of the
economy. It is a major employer of around 537 000 people, 40% being
doctors and nurses. Aged care provision is a mix of government, state,
religious, charitable and private enterprise. The private sector operates just
over one quarter of the residential care services and almost half of all high
care services and is very active in community care.
Aged care has become a significant part of the economy: indeed for some
private providers of aged care it is a major commercial opportunity.
However, as Australia moves into the first decade of the 21st century, it is

36
Sources: AIHW (2000b, 2008d).
37
(SCRCSSP 1999; SCRGSP 2008).


clear that ageing and aged care has become almost a national economic
obsession. This is because governments and the media are now alert to
the potential economic impact of the greying of Australia as a result of the
ageing 'Baby Boomer'. A quote from a 2004 Financial Review article
serves to illustrate this concern:
The effect of longevity on a world that is already short of children ... is
scary reading (it shows) a generational debt of $US45 trillion in America
that someone's kids are going to have to pay.... The social implications of
an ageing population are mind boggling. Imagine: walking frames will
outnumber strollers, incontinence pads will outsell nappies.
38

As well as the media debates on ageing and the economy and critical
economic structures such as tax and superannuation, government reports
and papers are also attempting to debate the issue-e.g. 'Queensland 2020:
A State for All Ages-A discussion paper about the ageing of the population
in Queensland'
39

38
[Macken, 2004, p. 28.]
39
(Department of Families, 2003)

Table 9
Resource Document RDN-030
From the Department of Health and Ageing - Attachment One
Table A9: The National Policy Context from website http://www.health.gov.au accessed 12
th
June 2009
Reference Organisation Policy description
Part VB of the National Health Act 1953
Aged Care Act 1997
Residential Respite Care Manual (Appendix to
the Residential Care Manual 1999)
Assistance for Carers Legislation Amendment
Act 1999

Australian Government These Acts and the Residential Care Manual (as it relates to residential
respite care) cover assistance to people who provided care for frail aged
and other people with a disability who have been assessed as requiring
nursing home level care.
Additional services in community settings that are substitutable for lower
levels of residential care are supported under this legislative framework, in
particular care packages and respite services that form an adjunct to the
Commonwealths aged care programs. These form part of the fabric of
community care services that are provided by a mixture of national, state
and territory and local government programs
Home and Community Care Act 1985 Australian Government The HACC legislation was a response to series of studies and reports
specifically on the frail aged component of primary care and reducing the
demand for residential placement from the late 1970s and 1980s It
introduced the concepts of a balance of care (institutional and community),
expanding care options, improved coordination and assessment, a tier of
basic maintenance and support services and an explicit focus on the
needs of carers.
Home and Community Care Review Working
Group (1988). First Triennial Review of the
Home and Community Care Program.
(Commonwealth) Department of
Health and Family Services
The Review Working Group to Commonwealth, State and Territory
Ministers set in train the continuous administrative reform agenda
emphasising coordination and planning across programs, and an
outcomes focus (p.7). The Review reinforced program boundaries, no
growth areas (rehabilitation, post acute, families in crisis, palliative care)
and exclusions (supported accommodation, appliances) while calling for
greater linkage and coordination (pp 10-11).


National Health Strategy (1991). The
Australian Health Jigsaw. Integration of
Health Care Delivery. Issues Paper No.1,
July 1991.
National Health Strategy Realignment and consolidation of programs was given specific attention under
the National Health Strategy in 1991. Recurring themes were overlap
excessive administration leading to duplication of services or to significant
gaps in services available (and) substantial problems (National Health
Strategy, 1991, page 11-12).
National Respite for Carers Program 1996

1997-98 Annual Report for the Department
of Health and Family Services, Australian
Government Publishing Service, Canberra.
Department of Health and
Family Services
Key elements of the 1996 $280 million Staying at Home Package were
implemented, including approval of a further 500 community aged care
packages; improved funding for aged care assessment; expansion of respite
care services for carers, particularly those caring for people with dementia;
and initiatives to improve continence management. (p.154)
A New Strategy for Community Care The
Way Forward, 2004.
Australian Government
Ageing
In August 2004 the Australian Government released A New Strategy for
Community Care The Way Forward, outlining ways of simplifying and
streamlining current arrangements for the administration and delivery of aged
and community care services. The aim of this strategy was to make it easier
for people to access the care that they need.
Consolidation of National Respite for
Carers Program elements
Australian Government,
Ageing
With reference to the reform agenda outlined in The Way Forward, a Request
for Application (RFA) process took place in 2005 for consolidating the location
and roles of the National Respite for Carers Program, the Carer Information
Support Program and Commonwealth Carelink Program.


Carers Australia (2006) Carers of People
with a Mental Illness Project. Final Report.
Prepared by Julie Nankervis and Dawn
Mirapuri for Carers Australia, June 2006.
Carers Australia, Australian
Government, Department of
Health and Ageing, Mental
Health Council of Australia
This report responds to a perceived failure to provide quality mental health
services to meet community need, which has resulted in a significant burden
on families and carers. Carers find that their role is often very stressful and
carries significant risks to their own mental health and wellbeing. The Carers
of People with a Mental Illness Project was developed in response to these
issues with the primary goal to strengthen the policy capacity of Carers
Australia to respond to the needs of carers of people with a mental illness by
developing practical solutions to address their needs, raise their profile and
obtain recognition. The objectives included a case study of the legislation in
the Northern Territory, improved networking and identifying mental health
services and/or services in other areas of health and/or disability with
successful programs in carer involvement/engagement consistent with the
National Practice Standards for the Mental Health Workforce and the National
Standards for Mental Health Services,
Development of a carer-specific intake
assessment tool, the Carer Eligibility and
Needs Assessment (CENA), 2005-2006
Australian Government,
Ageing
With reference to the reform agenda outlined in The Way Forward, a Request
for Tender was released to develop a carer assessment tool for use by a
range of carer support services.


2.2 Comply with duty of care implementation in home and community
settings and worker roles

Duty of Care

Duty of care is a term that refers to the legal requirement that places
responsibility on everyone that is, employers, employees and others-to
follow healthy, safe and considerate work practices.
Duty of care is a legal term and describes a duty to work responsibly
where your action(s) may foreseeably affect someone else.
Duty of care is part of the legal concept of negligence covered by common
law. A duty of care exists when someone's actions or failure to perform
actions could reasonably be expected to affect another person. You are in
a position where someone else is likely to be affected by what you do, or
do not do, and where, if you are not careful, it is reasonably predictable
that the other person might suffer some harm. You have a duty to be
careful, as what you do (or do not do) might affect your client. You
therefore need to:
ensure you understand exactly what the support you are providing is
and how it affects the client and that the client knows the nature of the
support and its consequences and agrees with provision of the
support.
To be successful in a claim for negligence a client must show:
you owed them duty of care
that you breached duty of care
that they, as the client, have suffered some loss as a result of this
which was foreseeable.
Difficulties arise in practice because it is difficult to decide what is
reasonable in particular cases to avoid foreseeable harm. If you find
yourself in such difficulties, immediately refer your concerns to your
supervisor for advice.

Standard of Care

The standard of care to which a given activity must be performed to meet
the duty of care is the standard that a reasonable person would in the
same circumstances meet, that is, what would be expected of a
'reasonable' person in your place?
The standard is determined by a range of factors that include:
what is practical to do in the given circumstances
the standards that are generally used in similar circumstances
any laws, regulations, policies and practices that apply in the particular
workplace situation


duty of care to other people who are present or involved
what is socially acceptable practice
what is culturally appropriate.
This results in the standard of care being different according to:
training, education and experience, including special skills
the situation
involvement of others.
It is no longer considered reasonable to place restrictions on older people's
freedom simply to ensure their safety or to create an absence of risk.
Priorities carers place on rights and preferences will vary from person to
person, time to time and situation to situation. Clients can be empowered
to take greater control over their own lives through carers actively
enlarging individuals' opportunities and experiences. It is important to be
able to 'balance rights and preferences' in relation to duty of care:
Clients will very often be reliant on carers for the realisation of a very
large number of their rights and preferences.
In attempting to uphold some of these rights and preferences, others
may be put at risk.
Duty of care dilemmas often arise because there is a conflict between
the different rights and preferences of people in residential care.
The carer's own perception and values about different rights and
preferences will be one of the influences on how duty of care
dilemmas will be resolved.
Different people see different rights as more important than others
according to their own values.
Duty of care is sometimes thought of as only being related to physical
safety, whereas it should actually be seen in the context of all of the rights
of people being supported by carers. A carer needs to adopt
commonsense and a flexible approach to respond to the personal priorities
of the individual client and not impose uniformity on all.
Carers need to be open to talking with and listening to their clients and
empowering them to take more control over their own rights and
preferences and to become less dependent on the carer or others for
realisation of their rights.

Duty of Care and Negligence

So what does duty of care really mean in a nursing home? For health care
professionals to be liable they must be lacking in their duty to the resident,
such that it can be said that the defendant acted in breach of a duty to
provide the resident with care, which was reasonable in the circumstances.


Health care workers can normally be expected to perform in certain ways.
When a carer fails to perform as required by the job that person is guilty of
negligence. For example, you would be guilty of negligence if your facility
had a policy that bed rails should be up at night and you forgot-allowing a
resident to fall out of bed and injuring themselves. The resident's rights
give assurance that care will be given properly, privacy be respected and
there will be no abuse. Residents will be treated as respected individuals,
capable of handling their own affairs and making their own decisions.

Breach of Duty of Care

This is the term used when there is a failure to meet the relevant standard
of care. This might be a carer doing something they should not have done,
or failing to do something they should have done. Again, it will depend on
whether or not the mistake was reasonable in the circumstances.

Duty of Care Dilemmas

These may arise when a carer is unsure about the capacity of the client to
make their own decisions. Informed decision-making must be voluntary
and there must be an understanding of the consequences of the decision.
The law assumes all adults are competent unless legally found not to be
so. Judging a client's competence is not the carer's role. In such dilemmas
there may be a number of rights involved. There could, for example, be an
issue between safety and restraint or privacy and safety.

Access and equity in aged care

A commitment to the principles of access and equity includes:
creation of a client centred culture;
a non-discriminatory approach to all people using the service, their
family and friends, the general public and co-workers;
ensuring the work undertaken takes account of and caters for
differences including: - cultural
physical
religious
economic/social.
Each person is an individual and has the right to be treated as such and as
an equal with all others. Differences must not only be respected but
provided for, so all clients have the equal opportunity to maintain their
individuality and quality of life.


The frail older person must be able to gain access to available care
services appropriate to needs. This includes ensuring proper access to
information, proper assessment of the needs of older people and ensuring
care is provided in their environment, or that transport is available to allow
them to reach care services.
Anti-discrimination in aged care
A person discriminated against on the basis of race, sex, ethnicity, marital
status, religious or political beliefs, or physical or intellectual handicap may
complain to the relevant antidiscrimination board or the Equal Opportunity
Commission.

Five principles are important to be considered:

1. Respect for persons - show respect for client goals, attitudes, beliefs
and culture.
2. Autonomy - the rights of clients to informed consent, independence
and self-reliance.
3. Non-malfeasance - avoid any deliberate harm during care.
4. Beneficence - active promotion of good.
5. Justice - fairness and equity in all care.
It is at all times important to observe the following two principles:
The right of access to appropriate health care of high quality,
delivered in an environment in which you feel safe, free from
discrimination, intimidation and abuse, and without regard for your
ability to pay. Individuals have the right to protection of health by
measures to prevent and relieve disease and disability.
The right to respect and dignity, the right to the best care possible,
to be treated as individuals and to be respected at all times.
Services are to be free of discrimination and exploitation. Persons
should be facilitated and supported in their attempts to maintain
their self-respect and self-esteem.

Complaints mechanisms
Clients have a right to make either an internal complaint direct to the
organisation or an external complaint to the Complaints Units, which are
handled by Aged Care Complaints Resolution Committees. Organisations
must provide a process for addressing complaints and making sure that
people are aware they can complain externally


Figure 9: Sample complaints/suggestions form

CONFIDENTIAL
Fitzroy Falls Aged Care Facility
MESSAGE TO MANAGEMENT
COMPLANTS AND SUGGESTIONS

Name: Date:
Complex/Wing:
Complaint Suggestion
Complaint/Suggestion:

Suggested Solution:

Final Action:

Outcome/Evaluation:

Signature: Date:
Effective:
Yes No
Date:


Employees should be aware that comments and complaints represent
opportunities for service improvement and are an important part of quality
control.
They can be resolved in a number of ways, including:
Informal - for straightforward comments, staff can generally resolve
these issues.
Formal - for more serious matters that need to be passed to a
designated complaints person or committee.
External review - where complaints cannot be resolved internally.
Management should have a policy on handling complaints that encourages
feedback from residents. Residents should be given clear information on
how to make a complaint and be assured that complaints are handled
fairly, promptly and confidentially. The complaints policy should assure
residents they are protected from any repercussions, reprisals or
victimisation.
Comments and complaints systems should include:
positive conflict resolution strategies;
sound policies and procedures;
ongoing staff education and training;
consumer information and education;
recording and monitoring of comments and complaints;
timely action on comments and complaints to improve service delivery.
Figure 8 above is a sample of a Complaints/Suggestions Form typical of
such documentation.


2.3 Demonstrate broad knowledge of ageing in place

Historically there was limited interest in the aged. This is only presently
being reversed. Lack of interest in the older population may be attributed in
the past to the low percentage of aged people in society so they were not
perceived as an important group in their own right. Today there is
increasing interest in the aged as a group, with special needs and rights.
The increasing percentage of the over 65 in the population creates the
need for better services, more cost effective services and has introduced
an increasing interest in quality of life for the elderly.
Aged care facilities have progressed from nursing homes where the elderly
went as a last phase of their life, to varied services for the older adult
where they are encouraged to be as independent and active as possible.
An increased interest in the aged has led to increased medical research
leading to extending life spans and a healthier and more active old age.
Old age and aged care is now considered to be a dynamic process.
From a cultural perspective, the older person has also suffered significant
disadvantages. The prevalent culture that surrounds us is youth oriented.
they are taught that young is beautiful and old is often portrayed as ugly.
Poems and fairy tales contain these negative stereotypes-the ugly
stepmother, evil old women and bad-tempered old men. Attitudes are now
changing and increased attention is being paid to reversing negative
attitudes and reinforcing positive attitudes towards ageing.

Challenging personal values and attitudes

If you hope to increase your knowledge about ageing and old age you
must make certain you have got rid of any myths and misconceptions
about ageing and old age.
Some stereotypes are based on fact. For example, many people think of
old people as hard of hearing. Although this is not true of all older people,
changes in the ear do make it difficult for many elderly people to hear.
Many other stereotypes are in reality myths, and have no truth in them at
all. Examine the following examples of myths and see which ones you
believe to be true.


Table 10: Myths about Ageing

MYTH TRUTH
After age 65,
you're on the way
down.

There is nothing magic about the age of 65 that
indicates an individual would start going into a
state of decline or that they are 'old'. Most people
at the age of 65 are still leading active
independent lives. People age at different rates.
People must retire
at 65 as they're
too old to work
well.

People often have no wish to cease all work at the
age of 65 and they have an accumulation of skills
and experience not necessarily found in the
younger employee. Their stability and reliability
often makes them excellent employees.
Old people are
past having sex.
The belief sexual activity is only for the young is
wrong and offensive to the older person.

The key concepts concerning myths and misconceptions of ageing appear
to be:
the elderly are a homogenous group
progressive intellectual deterioration
inevitable physical deterioration
loss of sexuality
social withdrawal and loneliness
the need to be looked after.
When people use the words òld age' or 'elderly people' or òldies' certain
images spring to mind which are different for all of us. We need to examine
our own images, how we get them whether they are fair and how they
might affect us at work. Attitudes and values are the basis of the beliefs,
that form our perceptions of, and responses to, social groups like the aged.
If your responses are based on stereotyped attitudes the result is likely to
be negative. Ageism in our society has many sources, all of which
combine to shape and influence our attitude to the aged.

Stereotypes

Stereotypes can be defined as characteristics assigned to entire groups of
people. Stereotypes, however, tend to be biased and often unflattering
ideas about the characteristics of particular groups of people. Stereotypes
about ageing and the elderly picture all members of the group as having
the same generally undesirable characteristics. Grey hair, short-
sightedness, deafness, wrinkles, bad temper and intolerance of the young


are common stereotypes of the old. You can often observe these
characteristics in cartoon characters. Stereotyping does not consider the
special characteristics of every individual.
Stereotyping tends to encourage certain attitudes and confirm undesirable
perceptions of the group it is applied to. This can cause what are known as
`self-fulfilling prophecies'-if the elderly are stereotyped often enough, they
start to believe in the truth of the stereotype, this in turn makes them start
to act in the way they are depicted.
The most common stereotype of the elderly is one of weakness and
dependency, with little to give to society. If we treat older persons as
incapable of looking after themselves and take control from them, they
may very soon believe they are unable to look after themselves and will no
longer try. Thus, we end up with the stereotype of the old as weak and a
burden on society.
Opposing the stereotyping of older people can be achieved by treating
each older person with respect for their individuality and uniqueness. Do
not presume your residents will want to do the same things, watch the
same TV shows or like the same foods.
Every older person in your care should be allowed to have as much
personal control over their life and as much choice in activities and
interests as is functionally possible. Your role is to help the elderly to
remain as independent as possible. Just as there is no typical younger
person there is no such thing as a typical older person. We all know the
saying 'you're as old as you feel'.

Media

The media also plays a part in on this negative stereotyping of the old.
Advertising portrays youth as being alive and vibrant while the aged are
preoccupied with their bowels and other problems. All the desirable
products are portrayed as used, liked and suitable for the young. The
young model all fashionable clothes; and catalogues portray the young
wearing and using the products. Even Mother's Day is often about being a
'young mother'.
The news media mainly highlight the achievement of youth. The old have
to do something very unexpected-something that the media feel does not
equate with age, such as climbing a mountain or sailing round the world, to
be worthy of a mention. Otherwise their only mention seems to be when
they have been attacked, robbed and hurt.
Media treatment of the old tends to exaggerate the stereotypes that exist.
Older people are seen as not very intelligent, in poor health and dependent
on the younger generation for their care and well-being. This leads to lack
of recognition of their knowledge, skills and vast experience. It leads to
under-utilisation of their talents and a general assumption that they are
`not good for much'.


You may come across the term 'ageism'. Ageism means discrimination
against people based on age. Ageism is often practised by society and
even by the aged as they come to believe some of the stereotypes and
misconceptions about themselves. Biased attitudes have long been freely
practised against the old, however in recent times older people have stood
out against these attitudes and practices and have found ways of speaking
out about their needs and hopes.

Language of ageing

Let us look at the words used to describe ageing. What do they actually
mean and what do they imply?
Chronological age is often used as a measure of ageing. At 65 people tend
to retire. They become a group for which we have many different names-
all of which imply 'being old'. Examples of some of these might be 'oldies',
'pensioners', 'senior citizens' or 'retirees'.
We have also coined names for the older age group that imply ill health or
deterioration. These might include 'geriatric', 'aged', 'senile' and
'demented'.
You may hear older people say 'Age is a state of mind' or 'You're as old as
you feel'. This tells us that the older age group does not appreciate the
connotations of many of the words applied to them.
As well as the language of ageing there is a tendency to address the aged
in a childlike manner. The use of words such as 'dearie', 'sweetie', etc. are
often heard when addressing the old. You must take care however that the
older person is comfortable with that language; some clients may view it as
disrespectful.

Perceptions of aged people among health professionals

An illustration of the effects of ageism can be found in the attitudes of
health professionals. Gething (1988) has reported that attitudes of health
professionals concerning people with disabilities tend to be more negative
than those of the general community.
Such attitudes become generalised to cover older people, many of whom
have disabilities (cited in Gething, 1990).
Spence et al. (1968) report that health professionals have a more
stereotyped view and show less understanding of the capabilities of older
people than do members of the general population. Negative attitudes may
then be reflected in health professionals' behaviour /cited in Gething,
1990).
People working in nursing homes only deal with a tiny per cent of the
elderly population. They are often ill, frail or seriously disabled, they may
also be confused and unhappy in their old age. An impression can easily
be formed that being old is the same as being ill and is difficult to deal with.


Carers may often, unconsciously, provide cues for the resident as to what
behaviour is expected. If the resident does not cooperate in the expected
or accepted manner then they are seen as uncooperative and may suffer
in the hustle and bustle of institutional life. It is easy for aged care workers
to accept and act on stereotypes of the aged, as on the whole they are
working with a much narrower range of older people-people who are in
need of care and attention and are dependent on others for carrying on
their daily lives.
The carer may tend to forget the diversity in age, in lifestyle and
personality that are represented in the persons in their care. They may
tend to forget that the majority of older people are not in residential homes
but live independently in the community, contributing to their families and
friends. They may tend to forget that older people are often involved in
charity and voluntary work, social groups and their own family networks
and that all these groups gain from their involvement.
Consciously guarding against stereotyping of the old when working in aged
care is an important part of the role of a carer.

Ageing as an individual process-coming to terms with the ageing
process

How old is old? This depends on whom you ask. Old depends on how you
feel. The over-65 age group is taken as the older age group for the
purpose of statistics, however, many 65 year olds will not feel or think of
themselves as old. Ageing does involve physical, psychological and
emotional changes, and social changes in lifestyle and how others view
us. Ageing is in part to do with attitude. Those who have a 'young' attitude
to life, keep active and have a positive outlook will seem much younger.
However, it is impossible to prevent inevitable physical, psychological and
social changes that come about with age. How people manage them is
very much a part of their fitness and individual attitude to life.

PHYSICAL CHANGES AS A NATURAL PART OF THE AGEING
PROCESS
Ageing is a natural process that begins at birth. Ageing is considered to be
all changes that occur normally with time. Ageing is a complex process
and varies greatly among people. There are many theories on ageing.
Ageing should not be confused with diseases that are more common in the
elderly.
Normal changes as a result of ageing are those changes that are seen in
all older persons. This might include things like tiring more easily, and
poorer vision and hearing. These sorts of change are due to alterations in
cells, tissues and organs as a result of ageing. Ageing in any individual
may involve a combination of genetic make-up, ability to adapt to stresses,
and emotional and social factors.


CHANGING NEEDS FOR PHYSICAL COMFORT, SLEEP AND BEST
As people grow their bodies pass through three stages:
1. early development
2. physical maturity
3. gradual decline.
Ageing is not a disease, but a natural part of living. It is a natural process
for every living thing. It should not be thought of as something negative,
unpleasant or ugly.
Wrinkles, grey hair, glasses and hearing aids may be difficult for some; this
is partly because our culture values youth, attractiveness and strength.
Physical changes, however, can contribute to the loss of self-esteem and
changes in self-image with age. The chances of illness and accident do
increase as our bodies age and the vigour and vitality of former years are
lost. This happens because:
older bodies are usually less efficient than younger bodies
older bodies are usually less able to handle stress
older bodies are usually less able to fight off bacteria.
Perhaps the most common complaints of the elderly are how much more
easily they tire and how little vitality they seem to have. Less sleep at night
seems to be needed; yet frequent short rest periods are generally needed.
Older people often report dissatisfaction with their sleep. Age-related
changes actually bring little change in the quantity of sleep, but there is
significant change in the quality of sleep and quantity of rest.
Age related problems in sleep and rest might include physical discomfort
(how familiar is 'I couldn't get comfortable last night'), affective disorders,
lower auditory arousal threshold (noises wake the older person more
easily), sleep apnoea syndrome or periodic leg movement syndrome.
These lead to the following changes:
longer time to fall asleep
more frequent awakenings in the night
less time spent in deep sleep.
Aged people moving into residential care may have a difficult time sleeping
in the changed environment. Poor sleep patterns are also associated with
anxiety, depression, sensory impairments and dementia.
Appropriate work practices in support of maintaining individual choice and
participation


The Care Plan
The most important tool for establishing appropriate work practices in the
aged care workplace is the individual Care Plan. Care Plans are the formal
expression of a process of needs assessment and negotiated individual
responses to the identified needs. An individual program of care is
negotiated with each resident. This helps to establish a sense of purpose
essential to the development of self-confidence and self-esteem. Regular
review of the plan involves the resident, care staff and professional staff.
Partnership and negotiation are important aspects of the planning of care.
Professional practice in aged care involves a partnership with the health
care team and clients (and/or their families, friends or significant others) to
assess their needs, preferences and expectations of care. The process
may include:
explaining the process of planning care
asking clients to review their needs
agreeing on goals for care
discussing ways goals can be reached
deciding how well goals have been achieved
deciding what should happen next.
There are many factors to consider in involving residents. How far do
residents want to participate? It may take some time to involve residents,
who may feel powerless in the residential situation. Partnership involves
residents sharing some private details with the carer and negotiating
agreement on needs and goals. Proper record keeping is essential.
When clients are confused or apathetic or have severe communication
difficulties, partnership will be more difficult and must be achieved in small
ways at whatever level possible.

The Planning Process

The planning process has five steps to provide a systematic rational
method of approaching care:
1. Assessing-collecting, verifying and organising data.
2. Diagnosing/analysing-forming a statement of the actual problems.
3. Planning-formulating goals and expected outcomes, setting priorities
and identifying interventions to help reach the goals.
4. Implementing-putting plans into action.
5. Evaluating-review and evaluate whether goals have been reached.
This is an ongoing process. You are constantly assessing, intervening,
evaluating, reassessing and re-diagnosing. A Care Plan is a dynamic
document to be used and reviewed regularly.


A good Care Plan will be clear, easy to follow and provide a rationale for
the interventions so that staff know why they are doing things, as well as
what to do.
In most facilities carers collect data on a resident and provide a
comprehensive picture of progress and problems. They will also make
suggestions as to what might be done to alleviate the problems. These
suggestions may be limited by skills and knowledge; however teamwork
will overcome this by helping arrive at a clear understanding of the nature
of the problems and what might realistically be done for them.
The result will be the identification of a management number of high
priority problems to be addressed by means of an agreed set of actions.
The combination of developing the Care Plan from assessments carried
out by carers, subjecting it to detailed discussion by the team who are
going to carry it out and formalising it as a 'prescription of care' results in a
clear statement for staff to implement the recommendations.
Care Plans come in many forms. Following is an example of a Care Plan.

Figure 10: Sample Care Plan.


Care plan

Care alerts (write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic

Communication
Preferred name:
Care needs:
Goal:
Vision Hearing
Aids glasses magnifying
glasses
Clean and fit glasses daily
Able to clean own glasses
Aids
hearing aids ( right left )
Adjust volume daily
Check batteries and clean aids
daily
Place objects in range of
vision
Read aloud -
letters/documents
Assist to write
Assist to use telephone
Gain attention before speaking
Speak loudly, clearly and directly
Allow extra time for response
Give step-by-step instructions
Use repetition when difficulty
persists
Other Other
Eye care required Ear care required
Speech and language Comprehension issues (For example: inappropriate
responses)
Language/s spoken English
Short term memory loss
Orientate to correct time
Speech disorder/s
Translate for care recipient
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Name: Date of birth:
Address:
Contact no:
Doctor: Doctors contact no:
Medicare no: Pension no:


Mobility
Care needs:
Goal:
Ambulation (walking) Transfers
ambulant (able to walk)
non-ambulant (unable to
walk)
independent weight bearing (able to stand)
non-weight bearing (unable to stand)
1-staff assist 2-staff assist
hip replacement knee replacement
amputee ( left right )
Aids walking stick zimmer
frame
wheelchair quad stick
wheeled walker
Aids bed rail slide sheet gait belt
hoist standing hoist
Hoist sling type and position of loop

Other Other
Provide direction
Supervise movement
Encourage to maintain
mobility
Other
Toileting and continence
Care needs:
Goal:
Continence
Bladder control continent incontinent catheter ( occasionally frequently total incontinence )
Bladder management Toilet (times )
Other
Bowel control continent incontinent constipation colostomy ( occasionally frequently total
incontinence )
Bowel management high fibre diet encourage fluid intake aperients bowel chart
Continence aids
Day Night
Toileting
Toileting aids commode urinal uridome kylie bed pan
over-toilet frame Other
Toileting regime independent supervise some assistance/prompt fully assist
Adjust clothing Position on toilet Encourage self care Clean perianal
area
Other


Showering, dressing and grooming
Care needs:
Goal:
Shower and washing
independent supervise some assistance/prompt fully assist
shower bath bed sponge flannel wash
Frequency Preferred time
Adjust water temperature Encourage to optimise self care
Other
Transfer walk to shower wheelchair Other
Showering aids shower chair Other
Toiletries normal soap deodorant aqueous cream moisturiser ( am pm )
Other
Hair care wash in shower wash in bath Preferred days
Grooming
Hair care independent supervise some assistance/prompt fully assist
Hairdresser
Facial hair wet shave dry shave Frequency
Hair removal Frequency
Nail/foot care independent supervise some assistance/prompt fully assist
Podiatry visits
Teeth none some ( upper lower ) all
Cleaning routine
Dentures none partial full ( upper lower ) Night in out
Cleaning routine
Dressing and undressing
callipers splints Other
Cultural dressing
Dressing assistance bra singlet buttons belt zips
stockings socks jewellery make-up shoes
Assist with selecting clothing Other
Pressure area and skin care
Care needs: Nil
Goal: (expected outcome)
Norton Scale Score [ x ] low risk [ ] medium risk [ ] high risk
Pressure relief aids bed cradle sheepskin cushion bedrail/protectors Other
Pressure area regime Reposition in bed Reposition in chair Frequency
special mattress (type ) personal chair
Other/specific orders
Skin care emollient cream to dry skin areas ( daily twice daily ) Preferred time/s


Eating and drinking
Care needs:
Goal:
Eating
right-handed left-handed
Preferred place to eat dining room bedroom Other Kitchen
Type of diet normal soft modified soft (minced) puree
Special diet high fibre diabetic enteral feeding (PEG/NGT)
Special instructions
Aids modified crockery modified cutlery bowl lipped plate
built up cutlery clothing protector Other
Drinking
right-handed left-handed
Aids modified cup clothing protector
Thickened fluids level 1 level 2 level 3
Type of thickener to be used
Sleep and settling routines
Care needs:
Goal:
Usual time to rise Usual time to bed Rest time ( am pm )
Preferred sleeping position Pillows required
Sleep Aids massage music hot packs Other
Room light on door open door closed bedrail/protectors Other
Night-time patterns
Other preferences
(For example: hot
drinks or snacks)

Night checks every hour every 2 hours Other
Medications
Current medications

eye drops ear drops Other See list of medications

pre-packed measure self-administer
Blood sugar level
testing
Frequency
Specialised care plans
Refer to specialised
care plans for
[x ] Medications

[ ] Pain management [ ] Wound care

[ ] Therapy [ ] Restraint management


OHS
Completed injury risk
assessment forms
Home environment Yes No
Client assessment Yes No
Social and human needs/activities
Care needs:
Goal: (expected outcome)
Frequency of visit/contact by family/friends
Religion beliefs/practices
Pastoral requirements Attends place of worship (day/s )
Cultural needs
Hobbies/interests Employment history
Pets Name/s Type/s
client manages pet requires prompt and assistance in pet care fully assist pet care
Social group/s
Preferred activity/games
Community care social outings (Frequency: )
Requirements
Taxi vouchers Yes No
Domestic needs/activities
Frequency ( daily every 2
nd
day weekly fortnightly Other
)
Requirements Shopping
Washing clothes
Cleaning
Cooking
Transport
Gardening
Other
Emotional support


Behaviour
Care needs:
Goal:

Additional comments (For example: special needs, restraint, routines, pain, palliative care, pacemaker)

Terminal care recorded Yes No
Date care plan evaluated (document in
progress notes)
Signature

Fitzroy Falls Aged Care Facility use only
Entered in progress notes Date
Signed Print name Position title
Review date

The Care Plan must be available for the team responsible for the care of
the resident along with invited specialists and, where possible, the key
relative or friend of the resident. The purpose of the wide availability is to
develop, or revise, the Care Plan. The Care Plan presented may be used
as a focus for team discussion and supplemented by reports from other
team members and specialists when required.


Monitoring

As the Care Plan is implemented team members must monitor its impact.
This is carried out by making brief notes and reporting observations
relevant to each of the problems being addressed. The findings of the
monitoring process should be discussed by the team members.

Progress Notes

These are notes recording the progress and response to treatments. Notes
should be integrated so they reflect continuity of care. All the professionals
contributing to care should record in these notes. All contributions of the
team should be available to all team members. Records are legally
accountable documents. Therefore, it is important that the person who
gives care records actions and observations. Progress recording provides
the up-to-date information health care workers need to provide appropriate
services and interventions for clients.


3. Demonstrate commitment to the
philosophy of positive ageing

3.1
Take into account personal values and attitudes when
planning and implementing work activities
3.2
Recognise and manage ageist attitudes through the support
of the appropriate person
3.3
Recognise the impact of consumerism on service delivery
3.4
Conduct work that reflects an understanding of the
individuality of ageing
3.5
Conduct work that minimises the effects of stereotypical
attitudes and myths on the older person

Introduction

Because most old people lead active and healthy lives the focus of this
plan is on promoting and supporting actions which contribute to
maintaining such a positive approach. This will provide benefits to the
whole community.

Positive ageing on a personal level is
about getting the most out of life.

Positive Ageing involves:
Understanding the process of ageing and getting older
Participating in a society which values and respects your contributions
as an older person
Being independent and enjoying a good quality of life
Being able to pursue social, cultural, educational and recreational
opportunities; and
Having the opportunity to choose from a variety of aged care options or
remaining at home with community care appropriate to need.
As individuals we experience the process of ageing differently. We dont all
have the same experience at the same time. As individuals there are many
steps we can take to ensure that we are taking good care of ourselves and
getting the most out of life. Organisations of all kinds can also assist by
promoting positive experiences of becoming older and by providing
appropriate services and facilities.


Table 11: Ten Principles of a Positive Ageing Strategy

1. Empower older people to make choices that enable them to live
a satisfying life and lead a healthy lifestyle.
2. Providing opportunities for older people to participate in and
contribute to family and community
3. Reflect positive attitudes to older people
4. Recognise the diversity of older people and ageing as part of a
normal part of the life cycle
5. Affirm the values and strengthen the capabilities of older
indigenous and ethnic groups and their extended family
6. Recognise the diversity and strengthen the capabilities of older
people
7. Appreciate the diversity of cultural identity of older people living
in Australia.
8. Recognise the different issues facing men and women
9. Ensure older people in both rural and urban areas live with
confidence in a secure environment and receive the services
they need to do so.
10. Enable older people to take responsibility for their personal
growth and development through changing circumstances.


Table 12: Ten Priority Goals of a Positive Ageing Strategy

1
Income Secure and adequate income for older
people
2
Health Equitable, timely, affordable and accessible
health services for older people
3
Housing Affordable and appropriate housing options
for older people
4
Transport Affordable and accessible transport options
for older people
5
Ageing in Place Older people feel safe and secure and can
age in place
6
Cultural Diversity A range of culturally appropriate services
allows choices for older people
7
Rural Older people living in rural communities are
not disadvantaged when accessing services
8
Attitudes People of all ages have positive attitudes to
ageing and older people
9
Employment Elimination of ageism and the promotion of
flexible work options
10
Opportunities Increasing opportunities for personal growth
and community participation

The above strategy should be developed to outline an action plan to
outline the possible actions, projects and activities that will improve the
wellbeing of older people. It should propose a process whereby other
agencies and organisations will commit to working together to deliver
on an action plan.


3.1 Take into account personal values and attitudes when planning and
implementing work activities

As mentioned previously in this unit the following definitions are being
used as a reference point for these performance criteria
Care Recipient refers to an adult with a chronic illness or disabling
condition or an older person who needs ongoing assistance with everyday
tasks to function on a daily basis. These tasks may include manAgeing
medications, transportation, bathing, dressing, and using the toilet. The
person needing assistance may also require primary and acute medical
care or rehabilitation services (occupational, speech, and physical
therapies).
Caregiver Assessment refers to a systematic process of gathering
information that describes a caregiving situation and identifies the
particular problems, needs, resources, and strengths of the family
caregiver. It approaches issues from the caregiver's perspective and
culture, focuses on what assistance the caregiver may need and the
outcomes the family member wants for support, and seeks to maintain the
caregiver's own health and well-being.
On the following pages are the fundamental principles for caregiving take
note as these will be used in the activity to follow:


Fundamental Principles for Caregiver Assessment
Participants would agree upon a set of seven basic principles to guide
caregiver assessment policy and practices:
1. Because family caregivers are a core part of health care and long-term
care, it is important to recognize, respect, assess, and address their
needs.
2. Caregiver assessment should embrace a family-centered perspective,
inclusive of the needs and preferences of both the care recipient and
the family caregiver.
3. Caregiver assessment should result in a plan of care (developed
collaboratively with the caregiver) that indicates the provision of
services and intended measurable outcomes.
4. Caregiver assessment should be multidimensional in approach and
periodically updated.
5. Caregiver assessment should reflect culturally competent practice.
6. Effective caregiver assessment requires assessors to have specialized
knowledge and skills. Practitioners' and service providers' education
and training should equip them with an understanding of the
caregiving process and its impacts, as well as the benefits and
elements of an effective caregiver assessment.
7. Government and other third-party payers should recognize and pay for
caregiver assessment as a part of care for older people and adults
with disabilities.
Guidelines for Practice
1. General Considerations
A. Public and private programs should recognize key dimensions
of family caregiving:
The unit of care is the care recipient and the caregiver. (This
builds on the hospice and palliative care movement that has
long embraced the Client/family as the unit of care.)
("Clinical practice guidelines for quality palliative care",
2004)
The caregiver is part of the care team and service plan.
Services should be consumer directed and family focused.
Caregiver assessment and support improves outcomes and
continuity of care for the care recipient.
B. The form, content and process for caregiver assessment should
be tailored based upon the caregiving context, service setting,
and program.
There is no set protocol to follow for caregiver assessment
and no single approach is optimal in all care settings and
situations.
Purpose, ethical issues, and technological resources and
capabilities all have to be considered; these vary by settings
and existing service programs.


C. The reasons for conducting a caregiver assessment need to be
clear to both assessor and caregiver. These are:
To identify the primary caregiver and other informal
caregivers.
To improve caregiver understanding of the role and what
abilities are needed to carry out tasks.
To understand the caregiving situationincluding service
needs, unresolved problems and potential risksin order to
meet the needs of the caregiver.
To identify services available for the caregiver and provide
appropriate and timely referral for services.
The process should include determining the care recipient's
eligibility for services that also help the caregiver.
D. Assessment findings should be used in care planning and
service interventions.
Assessment is not an end in itself but should empower
caregivers to make informed decisions and link caregivers
with community services.
E. Available information technology should be used to share
assessment findings and make it easier for the caregiver to
access help.
Who Should Be Assessed?
A. Any person who self-identifies as a family caregiver should be
offered a screening, leading to an assessment as appropriate.
B. Some families may require a group interview; others may need
multiple individual interviews.
C. When multiple caregivers are involved, conflict resolution may
be necessary.
3. What Should Be Included in a Caregiver Assessment?
A. Caregiver assessment should be driven by:
A conceptual framework
The service context and programs (e.g., focus of the
intervention)
Representation of subjective perceptions and
preferences along with objective characteristics of the
caregiver
Factors affecting an individual's ability to assume a
caregiving role: physical, emotional, cultural,
educational and environmental, including the care
recipient's ability to accept assistance.


B. Seven identified domains, and related constructs, are relevant.
These are applicable across settings (e.g., home, hospital) but
need not to be measured in every assessment. Domains and
specific questions may differ for:
Initial assessments compared to reassessments (the
latter focus on what has changed over time)
New versus continuing care situations
An acute episode prompting a change in caregiving
versus an ongoing need
Type of setting and focus of services.
Table 13: Recommended Domains and Constructs
Domains Constructs
Context
Caregiver relationship to care recipient
Physical environment (home, facility)
Household status (number in home, etc.)
Financial status
Quality of family relationships
Duration of caregiving
Employment status (work/home/volunteer)
Caregiver's perception of health and
functional status of care recipient
Activities of daily living (ADLs; bathing,
dressing) and need for supervision
Instrumental Activities of Daily Living (IADLs;
managing finances, using the telephone)
Psycho-social needs
Cognitive impairment
Behavioural problems
Medical tests and procedures
Caregiver values and preferences
Caregiver/care recipient willingness to
assume/accept care
Perceived filial obligation to provide care
Culturally based norms
Preferences for scheduling and delivery of care
and services
Well-being of the caregiver
Self-rated health
Health conditions and symptoms
Depression or other emotional distress (e.g.,
anxiety)
Life satisfaction/quality of life


Domains Constructs
Consequences of caregiving Perceived challenges
Social isolation
Work strain
Emotional and physical health strain
Financial strain
Family relationship strain
Perceived benefits
Satisfaction of helping family member
Developing new skills and
competencies
Improved family relationships
Skills/abilities/knowledge to provide
care recipient with needed care
Caregiving confidence and competencies
Appropriate knowledge of medical care tasks
(wound care, etc.)
Potential resources that caregiver
could choose to use
Formal and informal helping network and
perceived quality of social support
Existing or potential strengths (e.g., what is
presently going well)
Coping strategies
Financial resources (health care and service
benefits, entitlements such as Veteran's Affairs,
Medicare)
Community resources and services (caregiver
support programs, religious organizations,
volunteer agencies)

4. When Should Assessment Occur?
A. A caregiver assessment process should be used at several
points in time.
Initial information about the caregiver's perspective
should be obtained as early as possible when becoming
a caregiver is apparent and the caregiver is ready, as
shown by seeking advice or asking a question that
indicates distress, need or "a call for help."
Screening is distinct from assessment, and both are part
of a multidimensional, staged process.


In partnership with the caregiver, screening
should have the ability to branch and go deeper,
in a logical sequence involving different
professional disciplines where appropriate.
Screening should identify at-risk caregivers.
If the caregiver does not want to proceed with
screening, information should be provided on
how to get back in touch for assistance in the
future.
Reassessment should be built into the process to
identify any new challenges and to assess change over
time in the caregiving situation:
Update information as often as needed.
Provide the caregiver with a contact to call upon
if the situation changes.
Make a quick "check-in" call to the caregiver
periodically (e.g., every three to six months) to
ask "Has anything changed?" or "How are things
going?"
B. The opportunity for a caregiver assessment should be triggered
through:
Professional referralssuch as those from pharmacists,
physicians, clergy, parish nurses, home care workers,
Adult Protective Service, and the courts
Self-referral
Diagnosis of a medical condition
Decreased functional status of caregiver or care
recipient (e.g., no longer safe to leave care recipient
alone)
New Client, health plan enrolee, or Medicare beneficiary
Complaint from a care recipient
Care transitions (e.g., from home to assisted living or
nursing home, or from hospital to home)
Caregiver workplace issues (performance, attendance
problems)
Concern from another family member or friend.
5. How and Where Should Caregiver Assessment Be Conducted?
A. It should always be clear to the caregiver when an assessment
is taking place. That is, it should be explained explicitly that
information is being collected and that the primary purpose is to
help the caregiver.
Some caregivers may find the term "assessment"
objectionable, seeing it to suggest a test of their
competency.


Calling the process an interview to obtain the family's
perspective or a "caregiver interview" may be preferable
so long as the process and purpose are transparent.
Caregiver assessment should always be framed in the
context of "I'd like to know how we could help."
B. Whenever possible, the caregiver's preferences in conducting
the assessment should be determined and accommodated.
Some caregivers want to know the questions
beforehand or to do a self-screening first (online or
otherwise); others do not.
The location and time of day for conducting the
assessment should depend upon the caregiver's
situation and convenience, whether over the
telephone (which may not be optimal), in the home
(where the care recipient may be present), at the
caregiver's place of employment, agency office, or
online.
6. Who Should Conduct Caregiver Assessment?
A. A range of professionals can conduct caregiver assessments
(e.g., physicians, nurses, social workers, care managers).
Professional differences exist in the approach to
assessment and these differences can be strengths that
benefit the family.
Staying with the consumer focus can bridge
professional differences.
Working as a team across professional disciplines
allows for cross-fertilization so that the family comes out
ahead.
B. Assessors need to be trained in caregiver assessment and
have the requisite abilities, knowledge and skills.
7. How Should Care Recipient and Caregiver Assessments Be
Connected?
A. Strategies useful in some settings and practices to connect the
two assessments include:
Incorporating care recipient's needs and preferences
into the caregiver assessment
Integrating the caregiver in planning and assessment for
the care recipient, using a family-centered approach
Maintaining flexibility as to who conducts assessment
Using technology to enhance accessibility of
assessment information and integrating electronic
information systems across settings
Using the concept of a "care navigator" or "point person"
to integrate assessments and respond to care recipient
and family needs across settings.


3.2 Recognise and manage ageist attitudes through the support of the
appropriate person

What do you expect at your
age? You're not getting any
younger! Do these
statements sound familiar?

They are unjust
generalizations and
prejudicial statements that
assume all older adults
naturally become weak, sick
and forgetful. Older people
get sick from disease, not
"old age"

Activity ????

Lets have a quick look at your Current Knowledge About Ageing

Respond to the following questions to the best of your knowledge.
a. You are old at age? _______________________
b. There are _______________ older adults in Australia. Most older
people live in _____________________
c. Economically, older people are __________________________
d. With regard to health, older people are ___________________
e. Mentally, older people are _____________________________


Our Attitudes

Our attitudes are the product of our knowledge and values. Our life
experiences and our current age strongly influence our views about Ageing
and old people. Most of us have a rather narrow perspective, and our
attitudes may reflect this. We tend to project our personal experiences
onto the rest of the world. Because many of us have a somewhat limited
exposure to Ageing, we are likely to believe quite a bit of inaccurate
information. When dealing with older adults, our limited understanding and
vision can lead to serious errors and mistaken conclusions. If we view old
age as a time of physical decay, mental confusion, and social boredom,
we are likely to have negative feelings toward Ageing. Conversely, if we
see old age as a time for sustained physical vigour, renewed mental chal-
lenges, and social usefulness, our perspective on Ageing will be quite
different.
It is important to separate fact from myth when examining our attitudes
about Ageing. The single most important factor that influences how poorly
or how well a person will age is attitude. This statement is true not only for
others but also for ourselves.
Throughout time, youth and beauty have been desired (or at least viewed
as desirable), and old age and physical infirmity have been loathed and
feared. Greek statues portray youths of physical perfection. Artists' works
throughout history have shown heroes and heroines as young and
beautiful, and evildoers as old and ugly. Little has changed to this day
(Cultural Awareness and Critical Thinking boxes, below). Few cultures
cherish their older members and view them as the keepers of wisdom.
Even in Asia, where tradition demands respect for older adults, societal
changes are destroying this venerable mindset.
For the most part, mainstream Australian society does not value its elders.
Australia tends to be a youth-oriented society in which people are judged
by age, appearance, and wealth. Young, attractive, and wealthy people
are viewed positively; old, imperfect, and poor people are not. It is difficult
for young people to imagine that they will ever be old. Despite some
cultural changes, becoming old retains many negative connotations. Many
people continue to do everything they can to fool the clock. Wrinkles, gray
hair, and other physical changes related to Ageing are actively confronted
with makeup, hair dye, and cosmetic surgery. Until recently, advertising
seldom portrayed people older than 50 years of age except to sell eye-
glasses, hearing aids, hair dye, laxatives, and other rather unappealing
products. The message seemed to be, "Young is good, old is bad;
therefore everyone should fight getting old." It is significant that trends in
advertising appear to be changing. As the number of healthier, dynamic
"senior citizens" with significant spending power has increased, advertising
campaigns have become increasingly likely to portray older adults as the
consumers of their products, including exercise equipment, health
beverages, and cruises. Despite these societal improvements, many
people do not know enough about the realities of Ageing, and because of
ignorance, they are afraid to get old.


Table 13: Cultural Awareness

The Role of the Family
Cultural heritage may work as a barrier to getting help for an older parent.
Many cultures emphasize the importance of intergenerational obligation
and dictate that it is the role of the family to provide for both the financial
and personal assistance needs of older adults. This can lead to high stress
and excessive demands, particularly on lower-income families.
Nurses need to recognize the impact culture has on expectations and
values and how these cultural values affect the willingness to accept
outside assistance. Nurses need to be able to identify the workings of
complex family dynamics and determine how decision making takes place
within a unique cultural context.

Table 14: Critical Thinking

Caregiver Choices
What expectations does your cultural heritage dictate regarding
obligations to frail older family members?
Who in your family culture makes decisions regarding the care of
older family members?
Should Medicare or insurance plans pay low-income family
members to stay at home and provide care for infirm older adults?
To what extent should family members sacrifice their personal lives
to keep frail or infirm older adults out of institutional care?
Can filial obligations be met in a society that provides little support
or relief to caregivers?

Gerontophobia

The fear of Ageing and the refusal to accept older adults into the
mainstream of society is known as gerontophobia. Both senior citizens
and younger persons can fall prey to such irrational fears (Table 5).
Gerontophobia sometimes results in very strange behaviour. Teenagers
buy antiwrinkle creams. Thirty-year-olds consider facelifts. Forty-year-
olds have hair transplants. Long-term marriages dissolve so that one
spouse can pursue someone younger. Too often these behaviors may
arise from the fear of growing older.

Table 15 Ageing: Myth Versus Fact

MYTH
Most older people are pretty much alike.
They are generally alone and lonely.
They are sick, frail, and dependent on others,
They are often cognitively impaired.
They are depressed.
They become more difficult and rigid with advancing years.
They barely cope with the inevitable declines associated with
Ageing.
FACT
They are a very diverse age group.
Most older adults maintain close contact with family.
Most older people live independently.
For most older adults, if there is decline in some intellectual
abilities, it is not severe enough to cause problems in daily
living.
Community-dwelling older adults have lower rates of
diagnosable depression than younger adults.
Personality remains relatively consistent throughout the life
span.
Most older people successfully adjust to the challenges of
Ageing

40
The official citation that should be used in referencing this material is
http://www.apa.org/pi/Ageing/olderadults.pdf.

40
http://www.apa.org/pi/Ageing/olderadults.pdf.


Ageism
The extreme forms of gerontophobia are ageism and age discrimination.
Ageism is the disliking of Ageing and older people based on the belief
that Ageing makes people unattractive, unintelligent, and unproductive.
It is an emotional prejudice or discrimination against people based
solely on age. Ageism allows the young to separate themselves
physically and emotionally from the old and to view older adults as
somehow having less human value. Like sexism or racism, ageism is a
negative belief pattern that can result in irrational thoughts and
destructive behaviors such as intergenerational conflict and name-
calling. Like other forms of prejudice, ageism occurs because of myths
and stereotypes about a group of people who are different from
ourselves.
The combination of societal stereotyping and a lack of positive personal
experiences with the elderly effects a cross section of society. Many
studies have shown that health care providers share the views of the
general public and are not immune to ageism. Few of the "best and
brightest" nurses and physicians seek careers in geriatrics despite the
increasing need for these services. They erroneously believe that they
are not fully using their skills by working with the Ageing population.
Working in intensive care, emergency departments, or other high
technology areas is viewed as exciting and challenging. Working with
the elderly is viewed as routine, boring, and depressing. As long as
negative attitudes such as these are held by health care providers, this
challenging and potentially rewarding area of service will continue to be
underrated and the elderly will suffer for it.
Ageism can have a negative effect on the way health care providers
relate to older clients, which in turn can result in poor health care
outcomes in these individuals. Research by the National Institute on
Ageing reports that;
(1) older clients receive less information than do younger clients with
regard to resources, health management, and illness management;
(2) less information is provided to older adults on lifestyle changes such
as weight reduction and smoking cessation;
(3) limited rehabilitation is available for older adults with chronic
disease, despite studies demonstrating that individuals older than
85 years of age do benefit from rehabilitation programs; and
(4) only 47% of physicians feel that older adults should receive the
same evaluation and treatment for acute illness as their younger
counterparts.
Because an increasing portion of the population consists of older adults,
health care providers need to do some soul searching with regard to
their own attitudes. Furthermore, they must confront signs of ageism
whenever and wherever they appear. Activities such as increased
positive interactions with older adults and improved professional training
designed to address misconceptions regarding Ageing are two ways of
fighting ageism. The Nursing Competence in Ageing (NCA) initiative,
which was started in 2002, focuses on enhancing competence in
geriatrics by expanding nurses' knowledge, skills, and attitudes.
Research coming from this initiative can help nurses regardless of their
area of practice.


Age discrimination reaches beyond emotions and leads to actions. Age
discrimination results in different treatment of older people simply
because of their age. Refusing to hire older persons, barring them from
approval for home loans, and limiting the types or amount of health care
they receive are all examples of discrimination that occur despite laws
prohibiting them. Some older individuals respond to age discrimination
with passive acceptance, whereas others are banding together to speak
up for their rights.
The reality of getting old is that no one knows what it will be like until it
happens. But that is the nature of life-growing older is just the
continuation of a process that started at birth. Older adults are
fundamentally no different from the people they were when they were
younger. Physical, financial, social, and political conditions may change,
but the person remains essentially the same. Old age has been
described as the "more-so" stage of life because some personality char-
acteristics may appear to amplify. Old people are not a homogenous
group. They differ as widely as any other age group. They are unique
individuals with unique values, beliefs, experiences, and life stories.
Because of their extended years, their stories are longer and often far
more interesting than those of younger persons.
Ageing can be a freeing experience. Ageing seems to decrease the
need to maintain pretences, and the older adult may finally be
comfortable enough to reveal the real person that has existed beneath
the facade. If a person has been essentially kind and caring throughout
life, he or she will generally reveal more of these positive personal
characteristics as time marches on. Likewise, if a person was miserly or
unkind, he or she will often reveal more of these negative personality
characteristics as he or she grows older. The more successful a person
has been at meeting the developmental tasks of life, the more likely he
or she will be to face Ageing successfully. Perhaps the best advice to all
who are preparing for old age is contained in the Serenity prayer:
O God, give us the serenity to accept what cannot be changed;
courage to change what should be changed; and wisdom to
distinguish one from the other. - Reinhold Niebuhr

3.3 Recognise the impact of consumerism on service delivery
Serious questions are being raised about the appropriateness of using
intensive, expensive interventions to extend the lives of terminally ill
older people.
Financial concerns are forcing health care providers and society to face
ethical dilemmas regarding the allocation of limited health care
resources. This is a highly emotional issue with no easy answers. Many
people are alive today because of advances in medical technology.
Some of those who benefit are young, whereas others are old. Some go
on to lead lives of high quality; others never lead normal lives again. By
virtue of their training, physicians are inclined to try to cure everyone.
Most doctors do not feel comfortable allowing a Client to die, regardless
of the person's age. Most doctors will use all available technology to
save a life.
Reputable authorities, ethicists, and politicians have widely differing
points of view on this issue. Some believe that health care restrictions


on older adults are the ultimate in age discrimination. Others argue that
the benefits gained, which can usually be measured in months, do not
outweigh the costs. Private citizens examining this dilemma are equally
confused. Those who believe that health care costs are excessive
usually still want everything possible done to save the lives of their own
loved ones. This dilemma is moral, ethical, and legal, with no simple
right answer. The Critical Thinking box below is designed to increase
your awareness and insight into these problems.

Table 16: Critical Thinking

Your Understanding of the Health Care Dilemma
Should an 80-year-old person have coronary bypass surgery at a
cost of approximately $100,000?
Should dialysis be provided to individuals older than 65? older than
75? older than 85?
Should people older than 65 be candidates for organ transplants?
Should a respirator be used on a terminally ill Client?
Are feeding tubes a part of basic physical care, or are they
extraordinary means?
Should the individual, the family, or the physician decide the type
and amount of medical intervention necessary?
What should be the role of the government in health care?

Advance Directives

All adults who are 18 years of age or older and of sound mind have the
right to make decisions regarding the amount and type of health care
they desire. Because older adults are more likely to experience
significant health problems, the question of what and how much medical
care to administer must be addressed. Such important decisions are
best made during a stress-free time when the individual is alert and
experiencing no acute health problems. A person's wishes can best be
communicated using advance directives, which are legally recognized,
written documents that specify the types of care and treatment the indi-
vidual desires when that individual cannot speak for himself or herself.
Areas typically addressed in advance directives include
(1) do not attempt to resuscitate (DNAR) orders,
(2) directives related to mechanical ventilation, and
(3) directives related to artificial nutrition and hydration.


Two formal types of advance directive are recognized in most states:
(1) the enduring medical power of attorney and
(2) the living will.
Information about both of these is typically provided when a person
enters the hospital. Each Client is expected to make a decision about
the type and extent of care to be administered if his or her condition
becomes terminal.
These written documents are designed to help guide the family and
medical professionals in planning care. The family is often relieved to
have this information when making difficult decisions during a stressful
time. In general, advance directives are recognized and respected, but
various agencies, individual physicians, or health care providers may
have beliefs or policies that prohibit them from honouring certain
advance directives. Individuals should discuss their wishes with their
health care providers when these documents are written. Open
communication reduces the chance of questions, conflict, or legal
repercussions later. If irreconcilable differences exist between an
individual and the care provider, changes in either the document or the
care provider must be considered.
Enduring medical power of attorney transfers the authority to make
health care decisions to another person called the advocate. The
advocate may act only in situations in which the person is unable to
make decisions for himself or herself. Because the advocate must be
trusted to follow through with the older person's wishes, the advocate
specified in the document is usually a family member or friend. These
wishes are specified in writing and usually witnessed by unrelated
individuals to reduce the possibility of undue influence. Standardized
legal forms are available to initiate a power of attorney for health care.
A living will informs the physician that the individual wishes to die
naturally if he or she develops an illness or receives an injury that
cannot be cured. Living wills prohibit the use of life-prolonging measures
and equipment when the individual is near death or in a persistent
vegetative state. Living wills go into effect only when two physicians
agree in writing that the necessary criteria are met.

What does aged care cost?

The care for people living in aged care homes is expensive. Aged care
homes are subsidised so that care fees are affordable for everyone. On
average, the subsidy is currently around $42 880 a year for people who
need high-level care and $15 565 for those who need low-level care.
41

High-level care
All aged care homes must provide a specified range of care and
services at no additional cost to residents. These requirements vary
according to whether the resident has low-care or high-care needs.

41
http://www.agedcareaustralia.gov.au/internet/agedcare


There are some specified care and services that all residents receive
and additional ones that are provided for high-level care residents.
The specified care and services that must be provided by the aged care
home at no additional cost are listed below. If a home provides the
required range of specified care and services but the resident would like
certain other brands, or has individual specific needs, then the home
does not have to cover the cost of those products.
Hotel/accommodation services
All residents receive specified care and services relating to:
maintenance of buildings and grounds
accommodation
furnishings
bedding
cleaning services
general laundry
toiletries - bath towels, face washers, soap and toilet paper
meals and refreshments
social activities
provision of staff on call to provide emergency help.
Additional requirements for high-level care
High care residents must be provided with additional items, care and
services such as
goods to help them move themselves eg crutches, walkers
goods to assist with toilet and incontinence management
more basic toiletries such as tissues, toothpaste, denture cleaning
preparations, shampoo, conditioner and talcum powder
Personal care and services
All residents receive specified care and services including:
Assistance with the activities of daily living, such as:
o bathing and grooming
o using the toilet
o eating
o dressing
o mobility
maintaining continence or managing incontinence
communicating with other people


emotional support
treatments and procedures (such as assistance with taking
medication)
recreational activities
rehabilitation support
assistance in obtaining health practitioner services and access to
specific therapy services, and
support for people with memory loss or confusion.
Additional requirements for high-level care
High care residents must be provided with additional items, care and
services such as:
Nursing services and equipment, such as equipment to assist
with mobility, continence aids, basic medical and pharmaceutical
supplies and equipment, helping with medications, provision of
therapy services and short term oxygen.
Homes must also meet the requirements under the Accreditation
Standards for Residential Aged Care.

Low-level care
Low-level care is for people who need some help, but do not have very
complex ongoing care needs.
Low care includes:
accommodation-related services furnishings, bedding, general
laundry, some toiletries, cleaning services, all meals, maintenance
of buildings and grounds, and the provision of staff on call to
provide emergency assistance, and
personal care services assistance with the activities of daily
living, such as bathing, going to the toilet, eating, dressing, moving
around, maintaining continence or manAgeing incontinence,
rehabilitation support, and assistance in obtaining health and
therapy services.
The companies or other organisations that run aged care homes may
ask residents to pay two main types of charges based on income and
assets daily care fees and accommodation payments. The
government calculates and regulates maximum daily care fees.
Some fees are the same for everyone and some are based on income.
This website will help you to understand how these fees and payments
are calculated, based on your financial circumstances and your
particular care needs.


3.4 Conduct work that reflects an understanding of the individuality of
ageing.
Most of us, professionally and privately, find ageing an uncomfortable
subject. From a personal perspective, the reason is obvious: none of us
particularly relishes the fact of our own mortality or the prospect that
before our life is over we can expect its quality to be impaired by a
spectrum of age related disabilities and diseases. Professionally, ageing
evokes a curious mixture of reactions. For some, it is just too
complicated and frustrating a process to take seriously. For others, it
represents ultimate failure in a medical model founded on the idea of
curing disease. For a growing number, it is the most intriguing
biomedical problem of our time.
Is ageing a disease? Surely not; it is a normal part of the life cycle. But if
this is the case, what are we aiming for when we do research into the
ageing process? Surveys of public opinion about the desirability of
extending human life span show that, in spite of our seeming fascination
with the secret of eternal youth, we are deeply ambivalent about
making people live longer. We seem to be caught in a trap of our own
making. Great creativity and effort have been expended on preventing
premature death. But now that we have produced conditions in
Western countries in which five out of six infants can expect to see their
65th birthdays, we are much less sure what to do about all these older
people.
In recent years ageing has risen up the social and political agenda. It
has prompted high level attention from the United Nations, with its
research agenda on ageing for the 21st century.
42
There have been
many individual actions by governments, and in Britain these include the
introduction of the national service framework for older people
43
and the
multidisciplinary Foresight review.
44
However, the issues boil down to
two main challenges. Firstly, what can we do to meet the social and
medical challenges of a world in which a large (and still increasing)
fraction of the population is living to an age when intrinsic biological
constraints take their toll on health and quality of life? Secondly, what is
research likely to reveal about the ageing process that might alter the
situation yet further in the years to come?
What makes us age?
One of the strangest things about the ageing process is that, despite its
near universality among higher organisms, it is something of an artefact.
In the wild, aged organisms are extremely rare because most animals
die young. Because old age in nature is a rarity, any idea that the
ageing process has been actively favoured through natural selection
such as by evolving death genesto keep population size under
check, is almost certainly false. Put simply, we are not programmed to

42
United Nations. Research agenda on ageing for the 21st century. Geneva: UN, 2002.
www.un.org/esa/socdev/ageing/ageraa.htm (accessed 31 May 2009).
43
Department of Health. National service framework for older people. London: DoH, 2001.
www.doh.gov.uk/nsf/olderpeople/docs.htm (accessed 31 May 2009)
44
Foresight. Healthcare and ageing population panels. Joint Taskforce on Older People. London:
Department of Trade and Industry, 2000.


die. Quite the reverse; our bodies are programmed for survival. Even at
the last moments of life, nearly every function in every cell of our bodies
is still working to keep us alive. To be sure, there is a process of
programmed cell death (apoptosis), and we do see cells in the adult
body sometimes committing suicide by this means, but programmed
cell death in adults is almost entirely associated with survival of the
organism, such as by deleting damaged cells that might otherwise pose
a risk of malignancy.
This apparent paradoxthat we are programmed for survival but must
face ageing and death as surely as taxesis resolved when we
recognise that it is only in the past 200 years that human life expectancy
has risen much above 40 years. Before that, when life generally was
nasty, brutish and short, there was little evolutionary pressure for our
genes to invest in survival mechanisms that could keep the human body
in good shape for much longer than about half a century.
These considerations are the basis of the disposable soma theory of
ageing, which suggests that the biological determinants of human
ageing lie in the fact that our cell maintenance and repair systems
evolved when human life expectancy was only half what it is today.
45
,
46

The theory predicts that ageing results from a gradual accumulation of
faults in the cells and tissues of the body. Current research on the
mechanisms underlying ageing and age related diseases is focused on
understanding the kinds of damage that affect cells and tissues and on
the cell maintenance and stress response systems that protect us. One
clear conclusion is that there is no single mechanism of ageing. A large
number of maintenance and repair systems collectively provide the
network of cellular defence mechanisms that keep us going as long as
we do. It is the weak links in this network that may predispose us to
specific age related disorders, and it is to this network that we must look
if we wish to enhance the body's capacity to reach old age in good
health.
Research on basic cellular ageing can throw light on age related
diseases as well as on the normal ageing process. Many of the
important diseases of old ageincluding Alzheimer's disease,
osteoporosis, osteoarthritis, and even cancershow interaction and
overlap with normal ageing. For example, the bone loss that causes
osteoporosis in susceptible individuals is seen to some degree in all
older people. Similarly, the amyloid plaques and Neurofibrillary tangles
that characterise Alzheimer's disease may be found at autopsy in
people aged 70 years and above even if there was no clinical evidence
of dementia.
The individuality of ageing
One of the curious features of ageing is its unpredictability at the
individual level. Even when there is genetic predisposition for an age
related disorderas in people who carry two copies of the epsilon 4
allele of the gene for apolipoprotein E and are thus at increased risk of
developing Alzheimer's diseasethere is only a shift in the statistical
odds of developing dementia. One of the vital questions for research is
therefore to understand the interplay of genetic and lifestyle factors that

45
Kirkwood TBL. Time of our lives: the science of human ageing. London: Weidenfeld and Nicolson, 1999
46
Kirkwood TBL, Austad SN. Why do we age? Nature 2000;408: 233-8.


predispose to the development of age related disease or, conversely,
increase the likelihood of remaining in good health. Although there are
no genes specifically for ageing, it is clear from twin studies, for
example, that there is a noticeable heritable component to human
longevity. Estimates suggest that genes account for about 25% of what
determines length of life, and progress is being made in identifying
some of the genetic factors that may be involved.
47
,
48
,
49

The fact that genes explain only 25% of individual variability in ageing
means that 75% must be accounted for by other factors. These include
lifestyle variables, such as nutrition and exercise, as well as the
powerful effects of environment. Environment can have enabling or
disabling impacts on older age, with unsupportive environments (poor
transport and housing, crime, etc) discouraging an active lifestyle and
social participation, which in turn results in inactivity and isolation,
accelerating physical and psychological decline. These complex
interactions between genes, nutrition, exercise, and environment can all
be accommodated quite readily within a model of the ageing process as
one that is driven, ultimately, by an accumulation of random molecular
and cellular damage.

Healthier ageing on the horizon
The positive message from this research is that human ageing is
malleable and can be improved by either reducing exposure of the
body's cells and organs to damage or by enhancing cell maintenance
and repair. Comparative studies have shown that long lived animal
species accumulate damage at slower rates than short lived species
and that their cells have greater intrinsic resistance to a range of
stressors, such as the damaging reactive oxygen free radicals that are
produced as a by-product of the body's requirement for oxygen.
50

Certain short lived species, such as fruit flies and nematodes, are
readily amenable to the study of mutants with altered life spans. These
studies have consistently shown that increased cell maintenance and
stress resistance are associated with increased life span, and vice
versa.
51
Although ageing in humans is considerably more complex than
in these simple models, identifying the primary mechanisms that protect
against cellular damage may yield clues to slowing aspects of the
ageing process.
The idea that science should aim to postpone disabling conditions such
as Alzheimer's disease without necessarily extending life itself is a
concept commonly known as compression of morbidity. Whether it may
prove feasible to postpone age related diseases without postponing
ageing itself will depend on the extent to which we can separate ageing

47
Cournil A, Kirkwood TBL. If you would live long, choose your parents well. Trends Genet 2001;17: 233-
5.
48
Muiras ML, Muller M, Schachter F, Burkle A. Increased poly(ADP-ribose) polymerase activity in
lymphoblastoid cell lines from centenarians. J Mol Med 1998;76: 346-54.
49
Perls T, Kunkel LM, Puca AA. The genetics of exceptional human longevity. J Mol Neurosci. 2002;19:
233-8.
50
Kapahi P, Boulton ME, Kirkwood TBL. Positive correlation between mammalian life span and cellular
resistance to stress. Free Radic Biol Med 1999;26: 495-500
51
Kirkwood TBL, Austad SN. Why do we age? Nature 2000;408: 233-8.


and disease. It may be that, in order to delay these diseases in humans,
we need to delay the build up of several types of damage, including
processes as fundamental to ageing as oxidative damage.
Already, our understanding of ageing highlights some key issues. Since
ageing is caused by lifelong accumulation of damage, it begins early.
We need to recognise this continuum of ageing and design lifelong
approaches to healthy ageing. We need to confront issues of personal
choice (how to exercise and preserve it). We need to target biological
and psychological barriers to independence in older age. We should
engage in realistic discussion about what we want from research on
ageing, including issues on the end of life. Above all, we should
celebrate the longevity revolution; it has been hard won, and we must
make the most of it.

3.5 Conduct work that minimises the effects of stereotypical attitudes
and myths on the older person
We live in an age-segmented society which often excludes extensive
personal contact between people in different age groups. Many of us
have grandparents and even great-grandparents who may influence our
view of what ageing is about. On the other hand, we may believe that
their experience is atypical because it does not comply with some of the
more common views of later life. These views are often acquired as a
result of adopting stereotypical images of older people and their lives.
These stereotypes are frequently used as a means of attempting to
relate to our fellow beings.
A stereotype is not necessarily a negative image (though it is more
commonly so) when it is used to describe an older person. Stereotypical
images of older people often focus on the unwelcome aspects of
ageing, such as physical and mental decline, and negative personality
traits, which are assumed to be characteristic of older people.
Generally, these negative stereotypes are based on myths about
ageing. It is therefore essential that all carers involved in the care of
older adults examine their own preconceptions about ageing and clarify
their values surrounding their own ageing.
Nursing care based on false perceptions
is unlikely to be effective and may even
be detrimental to the older person.
Therefore, nurses need to distinguish between myth and reality, in
order to identify accurately the older persons strengths and
weaknesses.
Common beliefs about ageing are:
ageing brings an end to productivity
older people normally wish to disengage from society
older people are rigid or inflexible in their thinking and are set in
their ways
senility or mental impairment is an inevitable part of ageing
Ill-health is a normal part of ageing


Older people are unhappy because they are older
Older people are neglected by their family
Older people are asexual
Older people are unable to learn new things
Older people are isolated and lonely

Understanding Ageing and its Biological and Social Processes

To many, ageing and dying are synonymous. In Australia, dying is the
most culturally obscene subject. We talk easily about sex, money, hate,
and private family matters - but not about death. Ageing brings one
closer to dying. The desire to shun death, to separate it from living
experience and deny it existence, may be a major factor contributing to
negative feelings toward the aged. Dying is part of living, a part that can
be shared, although usually it is not. Some of the most meaningful
moments of living are experienced when sharing the dying process with
aged persons. These individuals are remarkably open, if allowed to be,
and have a strong desire to share the meaning of their lives, the
perspective they have gained, and their own thoughts about death. In
poignant times one can learn and care most fully.
An extremely old woman was given a sign saying, ENJOY LIFE. This
sign and a scene from her childhood hung directly in line with her gaze.
She talked about the scene, the colours, and the old grist mill depicted
there. "I'm about to give up the ghost, you know. I'm afraid, and I don't
know exactly why. I've lived the best I knew. I hope someone is here to
ease me to the other side." Having talked many times about death, her
comfort with the idea and sometimes desire for it were apparent, but, as
it drew close, she held onto each moment and savored it. Even those
who are dying in pain often see the remaining time as exquisitely
precious. One old man said, "I love this old earth. I'm going to hate to
leave her."
Blythe (1979) wrote about the affliction of "slow-motion departure" that is
a great fear of many aged-struggling, as Tithonus, the Greek mythical
figure, with the blessing of perpetual oldness, being unable to die. See
Chapter 24 for a discussion of the assistance nurses may provide for
the dying client.
52

Here the key challenges relate to issues such as understanding
Alzheimer's disease and associated disorders such as
Dementia;
cross-cultural issues;
identifying various diseases, disabilities and chronic conditions
affecting older adults;
general issues relating to health and health care;
the mental health of older adults, and;

52
Ebersole, P., Hess, P.; Toward Healthy Aging, Human Needs and Nursing Response; Mosby, St Louis
1990, p 45-47


the social construction of ageing, including attitudes towards ageing
and growing old.
From these issues arise many challenges, and it can also be shown in
these areas how much successful ageing can be influenced by
attitudes, particularly towards ageing and growing old.
Whilst much research is being carried out on the biological and
physiological aspects of ageing, it is increasingly being acknowledged
that ageing is a social and cultural phenomenon. Nowhere is this more
apparent than in the ways attitudes about ageing and growing old are
formed amongst children. There is an emerging literature which
suggests that children, adolescents and young adults develop negative
attitudes about older people and the processes of ageing. Indeed,
Lorge, Tuckman and Abrams (1954) in their pioneering research
concluded that, by the age of twelve or thirteen, most children already
viewed older adults as generally ill, mentally slower, forgetful, grouchy,
withdrawn, isolated, unhappy, unproductive and burdensome.
Studies since have confirmed that the young have entrenched, negative
views about ageing. For instance, Hickey and Kalish (1968) found that
the older the adults, the less pleasant will be the image of them held by
children; Kastenbaum and Durkee (1964) concluded that not only do
young people see older adults negatively, but they also tend not to think
of themselves as growing old. McTavish (1971) concurs by suggesting
that there is an overall personal rejection by young people of older
adults and prejudice against them; and more recent research (McGuire
1993; Slotterback & Saarnio 1996) has tended to verify that there is
widespread prejudice towards older adults and negative stereotyping of
them by children, adolescents and young adults.
53

As a practical guide to test the veracity of these claims, a group of
children aged seven to ten were asked to write a story on `What it is like
to be an elderly person' and then to compile word lists identifying the
characteristics of old people. The following was a typical story.
I don't know how an old person feels but I know I won't like being
old. I seem to think I will be cut off from the world and be put away,
like in jail. I'm afraid of being lonely and having no one there when I
need them. I'm going to be useless I know, but I don't want to be ...
I am going to do all I can now I'm still young ... before I have to be
shut up. It must hurt having no one there and only the occasional
visitor. I have a feeling I will get sick easily and have a heart attack
or stroke and die. It must be scary for an old person because they
know they're near to death. (Rachel aged 10 years)

These were some of the words they used to describe how older people
feel and what they do; in answer to questions they were asked.
How do old people feel? Sad, unhappy, dependent, lonely, funny,
useless, scared.

53
Bevan, Celia. Successful Ageing; perspectives on health and social construction; Mosby Publishers
Australia Pty Ltd 1998,


What do old people do? Knit, cook a lot, make faces, play, play
bowls, lie in bed doing nothing, gardening, look at photos, play
cards.

These reactions reinforce the view that stereotypes of older people
probably develop relatively early in children. To be using words such as
`scared', ùseless' and ùnhappy' when referring to old people indicates
that some children only view old age negatively. At present we can only
speculate about why children are developing stereotypical images of old
people. On the one hand, these images may be created and reinforced
by parents and teachers, particularly if they hold negative attitudes
towards older people and are misinformed about the processes of
ageing. This situation may be compounded if children do not regularly
interact with older adults in the home and school environment.
The media is perhaps a more pervasive influence responsible for these
children holding stereotypical views about growing old. Here the existing
research evidence seems clear and consistent, indicating that the more
people, and especially young people, watch television, the more they
tend to perceive old people in generally negative and unfavourable
terms. In other media, such as motion pictures and books (including
school textbooks), older people seem to be severely stereotyped. They
are more likely to be shown in the role of villain; rarely as the confident
and competent solver of problems; and frequently as gloomy and
forgetful characters.
What, then, are the implications of these findings for successful ageing?
First, it seems that our attitudes about older adults and the processes of
ageing are probably formed early in life. Once formed, the attitudes may
influence our thoughts and behaviour throughout our lives.
Second, people's attitudes towards ageing and growing old probably
have a profound influence on their own development towards old age
and may ultimately have a significant influence on their quality of life as
an older adult.
Thus, if children and young adults have negative attitudes towards older
people and about the ageing process, then they may become uncertain
about, and even antagonistic towards, the position of older people in the
community. Successful ageing, therefore may have as much to do with
how we socially and psychologically construct the meanings and
attitudes associated with growing old as it has with biological processes.


Activity xx.

1. As the workplace becomes more diversified in its values you need to
look at incidences when you the worker and a client/co-worker did
not share a common world view. Briefly describe three differing
perspectives.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
2. Describe the key values that may cause friction between yourself
and a client or co-worker.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
3. What sort of cultural / ideological values can be the hardest to come
to terms with and why?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


4. How might you be able to reduce this friction in the future?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Activity 11:
1. What is a myth about aged people?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

2. How does this impact on their lives?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
3. What is a stereotype of aged people?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
4. How does this stereotype impact on their lives?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
5. What is an assumption of aged people?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


6. How does this assumption impact on their lives?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Activity 12:

1. As you are aware consumerism impacts on service delivery. The
people who receive these services are referred to as for example a
client or Client, etc. Do you feel the service or the attitude of the
workers and the people who receive this service would be different if
this was changed or altered?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

2. What would be the impact on the rights of consumers on the
services you would provide?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


3. From Table 2: Ten Principles of a Positive Ageing Strategy
develop a strategy for your place of work or situation and address
the needs of your residents.

Stakeholder Individual Outcomes
1
2
3
4
5
6
7
8
9
10


4. Apply understanding of the
physical and psychosocial aspects of
ageing

4.1
4.2
Take into account physical changes associated with ageing
4.3
Recognise and accommodate the older persons interests and
life activities when delivering services
4.4
Assist the older person to recognise the impact physical
changes associated with ageing may have on their activities of
living

4.1 Outline strategies that the older person may adopt to promote
As in the acute care facility, the nursing assistant carries out the
procedures as taught, assisting in the health care of residents under the
direct supervision of a nurse. Basic physical care, as well as special
procedures, will be done to help these residents reach their maximum
degree of well-being. To be successful in this setting, you must:
be Client and caring.
understand the character of the older age group.
be able to care for persons who may be your own age and have
chronic illnesses.
be comfortable with the thought of your own Ageing.
have the stamina to provide the assistance needed by the
residents.
be able to derive satisfaction front being part of a slow progress and
small, if any, gains.
have a sense of humor.
be able to communicate effectively (Figure XX).
These attributes are important in any health setting, but in the long-term
care facility they become very necessary.
Many of-the residents will remain under your care for long periods of
time, even for years. You will develop relationships that become
important to both caregiver and care receiver. In those circumstances,
conuuunications take on greater Importance. Greater significance may
be attached to the attention to care or even the way thoughts are
expressed in words. Thus, the long-term caregiver is a very special
person, who works in an important area of health care.


Figure 10 Persons working in long-term care facilities must have
excellent communication skills,

Effects Of Ageing
Many residents in the long-term facility are advanced in age and have
one or more chronic, somewhat debilitating (weakening) conditions.
Sonic are mentally alert. Others are contused and disoriented.
There are, however, some features of Ageing that are characteristic for
most elderly residents. Do not expect every resident to exhibit the same
characteristics at the same chronologic (year) age. Remember that
Ageing is a natural, progressive process that begins at birth and
extends to death. Remember also that every resident is unique and
must he treated with dignity and respect.


4.2 Take into account physical changes associated with ageing when
delivering services

Physical Changes in Ageing
Some investigators believe we are born with a biological time clock.
This clock is programmed for a specific life span, barring accidents and
disease. As we move toward old age, changes that have been taking
place gradually become more evident. For example, the elderly person:
May lose vitality
May sleep less at night.
May benefit from rest periods during the day.
Stores less fluid in body tissue and is apt to become dehydrated.
This results in a loss of elasticity and resiliency in tissues.
Has fibrous tissue changes. -These decrease the tone,
mass, and strength of skeletal and smooth muscle.
Has sccretoty and endocrine cells that become less functional and
reduced nerve sensitivity.
Certain changes occur in every body system. "They do not necessarily
occur at the same rate In each system. These are listed in Table 31-1.

Emotional Adjustments to Ageing

Emotional adjustments to Ageing are basically extensions of the
adjustments the individual has made throughout life to the many
changes in circuntsrances. personality characteristics and ways of
reacting to stress are developed-fairly early in life and tend to become a
constant in an individual's personality. In leer, as a person ages,
personality traits become even more pronounced. The stress produced
the circumstances and illnesses that accompany old age do not
drastically alter the individual's personality, but they do tend to magnify
and in some cases distort, the basic traits.
Old people have the same emotional nerds and require the same
supports for good mental health as young people (Figure 9).-They need:
to be loved.
to have a sense of self-worth.
to feel a sense of achievement and recognition.
to have a degree of economic security
Although these needs are common to all human beings, regardless of
age, the means for achieving satisfaction and gratification of these
needs are greatly reduced for older people. The opportunities for social
exchange and sexual expression, the two major means of gratification,
are lessened as the years advance. The need for them does not
change, however. The attitude of the Western world toward old people
tends to relegate (place) them to positions of lesser and lesser


significance. The older people become, the more their self-image is
depreciated (devalued), both in their own eyes and in the eyes of
others.

Table 17 Physical Changes Of Aging

Body System Physical Changes
Integumentary
Hair loses color and becomes thinner
Skin dries, becomes less elastic; wrinkles
develop
Skin is fragile and tears easily
Bruises easily (senile purpura common)
Fingernails and toenails thicken
Sweat glands do not excrete perspiration
as readily
Oil glands do not secrete as much oil
There is increased sensitivity to cold
Skin discolorations (age spots) become
more common
Nervous
Problems with balance
Temperature regulation is less effective
Sensation of pain decreases
Deep sleep is shortened, more
awakenings during the night
Brain cells are lost but intelligence
remains intact unless disease is present
Decreased sensitivity of nerve receptors
in skin (heat, cold, pain, pressure)
Sensory
More difficult to see close objects
Night vision may decrease
Cataracts (clouding of the lens of the
eye) are more common
Side vision and depth perception diminish
Hearing diminishes in most elderly
persons
Smell receptors and taste buds are less
sensitive, so foods have less taste


Musculoskeletal
Less muscle strength
Less flexibility
Slower movements
Arthritis and osteoporosis common
Body becomes more stooped
Respiratory
Breathing capacity lessens
Urinary
Kidneys decrease in size
Urine production is less efficient
Emptying bladder completely may
become more difficult
Stress incontinence may develop
Digestive
Primary taste sensations of salt, sweet,
and sour decrease
Constipation increases
Flatulence increases
Movement of food through the digestive
system slows
Cardiovascular
Blood vessels less elastic, more
narrowed
Heart may not pump as efficiently,
leading to decreased cardiac output and
circulation
Endocrine
Decrease in levels of estrogen,
progesterone
Hot flashes, nervous feelings
Higher levels of parathormone and
thyroid-stimulating hormone
Weight gain
Insulin production less efficient
Diabetes mellitus more likely
Reproductive
Females:
Ovulation and menstrual cycle cease
Vaginal walls are thinner and drier
Males:
Scrotum less firm
Prostate gland may enlarge


Physical ailments, far more common in the elderly because of slowed
body processes, art superimposed (layered on top of) upon the changes
brought about by the natural aging process. Change of body image and
loss of the vigor and vitality (lively character) of former years arc major
losses the older person must accept-losses that further alter their self-
image and self-esteem. The caregiver can make an important
contribution by promoting the self-esteem of those being cared for.
In old age, some accommodations must be made in the attitudes or
psychological outlooks of all persons. The most healthy emotional
responses are based:
on philosophies that accept aging as a natural progressive stage.
in life attitudes that recognize the strengths as well as the limitations
of the body.
on a form of behavior that demonstrates interest in living here and
now.
Healthy psychological adjustments mean both a realistic appraisal of the
present circumstance and building on the positive values while coming
to terms with the negative aspects.
Some of your long-term care residents will have already made these
adjustments. Some will be in the process. Your supportive caring will be
important and helpful to each.
Specific Emotional Responses.
The elderly or infirm resident is apt to experience some common
emotional responses. Frustration is an emotion frequently experienced
by the elderly-frustration at physical limitations and at having less
control over their own lives. That is why it is important to allow the
elderly the opportunity to make as many decisions as possible. Signs of
frustration are often demonstrated by;
Aggressive behavior
Anger
Hostility
Demanding behavior
Complaining
Crying
Some residents even resort to manipulating families, staff; or other
residents in an attempt to relieve their feelings of helplessness (Figure
10).
Anxiety and fear may be expressed in periods of depression and
withdrawal. The depression experienced by the elderly is easily
understood. In many instances, they:
are cut old from their social support systems.
have had to make major adjustments in their lifestyles.
may have lost loved ones and friends.
may have very limited finances.


may truly feel that they no longer have any control over their
destinies or even of their day-to-day activities.
Figure 10: Residents may exhibit feelings of frustration and anger.

may have stretched their coping ability to the breaking point
because of physical weakness and disease processes.
Withdrawal, a common frustration response, is shown by:
Lack of communication
Temporary confusion
General disorientation as to time and place
You can play a major role in helping residents move successfully
through these periods by:
reassuring them that they will not be abandoned now that they are
no longer able to care for themselves.
treating each person with respect to reinforce self-esteem.
calmly helping your residents keep in touch with reality while
conveying your own feelings of compassion and caring.
reporting changes in behavior, mood swings, and emotional
responses to your supervisor so that the entire staff can form a
supporting network.
responding to the residents' negative attitudes by being willing to
listen and interact with them and emphasizing the positive.


Nutritional Needs
Malnutrition is a problem for the aged because the older person may
develop all apathy toward food that becomes progressive. Factors that
contribute to lack of appetite are:
Decreased activity
Inadequate teeth
Bad dentures
Decreased saliva
Diminished smell and taste
Poor oral hygiene
Eating alone
The diet for the elderly person should:
Be easy to chew and digest.
Contain decreased amounts of refined sugars, fats, and cholesterol.
Have adequate proteins and vitamins to provide for best bodily
function and repair.
Have many complex carbohydrates, found in fruits, vegetables, and
grains (Figure 31-10). These foods also are good sources of
vitamins and minerals, which tend to be deficient in the elderly diet.
Be monitored for weight Control. Obesity is a major nutritional
problem among the elderly and those who are inactive. The excess
weight increases the stress of existing conditions. Calories are
generally limited to about 2,000 calories for the average woman and
2,400 to 2,500 calories for the average man.

Because of loss of muscle tone, three intestinal problems are seen.
They are:
Constipation-difficulty in eliminating solid waste
Flatulence-gas production
Diverticulosis-small pockets (diverticula) of weakened intestinal wall

Dietary adjustments can help reduce these problems.
Soft bulk foods, such as whole-grain cereals and fruits and
vegetables, are helpful in overcoming the constipation.
Skins and seeds should be avoided to prevent diverticulitis, which is
an inflammation of the diverticula.


Figure 11
Elderly people require complex
carbohydrates for a healthy diet. From
How to Eat for Good Health, Courtesy
of National Dairy Council

The presentation and service of food are important in stimulating
appetites. Keep in mind the following:
Several smaller meals seem to be more easily tolerated than three
large meals.
Residents should be allowed to feed themselves as much as
possible. You may assist by cutting up the food into bite-sized
pieces. Even if you must do most of the feeding, allow the resident
to participate as much as possible.
Adequate liquid is absolutely essential. This need is frequently
neglected, leading to dehydration. You must encourage fluid intake
and be sure that the resident actually drinks the fluids (Figure 31-
11).
Fruit and vegetable juices, eggnogs, and soups can serve the dual
purpose of providing both nourishment and fluids.
Fluids must be offered at frequent Intervals between mews to
ensure adequate intake.

Preventing Infections In Residents

There are no additional or special infection control techniques in long-
term facilities. Effective and frequent handwashing is the best method
for preventing the spread of disease from resident to resident, staff
person to resident, or resident to staff person. Standard precautions
should be implemented in the care of all persons when contact with
blood, body fluids, secretions, excretions, mucous membranes, or
nonintact skin is anticipated. Isolation techniques are used for residents
with known infectious diseases.


Figure 12: Encourage fluid intake.

It is important to follow these procedures because it is easy for elderly
people to get infections. There are a number of reasons for this:
Body changes due to aging make older people more susceptible to
infection. The skin offers less protection because of its fragility. Any
break in the skin, such as a pressure sore or skin tear, can quickly
become infected.
Changes in the urinary system cause the bladder to empty less
efficiently. Urine left in the bladder contributes to urinary tract
infections.
The ability to cough and raise secretions is reduced. As a result,
there is decreased ability to get rid of bacteria from the lungs.
Elderly people do not always eat well and may be under nourished.
Elderly people have less resistance to disease because the imnunte
system becomes less effective with age.
Resistance to disease is reduced when residents have several
chronic health problems.


The elderly do not readily show signs of infection. This means they
may be sick for some time before you recognize the problem.
The elderly do not always develop a fever with an infection. The
average temperature for an older person may be one or two
degrees less than that of a younger person, Therefore, average
temperature may represent an Increase or fever.
Some elderly persons do not feel pain as acutely as younger
people. They may led no discomfort with a bladder infection, for
example.
The elderly do not readily develop signs of inflammatory
response. A skin infection usually shows redness, swelling,
heat, and pain. These signs may be missing or delayed in the
elderly person.
The elderly do not necessarily have an increase in the white
blood cell count. This is usually a sign of infection but is often
absent in the elderly.
Elderly people do not cough as frequently when they have
respiratory tract infections.
Residents who are disoriented may not comprehend or be able
to communicate feelings of pain or nausea.
The elderly are also more likely to develop serious complications
from infections. A simply urinary tract infection can result in
bacteraemia (blood infection), causing the resident to become
acutely ill. This can be fatal to a person who has little ability to copy
with additional health problems.
Prevention of infection in residents is an ongoing concern. There are
some steps that you can take to help in this process:
Assist residents to maintain an adequate fluid Intake.
This helps prevent urinary tract and respiratory tract infections and
keeps the skin healthier.
Assist residents to maintain adequate nutritional intake.
Report to the nurse when residents eat less or refuse food.
Assist residents to perform exercise programs established by the
nurse or physical therapist. Follow positioning schedules and order
for range-of-motion exercises and ambulation. This increases
circulation, thus lowering tile risk of pressure ulcers (a frequent
source of infection). Exercise also improves breathing, thereby
decreasing the risk of respiratory tract infections.
Attend to residents' personal hygiene needs. Regular bathing and
oral care help prevent infection. Inspect the body and mouth when
performing these procedures.
Toilet residents regularly who need assistance. This keeps the
bladder empty and also assures residents that they will receive help
when they need to urinate. Some residents hesitate to drink fluids
for fear they will be incontinent. When caring for incontinent
residents, be sure to wipe female residents using strokes from front
to back. 'This avoids contaminating the urethra with stool or vaginal
excretions.


Perform catheter care as directed. Avoid opening the drainage
system.
Observe residents carefully and report any unusual signs or
changes. Urinary tract infections may be discovered from changes
in the urine or by incontinence. In some cases, the first sign of any
infection is disorientation in people who art not usually disoriented.
For persons with dementia, a change in behavior may indicate an
infection. Incidents of falling often occur in residents with infections.
You will he asked to collect urine specimens for culture and
sensitivity. The specimen should be clean-catch. You may need
help when collecting the specimen. If it is contaminated because of
inadequate cleaning or improper collection, the results will be
altered.
Fighting infection in the long-term care facility is evervone's
responsibility. As a nursing assistant, you can do your part by
performing handwashing, universal precautions, isolation
techniques, and all principles of medical asepsis on a routine basis.
Help new employees to aaluirc these skills, and assist residents to
maintain good personal hygiene practices.

Keeping Residents Safe

Each year an estimated 30 to 40% of all nursing home residents fall.
There are several reasons for this:
Changes in vision and hearing that most older people experience,
which cause a loss of warning systems.
Problems with mobility resulting from arthritic changes, loss of
flexibility, and endurance.
Loss of balance related to inner ear changes.
Frequency of urination, leading to fears of incontinence that result in
unsafe toileting habits.
Disorientation and faulty judgment in persons who are mentally
incompetent.
Dizziness that may occur when coming to a standing position too
quickly.
External factors can also increase the risk of falls:
Use of medications that affect mental status, balance, and
coordination.
Unsafe use of assistive mobility devices.
Poorly planned environment.
Staff delay in attending to the needs of residents.


In an effort to reduce the number of falls, the environment can be
altered to meet the needs of elderly persons:
Aging changes in the eye cause older people to be more sensitive
to glare and to changes in lighting. They also have difficulty seeing
colors at the blue-green end of the spectrum. To prevent falls due to
faulty vision:
Use nonglare wax on floors.
Use blinds and curtains to prevent glare from windows.
Place mirrors to prevent glare.
Use nonglare glass in pictures.
Use bright nonglare lighting with constant, even illumination.
Use colors to mark tile edges of steps and curbs that serve as
caution reminders.
Use colors in the red and yellow range that increase residents'
ability to see changes in walls and floors.
Encourage residents to wear sunglasses (if not contraindicated)
and hats when they go outdoors.
Noise increases disorientation and can create anxiety even in alert
persons. This increases the risk of falls. Minimizing all noises
reduces this risk.
All tubs and showers should have chairs so residents can remain
seated throughout the procedure. Lifts for tubs avoid the needs for
the resident to stand in the tub. Avoid using oils that can make the
tub bottom slippery.
Check residents' clothing for fit. Loose shoes and laces, slippers,
long robes, and slacks increase the risk of filling.
Observe ambulatory residents when they get out of bed and chairs,
off the toilet, and when they walk
Give Instructions to residents who have unsafe habits.
Residents who self-propel their wheelchairs need instuctions on
how to enter and leave elevators , how to use ramps, and
reminders to use the brakes.
Dependent residents may benefit by learning self-transfer
techniques. Check with the nurse to see if this is possible.
When you help dependent residents transfer, always use the
method indicated in the care plan.
Side rails are a frequent cause of falls. Many facilities leave side
rails down on one side for residents who can safely transfer without
help. In some situations, half rails are more effective.

Other Safety Concerns
Elderly, people are at risk for other injuries such as accidental
poisoning, choking, thermal injuries, and skin injuries.


Safety in long-term care facilities is a major concern. Unlike hospitals,
residents are given the freedom to move about the facility as they
desire. For this reason, the entire building must be free of hazards that
contribute to accidents. All employees need to be constantly aware of
the residents' safety.

4.3 Recognise and accommodate the older persons interests and life
activities when delivering services.

Exercise And Recreational Needs

Residents in long-term care facilities need the stimulation of planned
recreation and exercise. The type of activity must be carefully tailored to
the needs and abilities of the residents. Health workers in these facilities
are often responsible for coordinating this aspect of care.
Recreation
It is important for those who do the activity planning to keep in mind:
The age and possible physical limitations of the participants.
The fact that older people have less coordination and are more apt
to have hearing and vision deficiencies.
The fact that recreation with a purpose is considered the most
stimulating and enjoyable by mature people.
That activities planned by the participants are generally the most
successful. Shows and skits call for many different talents. Exhibits,
sales, and making gifts for others are some other examples of
activities that combine recreation with purpose. These types of
activities are usually enjoyed by everyone. Most facilities have a
special room where out-of-bed residents can gather.
With care, activities that meet special rehabilitation objectives can be
planned. For that reason, the occupational therapist is a valuable
person who can serve in a consultant capacity, both in care facilities
and recreational centers. Recreational planning can thus combine
physical and rehabilitative activities with enjoyment.
Exercising, singing, and clapping hands to music can be enjoyed by
bed residents, wheelchair residents, and those who are confused
For residents who are ambulatory, dancing can be stimulating as
well as enjoyable.
Handicrafts, games, television, and conversation all offer a measure
of entertainment to the less active.


Figure 14: There are many exercises that people in wheelchairs can
do.

General Hygiene

Cleanliness of the skin is essential, but a full daily bath for the older
person is neither necessary nor advisable. In fact, most elderly are
reluctant to bathe daily. Hygiene also includes care of the hands and
feet, hair, facial hair, mouth, and observations of the eyes, ears, and
nose.

Partial Baths
Although a daily bath is unnecessary, frequent sponging of specific
areas is necessary. The face, groin, underarms, and other body creases
need regular cleaning and care. Use standard precautions when
cleaning the eyes and genital area.
Skin areas that touch must be kept free from perspiration and should
not be allowed to rub together. Whenever moisture, perspiration, urine,
or feces are present, skin breakdown is possible. Gently wash and dry
local areas.
Total Baths
Bed baths clean the skin, but they art a rather passive activity for the
resident. Therefore, a tub or shower bath is desirable two or three times
a week to stimutate the resident.
Hand and Foot Care
As we age, fingernails and toenails become thickened and brittle. They
split frequently because of decreased peripheral circulation. Fingernails
can be cleaned during the morning care period. They should not be
neglected.


A soft brush and blunt-edged orangewood stick will clean the nails
without causing injury.
The hands can be soaked in warm water and the cuticles pushed
back gently with a towel.
Softening creams and olive-oil soaks help to soften the cuticles.
Fingernails should be cut and filed, following the contour of the
fingertips (check your facility policy).
Care should be taken not to injure the corners; improper cutting of
fingernails and toenails is the biggest single cause of infections.
Foot care should also be a routine part of morning care. This should
include:
Careful washing and drying of the foot (Figure 16).
Close inspection for any abnormalities.
Application of olive oil, lanolin, cocoa butter, hand cream, or lotion
to dry, scaly slain.
Application of a very light dusting ofpowder to perspiring feet.
Cutting toenails straight across (check your facility policy).
Thickened nails, which are difficult to cut, or nails of diabetic
residents that need to be cut should always be reported to your
supervisor.
Providing slippers or shoes that fit well and are in good repair.

Guidelines For bathing The Elderly
Some soaps may be drying. Superfatted soaps are less drying and
less irritating.
The skin of an elderly resident is easily damaged and takes a long
time to heal because of inefficient general circulation, so care must
be taken in handling the skin.
Dry the skin by patting gently rather than by rubbing. All contact with
the skin must be gentle. Even pulling a sheet from under a resident
too rapidly can cause trauma.
Lotions should be applied to dry areas to protect them. Bath oils
lubricate the skin, but they are dangerous because they make the
bath tub slippery. It is better to apply lotions directly to dry areas of
skin.
General safety factors and the resident's physical limitations should
be considered before giving a tub or shower bath. Placement of
hand rails, and availability of tub and shower seats or hydraulic lifts
(Figure 15), should be checked. Be sure you know how to use the
hydraulic lift before trying to use one with a resident.
Warm baths may decrease cerebral circulation. This can lead to
confusion. Warm baths may be best just before the resident retires.
Elderly people tend to be sensitive to deodorants, so care should be
used when applying them.


Inspect the resident's skin over bony prominences for signs of skin
breakdown, including redness, warmth, and ischemic pallor.

The skin should be carefully observed for abnormalities and care must
be taken not to disturb them. Any change in color, size, or texture
should be reported immediately. Cancer of the skin, often seen in the
elderly, has an excellent cure rate (93%) when treated early. This is
because skin cancer tends to grow slowly and the cells tend not to
spread. These lesions are usually painless. All skin lesions are suspect.
You must immediately report any changes noted in a resident's skin.

Figure 15: Check Shower Seats and Hydraulic Tub Lifts Before Using
Them.

Figure 16: Foot Care Is An Important Part Of Daily Hygiene.

Note: Check facility policy regarding nail and foot care for diabetic
residents.


Hair Care
Hair changes in amount and color as a person ages. "These changes
are part of the normal aging process. (Greying or loss of pigmentation
(color) is usual. Some greying may be evident as early as the second or
third decade of life.
Genetics probably plays an important role in the change rate. As
more and more pigment is lost, the hair becomes white.
Decreased oil makes the hair dull and lifeless.
The amount of hair may he reduced in both males and females, and
the texture becomes coarser in other areas such as the eyebrows
and face.
Balding is an aging characteristic that first appears at widely varying
ages. Again, genetics has a strong influence.
Hair care is important in maintaining the resident's overall personal
appearance.
Hair should be styled and neatly arranged.
An order is required for a shampoo to be given once or twice a
month.
Dry, shampoos are also available. They simplify shampoos for
residents confined to bed.
A mild conditioning shampoo is best.
A dryer will dry the hair quickly, decreasing the chance of chilling.
The resident must be kept out of drafts while the hair is being washed
and dried.
Shampoos are more safely given in bed; if the person is seated, a
shampoo board can be used. Bending is difficult for older persons and
their decreased sense of balance is apt to result in a fall. Shampoos
may also be given in the tub or shower.
Hair care may be provided by a beautician or bather, if available, or
by a family member or nursing assistant.
Facial Hair
Elderly, women tend to have an increase in the growth and coarseness
of the hair on their chins and upper lips. Thesecan be removed:
with tweezers.
by electric needles used by a professional
by shaving, with a physician's order.
Facial hair may also be lightened by mildly bleaching it. Elderly men
need to be shaved regularly, usually daily. You may need to:
only provide the equipment.
use a safety razor to shave the Client yourself.
assist the person to obtain barbering services.


Mouth Care
The condition of the teeth affects the aged person's total health.
Hygiene routines and observations are your responsibility when an in
individual is no longer able to do these things for himself.
Natural Teeth. Poor oral hygiene can result in loss of appetite and
weight, and may be the focus of any infection. Even if teeth are missing,
the remaining teeth , should be cleaned regularly. Dental checkups
should be done as often as in younger years.
Dentures. False teeth, called dentures, must be cleaned daily
Check the mouth and gums routinely for signs of irritation. Use a
soft brush to clean mouth and gums.
Teeth should be checked and polished during periodic dental
examinations.
Mouth care is especially important for the bed resident who has lost
teeth and is no longer able to keep dentures in the mouth. Check the
mouth and gums for irritation. Dentures should be inspected for cracks,
rough edges, and broken parts.
A commercial mouthwash, a warm wash of saline solution, or
baking soda should he used before and after meals.
Glycerine and lemon, applied with applicators between meals, are
very refreshing.
Lips should be Inspected tier excessive dryness or fissures.
Creams, petroleum jelly, or glycerine applied to the lips can prevent
fissures from developing into deep sores and infections,

Eyes, Ears, and Nose
Eyes, ears and nose should also be observed daily for any signs of
irritation, redness, drainage, or excessive dryness of the skin that could
lead to breaks and fissures. Observations of this nature by staff
members should be part of routine care.

Mental Changes
Mental deterioration is not a normal part of aging. However, as people
age, the risk of mental deterioration increases. Mental deterioration may
stem from physical (organic) or emotional causes. A combination of
both may occur in the residents in your care. Periods of mental
confusion are often temporary. They may be due to unusual stress,
such as an infection; sudden injury, such as a fracture; or transfer to an
unfamiliar environment. In some situations, the changes may signify a
progressive deterioration of mental abilities. The term dementia refers to
any disorder of the brain that causes deficits in thinking, memory, and
judgment.


4.4 Assist the older person to recognise the impact physical changes
associated with ageing may have on their activities of ageing

As people grow old, the likelihood of experiencing age-related losses,
for example loss of personal identity, physical mobility and social
autonomy, increase. Such losses may affect a persons ability to acquire
or maintain the relationships they want, and to maintain their
independence and self-determination in caring for themselves, resulting
in a higher incidence of depression.
Depression is generally recognised as one of the principal mental
disorders afflicting older people. The manifestation of depression in the
elderly, however, calls for our close attention. This is mainly because
there are certain uncertainties about how common it is, and health as
well as welfare professionals and government departments do not fully
recognise the prevalence of depression. The reality is that older people
are faced with a number of medical, social, economic and attitudinal
problems. These are frequently accompanied by events such as
bereavement and loss of independence, accompanied by emotions
such as grief, loneliness, hopelessness, helplessness and
powerlessness. Furthermore, the suppressive effects of society, the
culture of professional practice, and government policies and directives
are added causes of such depression.
The question needs to be asked: Is the depression experienced by
elderly people the result of unavoidable life circumstances? or is it
thrust upon the person by society, by professionals involved in their
care, and by government policies and local procedures which affect
individuals adversely and may restrict their independence and freedom
of mobility?
Investigating the occurrence of depression is important in the care of
older people because feelings of identity and integrity are important for
an elderly person to be able to maintain a healthy lifestyle. There is a
connection between the traditional diagnosis of clinical depression and
the notion of oppression, giving a definition of social depression.
The culture of practise in aged care needs to be reflected upon and
strategies implemented in order to avoid creating social depression. We
need to empathise with this and develop sensitivity to what is occurring.
A rigorous approach needs to be taken towards empathy. Empathy is a
fundamental component of any interaction between professionals and
an elderly person, and will be conducive to a contemporary culture of
care.
Caring is about empathy.
It is not about skill in procedures, which is easier for professionals to
acquire. What is more complex than acquiring skills is the development
of the caring attitude and the personal philosophies that promote
effective professional practice?
You need to reflect on opportunities in your professional practice. It
also gives you an opportunity to decide how much the culture underlying
what you do needs to be changed.


It has been demonstrated that Australia and New Zealands populations
are growing older. This trend is also evident in the Client population in
the health care and welfare sectors. Hospital clients are seen as older
and suffer from more acute illnesses. Elderly people in the community at
large and using social and community support are also perceived by
health care and welfare professionals to be older and suffering from
severe chronic illnesses and severe disabilities.

Growing old presents a variety of threats to independence

Growing old presents a variety of threats to independence. Many older
people are faced with multiple medical and surgical interventions and
with changes in lifestyle. Two common examples of possible stressors
that may handicap older people or limit their options in life are illness
and retirement. The degree of physical and mental illness experienced
by elderly people will determine the level of dependence necessary on
carers, family members and professionals. The older persons
autonomy is thus threatened, and their ability to maintain control over
their general activities and decisions is challenged and seen to be
threatened.
A few elderly people in such situations respond with optimism and
vigour, but most begin to see the future as bleak. Those who have
enough energy, vigour and determination are able to deal effectively
with the stressors, thus achieving a greater degree of emotional and
physical well-being.
54
have suggested several hypotheses to explain the
increased use of passive strategies of coping by these older people.
They state that the current generation of older people does not cope
with problems in ways which are based on orientation to action. They
also assert that there is a developmental hypothesis which suggests
that as people age, events within or outside them result in a more
passive approach to solving problems. In addition, the researchers
claim that the experience of losses and negative stereotyping lead older
people to believe that there are fewer positive outcomes available to
them, so they should not invest too much energy attempting to resolve
their problems.
It can be readily stated that loneliness, helplessness, hopelessness and
powerlessness are common feelings expressed by the elderly and that
these feelings do have a profound effect on both their physical and
psychosocial well being. These are all negative emotions, often
associated with low self-esteem. For example, loneliness can threaten
feelings of personal worth, undermine confidence in interpersonal
relationships and disrupt decision-making abilities and thought
processes.
55

Powerlessness is generally described as a feeling of lack of control over
a current situation or immediate happening, in which ones actions are
not seen as significantly affecting the income.

54
Folkman, S., Lazarus, R.S., Pimley, S. & Novacek, J. 1987 Age differences in stress and coping
processes. Psychology and Aging, vol 2, pp. 171-84.
55
Copel, L.C. 1988, Loneliness, Journal of Psychosocial Nursing, vol 26, no. 1, pp. 14-19.


Hopelessness may be described as a state in which the individual
elderly person sees very limited or no alternatives or personal choices.
It is observed that when people feel hopeless they are passive and
cannot mobilise resources on their own behalf Loneliness can be
defined as the painful awareness that ones social relationships are
deficient, causing one to feel excluded, unloved, constricted and
alienated.
Loneliness is commonly defined as the unpleasant experience that
occurs when a persons network of social relationships is deficient either
qualitatively. Loneliness related to separation from family, friends and
spouses was evident in these narratives.
Social loneliness generally results from the older persons lack of
affiliation and identification with an acceptable family member, friend or
spouse. Their feelings of boredom and aimlessness lead to an anxious
search for company and activities. Emotional loneliness is clearly
evident in all those who have lost their partners or for those who talk
and think about the loss of their partner. Coupled with declining health,
separation from this person and was seen to increase the likelihood of
hopelessness, helplessness and powerlessness.
Hopelessness was found to be closely linked to loneliness. Older people
generally perceived that being without hope for the future believed that
life could not possibly improve. Losses are viewed as being irrevocable,
and their problems as unsolvable. Hopelessness and loneliness can
occur separately, alternately, or consecutively. The occurrence of
hopelessness may precipitate or increase the likelihood of loneliness.
These feelings of grief, loneliness, helplessness and hopelessness can
be related to culture. The organisation of society and the culture within
professional practices, and the values of both, influence the well being
of older people. The relevance of culture to the well being of the older
person must be included.
Australias multicultural society has citizens from all parts of the world,
including its own indigenous Aboriginal culture. Despite Australias
diverse population, the country has largely developed a post-modern
western way of life which includes its attitudes to human rights issues.
As an advanced western society Australia enjoys all of the acquired
benefits of longevity and health. Some might even argue that Australia
exceeds other western cultures by offering a lifestyle to its habitants
which enhances their quality of life. If one is to believe these statements
and the connection they have to longevity and the issues of health, then
Australia is certainly a country where older adults have the opportunity
to live full and complete lives well into their seventies, eighties and
nineties.
This perception of healthy ageing depends on our personal views of
how we live out the later years of our life. Some people believe that
because of healthier lifestyles more people live longer and have fewer
years spent in disability and major illness. Others, however, argue that
with the advance of medical technology people may live longer but may
experience longer periods of chronic illness and disabling conditions.
The third option is that both groups will exist simultaneously, meaning
there will be a group of healthy people living into their advanced years
whilst another group will experience prolonged illness and disability.


What might be considered an example of successful ageing is offered
by Ford and Oliver (1995)
56
. They described the journey of Bill Ford, an
older adult who experienced a stroke which left him with a serious
physical disability. Their paper challenges the negative imaging of
ageing and disability, and instead focuses on personal growth,
challenges and courage. According to Ford and Oliver, neither age nor
disability could diminish Bill Ford. He transcended the negative aspect
of his physical disability by writing to his family and sharing his
experiences, feelings, struggles, and joys through letters and poetry
which have since been complied into a book titled Stroke of Genius.
The importance of socialisation and visiting with family and friends
cannot be overemphasised. For some older adult groups, the strongest
predictors of life satisfaction are their interaction and socialising with
others. Many people participate in leisure activities for the sole purpose
of the social benefits.
For older adults living in rural areas of Australia social interactions with
the local community may very well be the major source of their leisure
activity.
As service providers, we need to maintain an open mind, recognising
the unique characteristics of each individuals life. We have never
walked in their shoes, and therefore we do not know all about who they
are, how they feel, who is closest to them. There are instances where it
may not be a family member, but a close member who is always there
for them. This person fulfills the role of advocate and should not be
overlooked.
Family members have a history, which we cannot possibly begin to
know about. After traumatic childhoods siblings may never have
expected to spend time with their brother or sister with a disability.
Problems occur as the parents age and want to plan for their son or
daughter but who will care for them?

Activity 6
Now that you have considered who your clients are, the different
contexts in which you might be providing care, the standards for that
care and your duty of care, you can look at how you demonstrate an
understanding of the physical and psychosocial aspects of ageing.
Your task is to:
1. outline strategies that the older person may adopt to promote
2. take into account physical changes associated with ageing
when delivering services when developing these strategies
3. recognise and accommodate the older persons interests and
life activities when delivering services in these strategies
4. using these strategies develop an outline to assist the older
person to recognise the impact physical changes associated
with ageing may have on their activities of living.

56
Ford. D. & Oliver. J. 1995, Stroke of Genius, Proceedings of the National Rural Conference on Ageing
Re-writing the Future, ed. C. Saw, Charles Sturt University, Albury, New South Wales.


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5. Apply understanding of changes

5.1
5.2
Take into account physical changes associated with ageing
5.3
Utilise knowledge of common problems associated with
ageing when delivering services
5.4
Assist the older person to recognise the impact that changes
5.5
Communicate situations of risk or potential risk associated
with ageing to the older person

5.1 Outline strategies that the older person may adopt to promote
On a broad level, healthy ageing is an individual, community, public and
private sector approach to ageing that aims to maintain and improve the
physical, emotional and mental wellbeing of older people. It extends
beyond the health and community services sectors as the well-being of
older Australians is affected by many different factors including socio-
economic status, family and broader social interactions, employment,
housing, and transport. Social attitudes and perceptions of ageing can
also strongly influence the wellbeing of older people, whether through
direct discrimination or through negative attitudes and images.
The concept of healthy ageing was first defined by the World Health
Organization. The UN Plan of Action on Ageing, drafted by the 1982
United Nations World Assembly on Ageing, views ageing as a lifelong
process and focuses on improving the wellbeing of people as they age.
The United Nations Plan recognises that health promotion for older
people should aim to promote activities, initiatives and structures, which
enhance wellbeing and health, choice and independence and quality of
life for all ages. Efforts should also focus on the early diagnosis and
minimisation of the complications of lifelong disability and chronic
illness, as well as the prevention of acquired or later onset disabilities.
An important question now is whether the improvement in life
expectancy involves increasing years of healthy living, whether it
involves increases in years of illness, or both?
Not only are people living longer, but they are experiencing different life
circumstances and opportunities to their parents, including, for example,
longer periods in retirement which is often involuntary. Older people are
beginning to realise the potential for more positive experiences of
ageing and people growing older today have rising expectations of
quality of life as well as length of life.


Healthy ageing strategies should be developed with the intention of
achieving, as far as possible, the following outcomes:
Preventing, postponing or reversing adverse health conditions;
Maintenance and/or recovery of function after health problems;
Enhanced quality of life through improved physical and emotional
wellbeing;
Compressing disability to the end of the lifespan;
Minimising incidence of illness through life;
Increasing participation in health maintenance and enhancement
activities by older Australians (active ageing);
Greater contribution by governments, health service providers,
researchers, business and the community in a public health
approach to ageing; and
Sustain the delivery of health services at a fixed percentage of
Gross Domestic Product.
It is important to set realistic goals when considering health promotion
for older people. The definition of health as a positive state of wellbeing
is a useful starting point and this should be linked with peoples self-
perceptions of health rather than setting goals or measuring advances
against arbitrary points. The majority of older Australians living in the
community rate their health as good, very good or excellent (64 per
cent) according to the 1995 National Health Survey. Just over one-third
(36 per cent) reported their health as fair or poor, with people in older
age groups rating their health more poorly than those at younger ages.
57

A survey of Australias war veteran population revealed that 43 per cent
consider there are things they could do to improve their health.
58
Health
promotion strategies can be addressed to any number of groups
including:
Older people who are currently well;
Older people experiencing some illness or disability;
People living in discrete communities eg retirement villages;
Wider population in preparation for healthy ageing;
Wider population including those people with existing disabilities
who are likely to face particular issues in ageing;
Members of various workforces (eg. health, community services,
government, recreation and aged care industries);
Carers of older people; and
Stakeholders and opinion-makers to influence beliefs, attitudes and
behaviours related to ageing and older people.
A goal of healthy ageing is to provide the conditions to allow people to
move in a positive direction to improve their health and wellbeing.

57
Australian Institute of Health and Welfare (1998) Australias Health Cat No AUS 10 Canberra
58
Commonwealth Department of Veterans Affairs (1998) Australian Veterans and War Widows Their
Lives Their Needs Canberra


Healthy ageing is not a competition, it is not about being the best in a
population at some activity or on a scale, and subsequently, it is not
about losing. There is scope for everyone to win through gains in
individual health. Social and productive activities that require less
physical exertion may complement exercise programs and may be
alternative interventions for some older people.
59

It is important to realise that older people are a diverse population
including people who may have:
a history of participation in health enhancing activities eg. sport,
physical activities and social activities;
had minimum involvement in health enhancing activities;
a current interest in undertaking health enhancing activities;
reduced physical capacity;
reduced mental capacity;
long-term disabilities;
age-related disabilities;
a combination of several of these factors; and
varying levels of support and motivation to participate in healthy
ageing activities.
There is evidence that older people prefer and benefit from
intergenerational contact and that age-integrated approaches should be
used wherever possible.
Providing opportunities for people of all ages to participate in strategies
and widening the approach of those that traditionally focus on younger
people may increase the likelihood of participation among older people
and reduce feelings of exclusion.
60

Healthy lifestyles are as influential as genetic factors in helping older
people avoid the deterioration traditionally associated with aging.
People who are physically active, eat a healthy diet, do not use tobacco,
and practice other healthy behaviours reduce their risk for chronic
diseases and have half the rate of disability of those who do not.
Walking, running and swimming should be part of a healthy ageing
lifestyle.
Regular physical activity has been shown to contribute to both
improvements in physical and psychological function including reduction
of depressive symptoms. It contributes to a healthier independent life
style by significantly improving the functional capacity and quality of life
for older people.

59
Glass, Thomas A et al (1999) Population based study of social and productive activities as predictors of survival
among elderly Americans, British Medical Journal 1999: 319: 478-483
60
Howe, A and Donath S (1997) Wellbeing and Outlook on Ageing: A Study of Attitudes of Australians Aged 55 to
75 National Ageing Research Institute


The benefits to older peoples quality of life include:
Fun / enjoyment
Social benefits
Mental health benefits
Physical enhancement
Enjoying the grandchildren
Getting into the bath
Cutting toe nails
Caring skills
Benefits have also been demonstrated in the older frail Client through
gains in muscle strength resulting in improvements in functional aspects
of daily living

5.2 Take into account physical changes associated with ageing when
delivering services.
Understanding the health and physical changes associated with ageing,
and the extent to which they are influenced by social and economic
factors, is important for individuals involved in social policy
development, program planning and administration, and the delivery of
services to an ageing and elderly population.
The demographic revolution and the greying of Australia is complex and
has necessitated a re-categorization of who is old. It is important to
differentiate between the young old, those persons aged (65-74),
those who are old-old, aged (75-84), and older-old, those who are
aged 85 and older. There is general agreement that the needs are
different for each group as are the services to be provided. However,
human ageing is individualized, as it occurs at different rates in different
body systems. Therefore, use of chronological age as an indicator of
health is misleading.
Ageing is neither a disease nor an illness but it does increase an
individuals susceptibility to disease and disability. The ageing process
is characterized by a decrease in the reserve capacity of the bodys
organ systems. This decrease in reserve systems alters the bodys
homeostatic equilibrium, which is essential to a persons functional
capacity. Once this capacity is disturbed, its not easily restored.
Therefore, older adults must be more concerned with healthy lifestyles
for health maintenance.
The rapid growth in the number of older persons challenges both
medical and social science researchers to expand the knowledge of the
physical ageing process as it relates to health promotion and disease
and disability remediation or prevention, and to develop policies that
support social and economic factors that influence healthy ageing.
Understanding the subtleties of physical ageing and health sensitizes
the student to the diversity that exists in working with elders in the
ageing service network.


Activity 9

Can you identify and describe the physical changes that accompany the
ageing process, and can relate these changes to social and economic
factors which influence the health status of older individuals?
1. Describe physical changes in body systems which are
characteristic of the ageing process.
2. Discuss the effect of social and economic factors on elders
health status.
3.
i. Identify two health problems common to the elderly,
ii. Discuss the individual, environmental, institutional, and
societal factors that contribute to their development, and,
iii. Discuss how they limit elders ability to live independently.

4. Analyse individual, familial, community, institutional, and
governmental responses to the two health problems described in
Criterion
5. Present health promotion and health maintenance strategies
which could prevent or limit the incidence and severity of the two
health problems.

5.3 Utilise knowledge of common problems associated with ageing
when delivering services.
While people are living longer they are not always living healthier.
Ageing well is about emotional wellbeing, as well as good mental and
physical function. Socialising and participating in physical activity and
eating healthy foods are good for both your clients emotional and
physical health.
Chronic health conditions, common in older age, can often be related to
lifestyle risk factors, such as lack of physical activity and poor nutrition.
The good news is that lifestyle risk factors can be reduced: all it takes is
commitment and learning new strategies to replace old habits.
Some chronic conditions, such as osteoporosis and incontinence, are
common in older people, so it is important to discuss with your clients
health practitioner ways to improve bone health and bladder function.
For women, regular pelvic floor exercises are important in managing
urinary incontinence.
Preventing and managing osteoporosis requires a lifelong intake of
calcium, a nutritious diet, adequate Vitamin D and an active lifestyle.
Falls are common in older people and can result in broken bones. There
are many ways that people can reduce their risk of falling.
Following are some of the common problems associated with ageing
when delivering services.


Osteoporosis
Important Tips
1. It is never too late to start healthy bone habits, but the earlier in life,
the better for your clients bones.
2. It is important that your client has seen their health practitioner
before starting an exercise program.
3. Exercises that promote balance such as Tai Chi and exercises that
strengthen muscles, such as walking, will help prevent falls.
4. There are plenty of inspirational older people who remain physically
active as they age.
5. As your client ages, they need more calcium as their body becomes
less efficient at absorbing calcium. If you find that your client cannot
get 3-4 serves of dairy products per day. It may be needed to talk to
your clients health practitioner about taking calcium supplements.
6. Vitamin D is required for healthy bones. The main source of vitamin
D comes from the sun. If your client finds it difficult to get outdoors,
vitamin D supplements may need to be discussed with your clients
health practitioner.
7. Healthy eating and an active lifestyle can both help in the prevention
and management of osteoporosis.
Health Issues
Chronic health conditions, common in older age, can often be related to
lifestyle risk factors, such as lack of physical activity and poor nutrition.
The good news is that lifestyle risk factors can be reduced: all it takes is
commitment and learning new strategies to replace old habits.
Being familiar with how your clients body works, what is considered
normal and abnormal, will better help you identify early any potential
health challenges and allow you to take action.

Arthritis
What is it?
Arthritis literally means inflammation of the joint. There are
approximately 150 conditions that can be classified as arthritis. The
most common symptoms are pain, swelling and stiffness in one or more
joints, and fatigue. Three of the most common types of arthritis are
osteoarthritis, rheumatoid arthritis and gout.
Osteoarthritis
Osteoarthritis is the most common type of arthritis. It occurs when a joint
between two bones becomes worn (the cartilage becomes damaged). It
mainly affects women and those over the age of 45, however most
people will have some symptoms with increasing age. It usually occurs
in the fingers and large weight-bearing joints such as the hips,
shoulders, knees, and lower spine and can also occur when a joint has
been previously injured.


Rheumatoid Arthritis
Rheumatoid arthritis causes inflammation around joints and other
organs of the body and occurs when the bodys immune system attacks
its own tissues. When this happens, the tissue surrounding a joint (the
synovial membrane) becomes thickened and inflamed. This causes the
body to produce larger than normal amounts of fluid in the joints
(synovial fluid) which leads to swelling, pain and stiffness. Rheumatoid
arthritis is most common between the ages of 25 to 50 and women are
three times as likely as men to develop it.
Gout
Gout occurs when there are increased levels of uric acid in the blood
which the body cannot excrete, causing tiny crystals of uric acid to
crystallise in the joints. This causes irritation, pain and tissue
inflammation. It usually affects one joint at a time, commonly beginning
with the joint of the big toe; although it can go on to affect the ankles,
knees and hands. It is more common in men, particularly between the
ages of 40 to 50. If women develop gout it tends to be after menopause.
Management of arthritic conditions
There are many treatments available for arthritis which can help to ease
pain, maintain flexibility and slow further development. Treatments may
include:
Physical activity and exercise
Physical therapies (e.g. physiotherapy or occupational therapy)
Medicines (prescription, non-prescription or complementary
therapies)
Healthy eating
Relaxation or meditation (pain management strategies)
Resources
Arthritis Australia - www.arthritisaustralia.com.au
Arthritis Victoria - www.arthritisvic.org.au
Bone health for life - www.bonehealthforlife.org.au
Living with arthritis: The Complete Self-care Guide By Dr David
Hunter


Bladder and bowel
In Australia over three million women experience urinary incontinence.
Any woman who has ever gone through pregnancy and childbirth, or
menopause, will know that the effects on self esteem, body image and
morale, sexuality and overall quality of life can be devastating.
Doing regular pelvic floor exercises every day can reduce the risk of
incontinence by strengthening your clients pelvic floor muscles to help
support your clients bladder and bowel. This will help improve bladder
control and can reduce or stop leakage. Regular gentle exercise, such
as walking is also important.
About the pelvic floor
The pelvic floor is a very important muscle - and it's one that doesn't
gets talked about, or exercised, enough. Pelvic floor muscles are the
layer of muscles spanning underneath the pelvis.
Along with abdominal and back muscles, the pelvic floor helps to
stabilise and support the spine, digestive system, pelvic and
reproductive organs (including bladder, bowel and uterus) and it plays
an important role in preventing incontinence and supporting the pelvic
organs.
Risk factors for pelvic floor weakening
Pregnancy and childbirth, particularly for multiple, large birth weight
(over 4kg) or instrument-assisted births, or where there has been
severe perineal tearing or long labours
Straining or constipation
Chronic coughing, including asthma, bronchitis or smoker's cough
Heavy lifting, such as at work or during gym training
Being overweight or obese
Lower levels of oestrogen after menopause or when breastfeeding
Pelvic or abdominal surgery
Benefits
Improved control over bladder and bowel function
Reduced risk of prolapse (sagging of internal organs)
Better recovery from childbirth and surgery
Increased sexual sensation
Increased social confidence and quality of life
Resources
Urinary incontinence: busting the myths
(www.jeanhailes.org.au/content/view/413/546/)
Incontinence: The Hidden Epidemic (Womens Weekly Series)
Womens Waterworks: Curing Incontinence By Dr Pauline Chiarelli


Breast Cancer
What is Breast Cancer?
Breast cancer is an abnormal growth of cells which, in the breast, starts
in the milk ducts. It may grow into surrounding tissues and spread
ultimately to other organs of the body.

Figure 17: Diagram of breast

Breast cancer is the most common cause of cancer deaths in Australian
women. However, whilst we should be responsible about looking after
our breast health, it is important to remember that many more women
die of heart disease and stroke in Australia than they do of breast
cancer.
Who is most at risk of developing breast cancer?
All women over 50 years of age
Women who have had a previous breast cancer
Women with a family history (mother, daughter or sister) of breast
cancer

EARLY DIAGNOSIS is the key to successful treatment.
FACT - 9 out of 10 breast lumps are not cancer.
75% of breast cancers occur in women over 50
Men have less than 1% of breast cancers


Mammography
For women 50-69 years
As breast cancer is most common in women over 50, BreastScreen
offers free screening mammography to women over this age. It is
recommended that your client has a mammogram every two years. This
is the age group in which the benefit of screening mammography has
been shown to be the greatest. Reminders are sent to this age group.
For women 70 years or older
BreastScreen Australia offers free screening mammograms every two
years for women aged 70 years and older. Whether your client attend
will depend on your clients general health, whether your client has any
other diseases or conditions, and your clients personal preference.
Breast cancer survival
Over the last 10 years the number of breast cancers survivors has
increased due to early diagnosis and better treatment. Australia has one
of the lowest death rates from breast cancer.
Further resources
BreastScreen Australia
National Breast and Ovarian Cancer Centre
Breast Cancer Network Australia
Cancer Council Australia
Cancer Prevention: Reducing the Risk (Womens Weekly Series)

Cholesterol
What is cholesterol?
Cholesterol is a fatty substance produced naturally by the body and is
found in our blood. It is essential for the function of every cell in the
human body but is a problem when there is too much of it in the blood.
About two thirds of the cholesterol in our blood is made by the liver.
Much of it also comes from foods, especially those high in saturated
fats.
What is high density lipoprotein (HDL) and low density lipoprotein
(LDL) cholesterol?
Cholesterol appears in the blood in different forms. LDL cholesterol is
known as bad cholesterol as it tends to clog blood vessels. When a
blood cholesterol reading is high it is usually because LDL levels are
high. HDL cholesterol is sometimes called good cholesterol and can
actually help unclog the arteries. High HDL levels can be a good sign as
long as the LDL levels are not high as well.


What are triglycerides?
When we eat fats in food they form triglycerides that are absorbed into
the blood and either burned for energy or deposited into the bodys fat
stores. High levels of triglycerides often go together with low levels of
good (HDL) cholesterol or high levels of bad (LDL) cholesterols.
Why is high cholesterol a problem?
A certain amount of cholesterol is necessary for the normal functioning
of your body, but too much of it is dangerous, especially for your heart.
A slow build up of cholesterol in the inner linings of the hearts arteries is
one of the main underlying causes of heart disease. Bad cholesterol can
build up in arteries, narrowing them and making it harder for blood to
flow through. Narrow arteries can become clogged, stopping the flow of
blood completely. Clogged arteries may result in a lack of oxygen to the
heart (a heart attack) or the brain (a stroke).
High blood cholesterol is one of the three main risk factors for heart
disease. The other two risk factors are cigarette smoking and high blood
pressure.
Do cholesterol and triglyceride levels vary?
Yes. Cholesterol levels tend to rise and fall from week to week. Two or
three blood cholesterol readings may be needed to give an idea of your
clients true level. Triglycerides go up and down after each meal.
Does menopause affect your clients cholesterol?
Yes. Blood cholesterol tends to rise after menopause. Women on
hormone therapy may find that their blood cholesterol drops.
What foods contain high levels of cholesterol?
Any food that is high in saturated fats contains high levels of cholesterol.
How can you reduce your clients cholesterol?
Reducing your clients cholesterol to a target level can help reduce your
clients risk of heart disease. Lowering bad cholesterol can stop, and in
some people, even reverse the damage already done.
Eat a healthy diet
Maintain a healthy weight
Take part in physical activity most days of the week
Stop smoking
Keep your clients blood pressure at a normal level


Incontinence
What is Incontinence?
Many women report symptoms of both urge and stress incontinence.
Incontinence is leakage of urine when it is not meant to happen. It is
caused by loss of bladder control and it can occur at any time.
This common and distressing condition affects about one million people
in Australia. It affects men and women of all ages but it is most common
in women and older people.
Incontinence can often be cured and even where this is not possible,
there is much that can be done to improve it - no matter what your
clients age. Many people, however, are too embarrassed to ask for
help.
If your client has a problem with incontinence, seek management of the
problem as soon as possible. Modern treatments are very successful
and, for many people, simple exercises and bladder training programs
can help considerably. But if the problem is left untreated, it may be
more difficult to treat successfully later on.
Types of Incontinence
The most common types of incontinence are:
Urge Incontinence: The bladder muscle contracts without warning
and, if the bladder is partly full, this forces urine to leak out. When it
happens, the person often feels that they have "got to go", but it can
be difficult to reach the toilet in time.
Stress Incontinence: This can be likened to a 'leaky tap'. It is
caused by weakness in the urethral valve (the valve that controls
urine flow) and/or weakness in the muscles that surround and
support this valve, including the pelvic floor muscles. Urine leaks
when the person exerts themself; for instance, when sneezing,
coughing, laughing or jumping.
Overflow Incontinence: Occurs when the bladder fails to empty
properly, becomes over-full, and then tends to dribble or leak. It may
be caused by poor contraction in the bladder muscle, or by certain
neurological or medical conditions. It can be worsened by chronic
constipation.
Continuous Incontinence: May be due to a fistula (a hole or
abnormal passage between the bladder and vagina). The client
experiences continuous leakage of urine.
Frequency: Is the need to pass urine very often, day and night. It
can be associated with various types of incontinence, but it can also
happen without incontinence.
Causes of Incontinence and Urinary Problems
As women age, their pelvic floor muscles - the 'sling' of muscles that
support the bladder, bowel and uterus - stretch and weaken. A number
of factors may contribute to this weakening, including the long-term
effect of pregnancy and childbirth, being overweight, chronic
constipation, chronic cough, frequent lifting of heavy objects and


changes in hormone levels after menopause - specifically, a lack of
oestrogen.
Inflammation of the bladder - known as 'cystitis' - can cause pain when
your client passes urine. Cystitis may be caused by an infection, or by
other problems, and it needs medical treatment. Your client can help to
prevent it by drinking plenty of water and including cranberry juice
regularly in their diet.
Loss of oestrogen after menopause can cause cystitis-like symptoms,
especially night time frequency.
'Cystocoele' is a stretching and weakening of the wall between the
bladder and vagina. It can cause symptoms like frequency or
incomplete bladder emptying, and your female client may feel she has a
lump in her vagina.
Some women find they go to the toilet very frequently simply to try to
avoid the chance of leakage

Diabetes
Type 2 Diabetes explained
Diabetes is a condition in which there is too much glucose (a type of
sugar) in the blood. This happens because the bodys method of
converting glucose into energy is not working as it should. Blood
glucose levels are controlled by a hormone called insulin.
Type 1 diabetes (formerly called Insulin Dependent Diabetes
Mellitus or Juvenile Onset Diabetes), occurs when the body does
not make enough insulin. It usually affects people under 30 years of
age, but can occur at any age. Type 1 diabetes affects
approximately 10 -15 per cent of people with diabetes.
Type 2 diabetes (formerly called Non Insulin Dependent Diabetes
Mellitus or Mature Age Onset Diabetes), usually occurs in people
who are over the age of 50 years and have a family history of
diabetes. Being overweight and inactive also increases your risk. In
people with Type 2 diabetes (85 - 90 per cent of all diabetes) the
body does not use insulin properly, does not produce enough insulin
or both.
Gestational diabetes develops during pregnancy and usually disappears
after the birth of the baby. Women who have had gestational diabetes
are at much greater risk of developing Type 2 diabetes and these
women should be tested every year for diabetes.
Pre-diabetes (sometimes called impaired glucose tolerance, or impaired
fasting glucose) is where blood glucose levels are higher than normal,
but not at the level of diabetes. People with pre-diabetes are at
increased risk of developing Type 2 diabetes and are at increased risk
of heart disease.
Polycystic ovary syndrome (PCOS) is a common condition in women
that increases the risk of diabetes and potentially heart disease in
women.


Potential risk of developing Type 2 diabetes
People who:
Are over 45 years of age and have high blood pressure, are
overweight or have a family member with diabetes
Are over 55 years of age
Have heart disease or had a heart attack
Have/had gestational diabetes
Have pre-diabetes
Have Polycystic Ovarian Syndrome
Are over 35 years of age and are an Aboriginal or Torres Strait
Islander or are from Pacific Islands, Indian subcontinent or Chinese
cultural background.
Signs and symptoms of Type 2 diabetes
Increased thirst
Slow healing of cuts
Frequent urination
Itching, skin infections
Feeling tired and lethargic
Blurred vision
Constant hunger
Unexplained weight loss
With lifestyle changes, people who are at risk for diabetes or pre-
diabetes may reduce their chances of developing type 2 diabetes and
its associated complications.
Diabetes, Midlife and Menopause
The risk of developing pre-diabetes, diabetes and heart disease
increases significantly at midlife and beyond. As we age, weight gain is
common. Weight gain, particularly concentrated around the abdomen, is
associated with a greater risk of developing Type 2 diabetes.
Cardiovascular disease is the leading cause of death in
postmenopausal women. Diabetes significantly increases the risk of
developing cardiovascular disease.
Complications of diabetes
Diabetes related complications include damage to the blood vessels
and nerves that often cause problems to the eyes, kidneys, heart and
feet. However, the risk of developing such complications can be
minimised by:
Managing blood glucose levels
Managing cholesterol and triglycerides (blood fats)
Not smoking


Managing high blood pressure
Appropriate foot care
Regular medical reviews to check the backs of eyes, blood
pressure, kidney and nerve function
Making Sensible Lifestyle Changes
Almost one in four Australians aged 25 years and over has either
diabetes or pre-diabetes. A healthy lifestyle reduces the risk of
developing Type 2 diabetes and forms the cornerstone of management
once a person has been diagnosed with diabetes.
Healthy Eating
Healthy eating is the basis of managing and preventing diabetes. The
Dietary Guidelines for Australian Adults (2003) recommends:
1. Enjoy a wide variety of nutritious foods by eating plenty of
vegetables, legumes, fruit and wholegrain cereals. It is important to
also include lean meat, fish, poultry and/or alternatives. Reduced fat
dairy products are preferred and water is the best fluid option.
2. Take care to limit saturated fat and moderate total fat intake, choose
foods low in salt and limit alcohol if you choose to drink. Only
moderate amounts of sugars and foods containing added sugars are
recommended.
3. Prevent weight gain by being physically active and eating according
to your energy needs.
4. Care for your food through preparing and storing it safely.
Be active
Everyone can benefit from regular physical activity. The National
Physical Activity Guidelines for Australians recommend a minimum of
30 minutes of moderate activity on most days of the week, plus being as
active throughout your day as possible.
Think of movement as an opportunity, not an inconvenience.
Be active every day in as many ways as you can.
Put together at least 30 minutes of moderate intensity physical
activity on most, preferably all, days.
If you can, also enjoy some regular, vigorous exercise for extra
health and fitness.
Recent research has shown that even the most inactive or sedentary
people can gain health benefits if they become even slightly more
active.
Small increases in daily activity can come from little changes carried out
throughout the day.
It is important to remember that some activity is better than none, and
more is better than a little.


Choose an activity that your client will enjoy doing and one that will fit
into their daily routine. Your client can exercise with a friend or a group
or on their own.
Over time, regular exercise actually will increase your clients energy
levels and improves their ability to sleep.
If your client has diabetes their doctor should be consulted before
starting a physical activity plan.
Medical treatment
A variety of medications including tablets and insulin, are available to
treat diabetes.

Heart Disease
What is heart (cardiovascular) disease?
Cardiovascular disease affects either the heart or major blood vessels
(arteries) supplying the heart, the brain and other parts of the body. It is
the number one killer of both men and women in Australia.
What causes heart disease?
From early in life, fatty cholesterol deposits called plaque gradually build
up on the walls of arteries. Over time this causes a narrowing of the
arteries, resulting in reduced blood flow to the heart and other vital
organs. These cholesterol plaques can rupture at any time and cause
blood clots to form in the blood vessels which block the artery. This
blockage of blood supply can lead to chest pain (angina), heart attacks
and stroke.
What is a heart attack?
When an artery to the heart becomes completely blocked, an area of
heart muscle is starved of oxygen and consequently dies.
Symptoms of a heart attack
Symptoms include lasting, severe, central chest pain and sometimes
pain spreading down the left arm or into the jaw. Anyone experiencing
this should go to hospital immediately, or call an ambulance, as early
treatment for heart attack can save your life. Even mild chest pain,
breathlessness or bouts of unexplained indigestion should be discussed
with your health practitioner to ensure that these symptoms are not
indicating underlying heart disease.


What is a stroke?
A stroke is the blockage or rupture of a blood vessel in the brain,
causing damage to surrounding brain tissue.
Symptoms of a stroke
Stroke symptoms depend on which area of the brain has been affected,
and can include severe headache, dizziness and confused speech. A
stroke often occurs without warning, and weakness or paralysis down
one side of the body, loss of speech, loss of swallowing reflex and
sometimes unconsciousness may result. Hospital or ambulance
treatment is urgently required.
What are the major risk factors for cardiovascular disease?
High blood pressure
Elevated blood cholesterol
Family history (if the relative was under the age of 65 years when
the cardiovascular disease developed)
Cigarette smoking
Diabetes
Excess body weight, especially when abdominal fat is increased
Lack of exercise
High blood pressure
Blood pressure is classically provided as two values, the systolic or
upper level and the diastolic or lower level. Put simply, when the heart
pumps, roughly every second it momentarily increases the pressure in
the blood vessels (the higher systolic pressure). Then in the brief pause
between the heart beats the pressure falls again (the lower diastolic
pressure). Ideally blood pressure should be 130/80 or below most of the
time. Blood pressure does fluctuate, but consistent higher levels can
damage artery walls and the heart itself, increasing the risk of
cardiovascular disease, especially stroke. Apart from family history, risk
factors can be improved by healthy nutrition and lifestyle. Have your
blood pressure checked regularly.
Elevated blood cholesterol
Cholesterol is the term used to describe the small particles that the
human body uses to carry fats around in the bloodstream. Our diet
contains cholesterol in animal products however we also make
cholesterol from fat. The amount of cholesterol in our blood is not only
determined by our diet (primarily our fat intake), but also by our family
history via genetic influences.
There are several types of cholesterol. The low density cholesterol
(LDL) has been labelled the 'bad' type as it tends to deposit cholesterol
in unwanted areas, chiefly in the wall of the blood vessel leading to
cholesterol plaques. The high density cholesterol (HDL) labelled the
'good' type, tends to carry cholesterol away from the blood vessel walls
back to the liver for processing. The balance of these cholesterol types,
as well as the total cholesterol level in the blood, is important.


So all people even those with healthy diets and low body weight
need to have their levels checked regularly.
What are the symptoms of high blood pressure and elevated
cholesterol?
Often none. This is why it is so important that all adults over the age of
40 have blood pressure checks at least once a year and cholesterol
checks as appropriate after discussion with your clients doctor. If your
clients blood pressure or cholesterol is elevated, then appropriate
treatment is necessary to ensure the normal levels are maintained.
Treatment of both these risk factors substantially reduces the risk of
heart attack and stroke.
Factors that can influence high blood pressure
Family history (if the relative was under the age of 65 when the
cardiovascular disease developed)
Cigarette smoking
Diabetes
Excess body weight, especially when abdominal fat is increased
Lack of exercise

What can you do to reduce your clients risk?
Get them to enjoy a wide variety of healthy foods
Limit animal (saturated) fats as much as possible, e.g. choose lean
cuts of meat, trim off excess fat, grill rather than fry
A little fat is okay - use mono unsaturated fats, e.g. olive oil for salad
dressing and cooking
Choose calcium-rich, low-fat dairy products
Include phytoestrogen foods like soy products, legumes (chick peas,
lentils, red kidney beans, etc.), rice, grains, nuts and alfalfa regularly
in your clients diet
Eat fish high in omega-3 fatty acids twice a week
Reduce your clients salt intake
Maintain a healthy body weight
Avoid them smoking
Exercise regularly aim for 30-40 minutes of physical activity at
least three times a week
Use relaxation techniques to reduce stress
Discuss medications for high blood pressure and high cholesterol
with your clients health practitioner


What about supplements?
It is important to note that although ongoing studies with combinations
of phytoestrogens, antioxidants and micronutrients are awaited with
interest, there is insufficient data to recommend the consumption of
isolated supplements for prevention of cardiovascular disease. In
contrast, the consumption of diverse and balanced diets, which are rich
in foods containing many nutrients, including antioxidants and
phytoestrogens, can be safely recommended.
What about medications?
The treatment of high cholesterol and high blood pressure may require
the addition of medications. These medications are introduced if lifestyle
measures are not sufficient or levels are especially high. Treatments
with blood pressure and cholesterol lowering medications have proved
extremely effective in reducing all cardiovascular disease in high risk
individuals but they need to be taken consistently.
Does hormone therapy (HT) have effects on cardiovascular disease?
Women taking HT (also known as hormone replacement therapy
HRT) appear to have a lower risk of heart disease, but there may be
many reasons for this. HT, in tablet form, reduces cholesterol as well as
having favourable effects on the blood-vessel wall. However, it also
increases the risk of blood clots forming when blood-vessel plaques
rupture. Currently HT should be avoided in women with established
heart disease.

Irritable bowel syndrome (IBS)
Irritable bowel syndrome (IBS) is a condition which affects the digestive
system. IBS is more common in women than men and symptoms often
first begin in the late teens to early twenties. It is unusual for someone
over the age of 40 to experience symptoms of IBS for the first time.
Types of irritable bowel syndrome
There are three main types of IBS:
Constipation predominant
Diarrhoea predominant
Alternating constipation and diarrhoea
Symptoms
Symptoms of IBS may include:
Abdominal pain or cramping
Constipation or diarrhoea (or alternating between both)
Bloating
Abnormal bowel habits
A sensation following a bowel movement that the bowels have not
been fully emptied


Mucus in stools
Nausea
It is important to note that none of these symptoms are exclusive to IBS.
If you suspect that your client has IBS you should seek medical advice
to ensure that your clients symptoms arent in fact the result of other
conditions such as coeliac disease, lactose intolerance, bowel infection,
or other bowel disease.
There is no specific test for IBS instead, other tests are performed to
exclude similar conditions.
What causes irritable bowel syndrome?
The exact cause of IBS remains unknown; however certain factors have
been identified as being likely to trigger attacks in susceptible people.
These can include food intolerance, infection, diet, stress and certain
medications.
Treatment
Unfortunately there is no cure for IBS; however symptoms can be
managed and controlled. Identifying what triggers your clients
symptoms is an important place to start.
Treatments may include:
Increasing fibre intake
Making changes to your clients diet (e.g. avoiding trigger foods,
maintaining a healthy and balanced diet, increasing water intake)
Pain relief medications
Medications/treatments to treat diarrhoea and/or constipation
Stress management
Seeing a dietitian
Resources
Better Health Channel - http://www.betterhealth.vic.gov.au/
The Gastroenterological Society of Australia (GESA) -
http://www.gesa.org.au/
Dietitians Association of Australia (DAA) website -
http://www.daa.asn.au/


Activity 10
There are many common problems associated with ageing when
delivering services. A large amount of these problems are discussed in
the community via way of news reports, seminars, online discussions,
blogs, etc. You are to choose a common problem and develop a simple
strategy to deliver care for this problem to a client. Discuss with your
group why you chose this problem and then deliver a 10 15 minute
presentation of your choice.

5.4 Assist the older person to recognise the impact that changes

Long-term care is an increasingly important and rapidly changing
component of today's health care delivery system. Four out of every ten
people turning age 65 will use a nursing home at some point in their
lives, and many will need home care and other related services as well.
As the population ages, the need for these services will continue to
grow, particularly for women. Long-term care services are essential to
many younger populations as wellchildren with disabilities, people
with mental health problems, people with Alzheimer's disease, people
with acquired immunodeficiency syndrome (AIDS), and others.
We need to understand how best to improve and integrate preventive,
acute, chronic, rehabilitative, and long-term care for the purpose of
reducing illness burden and improving health-related quality of life of our
clients. It goes without saying that it will also assist the older person in
recognising the impact that changes associated with ageing may have
on their activities of living.
To progress in this area will require specific attention to the following
components of care.

Prevention.
Preventive interventions are an integral component of promoting healthy
aging, but important gaps remain in our knowledge about the efficacy,
appropriateness, and cost-effectiveness of specific preventive strategies
in older people. Specific attention needs to be paid to the following
issues that affect older people:
Appropriateness of outcome measures used.
Effects of comorbidity, competing risk, advanced age, and individual
utilities on optimal screening strategies.
Efficacy of behavioural interventions to reduce risk.
We also need to find ways to improve efficiency and reduce the risks of
preventive interventions in older clients.


Chronic care.
Eighty-five percent of people age 65 and older report at least one
chronic condition; more than half report at least two; and more than a
quarter report three or more. We need to concentrate on the outcomes
and effectiveness (including cost-effectiveness) of clinical and
organisational interventions that prevent morbidity from these
conditions. There is a need to develop and use working models of
collaborative care for chronic illness between doctors and clients, as
well as to assess the effectiveness of these models.

Comorbidity.
Much research on the elderly has been disease or symptom specific.
You now need to understand the impact of comorbidity. While significant
progress has been made in the clinical management of common chronic
diseases, much less is known about the impact of comorbidity
including both physical and mental health comorbidities on disease
management and clinical outcomes. Competing risks from multiple
conditions in an individual will influence client and physician decision
making processes. Comorbidity must also be considered in quality
measurement and quality improvement efforts.

Long-term care.
Gaps in knowledge for this population include clinical issues and
organisational concerns. Information is needed on how to prevent
institutionalisation, and on cost-effective models of community-based
long-term care. Because long-term care creates a large burden on the
family, improving the effectiveness of informal care, as well as relieving
caregiver burden is needed. Health status measures in long-term care,
especially measures that are adapted for the cognitively impaired,
quality measures for long-term care settings, and health-related quality
of life (HRQOL) measures are also needed to improve.

Best practices across settings of care.
We need to learn how to coordinate the delivery of care across multiple
sites and settings of care, including outpatient, hospital, rehabilitation,
subacute care, home care, long-term care (institutional and community
care), and community-based social services. The standards of
rehabilitation, home care, subacute care and the policies and
procedures of your organisation can inform you of how to care for your
client in your situation

Client decision making.
Older people face many complex choices, such as treatment and
insurance, about their health care. You need to determine how to best
insure that clients are informed and are active participants in the
decision making process. One needs to focus on improving client
communication and interpersonal quality of care.


Enhancing Client safety.
Unique issues need to be addressed in order to enhance safety for
elderly clients. Their unique constellation of comorbidity, use of multiple
sites and settings of care, and polypharmacywithin the context of a
higher prevalence of functional impairments, including cognitive
impairmentplaces the elderly at increased risk for medical errors. This
risk is compounded by the lack of awareness among many providers
about general principles of geriatric management.

5.5 Communicate situations of risk or potential risk associated with
ageing to the older person.

The medical achievements in the past few decades are such that
Australians are living longer and healthier than ever before. Australian
life expectancy is amongst the highest in the world. Its important to
acknowledge this and to support the innovative work thats allowed it to
happen.
The international evidence suggests that health will continue to improve,
but that certain causes of disability will become more prominent.
Chronic diseases such as diabetes and heart disease are common in
the older population. Older clients should be empowered to manage
their own health problems, with assistance from their GP, through the
development, funding and implementation of self-management
programs.
The provision of oral health care is critical to the general health of older
Australians because of its impact on nutrition. There remains an
inadequate recognition of the importance of oral health for older people.
Where a worker is aware that an older person may be placing
themselves at risk or is in a position of imminent danger, that worker
has a duty of care to act to minimise harm or injury.
The aged care worker cannot be expected to be able to predict when
and where someone will get hurt. When determining whether injury is
likely, you must rely on:
what you already know about the older persons capabilities to carry
out similar tasks
what you know about the persons awareness of the risks involved
and how to avoid the same risks
how well-equipped the person is to deal with the risks as they arise
what you can learn from relevant assessments or reports regarding
the person and their ability to manage the task
fact and not on rumour; there should be no assumptions made
without checking all the facts as to what can or cannot be done.
Ultimately, you must use knowledge and skills to assess the degree to
which injury to an older person is foreseeable. In determining what
precautions should be taken to minimise risk and possible harm it is
advisable to consider what precautions the general community would
think reasonable.


When deciding on precautions, or a line of action, make sure you guard
against letting your own values intrude on the situation. People are
entitled to make their own decisions. What you think of as being a risk
may not be seen as such by an older person in your care.
For example some older people would consider horse-riding a risky
pastime, while others would consider this to be a reasonably safe past-
time given the right precautions. People have the right to choose
activities they wish to be involved in.
In establishing reasonable precautions the aged care worker must be
alert to the fact that the rights of older people should not be diminished.
If a right is encroached upon, the worker must look for the solution that
upholds duty of care but lessens the interference with the rights of the
consumer.
Consider this: it is illegal to lock the doors of a hostel for people with
disabilities. But what if there are people in the hostel who are known to
wander aimlessly? There are several busy roads in the immediate area.
If the door is not locked and a person does leave and becomes
seriously injured has there been a breach of duty of care?
In such situations we must consider what is reasonable and we must
always look for the course of action which involves the least possible
restriction on peoples rights. It is never reasonable, in protecting people
from injury or harm, to restrict people or to violate their rights or
freedoms any more than is necessary in the circumstances.
Ask Yourself
Would failure on my part to take care be likely to lead to some sort
of injury or damage to the person?
What would be reasonable to do in this situation?
Am I choosing the course of action that will place the least
restriction on the consumer?
Older people and risk
Consider how you would respond if an older person you are providing
support to is engaging in behaviour you believe to be dangerous or
risky.
who would you seek guidance from?
how would you approach the older person concerned?
When do you report unusual behaviour that has been observed. There
are a number of risk factors to be aware of when dealing with an aged
person:
a medical disorder e.g. epilepsy
an aged related disease e.g. dementia
anxiety from conflict
past or current substance abuse
grieving or distress
high levels of frustration or stress.


Many of these factors may be confidential. Some aspects of an aged
care persons history may only be released on a need-to-know basis.
This means some facts may be private. However, there may be
behavioural changes that relate to a known condition.
Report any changes in behaviour that concern you to your supervisor. If
the behavioural changes are slight, you may consider:
naming the problems, writing a brief note e.g. Mrs. R. appeared
disoriented today, she did not seem herself.
look for possible causes
think about possible solutions
report to your supervisor.
It is important not to act in isolation. A team approach ensures
appropriate decisions are made. Other family members may need to be
involved. Inappropriate behaviour may have a reasonable explanation. It
may also need to be looked at with the knowledge of past events. If
immediate action is required to safeguard the older person, be sure to
document and report your actions as soon as possible.

Confidentiality
Sometimes as an aged care worker, you may be required to make a
report to a supervisor about a clients change in behaviour. Talking
about a client can involve discussing confidential information. You may
be doing this to protect the consumer or others from injury.
In these cases the onus is on you to justify the need to break
confidentiality. As with all other aspects of duty of care the issue
becomes doing what is reasonable to protect the consumer and others
from injury.
It is also your responsibility to select a professionally appropriate forum
to discuss a client and his/her care.
If you have a regular meeting with your supervisor or a time that your
supervisor sets aside for consultations, use this time. Do not resort to
informal chats in passageways or in the staff room over lunch.


6. Support the rights and interests
of older person

6.1
Encourage and support the older person and/or their
advocate/s to be aware of their rights and responsibilities
6.2
Conduct work that demonstrates a commitment to access and
equity principles
6.3
Adopt strategies to empower the older person and/or their
advocate/s in regard to their service requirements
6.4
Provide information to the older person and/or their
advocate/s to facilitate choice in their decision making
6.5
Recognise and report to an appropriate person when an older
persons rights are not being upheld

6.6
Provide services regardless of diversity of race or cultural,
spiritual, or sexual preferences

6.7
Provide information to the older person and/or their
advocate/s regarding mechanisms for lodging complaints

6.1 Encourage and support the older person and/or their advocate/s to
be aware of their rights and responsibilities

Traditional meaning
Advocacy means different things to different people. Its plain English
meaning is that advocacy is supporting another persons cause. This
idea of people representing others has gathered strength in the last 20
years, particularly in disability areas. It has been thought that sometimes
people benefit from having others speak out on their behalf.
Consumers of health services and carers associated with health
services have strong cause to participate in decisions about the
services and to ensure that their views about a range of related issues
are expressed and heard. Sometimes, perhaps when a consumer or
carer is particularly vulnerable, it is useful to have someone to speak on
behalf of the person.
Advocacy in an aged care context means that the worker acts for and
on behalf of the client. To act as an advocate for a client the worker
must ensure that the client is provided with adequate and accurate
information relating to their care, and must support the client in any
informed decisions they make about their care. In this way the worker
meets the ethnical requirements of honouring a clients right to self-
determination. Ethnics in aged care involve respecting a clients right to:
be informed
Make decisions and choices
Confidentially


Privacy and dignity
Hold their own cultural and religious beliefs
All the workers in the aged care sector have a responsibility to ensure
that, in relation to aged care practices, the client is assured of safe and
competent care and that their rights will be protected.
It is worth noting that advocacy isnt confined to the relationship
between aged care workers and their clients. You will find advocacy
being applied in a myriad of different workplaces and environments and
therefore it takes on many different forms. Within the scope of this unit
of competency advocacy means supporting clients to voice their
opinions or need and to ensure their rights are upheld, and may
include:
Assisting clients to identify their own needs and rights
Meeting clients needs in the context of organisational requirements
Supporting clients to ensure their rights are upheld
Awareness of potential conflicts between clients needs and
organisational requirements.
Providing accurate information
There are many ways of undertaking advocacy. Consumers and carers
can influence how services are provided to them on a day-to-day basis
and can look for ways to have their views heard by health professionals.
They may participate in the training of health professionals. Some
people will be involved in influencing the structure or policies of their
local service and so may gain a place on a planning committee or a
committee of management or participate in service evaluation. Others
will see benefit in trying to influence State/Territory or national structures
and gain membership on committees or working parties at this level.
How is advocacy undertaken?
Advocacy, in the first instance, is something that individuals undertake
according to their own requirements and expectations. Each person will
have a different personal purpose for engaging in advocacy and his or
her actions will reflect this. Some will want to act at a local personal
level, others at a higher level of influence on matters of national
importance.
No matter how small or personal, every advocacy action is valid and
important.
Increasingly, consumers and some carers are finding opportunities to be
employed as paid consultants and to more consistently participate in
service design and organisation. Some consumer and carer
organisations have moved into direct service provision as a way of
ensuring that particular needs are adequately met. Some people see
community issues as being a particular problem and choose to engage
in community education and community development and radical action.
All people feel particularly vulnerable at times and unable to adequately
express their needs and requirements. Some may want another person
to advocate on their behalf. This form of advocacy is a very legitimate
form of advocacy, provided the authority of the vulnerable person is
accorded the utmost respect at all times.


There is no one way or right way to undertake advocacy. It is something
that happens every time a consumer or carer speaks out in support of
his or her own cause or that of the peer group. Sometimes the activity is
effective and things change for the best, sometimes nothing happens as
a result and sometimes it feels like things might have got worse.

6.2 Conduct work that demonstrates a commitment to access and equity
principles
Within a general community certain behaviours are considered either
acceptable or unacceptable. The way that a particular behaviour is
perceived, and either accepted or rejected, may differ markedly
between the various groups that make up the community. Group ethics
will not always be the same as broader community ethics.
Many of the sanctions (positive and negative) that support community
ethics are informal, but some are formalised in legislation and
maintained by social institutions such as the police and the law courts.
Some professional groups have special ethical codes that prescribe
correct and responsible conduct. For example, nurses, teachers,
lawyers and others are expected to follow strict guidelines setting out
appropriate professional behaviours for general and particular
situations. Some consumers and carers have been critical of certain
aspects of professional codes of ethics or, rather, of the way that these
are interpreted and used in the health system.
An ethical framework for advocacy
Since advocacy is directed fundamentally towards issues of justice and
equity, consumer and carer advocacy activities are strongly
underpinned by ethical understanding. Advocacy is about consumers
and carers being valued as equal citizens. It is about empowerment. If
there is a 'code of ethics' for consumers and carers, it is based on a
platform of human rights. Some consumer groups, in particular, have
begun to define this ethical framework through the creation of 'bills of
rights'.
In the context of the Australian health system, the Mental Health
Statement of Rights and Responsibilities developed within the National
Mental Health Strategy, acknowledges the importance of the
contribution of consumers and carers at all levels of mental health policy
and service provision. This document has important implications for
consumer and carer advocacy. It provides an officially sanctioned
ethical framework within which advocacy can be conducted. It implies
that it is ethically appropriate to pursue rights, equity and justice as
expressed in the Statement. While consumers and carers may debate
the relative worth of the Statement in the 'real world', its recognition of
the right to pursue issues of justice and equity is an important
contribution to consumer and carer advocacy.
Some consumers and carers argue that the Statement does not go far
enough in recognising the entrenched inequities of power distribution in
society as the basis of injustice in mental health. It is possible that the
Statement will be further developed on the basis of lessons learned
from increasingly empowered consumers and carers. The issue of


whether self-empowerment succeeds from revolution or evolution is an
ongoing consideration for consumers and carers, as well as for other
disenfranchised groups.
A few basic perceptions about rights and responsibilities are worth
noting:
Rights are not the special entitlement of the few. Everybody has a
right to be listened to. This does not mean that everyone should
have the same views and opinions but, rather, that people's views
and opinions especially about their own lives should be treated
with respect. This is a right often ignored by those in positions of
power. It is a right frequently denied in certain relationships,
including those between service providers and consumers or carers,
and those between consumers and carers.
In seeking to reclaim basic rights, some people pursue them
vigorously. There are times when this is necessary. Excessive
vigour is sometimes interpreted as 'aggression' and can lead to
antagonistic responses. This can be because the rights of one
person conflict with those of another. More often, however, there is a
lack of understanding and/or a fear of change at the root of
antagonistic responses.
Rights go hand in hand with responsibilities. Among the rights that
consumers and carers are most concerned with is the right to be
responsible. As with all ethical matters, the question of what
constitutes responsible behaviour is subject to many interpretations.
At the same time, suggestions that basic human rights can be
denied to those who fail to measure up to someone else's notion of
responsibility are quite unjustifiable. The whole point about rights is
that they are fundamental and unconditional entitlements.
Social justice
Consumers of health services are traditionally considered vulnerable at
certain times and requiring special legislation or policy to ensure their
protection. Providing additional protection within a context of social
justice is an ethical principle applied particularly to consumers of health
services. Depending on the circumstances, additional protection may
offer consumers greater opportunities for empowerment, or it may
grossly dis-empower them.
Social justice is grounded in the notion that people have rights and that
everyone's rights need to be considered and taken into account. The
worst examples of infringement of rights should be addressed as a
matter of importance. Sometimes balancing the rights of different people
is a very difficult exercise. However, the difficulties involved are often
amenable to negotiation, education and mediation. Insoluble difficulties
can be drummed up as an excuse for a failure to pursue social justice
issues.
Even with the weight of legislation and policy behind the pursuit of
rights, there will be those who do not recognise the essential principle of
equal opportunity. There will often be some disagreement about
priorities: which rights are more important to pursue for which group at
what time. Some individuals and institutions will find it difficult or even
impossible to accept or understand advocacy activities and may create
obstacles to this kind of activity.


Confidentiality
Confidentiality is about consumers and carers having control over who
has access to information about them and in what form.
There are many issues around confidentiality and they are neither as
straight forward or as obvious as they might, at first, appear.
Consumers' and carers' understanding of confidentiality is not
necessarily identical. What consumers and/or carers mean by
confidentiality is also likely to be quite different from what service
providers mean.
Confidentiality means that information, given in the belief that it will
go no further, is not discussed with others.
Confidentiality means that you do not identify a person to a third
party (or parties) without that person's permission and their clear
understanding of how, where, and to whom identification will occur.
Confidentiality means that you do not discuss another person's
affairs where you could be overheard by those not directly
concerned, for example, in hospital corridors.
Confidentiality means treating any information you have about
another person with respect for their privacy.
Confidentiality does not mean that when quoting a consumer or
carer you should routinely render your source anonymous or reduce
her/him to a first name only. This is stigmatising and disrespectful if
you have not consulted the person. Consumers have different needs
and experiences. Some consumers are proud of their 'loony' status
and want more than anything to be listened to, to be heard and to be
acknowledged. If you are intending to print or publish material
written by a consumer or which mentions a consumer, always ask
how he/she would like to be acknowledged. DO NOT assume that
they will be embarrassed and ashamed about their name being
used.
Confidentiality does not mean withholding relevant information from
another person or persons under the guise of professional
behaviour.
Confidentiality does not mean discussing the affairs of someone you
are representing in confidence with everyone except that person.


6.3 Adopt strategies to empower the older person and/or their advocate/s
in regard to their service requirements

Consumer and carer advocacy can be about putting a personal view or,
occasionally, the view of another individual. Sometimes it is about
putting the view of a group, organisation or network.
Advocacy incorporates the notion of consumer or carer 'representative';
that is, of people who are asked to 'represent' a group or a cause. Being
clear about the intent or purpose of representation, from the point of
view of the person or group making the request, is important. Are you
being asked to represent your own views as an individual; the views of a
particular group of consumers or carers or the views of an organisation
with which you are associated? Perhaps you are not really being asked
to represent anything but, rather, just to be there so that people can say
they have included consumer or carer representation.
People who are asked to represent a group must take care not to
assume that they know what the group wants them to say. Any such
careless assumption can easily lead to misrepresentation of the group
interests. Consumer and carer representatives can create processes for
consultation with other group members to ensure that the consensus
position is represented as fairly and honestly as possible.
Just as the representative has a responsibility to her/his group, the
group has a responsibility towards its representative. Representatives
require active support from those they represent. Members of the group
can assist by being prepared to participate in consultation and to make
their views known.
It is unfortunate that debates regarding the limitations attached to
consumer and carer participation are often based on arguments about a
person's capacity to represent a group or constituency. Such arguments
never seem to arise in the context of representing provider groups,
administrators or others.
When people do not say what somebody else wants to hear, one of the
most common ways of negating their contributions is to accuse them of
not being representative.
In some situations it may be difficult for a consumer or carer to be true
to the diversity of the group he/she represents without weakening
his/her case. Representatives should ensure that a range of viewpoints
have been heard and respected but, in the end, it is impossible to
represent everyone.
A consumer/carer delegate must not allow him/herself to be silenced by
misleading accusations of non-representativeness.
The 'professional' consumer/carer
Sometimes a person is denounced as a 'professional' consumer or a
'professional' carer. These terms are used to cast doubt on that person's
legitimacy as a consumer or carer. Carers have found that this
derogatory label is frequently applied to those who do not actually share
a house with a person living with mental illness. These are individuals
who nevertheless see themselves as 'carers' and who believe that they
have important perceptions to share with service providers and/or the


community. Many consumers, as they become more politically
experienced and more confident, have found themselves accused of
being 'professional' consumers. Sometimes the accusation is made
directly but, more often, it is said behind people's backs.
Unfortunately this sort of put-down sometimes comes from within the
consumer and carer groups themselves.
People who have been tempted to criticise others by using this type of
language might find it useful to question their own motives. In that way
they can discover the real issues behind their anger. Consumers and
carers who know that they may be targets for this type of criticism can
consider the following:
Think of a response that does not involve you in a power struggle if
directly confronted. Some people just reply: 'Yes, I pride myself on
my professionalism. Thank you.' They deflect the intended insult by
deliberately misunderstanding it. They take the word 'professional'
to mean organised, diligent, ethical, experienced. Of course, many
consumers or carers working in 'the system' would want to be
described as 'professional' in this way.
Explore your own presentation as consumer or carer. Do you come
across as a 'know-it-all' or as being arrogant? Do you 'hog the floor'
at meetings? If you are representing others, do you consult with
them? Do you take questions back to your group? It might be that
you need to modify the way you present yourself.
It is important that politically experienced consumers and carers make
themselves available to others so that the skills can be passed on. This
is the way, for instance, that psychiatrists are trained. Medical school
graduates are supervised (or mentored) by experienced practitioners
before they are admitted to the College of Psychiatrists. Formal
arrangements are in place to implement this model in psychiatry.
Although consumer and carer organisations do not have the guidance of
formal accreditation procedures, they can benefit from maximising
opportunities for more people to gain experience and confidence in
different kinds of participation.
Other people sometimes see consumers and carers as representing a
collective opinion even when they are not formal representatives. Some
experiences of consumers or carers are collective. They speak
informally with their peers and gather a wealth of information that helps
to broaden their consumer or carer perspective. Despite this common
ground there are also very different experiences across the consumer
and/or carer communities and respect for differences is a central
proposition for effective advocacy.
The word 'representative' or 'rep' is often used carelessly to describe
people who are not, and were never meant to be, representative of any
constituency. For example, someone might say: 'Oh, you mean Sandy! I
think shes the consumer rep on that committee'. More attention to detail
would reveal that Sandy is in fact a member of that committee and holds
a position that is reserved for someone who is a consumer. This is very
different from being a representative.


The challenge in advocacy is to maintain a strong sense of the
collective (shared) consumer or carer perspective, while being
respectful and sensitive to individual and minority differences. One way
to stay in touch is to be part of a consumer or carer organisation where
views are exchanged regularly and where individuals can remain
constantly aware of the broad thrust of collective opinion. It is also
useful to refer to the increasing number of consumer and carer
publications: books, participation kits, pamphlets, newsletters and
others. Sensitivity to differences within the consumer or carer
movements can be developed by listening to as many people as
possible, whether these individuals are members of a group or not. It is
particularly important to consider the views of ethnic minorities, women,
gay and lesbian consumers and carers and elderly people (consumer
and carer). Without this attention to difference, the ideal of increasing
consumer and carer participation and self-determination becomes
impoverished and elitist.
Accountability and responsibility
Each person is accountable to him/herself and to others who may be
affected by his/her words and actions or, for that matter, by his/her
silences and inaction. Being accountable means that you need to be
able to justify your words and actions in a given context. You need to be
able to give an account of what you did and why.
In some cases you may be required to be formally accountable to an
employer, funding body, group, or person (for such things as reports,
invoices). In other cases, accountability may mean taking responsibility
for your role in a less formal or structured way.
You may find yourself in a situation where you are accountable to more
than one person or group. For example, if you are a consumer or carer
representative on a committee, you may be accountable to the
committee itself and a public or private funding body, as well as to the
people (consumers, carers) you are there to represent. If, for some
reason, the interests of the three groups do not coincide, then your
primary accountability is to the group, person, or persons that you
represent.
Examples
1. A consumer is elected to represent a group on a government
committee. Some of this work involves material that the government
wishes to remain confidential. The consumer is told not to tell
anyone, including members of the group she is representing.
To whom is the consumer accountable?
How could the consumer resolve this dilemma?
2. A carer is nominated to fill a vacant position on a project advisory
committee. He knows that he is there because he has had a lot of
experience in various carer organisations. However, he has not
been asked on to this committee as a representative of any of these
organisations.
To whom is this carer accountable?
Can he ask another carer (or carers) for an opinion on a difficult
issue?


In both examples you are accountable to yourself. You need to believe
that you have acted correctly and according to your own understanding
of your role, values and ethics.

Being Prepared
Undertaking advocacy activities has its risks for individuals. The act of
putting forward a position in an attempt to produce change or to
maintain the impetus of important things that are happening also means
putting yourself forward. Even when acting with or on behalf of a group,
advocacy is still a very personal event. Giving of yourself in this way
means personally feeling good about the gains that are made. It also
means feeling disappointed, frustrated and even hurt when things do
not go so well.
Assessing the risks both to yourself and to the effectiveness of the
message you are delivering is important. Being well prepared and
organised is a good way of reducing the risk of being ineffective and of
minimising stress. It is also useful to take account of your personal
resources, recognise personal boundaries, take care of yourself and
work through your motives for being involved.
Judging your preparedness to expose yourself to the risk of
disappointment, perhaps through hearing stories told by others, is
another way of reducing risk. If you feel particularly vulnerable it may be
better to postpone an opportunity than to proceed with it. However, the
risk may be worthwhile; only you can decide. Having people around to
provide support when things are not going so well, or to join you in
celebration of success, can prove invaluable.
Being prepared is about getting organised; maybe sorting out some
routines and managing commitments. It is about creating networks,
finding people to undertake advocacy activities with, creating
opportunities for debriefing, sharing ideas and information. It is also
about developing new skills, increasing your knowledge about the things
around you and being open to new opportunities.

6.4 Provide information to the older person and/or their advocate/s to
facilitate choice in their decision making.
Being valued
Consumers and carers have a wealth of experience, wisdom,
knowledge and skills that can be used to have an impact upon health
systems and the broader community. Experience, to date, for most
consumers and carers, is that these capabilities are seriously
undervalued, especially within health service structures.
Relationships between consumers/carers and service providers are
invariably unequal: doctor/patient, provider/recipient, well/ill and so on.
There are very few examples of genuine partnership. Continued
advocacy activity needs to be directed towards shifting the balance of
power.


Traditional power relationships make it very difficult for consumers and
carers to be valued as equals when they engage in advocacy activities.
The challenge for consumers and carers is to engage in ways that will
increase recognition of their value. Valuing oneself is important but,
sometimes, this is particularly difficult to achieve or maintain.
Opportunities for demonstrating knowledge, skills and confidence will
increase feelings of self-worth. This will also encourage detractors to
modify or change their attitudes. Pursuing symbolic recognition of value,
like equitable financial reward for participation is also important.
Undertaking advocacy activity can be very rewarding, giving a sense of
achievement and real empowerment. It can also carry with it some
personal risk. It can be a gamble on fulfilment, success and
disappointment. Putting yourself forward, being exposed to new
situations, expressing your views is always challenging. Doing it in an
environment of unequal power and stigma, like that associated with
health issues, increases the challenge.

Burden of Responsibility
Consumers and carers who undertake advocacy activity talk, along with
their stories of achievement, about the burden of responsibility, the
stress of constant exposure, the sense of isolation and, inevitably, the
need to look after themselves. Because if they fall over in some way,
not only are they unable to continue the thread of their activity, but they
lose credibility. The cynics will say, particularly of consumers, 'His/her
voice can't be credible because he/she can't take it'.
But win or lose, the process of advocacy, approached sensibly, will
always make you a 'winner' because of its effectiveness in personal
growth. Engaging in the process of advocacy will educate the cynics
and provide you with invaluable learning for everyday life.
Even before you undertake advocacy activity, consider ways of
preparing yourself. Advocacy activity requires effort. It also requires
determination and commitment.
Your personal preparation is important. Do you have confidence that
you will be able to help with the issue? Are you clear about how much
you are prepared to do? Do you know how to maintain your own energy
and interest?
Advocacy needs to include the knowledge that change will come in
time. It may be useful to adopt an attitude of patience. Even if your
advocacy activity cannot be directly measured as an immediate
success, it is likely that the effort will contribute to change that is
realised at a later time. Where you have been able to present a
considered and reasonable position, it will help in breaking down the
stigma and misconceptions held around mental illness. It will stand as
part of a collective effort that eventually achieves broader systemic
change. Remember though that some people will never consider your
contribution to be reasonable.


Problem solving
One thing people can be sure about: there will always be problems.
Whether they are large or small, problems are part of life. While people
generally like to believe that they want to live in a problem-free world,
when they really think about it, life might be pretty boring. Generally,
people actually like to solve problems. If people don't find ways to
overcome problems they don't enjoy success. The problems people
really want to be rid of are the ones they can't solve.
While individuals enjoy the rewards that produce success, they also
enjoy the process that produces success. People will accept, and may
even seek out, problem-solving opportunities if the following four
conditions are met:
They must possess the skills needed to solve the problems that
arise
They must experience success in using those skills
They must be rewarded for successfully resolving their problems
They must not fear failure.
The opposite of this is equally true. People will avoid problem-solving
situations when:
They are unsure how to solve their problems
They do not experience success after trying to solve a problem
They feel their efforts are not appreciated
They sense they have less to lose either by doing nothing or by
shifting responsibility.

Types of problems
People encounter all sorts of problems, both technical and non-
technical, which need solving. Two main types of problems are close-
ended and open-ended.
Close-ended problems
Close-ended problems are those which have single correct solutions or
sets of solutions. Often the solution doesn't need to be tested. For
example, you walk into the room where you are attending a meeting and
the light won't come on. You can quickly narrow the problem down to a
small number of solutions:
1. The light bulb has blown
2. The fuse has blown
3. The power has been cut off.

By seeing that the rest of the lights are on you quickly find out the bulb
has blown. The following questions may help you determine if a problem
is close-ended:


How much is known about the problem?
Is complete and adequate information known?
Do procedural methods already exist for solving the problem?
The more questions that you have answered with 'yes', the more likely
you are faced with a close-ended problem. These problems are not
usually difficult to solve. In fact, individuals can usually handle close-
ended problems themselves, without calling for the problem-solving
capabilities of others. Unfortunately open-ended problems are a
different matter.
Open-ended problems
Open-ended problems do not have simple solutions because, unlike
close-ended problems, you don't have the information to solve the
problem readily at hand, or else the information is not readily
understood. These sorts of problems are often a whole range of
problems which manifest themselves as one problem. Like a jigsaw
puzzle, there are interconnecting pieces which must be viewed
separately. For example, how do you change the culture of an
organisation? Each part of the culture is a piece of the puzzle. Taking it
apart and changing it creates a new picture. There is no 'correct'
answer.
The only 'correct' answer to an open-ended problem is the answer that
works best.
Groups are best suited to 'solving' open-ended problems. Groups bring
information and experience to problems and, through 'brainstorming'
together, can come up with workable solutions. As a team, the group
needs to process and filter information to test, refine and finally select
the best solution. The real criterion for the correctness of the solution is
the group's acceptance of the decision as correct.

6.5 Recognise and report to an appropriate person when an older
persons rights are not being upheld.

There is no limit to where advocacy activities can and should be
undertaken. It may be in the doctor's office, the local health centre, a
hospital, talking among friends and neighbours, through letters to the
local paper, through talking to senior managers of health services or
politicians, in the nursing home, through presentations to health
professionals at a university.
Over the years there have been many opportunities for consumers and
carers across the nation to state in which areas their advocacy activities
are most important. By and large, the message is that concentration of
effort is needed on getting the big picture right: on systems advocacy.
This means those things like legislation, policies, administration,
organisation, systems, attitudes and professional practices. It can then
be anticipated that the needs of individuals will be far more readily
addressed or, at the very least, easier to negotiate.


Consumers and carers have said that they identify three situations, in
particular, where they must have a voice:
The health system and influence on the way services are designed
and delivered
The higher education system and influence on the way health
professionals are educated and trained
The broader community and influence on the perceived prejudices
that lead to stigmatisation.

6.6 Provide services regardless of diversity of race or cultural,
spiritual, or sexual preferences.

Dealing with organisational culture
Large systems, like health services, are very complex to organise and
manage. They involve many people, each needing to find his or her
place in the organisation as well as to do their work. Every organisation,
irrespective of size, has its own culture. Sometimes an organisation's
culture can be identified through what it says or writes about itself.
Usually though, the culture tends to surface in the way people who are
part of the organisation think, talk and behave. The cultural identity of an
organisation is influenced by its purpose, history and experiences.
People in the organisation, especially those in positions of power, affect
what is seen as important and influence beliefs and values. Over time,
people in the organisation adopt the beliefs and values of the
organisation and become part of that culture. This can sometimes mean
that they think and behave in certain, sometimes predictable ways, in
keeping with what is generally expected in the organisation.
All organisations exhibit aspects of cultural identity.
Consumer and carer organisations are no less prone to this than service
organisations.
Organisational culture can be a 'good' thing. It helps create order
around complex differences, it provides a strong focus for an
organisation's survival and it creates cooperative strength for an
organisation. The people within the organisation are supported through
being part of a collective. They are provided with a level of certainty and
predictability and are able to operate freely within certain limitations.
Organisational culture also gives people clues about whether they want
to be part of a particular organisation or whether their personal values
are so different that joining would be intolerable. Whether as a worker or
as a voluntary member, people can exercise choice about whether they
join, stay in or leave an organisation.
Organisational culture can also be a 'bad' thing. Particularly in very large
organisations the culture can become somewhat stagnant and resistant
to change. Alternatively, sweeping changes, such as those brought
about by massive cost-cutting, can cause cultural changes so traumatic
that workers within the organisation are left floundering. The subtle
assumptions and perceptions associated with organisational cultures


can be dangerously limiting to the organisation as a whole and to the
individuals within it.
The big challenges for advocacy are around potential culture clashes. It
is quite possible that what one person or group wants to present, or how
they intend to present it, does not fit well with the culture of the
organisation to which they are presenting. The more that is known of the
culture of an organisation, the more likely the success in influencing it.
Messages can be tailored to fit and be delivered in accordance with
achieving the best hearing and response.
Organisations are made up of individuals who bring with them elements
of other cultures. These individuals are not just governed by the culture
but are part of the influence working on it. Gaining acceptance or
agreement from an individual in an organisation may be insufficient if it
does not fit well within the larger organisation. It may, however, have
introduced a level of influence that begins to shape cultural change.
Cultures can and do change, but they do so very slowly. It is worth
remembering that todays advocacy activity can influence the
organisation of tomorrow.

6.7 Provide Information to the older person and/or their advocate/s
regarding mechanisms for lodging complaints

Various laws exist that provide an infrastructure to formal understanding
of justice. From a consumer and carer perspective, some laws appear
to advantage those with power and disadvantage those without.
Legislation is constantly under review. It can be both responsive to
social changes and reactive to social unrest.
Laws may be State/Territory specific or have national application. The
differences between States/Territories represent a challenge for activity
in pursuit of change at a national level.
Some legislation is particularly relevant to mental health interests. The
various States/Territories maintain their own mental health acts that
continue to go through amendments towards a more consistent national
outcome.
Some legislation has been represented as enabling for people with
disabilities or proactive in ensuring no disadvantage in a general sense.
The Disability Discrimination Act is an example of the former and equal
opportunity legislation an example of the latter.
Addressing legislation through advocacy is particularly complex. It is a
political process requiring negotiation of substantial hoops and hurdles
to bring about change. It is also a conservative process. Existing laws
need to be demonstrated to be inappropriate before change is
Advocacy may be directed to legislative change through organised
political activity. Alternatively, it may be directed towards issues of rights
infringement, inequity and injustice that current legislation may be seen
to perpetuate.


References
Hutchinson M and Ausland T User Participation in the Mental Health
System, Mind, London, pp13-20
Mental Health Consumer Outcomes Task Force (1991) Mental Health
Statement of Rights and Responsibilities, Australian Government
Publishing Service, Canberra
Disability Services Act 1992 (Commonwealth)

NACAP
The National Aged Care Advocacy Program (NACAP) is a national
program funded by the Australian Government under the Aged Care Act
1997. The NACAP aims to promote the rights of people receiving
Australian Government funded aged care services.
Under the NACAP, the Department of Health and Ageing funds aged
care advocacy services in each State and Territory. These services are
community-based organisations which are there to give your clients
advice about their rights, and help them to exercise their rights. Aged
care advocacy services also work with the aged care industry to
encourage policies and practices which protect consumers.
If your client lives in an Australian Government aged care home or
receive Australian Government funded aged care services in their own
home, and would like to speak to someone about their rights, your client
or your clients representative can contact one of the advocacy services.
These services are free and confidential.

Aged Care Complaints Investigation Scheme
The Aged Care Complaints Investigation Scheme is available to anyone
who has a complaint or concern about an Australian Government-
subsidised aged care service (residential or community care).
Working together to fix the problem
The Complaints Investigation Scheme (CIS) is available to anyone who
wishes to provide information or raise a complaint or concern about an
Australian Government-subsidised aged care service, including:
residents of aged care homes;
people receiving community aged care packages or flexible care; or
relatives, guardians or legal representatives of those receiving care.
What is the Complaints Investigation Scheme (CIS)?
The CIS:
is a free service which investigates concerns raised about the
health, safety and/or well-being of people receiving aged care;
has the power to investigate these concerns and require the service
provider, where appropriate, to take action; and


is able to refer issues that may be more appropriately dealt with by
others (eg. police, nursing and medical registration boards).
You may download these documents in PDF and HTML format from
their website:
The Aged Care Complaints Investigation Scheme - Plain English
Brochure
The Aged Care Complaints Investigation Scheme - Information for
Residential Aged Care Workers

What concerns can you raise?
The Aged Care Act 1997 (the Act) sets out the responsibilities of
approved providers who receive Australian Government funding to
provide care and services to care recipients. The CIS can investigate
information or complaints about cases where an approved provider may
not be meeting their responsibilities under the Act.
The information, complaint or concern may be about anything regarding
the care and services provided to aged care recipients. For example
care, catering, financial matters, hygiene, equipment, security, activities,
choice, comfort and safety.
Who can contact the CIS?
Anyone can contact the CIS with a complaint or a concern - care
recipient, family member, care provider, staff member, GP etc.
Complaints can be made openly, anonymously or your name can be
kept confidential.
Your client may want to talk to your aged care manager first - some
issues can be resolved easily. If your client is uncomfortable doing this,
or isnt happy with what has happened with their complaint, they can
contact the Aged Care Complaints Investigation Scheme directly.
If required, the CIS can provide access to:
an interpreter service;
a TTY (deaflink) phone service; or
a free and confidential advocacy service.
Representatives of advocacy services may:
inform you of your rights and entitlements;
tell your client about the help they can provide; and
assist you to voice your concerns with the CIS.


How can you or your client provide information, raise a concern or make
a complaint?
You can you provide information or make a complaint either on free-call
1800 550 552 or in writing to:
C/- Department of Health and Ageing
GPO Box 9848
In your Capital City.

When you contact the CIS they will:
listen to and clarify your clients concerns;
explain how the CIS works; and
inform your client of their right to have the assistance of an
advocacy service if they wish.
The CIS will, where appropriate:
take detailed notes and record information in the CIS database;
decide if the information provided relates to an approved provider's
responsibilities;
refer the matter to another agency if that is more appropriate;
investigate the information they receive to determine whether or not
a service provider is providing appropriate care and services;
tell providers who have not met their responsibilities what they have
to do to address an issue and specify the timeframe in which this
must be done;
provide feedback on the outcome of the contact.
There are however, some matters the CIS cannot deal with. For
example, they cannot say who should make financial, legal or health
decisions on behalf of a care recipient. They cannot comment on
industrial matters such as wages or employment conditions or provide
legal advice on any problems.
Who manages the CIS?
The CIS is managed by the Office of Aged Care Quality and
Compliance within the Department of Health and Ageing. If your client
has any concerns about the way the CIS has handled their complaint or
concerns, your client can raise them with the CIS Manager in their State
or Territory. Alternatively, your client can contact the Aged Care
Commissioner.
Aged Care Commissioner
The Office of the Aged Care Commissioner has been established to
independently review the way in which the CIS handles complaints. The
Aged Care Commissioner can look at decisions made by the CIS in
relation to the investigation of complaints and also has the power to


examine, as a result of a complaint or on their own initiative, the CIS's
administrative processes for investigating complaints.
The Office of the Aged Care Commissioner can be contacted during
business hours on free call 1800 500 294.
Further information can be found on the Office of the Aged Care
Commissioner's website at http://www.agedcarecommissioner.net.au
CIS Privacy Statement
You may download this document in PDF format from the website
Australian Government agencies must comply with the Information
Privacy Principles (IPPs) set out in the Privacy Act 1988 (Cth). The
IPPS cover the collection, storage, quality, use and disclosure of
personal information about individuals.
The Aged Care Complaints Investigation Scheme (the Scheme) is
administered by the Office of Aged Care Quality and Compliance in the
Australian Government Department of Health and Ageing. The Scheme
complies with the IPPs contained in the Privacy Act 1988.
Why might the Scheme collect personal information?
The Scheme might collect and use personal information for the purpose
of performing its functions as set out in the Investigation Principles 2007
made under the Aged Care Act 1997.
Personal information may be collected by the Scheme in response to a
particular concern or complaint. When a concern is raised with the
Scheme, its officers may collect personal information which relates to
the complaint from any of the following parties: the person raising the
concern, the affected care recipient and/or their relatives or
representatives, the relevant approved provider and/or their staff. This
personal information may be used by the Scheme to assess whether
the approved provider has met its responsibilities under the Aged Care
Act 1997.
Does the Scheme disclose the personal information that it collects?
The Scheme has procedures to ensure that personal information is
protected against misuse and is not unlawfully disclosed.
The Scheme must ensure that any request for confidentiality is complied
with unless doing so would harm the investigation, or pose a risk to the
informant or the affected care recipient. The Scheme must take all
reasonable steps to notify the informant before deciding not to comply
with a request for confidentiality.
Under section 16A.10 of the Investigation Principles 2007 personal
information collected by the Scheme may be referred to another
organisation. Referrals to another organisation are made where a
concern raises issues that require, or may require, action by the other
organisation.
Personal information collected by the Scheme may be disclosed to, and
used by, relevant officers of the Department of Health and Ageing for
the purpose of taking compliance action against an approved provider
under the Aged Care Act 1997.


Personal information collected by the Scheme may also be used or
disclosed in accordance with part 6.2 of the Aged Care Act 1997 or
where otherwise permitted or required by law.


Activity 13:

1. As we look at the clients rights and responsibilities we see that their
needs to be a process for compliments and complaints. How would
we disseminate (distribute) this information and how would it be
explained to clients?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
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2. Use the following statement from the Department of Health and
Ageing and from your knowledge describe how the process for client
complaints would help in this example.
There is a power differential, which does not exist with other
customers. Many homes do not understand how easy it needs to be so
that people will complain. Unlike other customers, residents are a
captive market. They cant easily withdraw themselves or their capital.
They might feel it ungrateful to complain if theyre happy with the other
95% of the service theyre getting from an aged care home
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________________________________________________________
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Activity 11:
1. How does your workplace demonstrate a commitment to access and
equity for clients?
________________________________________________________
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________________________________________________________

2. How does this commitment to access and equity impact on your
position and your work?
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3. You are to present a case study of a diverse older client and explain
your role in supporting their rights and interests,
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Activity 12:
When looking at how strategies are adopted to empower the older
person and/or their advocate/s in regard to their service requirements
we need to look at the information provided so as to facilitate choice in
their decision making.
You are to discuss how a service would work for, with and against the
client in each case. This is of course an imaginary service.
Client 1.
Mrs Beattie is an elderly woman who lives alone. She is the widow of a
successful businessman. Throughout her life she has been accustomed
to having everything just so. Her husband looked after her quite well
and she wanted for nothing. They had no children and she has no
nearby relatives. She is now confused and forgetful. Her health has
deteriorated and she is finding life increasingly difficult. The house is
very large and she insists on keeping it just as it was when her husband
was alive. She referred herself to the service.

Elements of
Responsive
Services
Against
(putting the
service first)
With
(treating service
needs and client
needs equally)
For
(putting client
needs first)
Flexibility
(when and how
services can be
provided)

Choosing the
right worker
(selecting who
will provide the
service)


Activity 13:
You are to discuss how a service would work for, with and against the
client in each case. This is of course an imaginary service.
Client 2
Dr Stork is a bossy, dogmatic man who has a traditional view of the
roles of men and women. He has Alzheimers disease. His wife is run
off her feet trying to please him. As his dementia progresses he is
increasingly unable to dominate the household. Mrs Stork has
responded by doing less and less. She is depressed and does not know
how to get assistance. The house is run down. The referral has come
from the GP.
Elements of
Responsive
Services
Against
(putting the
service first)
With
(treating service
needs and client
needs equally)
For
(putting client
needs first)
Flexibility
(when and how
services can be
provided)

Choosing the
right worker
(selecting who
will provide the
service)


Activity 14:
1. Part of the decision making process is how the clients participate in
the service. Discuss this statement.
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2. How would you encourage this participation in this decision
making?
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Activity 15:

Using the statement below from; Equal treatment, equal rights; Ten
actions to end age discrimination, Published by: HelpAge
International
So although age should not limit basic rights to inclusion and
participation, older people are accustomed to exclusion and therefore
often hesitant or cynical about involvement. HAI research across the
world on older people in emergency situations shows older people's
greatest priority is to be seen, heard and understood. All older people,
regardless of their circumstances, have the absolute right to full social
participation. It is important, therefore, to act against the denial of those
rights, especially for the oldest and most frail, who are frequently
women.

1. In your experience what would be some of the rights of a person
that could not be upheld and how you would assist in correcting
this?
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2. How would you encourage this attitude in the workplace?
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3. What are three options that are available to assist the person in having
their rights upheld?
a. _________________________________________________________________
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b. _________________________________________________________________
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________________________________________________________________________
c. _________________________________________________________________
________________________________________________________________________
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________________________________________________________________________
________________________________________________________________________

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