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Is your model of care an enabler or disabler?

In Australia, aged care and disability organisations provide support for people who are unable to perform tasks for themselves as a result of disability or the ageing process. I believe there is a vast difference between passive care that can further disable a person – and active care that enables the person. Providing passive care involves a care giver giving care to a recipient, which can result in further disabling of the recipient as they become more and more dependent on the care giver.

Providing active care, on the other hand, can be likened to providing a service, where the person with a disability or who is ageing (‘the client’) is actively encouraged and equipment and support are provided so they can do as much as possible for themselves. This enablesthe client, as the support worker only assists where the client is unable to complete the task themselves.

The five mistakes made that contribute to disabling support services and how enabling care can be created.

Mistake 1: Generic care services are provided

The care plan is often based on a brief discussion with the client based on what they can and can’t currently do for themselves and relies on the existing care environment and equipment available. The support worker has been given a list of what to do and often ends up doing more than is necessary for the client, which gradually reduces the client’s functional abilities. Thus disables the client long-term.

Principle 1. Engage a health professional who has expertise to conduct a thorough care needs assessment to provide tailored care.

A health professional with specialist expertise in manual handling, understanding a clients diagnosis and how this impacts on their abilities, along with knowledge of up to date aids, equipment and home environment modifications, is ideal. They can provide recommendations on how to maximise a person’s functional abilities through prompting, setting up the tasks in a different way, using equipment to enable the client, so the care can be completed comfortably and safely for both parties and importantly in an engaging way for the client.

Mistake 2: Relying on the support worker to ‘fill the gaps’.

When a client is unable to perform a task, the default solution is for the support worker to provide assistance – that is, they ‘fill the gaps’ of what the client is unable to do. This increases the physical assistance provided and thus disables the client. It also requires the support worker to do more than is necessary and thus increases the risk of sustaining a manual handling injury.

Principle 2. Use equipment that enables a client to be able to do more independently.

It can be as simple as a long handled sponge and shower hoses to clean hard to reach areas, a shower chair to sit on and providing a shower caddy or a self dispensing unit on the wall so the client can reach their showering items for themselves. Slippery sheets on the bed and a bed rail can enable the client to turn themselves over. I could write 100’s of blogs just on equipment itself!

This equipment can be recommended from a care needs assessment as outlined in principle 1. The organisations manual handling training program should also expose support workers the latest innovative equipment that can enable clients and minimise physical assistance by the support workers. This training should be provided by a health professional with expertise in manual handling and risk management, as outlined in Principle 1. This way you equip support workers with the knowledge and skills to be able to identify equipment that could enable a client in all their care routines they attend to.

Mistake 3: There is no effective system in place within the care organisation for reporting issues or potential problems.

Often, support workers may see risks or ways to improve a service, however, don’t want to appear to be whining or to ruin their relationship with the person receiving the service by reporting these issues to their manager. In some cases, there is a system, but support workers advise that when they report an issue, nothing happens. As a result, support workers feel discouraged from reporting risks and potential improvements and the service remains disabling or risky.

Principle 3: There is a clear, easy reporting system that enables support workers to report problems, near misses and suggestions to improve care.

Clients, support workers and management are trained in this process so that issues are reported promptly and management reacts efficiently and effectively. This acts as positive reinforcement so that workers and clients continue to report issues and the organisation and care services continue to improve. This is what creates exceptional quality care. In the changing and every increasingly challenges care environment, this is how your organisation can differentiate itself in the marketplace. Positioning your organisation as a provider of choice for both employees and clients.

Mistake 4: There is no documented, tailored care plan.

Often, support workers rely on being told about the client’s care needs by another support worker or only have access to limited information. Care services are therefore provided inconsistently and differently, depending on which support worker is on duty. This is confusing for the client, can disable them and also result in behaviours of concern, particularly in relation to dementia, intellectual disability or brain injury.

Principle 4. Each care organisation has a system for assessing and documenting a client’s care needs, so that:

  1. a highly tailored care plan can be developed.

This is written in simple, easy to understand language. Step by step instructions with photos demonstrate key features of equipment, how to set up the task and how to prompt the client to enable them to complete as much of the task as possible.

2.  manual handling risks can be identified and controlled for the support worker, to make their job easier and safer.

Support workers, including casual staff, are provided with task-specific training based on these plans. Charts and diagrams at strategic places help to remind staff of safe and effective work practices, but they are not a substitute for specific training.

Mistake 5: The care needs of a client are not reviewed regularly.

Often, care continues for years without anyone being aware of a change in the status of the person receiving care. For example, their function may have deteriorated or may in fact have improved. Alternatively, new equipment or techniques may become available, however no one is aware of this and thus care remains constant with risks and disabling practise continuing to occur rather than taking advantage of advances in equipment, technology or work practices.

Principle 5: Regular reviews of the client’s care needs occur.

The system outlined in Principle 4 can facilitate care need reviews when required. These are completed by a person with expertise as outlined in Principle 1. This ensures care continues to maximise the clients abilities and minimise the risk of manual handling injuries for Support Workers. A system of reviewing a clients care needs on a yearly basis or other set timeframe can also assist.

In summary, care that is enabling and engaging for the client with a disability or who is ageing means exceptional quality care. Exceptional quality care can occur with the framework of the ‘right equipment’, the ‘right expertise’ and the ‘right education’. These are all principles of “SmartCare” and should be incorporated into a care provider’s manual handling training, assessment of care needs and risk management systems. In addition, a highly effective system and procedures that facilitates assessment and development of tailored, individualised care plans with regular reviews to accommodate for any changes in the person’s abilities during their personal care tasks. Its all about enabling rather than disabling clients abilities.

If you would like further resources or support to provide enabling exceptional care then jump onto our website www.riskmanaged.com.auor give us a call on 0429 841 049. We love what we do. Here’s to life, freedom & happiness for all.

Care providers – are transport services a risk to your business, staff and passengers?

The need for transport

Transporting people with a disability or who are ageing is a fundamental service provided by the vast majority of disability and aged care providers. Transport connects people between their home life and their community. It’s the bridge for life, freedom, connection and happiness. Without transport, people can become isolated and more disabled. Transport services are vital however should not be a risk to Support Workers or passenger’s health, safety and life.

The need for SAFE transport practices

For clients

People living with a disability or who are ageing are dependent on and trust their care provider to transport them safely. Yet, it is astounding how unsafe many people travelling with a disability are, when in the care providers. They are at risk of injury or even death when travelling. We see passengers and staff at risk day in and out in our work and it really concerns (and at times horrifies me).

For support workers

Support workers can be exposed frequently to the physically demanding tasks of assisting clients in and out of vans, securing them in confined spaces and operating specialised equipment. Assisting with transport can also be a stressful job, meeting timeframes, managing behaviours of concern by passengers and not knowing the best way to complete this job. These support workers can be at high risk of sustaining a significant injury whilst transporting clients.

For the organisation

If clients and support workers are at risk of incurring injuries, then management is at risk of managing these injuries, escalating premiums and possible litigation. The Workplace Health and Safety Act 2011 clearly states the need for employers to provide sufficient training for an employee to be competent and to manage risks adequately when performing high-risk tasks. Additionally, care providers must meet their duty of care and quality standards.

The three critical mistakes made when transporting people with a disability:

  1. Inadequate training

Often, support workers receive little or no training in how to safely assist a person with a disability in and out of the van and secure them while seated in the van. They also need to know how to operate lifting platforms and restraint systems to secure people seated in wheelchairs for travel. This requires specialist knowledge and skills.

 

It is not enough to hand a support worker a set of keys and expect them to safely transfer their clients, let alone operate this highly specialised equipment without training. It is also inadequate to rely on ad-hoc training methods such as a support worker who has provided transport services training new Support Workers on how to complete these tasks. This just introduces another risk – that unsafe practices are passed down to new workers and so become entrenched.

 

The Right Education?

Care providers develop a yearly training schedule, which ensures all Support Workers undertake repeat, task-specific training before a support worker attempts this task. Check your trainer has expertise in risk management and people moving and handling. This will ensure your staff become familiar with the risks to both their passengers and themselves and how to reduce these during transport. Also ensure, the trainer is familiar with the safe use of the equipment used during transport. Even better still, make sure your trainer is familiar with adult based training principles to deliver highly engaging training where the Support Workers will transfer their knowledge back into their workplace.

 

  1. A one-size-fits-all approach is taken when purchasing disability accessible vehicles.

When purchasing a vehicle, it is important to consider more than just the budget. While no one vehicle will suit every organisation, it is a disaster waiting to happen when a care provider purchases a vehicle that requires support workers to be contortionists and elite athletes as they load and secure clients, walking aids and wheelchairs in cramped spaces with insufficient handholds footholds or storage areas. This is commonplace in the care industry. As a result, care and transport is not dignified or comfortable for the passengers either.

 

How to select the right expertise?

Before purchasing a vehicle, it is essential to engage a manual handling expert to consult with clients and support workers and conduct a transport assessment. They will provide recommendations around how to reduce people moving and handling risks and assist in planning the best layout and features in a vehicle, to ensure that the vehicle caters for as many of your needs as possible. This makes the Support Workers job easier and more efficient so they get back to loving their work. It enables the passengers to do more for themselves and a comfortable and dignified ride, and reduce behaviours of concern amongst your customers.

 

  1. Lack of awareness of aids and equipment

The third mistake that is often made is simply a lack of awareness of all the great, innovative aids and equipment that are now available to make this transporting job easier for support workers and safer for those travelling.

 

How to stay abreast of and select the right equipment?

The manual handling expert will assist you to work with an equipment supplier that is a specialist in the area of transport. It is paramount that you consult with these specialists to plan the best vehicle options that meet your highest priority needs within your budget.  They’ll look at everyone’s needs and suggest aids and equipment and vehicle floorplans and designs that are best suited for your clients and support workers, to make the job of transporting as easy and pleasurable as possible.

 

This is also whereby using trainers with transport expertise they will update and expose your staff to this equipment to keep abreast.

Remember why you’re doing this:

At the end of the day:

  • people with a disability or who are ageing need to be able to get out and about in the community to live their lives – safely, comfortably and in a dignified way
  • support workers need to be able to do their jobs safely, without risking their physical or mental health and love what they do
  • care providers need to comply with the regulations and their duty of care to keep their workers safe and to provide safe, dignified care for their clients

 

Got a minute?

We would love to hear from you if you’re nailing this area or if you’d like some additional resources.

Jump on our website: www.riskmanaged.com.au You’ll find a video series for support workers – they can access this for free and it’s got lots of tips and tricks on how to use wheelchairs safely in the community and make the job a lot more comfortable and easier for everyone involved.

Or if you would like some more guided support contact us at 0429 841 049 emmasmall@riskmanaged.com.au

We love what we do.

Manual handling – is it relevant when working with a person with intellectual disability?

Manual handling issues with people  with  disabilities 

When working in the care and disability industry, many people only associate manual handling challenges in relation to people living with physical disabilities. We have long been aware of the need to lift a person out of bed, assisting to shower and perhaps get into their wheelchair to start their day.

But manual handling can be an even bigger issue when working with a person with an intellectual disability.

What about those with intellectual disabilities?

Like many people, I wasn’t aware of the manual handling issues involved in caring for people living with intellectual disabilities. Then I began to work with many clients, or ‘participants’ as they are referred to by NDIS, living with intellectual disability. I witnessed first-hand so many manual handling risks and the adverse effects on all of those involved.

Clearly, there is a huge need for manual handling risk assessment and training when working with people with intellectual disabilities.

Let’s take a look at an example of how supporting someone with an intellectual disability requires the support worker to provide physical assistance and therefore are exposed to manual handling risks and what this means for all stakeholders.

 

Case study

John

John (not his real name) has a significant intellectual disability, is unsteady on his feet, is unable to verbally communicate and thus exhibits behaviours to demonstrate his preferences and dislikes. He loves riding in the bus to look around his community and attend his day program, but predictably, he dislikes disembarking at the end of the day and so and avoids this at all cost. The things he enjoys and is engaged in are over and John refuses to leave the bus at the end.

Exiting the bus

John is dropped off at his home by the bus that drops a number of clients to different homes and therefore needs John to exit in a timely manner so it can return other clients to their homes.

To date, two strategies have been tried:

  • Firstly, if John is left in the bus he will eventually leave of his own volition after an hour or so of sitting alone in the bus. Obviously, this isn’t an option as the driver needs to deliver other clients home and return the bus to its base and besides, support workers are reluctant to leave John unsupervised in the bus. John can fall down the steps an injure himself.

 

  • Secondly, the driver and two support workers in John’s home physically lift John out through the side door of the van. The issues that this brings for John, the support workers, the driver and the care organisation are bigger than Ben Hur. They are so much more than just the manual handling risks. Let’s take a look at them.

The issues

  • Manual handling: The driver of the vehicle injured his back and his organisation now has the exhausting process of assisting an injured worker to return to work, covering shifts with casuals, costs associated with training and employing casuals, unplanned escalating workers compensation insurance premiums, time and stress for management to manage the arduous return to work process. And that’s just the injury.

 

  • Legal issues:The care organisation can be found to be not meeting their legislative requirements under the Workplace Health and Safety Act. They have a duty of care to the Support Workers to provide a safe workplace, work procedure and adequate training to manage these risks. The care organisation has a duty of care and obligations to ensure John is not injured and that they meet restrictive practice requirements. That is, not restrict John against his will.

 

  • Reputation:Unfortunately, helping John to exit the bus occurs on a daily basis on a residential street with neighbours and onlookers watching the distressing process. What impact does this have on the care organisation’s reputation in the community? What impact does this have on the care organisation being able to position itself as a provider and employer of choice?

 

  • Retention of Support Workers:The support workers are doing the best job that they can with their knowledge, skills and capacity. They experience aches and pains, are stressed and are concerned that John may become injured. Understandably, support workers want to avoid this task of removing John. They don’t know of any better alternatives and many want to avoid this particular shift altogether. Finding the right support workers for the job is difficult in relation to recruitment and retention.

 

  • John:And let’s not forget about why there is a care service in the first place. It’s to support John to attain his goals under his NDIS plan, to choose to engage in daily living tasks he enjoys. John is frustrated as he’s unable to communicate verbally and as a result exhibits challenging behaviour to communicate his preferences. The manner in which John exits the vehicle is not comfortable, dignified or safe. John is being disabled rather than enabled and is not building on his living skills and independence.

It’s a really tough situation.

 

Working towards a solution – so it’s a win-win for everyone

So how can quality care be facilitated that’s a win-win for all stakeholders? Not just for John, but for thousands of people living with an intellectual disability who require personal care and support services?

 

Principles of quality care

There are five principles that can be implemented to establish a quality care solution for people in a similar situation as John. These include:

  1. Conducting a manual handling risk assessment with a specialist manual handling consultant.This identifies the hazards and prioritises the risk in terms of urgency. Recommendations are made around how the Care Organisation can minimise the risk of injury for both the Support Workers and John in the interim and long-term.

 

  1. An integrated approach between behavioural management support and manual handling.One impacts on the other, so an integrated, multi-disciplinary approach is required. Engaging a behavioural specialist shall provide expertise in understanding how to meet John’s needs to minimise behaviour that challenges in the first instance. When challenging behaviour is minimised so too is the manual handling risks and John’s choice and control maintained.

 

  1. A clear client care planoutlining recommendations including behavioural management strategies and recommendations to minimise the manual handling risks. This needs to be outlined in easy to understand language and steps for Support Workers to review as many times as they need to, to understand how to provide the support and minimise behaviour and risk.

 

  1. Provision of behavioural and task specific manual handling trainingwith the support workers to increase their confidence, support options and skills. Training engages the Support Workers to gain the knowledge and experience to implement the client care plan successfully.

 

  1. Regular review with support workers and Johnto ensure that the strategies and care plan are working successfully. This ensures consultation and that the risk management strategies are working and ultimately ensures your organisation is meeting legislative requirements under the WHS act.

 

Summary

Providing quality care for people living with intellectual disabilities often necessitates sound manual handling and behavioural strategies. Getting the right expertise, right processes and right training helps create a win-win for all stakeholders to facilitate exceptional quality care.

Your say

I would love to hear other people’s experiences and opinions and how we can create a win win for all stakeholders experiencing these challenging care experiences.

Beware of two worker standing transfers

Two care workers assisting a person with a disability with standing transfers always sounds alarm bells for me. I completed an assessment this week where a 90 year old lady was being assisted with standing transfers.

 

The second care worker was recently assigned by the agency as the first worker felt it was too hard. On assessment, the first care worker was needed to hold the client in standing whilst the second did the personal care. By assigning the second worker, we have normalized the practice of holding a client in standing whilst personal care takes place.

 

By doing this, the agency was open to two significant risks – risk of injury to the client in their care and an injury to their staff. The agency did not deal with the risk but the second care worker make the risk more invisible. They have now have now exposed two workers to that risk. By simply replacing the worker with equipment she could hold, the client was able to use their own skills to balance themselves in standing. By changing where equipment was placed and the task, transfers were shorter.  The family saved $10,753 in unnecessary care costs and they know their family member is safe.

What can research papers tell us about objective assessment?

I wanted to present a study this week to show an example of objective assessment of equipment solutions for manual handling.

Weiner et al. (2017).  Repositioning a passive patient in bed:  Choosing an ergonomically advantageous assistive device.  Applied Ergonomics, 60 (2017), 22-29. 

I love looking at studies like this as although they are for research and research is not what we are trying to do in practice, they give us a really great template for making clinical reasoning decisions.

The study aims to evaluate how the use of three devices for repositioning a person (of 75kg) in bed impacts the loading on the back of the care worker.

The three conditions were:

  1. Cotton sheets
  2. Regular slide sheet
  3. Molift Multitrans with lifting handles on the side

They measured the risk of loading on the lower back using

  1. Electro-gomiometer – this measures the physical deviation from neutral body and is an observation tool
  2. Borg Scale of Perceived Exertion – this measure the care workers experience of the task

We all know what neutral body looks like.  Breaking the task down into pieces you could easily do a checklist for how many times a person deviated from this neutral state when using device 1.  You could compare it with the second device you are looking at.

Secondly, you don’t need to use a borg scale, you can just get a care worker to rate their experience – 1 being really easy and 10 being really hard – what was the task like with device one versus device two?

What’s more, there is a table on page 28 of the study that gives a really nice argument of the products from that softer qualitative side that is also very important.  The data is clean as it is based on findings from the people who use it as opposed to the author’s opinion.  You can therefore use it to justify clinical reasoning too.

The conclusion of the study was that slide sheets are better than traditional cotton sheets and carrier for moving someone up the bed.  The carrier had the disadvantage of being hard to fit and remove while the slide sheet could be left under the person.  I don’t even think they were talking about in situ slide sheets designed to be left under the person here.  This study provides a great justification for these.

The Importance of Why
I was completing a manual handling assessment a few months ago with a client with a physical and intellectual disability.  I was asked to come in and assess whether the service was a one person or a two-person service as staff were starting to have difficulty.  I concluded that, in its current state, two people would be needed to provide personal care safely.  I also concluded that with an investment in some equipment we could reduce care to one.  The equipment was going to be over $1000 and I had to deliver this message to her parent. 

When I mentioned that the service would need to be two people, the client’s mother almost broke down.  She was devastated.  Her position was she did not want two people to have to deliver the service to her daughter.  I expressed my empathy with that situation, understanding what putting care up to two people can mean in terms of client budgets and resources.  The alternative of the equipment was still going to be a cost to the family.

I assumed this was fundamentally a financial stress for her.  I started voicing this to her and she looked at me and said, no, it is not about that at all.  She was so fearful that putting care up to two meant that she would not get a service from this company as they were already struggling with getting staff to provide services when one was needed.  She felt this had implications for respite care and beyond.  She needed care to be provided by one.

People take up a certain position all the time – “I want one person to look after my daughter”.    For us as assessors it is really important to know the interests behind those positions – the why.  Without knowing the why we can miss out on many opportunities to provide exceptional quality care.

Once I knew that attracting care workers to the service was a challenge, I was able to mold my intervention accordingly.

When writing my clinical reasoning for investment in equipment to the funder:

  • I was able to explain the cost savings for all parties by keeping care to one and so the return on the investment.
  • I was able to explain this was much more than cost, this was about the capability of a service to provide care to the family.

Similarly we were also able to identify and then address some of the other reasons why care was challenging:

  • The client had challenging behaviours such as hitting and screaming.  The staff did not know the strategies for managing these behaviours and so felt overwhelmed.  They found this added to the manual handling problems.
  • We were able to brainstorm some options to distract the client using sensory interventions such as soft sensory toys, music and fruit to eat (as a last resort).  This distracted her so personal care routines could take place with less stress.

Don’t forget to always ask why.

Can our use of risk assessment in mental health help us as health professionals make gains in manual handling?

Risk assessment is a process used in a variety of different industries to solve problems.  It involves three-steps including identification, assessment and control.  I have worked and lectured in two very different areas of practice where risk assessment is used, but it is implemented very differently.  Manual handling is one and mental health is the other.  In manual handling we use it in one way but in mental health we use it in two ways.  Can the way we use risk assessment is mental health help us make some gains in manual handling?

 

The problem

 

One of the problems I see in manual handling is that things are safe but they are not necessarily easy.  This can make things really hard for the care worker and the client.  As a health professional assessing this, I see many missed opportunities to make things easier because we have not aimed beyond safety, that is efficient and easier.  However, one of the problems with trying to make things easier beyond this marker of safety is the fear that they will move into territory where it starts to be dangerous or unsafe again.

 

How is risk assessment used in mental health?

 

I used to work on a mental health team here in Sydney.  Our team would cover the emergency department where people who were experiencing crisis, that is thoughts of harming themselves or others, would present.  When people who came into emergency with suicidal ideation, we would use risk assessment to make an assessment of that person.  Our aim during that assessment was to get someone from a state of danger to a state of safety.  This would involve an involuntary admission to hospital sometimes under the Mental Health Act or the person would be discharged into the community again but with support from our team.  The ultimate aim was to preserve life and move someone from a state of danger to safety.

 

From danger to safety

 

After the person was discharged home, our team would support them that evening in the community and the next day in terms of home visits or phone to help them plan remaining safe.  Our ultimate aim was to still move the person from a state of danger to a state of safety.  After a few days the person would reach a stage where they would be able to manage their own safety themselves.

 

From safety to life

 

At the stage it was determined that the person was safe, our team was no longer needed but we didn’t stop there.   Our team would then refer the person to another team.  This second team has a different aim.  Now that safety was achieved, they were focused on assisting the person to move from safety to life.  This is where risk assessment would be used the opposite way, to start taking risks.

 

Risk Assessment in manual handling

 

So how does this apply to manual handling?  In manual handling we are very good at making things safe but they are not always efficient.  Our interventions sometimes help the situation move from a state of danger to a state of safety.  Safety is quite a low measure and there are opportunities we could be missing to make things easier.

 

Risk identification

Risk assessment

Risk control

     

 

   

Divergent thinking

Convergent thinking

 

Figure 1:  Creative Risk Management

 

To help us do this I have developed a framework called creative risk management.  It has four steps – risk identification, risk assessment, divergent thinking and convergent thinking (risk control).  The only difference between this and regular risk assessment is a stage of exploration of ideas before we look at controlling the risk.

 

Research has found that equipment solutions solve manual handling problems.  Equipment therefore can make things safe.  I have been teaching health professionals for over ten years on how to prescribe equipment and I constantly see equipment solutions in place where they are not being used to their full potential.  We are therefore getting to safety and stopping there.  We are missing simple opportunities to avoid manual handling.

 

Much of the anxiety of moving to the next level from safety to life is confidence in what the equipment can do.  I see creative risk management as a learning tool to help gain confidence with what equipment can achieve and how.  I propose we start using this or models such as this in continuing professional development training events to start creatively exploring the equipment we use.  Once have explored and know our equipment well and robustly, we can start to implement some of our learning with our clients to achieve safe and efficient manual handling routines.

 

Want to find out more?  Register for one of our lunch and learns