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Identifying the continuing education needs of personal care workers in two residential aged care facilities by an appreciative inquiry study

Open AccessPublished:September 30, 2022DOI:https://doi.org/10.1016/j.colegn.2022.09.009

      Abstract

      Background

      Personal care workers make up most of the workforce in residential aged care facilities, but they are under-served by continuing education providers.

      Aim

      This study aimed to explore the Continuing Education needs of personal care workers from the perspectives of care staff at two residential aged care facilities in regional Queensland, Australia.

      Methods

      This appreciative inquiry study used a visioning activity to inspire thoughts of the ideal PCW during the interviews and focus groups about the continuing education needs of personal care workers.

      Findings

      Gaps exist in the preservice preparation and continuing education of personal care workers, despite a reliance on the personal care worker role to be the 'eyes and ears' of other health professionals. The personal care workers identified their aspirational education needs for ‘best’ practice.

      Discussion

      Personal care workers must be adequately prepared through evidence-based continuing education to respond to residents' emerging needs. However, there was an educational mismatch for them because the PCW curriculum does not adequately prepare the participants for their role. Identifying personal care workers continuing education needs will enhance practice and improve the quality of care. Improving personal care worker education will address several public concerns about the quality of care in residential aged care facilities.

      Conclusion

      The personal care worker preservice education curriculum is inadequate. Improved personal care worker knowledge and skills are possible when the participants inform the curriculum. Furthermore, if aspirational curricula are designed by potential participants, then continuing education can build ideal practices.

      Keywords

      Abbreviations:

      AI (appreciative inquiry), CE (continuing education), PCW (personal care worker), RACF (residual aged care facility), RN (registered nurse)
      Summary of relevance

      Issue

      Little is known about the suitability of the preservice and continuing education needs of PCWs to meet their educational needs for ideal practice.

      What is Already Known

      PCWs make up the bulk of the RACF workforce. A diverse range of RTOs provide their preservice education. There are differences in their preservice educational preparation.

      What this paper adds

      PCWs and their supervisors are ideally situated to identify the continuing education needs of PCWs working in RACFs. Targeted education that meets the needs of the PCW participants will increase their capabilities to respond to emerging needs. This box does not appear as it does here in the pdf version of the submission. Please could you check that it is complete?

      1. Introduction

      Personal care workers (PCWs) are crucial personnel in the residential and aged care facility (RACF) workforce. They make up most of the RACF employees. They are typically prepared for their role by a registered training authority provider. However, the homogeneity of the RTO curricula is unclear and possibly under-serves the PCWs and in turn their employing organisations. The paper describes an appreciative inquiry (AI) study to explore the continuing education (CE) needs of PCWs. Appreciative inquiry is a philosophy and a methodology that purposefully investigates the functional effectiveness of organisations. The methods used in this study involved the participants in a visioning activity to inspire their thoughts on the ideal PCW and identify the CE needs for best practice.

      1.1 Literature Review

      Australian Government projections for 2050 indicate the aged care workforce will need to quadruple (

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). To fulfil the prediction, Australia will require between 830,000 and 1.3 million workers (
      • Dhakal S.
      • Nankervis A.
      • Connell J.
      • Fitzgerald S.
      • Burgess J.
      Attracting and retaining personal care assistants into the Western Australia (WA) residential aged care sector.
      ;
      • Smith S.
      • Stevens S.C.
      Aged care system workforce: Training quality in NSW.
      ). The aged care workforce is made up of approximately 60%–70% of unregulated Health Care Workers (HCW), also named Personal Care Workers (PCWs), Personal Care Assistants (PCAs), and Assistants in Nursing (AINs) (;

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). The workforce distribution in RACFs is typically 42% comprising of the PCW care team and 14% of nursing supervisors and care providers (
      Australian Institute of Health and Welfare
      Department of Health 2020 Aged Care Workforce Consensus.
      ).
      To support and sustain the increasing demand for quality and safety, the care industry and consumers alike are reliant on a large, dependable, and skilled workforce (
      • Dhakal S.
      • Nankervis A.
      • Connell J.
      • Fitzgerald S.
      • Burgess J.
      Attracting and retaining personal care assistants into the Western Australia (WA) residential aged care sector.
      ;
      • Martyn J.A.
      • Zanella S.
      • Wilkinson A.
      Perspectives from practice: Complexities of personal care workers' education, regulation and practice.
      ;

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). However, there is widespread concern about the workforce's quality, focusing on the knowledge and skill limitations of PCWs and assessing and addressing poor educational practices (

      Australian Skills Quality Authority. (2013). Training for aged and community care in Australia. A national strategic review of registered training organisations offering aged and community care sector training. Retrieved 14 August from https://www.asqa.gov.au/sites/default/files/Strategic_Reviews_2013_Aged_Care_Report.pdf

      ,

      Australian Skills Quality Authority. (2022,. March 22, 2022). ASQA's Regulatory Risk Priorities for 2021–22. Retrieved August 10 from https://www.asqa.gov.au/how-we-regulate/regulatory-priorities/asqas-regulatory-risk-priorities-2021-22

      ;
      • Carryer J.
      • Hansen C.
      • Blakey J.
      Experiences of nursing in older care facilities in New Zealand.
      ). Therefore, an increase in the dependability of the aged care workforce's capacity and capability for safeguarding quality care is required to meet societal expectations (

      Australian Skills Quality Authority. (2022,. March 22, 2022). ASQA's Regulatory Risk Priorities for 2021–22. Retrieved August 10 from https://www.asqa.gov.au/how-we-regulate/regulatory-priorities/asqas-regulatory-risk-priorities-2021-22

      ).
      In late 2018, in response to growing public concern, the Australian Government announced the Royal Commission into Aged Care Quality and Safety (

      Royal Commission into Aged Care Quality and Safety. (2022). About us. Retrieved 14 August from https://agedcare.royalcommission.gov.au/about

      ). The first public hearings held in February 2019 identified staff training, staff levels, and skill mix as key issues (

      Royal Commission into Aged Care Quality and Safety. (2019a., 111 February, 2019). 11 February 2019 – Transcript [DOCX]. Retrieved 14 August from https://agedcare.royalcommission.gov.au/media/10091

      ). Scrutinising, the preparation and practice of PCWs in aged care services are on the Royal Commission's agenda (

      Royal Commission into Aged Care Quality and Safety. (2018). Terms of reference. Retrieved 14 August from https://agedcare.royalcommission.gov.au/about/terms-reference

      ).
      The PCW role is described as expansive and relatively complex (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ;
      • Dhakal S.
      • Nankervis A.
      • Connell J.
      • Fitzgerald S.
      • Burgess J.
      Attracting and retaining personal care assistants into the Western Australia (WA) residential aged care sector.
      ;
      • Martyn J.A.
      • Zanella S.
      • Wilkinson A.
      Perspectives from practice: Complexities of personal care workers' education, regulation and practice.
      ;

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). While providing most of the routine care for residential aged care facility (RACF) residents (
      • Dhakal S.
      • Nankervis A.
      • Connell J.
      • Fitzgerald S.
      • Burgess J.
      Attracting and retaining personal care assistants into the Western Australia (WA) residential aged care sector.
      ;

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ), ideal PCWs must have an adequate level of understanding of care requirements, be able to identify emerging problems (
      • Carryer J.
      • Hansen C.
      • Blakey J.
      Experiences of nursing in older care facilities in New Zealand.
      ;
      • Smith S.
      • Stevens S.C.
      Aged care system workforce: Training quality in NSW.
      ), and deal with challenging behaviours (
      • Carryer J.
      • Hansen C.
      • Blakey J.
      Experiences of nursing in older care facilities in New Zealand.
      ;
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ). Underpinning these requirements are expectations that PCWs will establish rapport and meet residents’ needs (
      • Dhakal S.
      • Nankervis A.
      • Connell J.
      • Fitzgerald S.
      • Burgess J.
      Attracting and retaining personal care assistants into the Western Australia (WA) residential aged care sector.
      ;
      • Prgomet M.
      • Douglas H.E.
      • Tariq A.
      • Georgiou A.
      • Armour P.
      • Westbrook J.I.
      The work of front line community aged care staff and the impact of a changing policy landscape and consumer-directed care.
      ). The PCW role requires interpersonal skills to communicate, negotiate, and respectfully support and advocate for the residents (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ;
      • Prgomet M.
      • Douglas H.E.
      • Tariq A.
      • Georgiou A.
      • Armour P.
      • Westbrook J.I.
      The work of front line community aged care staff and the impact of a changing policy landscape and consumer-directed care.
      ). However, a range of aged care providers, industry regulators, and peak bodies report that current PCW training is not meeting the sector's current skill needs (
      • Dhakal S.
      • Nankervis A.
      • Connell J.
      • Fitzgerald S.
      • Burgess J.
      Attracting and retaining personal care assistants into the Western Australia (WA) residential aged care sector.
      ;

      Leading Age Services Australia. (2018). Submission to the aged care workforce taskforce addressing the five imperatives. Leading Age Services Australia. https://agedcare.royalcommission.gov.au/system/files/2020-06/LAS.0001.0001.0016.pdf

      ;
      • Smith S.
      • Stevens S.C.
      Aged care system workforce: Training quality in NSW.
      ).
      The skill deficit remains despite numerous Registered Training Organisations (RTOs) offering Certificate III and Certificate IV programs (

      Australian Skills Quality Authority. (2013). Training for aged and community care in Australia. A national strategic review of registered training organisations offering aged and community care sector training. Retrieved 14 August from https://www.asqa.gov.au/sites/default/files/Strategic_Reviews_2013_Aged_Care_Report.pdf

      ). Over 90% of PCWs have an entry-level vocational qualification of Certificate III or IV in Aged Care or Individual Support (

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). However, without clear national competency standards nor established career pathways that recognise the work of the PCW, (

      Australian Skills Quality Authority. (2013). Training for aged and community care in Australia. A national strategic review of registered training organisations offering aged and community care sector training. Retrieved 14 August from https://www.asqa.gov.au/sites/default/files/Strategic_Reviews_2013_Aged_Care_Report.pdf

      ;

      Leading Age Services Australia. (2018). Submission to the aged care workforce taskforce addressing the five imperatives. Leading Age Services Australia. https://agedcare.royalcommission.gov.au/system/files/2020-06/LAS.0001.0001.0016.pdf

      ) the workforce's skills and knowledge are incongruent with RACFs organisational needs for the resident care. Hence, the poorly skilled, undervalued, and pressured RACF workforce revealed by the Royal Commission interim report is not surprising (

      Royal Commission into Aged Care Quality and Safety. (2019b). Interim Report: Negelct. Royal Commission into Aged Care Quality and Safety. Retrieved 13 November from https://agedcare.royalcommission.gov.au/publications/interim-report-volume-1

      ). In response to the final report from the Royal Commission, the (

      Commonwealth of Australia. (2021). Australian government response to the final report of the royal commission into aged care quality and safety. Canberra Retrieved from https://www.health.gov.au/sites/default/files/documents/2021/05/australian-government-response-to-the-final-report-of-the-royal-commission-into-aged-care-quality-and-safety.pdf

      ) recommended the skills, knowledge and capabilities of the existing workforce need upgrading along with a review of undergraduate curricula to address any changes in the knowledge, skills and attributes of students.
      In November 2017, in response to industry training shortfalls, and pervasive concerns regarding sustainable training and development in the aged care sector, the Australian Government, established the Aged Care Workforce Strategy (ACWS) Taskforce (
      • Carryer J.
      • Hansen C.
      • Blakey J.
      Experiences of nursing in older care facilities in New Zealand.
      ;

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). Several submissions were made to the Taskforce by lobby groups and peak bodies, advocating a national approach to building and developing viable training frameworks to support aged care providers to deliver quality care (

      Leading Age Services Australia. (2018). Submission to the aged care workforce taskforce addressing the five imperatives. Leading Age Services Australia. https://agedcare.royalcommission.gov.au/system/files/2020-06/LAS.0001.0001.0016.pdf

      ). However, questions continue to be raised about precisely what additions or changes to education, training, and development are needed to meet current demand (
      Aged Care Workforce Strategy Taskforce
      A Matter of Care Australia's Aged Care Workforce Strategy.
      ;

      Leading Age Services Australia. (2018). Submission to the aged care workforce taskforce addressing the five imperatives. Leading Age Services Australia. https://agedcare.royalcommission.gov.au/system/files/2020-06/LAS.0001.0001.0016.pdf

      ).
      The Royal Commission into Aged Care Quality and Safety (2019) will provide recommendations on fundamental aspects of Aged Care such as staff recruitment, education, and training. However, negative perceptions of PCWs as a low-skilled, low status, low paid care workforce in aged care are internationally persistent (
      • Carryer J.
      • Hansen C.
      • Blakey J.
      Experiences of nursing in older care facilities in New Zealand.
      ;
      • Smith S.
      • Stevens S.C.
      Aged care system workforce: Training quality in NSW.
      ). These perceptions continue to impact effective recruitment and retention (
      Aged & Community Services Western Australia Inc
      Career pathways: Aged care workers.
      ;
      • Lai D.
      • Cloyes K.G.
      • Clayton M.F.
      • Doyon K.
      • Reblin M.
      • Beck A.C.
      • Ellington L.
      We're the eyes and the ears, but we don't have a voice: Perspectives of hospice aides.
      ) and compound the concerns around increasing the aged care workforce's capacity and capability (

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ).
      Notwithstanding the RACF workforce challenges, adequate preservice preparation and CE is necessary to maintain knowledge and skills for safe and effective practice. PCWs in RACFs are required to know and do many things and keep abreast of the changing needs of their care recipients (
      Aged Care Workforce Strategy Taskforce
      A Matter of Care Australia's Aged Care Workforce Strategy.
      ;
      Australian Aged Care Workforce Strategy Taskforce
      A matter of care Australia's aged care workforce strategy.
      ;

      Martyn, J. (2016). Continuing education needs of Personal Care Workers in Residential Aged Care Facilities. 1–41.

      ). This paper aims to present the findings from a qualitative appreciative inquiry study that identified the continuing education needs of PCWs in two residential aged care facilities.

      1.2 Participants, ethics, and methods

      A combination of focus group and interview methods were used in this qualitative study based in two RACFs located in regional Queensland, Australia. The aim of the study was to identify the ideal PCW characteristics and explore the CE topics needed to support PCW practice. An appreciative inquiry (AI) philosophy and framework underpinned this study. AI is both a philosophical and methodological approach seeking to find what works well within organisations (
      • Egan T.M.
      • Lancaster C.M.
      Comparing appreciative inquiry to action research: OD practitioner perspectives [Article].
      ). The participants informed the study design through their prospective visioning of the characteristics and educational needs of the ideal PCW. That is, they were asked to imagine and describe the ideal PCW to initiate strengths-based discussions. Prospective visioning in AI studies ensures the participant's perspectives about effective practices are the focus (
      • Shuayb M.
      Appreciative inquiry as a method for participatory change in secondary schools in Lebanon.
      ). AI research acknowledges but does not focus on problems (
      • Egan T.M.
      • Lancaster C.M.
      Comparing appreciative inquiry to action research: OD practitioner perspectives [Article].
      ). Instead, AI methods purposefully investigate positive aspects of organisations to enhance functionality (
      • Egan T.M.
      • Lancaster C.M.
      Comparing appreciative inquiry to action research: OD practitioner perspectives [Article].
      ;
      • Shuayb M.
      Appreciative inquiry as a method for participatory change in secondary schools in Lebanon.
      ).
      The principal author of this paper (JM) was a PhD graduate with experience in Appreciative Inquiry research design. As the chief investigator of all methodological aspects of the study JM led the data collection, research analysis and reporting. The participants were purposefully recruited from two RACFs due to their insider familiarity of the topic, and the accessibility to the facilities. The participants were invited on a flier displayed in the staff break out area. They gave written consent before being involved in any research activities. The interviews and focus groups enabled conversations with two groups of staff. Group 1 participants were in leadership roles, including Clinical Manager (CM), Residential Manager (RM), education coordinators, Registered Nurses (RNs), and Enrolled Nurses (ENs). In these roles Group 1, contributed to the CE of PCWs. Group 1 interviews were privately conducted by the principal author (JM) in the workplace and included a discussion about their perceptions of the education needs of PCWs and how best to meet those needs. Group 2 participants were the RACF PCWs. Group 2 participated in focus groups conducted by JM in a closed meeting room in the workplace. Questions such as, what are the characteristics of the ideal PCW, how do they behave? and what makes them the best? were posed in the focus group brainstorming session to prompt the participant-visioning activity. As the participants identified different attributes, JM scribed the ideas verbatim onto a whiteboard and categorised them under the headings of knowledge, skills and attributes. Hospitality and administration staff were excluded from this study.
      RACF 1 had 110 beds and a greater than 98% occupancy rate with 110 carers consisting of Managers, RNs, ENs, and PCWs. Facility 2 had 100 permanently occupied beds, one occasionally occupied respite bed, and was staffed by 11 RNs, 1 CM, 1 RM, 3 ENs, and 59 PCWs.
      The interview and focus group questions were prospectively designed to identify the knowledge, skills, and attributes of the ideal PCW and then explore the CE topics needed to develop the ideal PCW. Group 2 participants were first asked to describe the knowledge, skills, and attributes of ideal PCWs and then list the CE needs of those PCWs. All interviews were audio recorded and took less than 1-hour to complete. The focus group responses were written on a whiteboard for the participants to reflect on while identifying CE needs.
      The participants prioritised their education needs from the topics listed and described their reason for the ranking. A thematic analysis of the interview and focus group data identified recurring concepts of ideal PCW characteristics, CE topics, and preferred modes of CE delivery. This study was approved by the University of Sunshine Coast Human Research Ethics Committee (Approval no: A/16/824), funded by PHN Central Queensland, Wide Bay, Sunshine Coast, and supported by the host facilities.

      1.3 Findings

      The participants in this AI study shared their insights of the PCW role from their experience in two regional RACFs in Queensland Australia. The AI research philosophy and methods encouraged participants to describe exemplary practices. The findings were categorised throughout the study to highlight what the participants referred to as the characteristics of, and education needed to be ‘best’ PCW. The final category was related to the inadequacy of the preservice education to be the ‘best’ PCWs.

      1.4 Characteristics of the ‘best’ PCW

      Eight PCW supervisors were interviewed. They described the diverse role of the PCW in providing direct care to residents. The complex nature of the carer/resident relationship meant that PCWs were relied on to be the frontline eyes and ears of the RNs. Group 1 wanted the PCWs to have fundamental knowledge and skills to provide care for the residents and to support the RNs. However, in their experience, PCW preservice educational preparation was disparate. They said they [the PCWs] all train differently' because the certificate level programs are inconsistent. The foundational education does not provide them with the level of knowledge and skills required by RACFs. They are all prepared differently.
      Group 1 participants agreed that the 'best' PCW had good interpersonal skills, such as a personality to care and good communication and ethical practice. Group 1 explained that a personality to care was sought at recruitment, saying that PCWs need to have the right attitude to be a good fit and a team player. They said that student placements were an ideal opportunity to observe the practice of PCW students, evaluate them for potential recruitment and identify those student PCWs who had the desired attributes listed in Table 1.
      Table 1Attributes of ideal PCWs identified by Group 1.
      ProfessionalRespectfulReliable
      Person-centredGood CommunicatorNot being task orientated
      AdaptableHolistic approachPeople person
      FlexibleEmpatheticHave career aspirations
      Twenty-three PCWs volunteered to participate in this study. They are Group 2. Group 2 responses agreed with Group 1, but their visioning activity identified several more attributes of the ideal PCW. Like their supervisors, Group 2 focused on the personal characteristics of the ‘best’ PCW. Table 2 outlines the attributes that Group 2 identified, showing that interpersonal and organisational skills featured in their responses more than technical skills or clinical knowledge.
      Table 2Attributes of ideal PCWs identified by Group 2.
      AccountableAware of surroundingsCalm
      CaringCommittedCompassion
      ConfidenceDedicatedEmpathetic
      EntertainingExcellent attention to detailsExcels in the job
      GenuineGood communicatorGood listener
      Good sense of humourGood time management skillsHappy
      Has appropriate knowledge of legislation and clientsHas broad experienceHas initiative
      HumbleKnowledgeableKnows how to prioritise
      Knows how to take care of themselvesManagement enablersOpen
      Punctual/timelyReliable and honestResident care goals
      Respectful of the workplace, families, clients, colleaguesSociableSupportive
      Takes pride in dressTeam playerTransparent
      TrustworthyUses intuition
      There was consensus between Group 1 and Group 2 focussing on the interpersonal and not technical skills of PCWs when they described the knowledge, skills, and attributes of the ideal PCW. For example, skills such as time management and communication were listed but resident care activities such as hygiene, mobilising and feeding did not feature as characteristics of the ideal PCW for these participants. Instead, both groups described the ‘best’ PCW in terms of personal attributes, including caring, compassion, and commitment. Other common attributes of ideal PCWs identified by both groups were respect, reliability, empathy, and good communication.

      1.5 CE to be the ‘best’ PCW

      Group 1 discussed CE about identifying workplace hazards. For example, personal and resident risk management and Occupational Health and Safety. Group 1 identified that PCWs needed to be reminded about topics that they assumed were in the pre-service education program. For example, mouth care and pressure area care and assisting with ADLs and blood glucose monitoring, and taking vital signs. Group 1 recommended short in-service sessions on these topics to refresh the PCWs knowledge and skills.
      Group 2 focus group findings reflected those of Group 1. However, their focus was on Manual and Food handling, Assisting with ADLs, and Infection control. Group 2 listed mandatory training topics offered by the host RACFs as necessary, even though the topics were included in most pre-service education programs. For example, hand hygiene, documentation, and assisting with medications.
      Group 1 explained that the online and written CE packages provided in the workplace were OK but not as effective as learning together. They said PCWs prefer short face-to-face sessions and peer mentoring as the models for delivering education. Group 2 also described work-based, free, and face-to-face education as the best mode of CE delivery.
      Both groups identified several topics that they suggested would enhance PCW practice and enable PCWs to function more effectively in the workplace. The top ten topics recommended are listed below in Table 3. Half of these topics are personal development topics making them related to the earlier findings of the characteristics of the ideal PCW.
      Table 3CE topics to enhance PCW practice.
      Leadership and mentorship skillsTime management skillsMotivation and self-awareness (for example, personal needs and limits)Role recognition (for example, appropriate dress and duty statement)Communication skills: Ability to question and listen; Resume writing
      Mental healthDefensive handling; Restraint and human rights; Behaviour managementManual and food handlingHygieneInfection control; Personal Protective Equipment (PPE)

      1.6 Inadequate preservice education to be the ‘best’ PCW

      Both participant groups agreed that newly qualified PCWs are often not work-ready because of their preservice education limitations. Group 1 acknowledged that PCWs have a desire to learn but they were education starved even though they want to grow. Furthermore, some of the skills identified in Table 1 as necessary for the role were not offered in some RTO curricula. Group 1 participants were unanimous in their opinion that PCWs are the crucial personnel of their facilities, but the Certificate level programs were inconsistent and inadequate to prepare them for their role. For example, anatomy and physiology are needed to understand the specialised care of residents but the preservice programs had gaps in the educational preparedness of PCWs.
      Group 1 was generally dissatisfied with the preservice education of PCWs and, particularly, the short clinical placement timeframes. They said that 80 hours of placement was insufficient to develop the skills needed for good PCW practice. They recalled that 200 practical hours were the norm, but now some placements are 80 hours or less. Group 1 described PCW knowledge and skills shortfalls being realised during student placement or employment commencement. They assumed that topics such as infection control and manual handling were standardised in the preservice education programs of PCWs and added that student placements were too short to evaluate the application of those concepts in practice.
      Overall, the ideal PCW was described in similar terms by both participant groups. They identified the ‘best’ PCW as having advanced communication, interpersonal and teamwork skills. They described the ‘best’ PCW's characteristics as attitudinal and behavioural qualities (Table 2) rather than technical or clinical skills. However, when suggesting the CE to maintain the ideal PCW level, the participants included clinical education, such as manual handling and infection control to make up for the inadequate pre-service educational preparation of PCWs.

      2. Discussion

      These findings reinforce a Royal Commission into Aged Care Quality and Safety preliminary outcomes highlighting the need to focus on PCW education for quality service delivery (

      Royal Commission into Aged Care Quality and Safety. (2019b). Interim Report: Negelct. Royal Commission into Aged Care Quality and Safety. Retrieved 13 November from https://agedcare.royalcommission.gov.au/publications/interim-report-volume-1

      ). PCWs must be adequately prepared through evidence-based CE to respond to residents' emerging needs. However, there was an educational mismatch for these PCWs confirming the findings from other studies (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ) and earlier workforce surveys (

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ) that PCW's educational programs do not adequately prepare them for their role. Some enabling factors for developing a responsive workforce are identified in this study.
      Corresponding to earlier studies, dementia and palliative care were identified as necessary PCW CE (
      Aged & Community Services Western Australia Inc
      Career pathways: Aged care workers.
      ;

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ;
      • Tieman J.
      Hundreds of nurses download new Pallliagednurse app [Advertorial].
      ). Similarly, aggression management and restraint education were ranked highly as learning needs (

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). The majority of PCWs (80%) who responded to The National Aged Care Workforce Survey (2016) (

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ), indicated that they had completed workplace training in the previous 12 months, but it was mandatory training (

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). Mandatory training such as Fire Safety, Hand hygiene, and Elder Abuse, while identified in this study, is intended to meet legislative requirements (

      Aged Care Quality and Safety Commission. (2018). Guidance and resources for providers to support the aged care quality standards. https://www.agedcarequality.gov.au/sites/default/files/media/Guidance_%26_Resource_V11.pdf

      ). Mandatory training does not develop the interpersonal attributes that this and other studies (

      Australian Skills Quality Authority. (2013). Training for aged and community care in Australia. A national strategic review of registered training organisations offering aged and community care sector training. Retrieved 14 August from https://www.asqa.gov.au/sites/default/files/Strategic_Reviews_2013_Aged_Care_Report.pdf

      ;

      Community Services and Health Industry Skills Council. (2015). Environmental scan 2015: Building a healthy future. Retrieved 12th August from http://www.cshisc.com.au

      ) identified as necessary. For example, RACFs want and need capable PCWs with the right attitude to be team players. Interpersonal skills were a prioritised in these findings as foundational for good practice. The PCW supervisors highly regarded personality interpersonal traits over technical acumen. They focused on people skills in addition to qualifications and experience (

      Australian Government. (2015). Personal Care Workers Australia (ISSN: 2201-7070). https://docs.employment.gov.au/documents/personal-care-workers-AUSTRALIA

      ). Ineffective communication and teamwork skills were reported as making PCW applicants unsuitable (

      Australian Government. (2015). Personal Care Workers Australia (ISSN: 2201-7070). https://docs.employment.gov.au/documents/personal-care-workers-AUSTRALIA

      ). Hence, CE focussing on functional or statutory risk mitigation topics rather than those that could develop a compassionate contemporary workforce (
      • Dhakal S.
      • Nankervis A.
      • Connell J.
      • Fitzgerald S.
      • Burgess J.
      Attracting and retaining personal care assistants into the Western Australia (WA) residential aged care sector.
      ;
      • Smith S.
      • Stevens S.C.
      Aged care system workforce: Training quality in NSW.
      ) is minimalistic and short-sighted. Developing the skills identified in this study, although not mandatory training, would enhance the role of PCWs and improve the resident experience.
      PCWs spend significant time communicating with residents while undertaking direct care activities. PCWs have been observed communicating with residents for up to two hours per shift (
      • Qian S.
      • Yu P.
      • Hailey D.
      • Zhang Z.
      • Davy P.
      • Nelson M.
      Time spent on daytime direct care activities by personal carers in two Australian residential aged care facilities: A time–motion study.
      ). This communication is social, instrumental to the task at hand, and essential for consumer-directed care (
      • Prgomet M.
      • Douglas H.E.
      • Tariq A.
      • Georgiou A.
      • Armour P.
      • Westbrook J.I.
      The work of front line community aged care staff and the impact of a changing policy landscape and consumer-directed care.
      ;
      • Qian S.
      • Yu P.
      • Hailey D.
      • Zhang Z.
      • Davy P.
      • Nelson M.
      Time spent on daytime direct care activities by personal carers in two Australian residential aged care facilities: A time–motion study.
      ).
      These findings suggest that the certificate-level preparation of PCWs fails to respond to known educational needs. Additionally, inconsistent RTO curricula lead to confusion about PCW education, training, and scope of practice (
      • Carryer J.
      • Hansen C.
      • Blakey J.
      Experiences of nursing in older care facilities in New Zealand.
      ;
      • Martyn J.A.
      • Zanella S.
      • Wilkinson A.
      Perspectives from practice: Complexities of personal care workers' education, regulation and practice.
      ;
      • Smith S.
      • Stevens S.C.
      Aged care system workforce: Training quality in NSW.
      ). For example, a quick internet search found programs with the same codes and titles, but varying curricula (

      Australian Skills Quality Authority. (2013). Training for aged and community care in Australia. A national strategic review of registered training organisations offering aged and community care sector training. Retrieved 14 August from https://www.asqa.gov.au/sites/default/files/Strategic_Reviews_2013_Aged_Care_Report.pdf

      ;
      • Dhakal S.
      • Nankervis A.
      • Connell J.
      • Fitzgerald S.
      • Burgess J.
      Attracting and retaining personal care assistants into the Western Australia (WA) residential aged care sector.
      ;
      • Martyn J.A.
      • Zanella S.
      • Wilkinson A.
      Perspectives from practice: Complexities of personal care workers' education, regulation and practice.
      ;
      • Smith S.
      • Stevens S.C.
      Aged care system workforce: Training quality in NSW.
      ). Some programs include an elective about assisting clients with medications (

      Austcare. (2020). What does this Cert IV course involve? https://austcare.com.au/ageing-support-cert-iv/

      ), whereas others offer communication (), and yet others offer business technology (). The curricula from the RTO providers are not identical, and surprisingly, communication is not a core course of all programs.
      Adding to the complexity is that PCWs prefer education delivered face to face (f2f) (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ) but RTOs and RACFs alike are opting for more online modes. The Internet search revealed an RTO delivering content in 1228 hours of online self-paced course work, including vocational placement (). Another offers 1235 hours of content in blended and online modes (). Some have a practical component requirement including 120 hours of vocational placement in the delivery hours of the program (), and others add mandatory in-class activities (

      Austcare. (2020). What does this Cert IV course involve? https://austcare.com.au/ageing-support-cert-iv/

      ). So, based on these findings, the pre-service education limitations are greater than curriculum gaps alone. Hence, the educational standards of PCW graduates are diverse.
      Such variation in PCW education leaves little doubt that RACFs must bear the burden of upskilling their core staff 'on the job,' often through episodic facility-specific educational activities (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ). Providing funding for more prospective rather than retrospective approaches to PCW CE would enhance the quality of care because RACF residents are a diverse group with complex needs (

      Australian Institute of Health and Welfare. (2020a). Australia's health 2020 data insights. (Australia's health series no. 17. https://www.aihw.gov.au/getmedia/be95235d-fd4d-4824-9ade-34b7491dd66f/aihw-aus-231.pdf.aspx?inline=true

      ). RNs rely on feedback from PCWs to plan appropriate resident care (
      • Lai D.
      • Cloyes K.G.
      • Clayton M.F.
      • Doyon K.
      • Reblin M.
      • Beck A.C.
      • Ellington L.
      We're the eyes and the ears, but we don't have a voice: Perspectives of hospice aides.
      ). PCWs deliver most of the direct care and despite being described as the crucial ‘eyes and ears’ of the RN in this and other studies (
      • Lai D.
      • Cloyes K.G.
      • Clayton M.F.
      • Doyon K.
      • Reblin M.
      • Beck A.C.
      • Ellington L.
      We're the eyes and the ears, but we don't have a voice: Perspectives of hospice aides.
      ;

      Martyn, J. (2016). Continuing education needs of Personal Care Workers in Residential Aged Care Facilities. 1–41.

      ) their contributions to care planning are overlooked. In some instances, because of their proximity to the residents, PCWs provide first aid and rescue residents from deterioration (
      • Shi C.
      • Xu Y.
      • Chen Y.
      • Pu H.
      • Yu Q.
      • Wu X.
      • et al.
      Perceptions and experiences of risk management by managers of residential aged care facilities: A qualitative study from Hunan Province, China.
      ). For this reason, they must know what to do when facing an emergency (
      • Shi C.
      • Xu Y.
      • Chen Y.
      • Pu H.
      • Yu Q.
      • Wu X.
      • et al.
      Perceptions and experiences of risk management by managers of residential aged care facilities: A qualitative study from Hunan Province, China.
      ). Despite this valuable contribution to resident care and safety, PCWs remain inherently undervalued by unclear and inconsistent roles (;
      • Graham F.
      • Eaton E.
      • Jeffrey C.
      • Secher-Jorgensen H.
      • Henderson A.
      Specialling” and “Sitters”: What does communication between registered nurses and unregulated workers reveal about care?.
      ;
      • Lai D.
      • Cloyes K.G.
      • Clayton M.F.
      • Doyon K.
      • Reblin M.
      • Beck A.C.
      • Ellington L.
      We're the eyes and the ears, but we don't have a voice: Perspectives of hospice aides.
      ), inadequate education (
      • Martyn J.A.
      • Zanella S.
      • Wilkinson A.
      Perspectives from practice: Complexities of personal care workers' education, regulation and practice.
      ) and unregulated except for the Health Worker Code of Conduct (;

      Australian Health Minister's Advisory Council. (2014). A National Code of Conduct for health care workers. http://www.coag.gov.au/Health

      ) which barely applies to their practice (
      • Martyn J.A.
      • Zanella S.
      • Wilkinson A.
      Perspectives from practice: Complexities of personal care workers' education, regulation and practice.
      ). The absence of explicit communication results in ineffective care (
      • Graham F.
      • Eaton E.
      • Jeffrey C.
      • Secher-Jorgensen H.
      • Henderson A.
      Specialling” and “Sitters”: What does communication between registered nurses and unregulated workers reveal about care?.
      ). Similarly to other studies, the PCWs in this study demonstrated their value by functioning as an extension of the ‘eyes and ears’ of the RNs (
      • Graham F.
      • Eaton E.
      • Jeffrey C.
      • Secher-Jorgensen H.
      • Henderson A.
      Specialling” and “Sitters”: What does communication between registered nurses and unregulated workers reveal about care?.
      ).
      Purposeful communication between the PCW and the RN to deliver details about the condition of the residents is essential for quality care. However, as described by
      • Graham F.
      • Eaton E.
      • Jeffrey C.
      • Secher-Jorgensen H.
      • Henderson A.
      Specialling” and “Sitters”: What does communication between registered nurses and unregulated workers reveal about care?.
      , this benefit that the PCW role offers the RN in care planning is sometimes undervalued demonstrating a deficit to realising the potential of the PCW role in all health care contexts. Furthermore, there is a risk of PCWs working outside their scope of practice and placing residents at risk if they are not adequately prepared for their role and involved in care planning (

      Australian College of Nursing (ACN). (2019). Regulation of the Unregulated Health Care Workforce across the Health Care System – A White Paper by ACN 2019. https://www.acn.edu.au/wp-content/uploads/white-paper-regulation-unregulated-health-care-workforce-across-health-care-system.pdf

      ).
      Neglecting PCW educational needs is significant. It contradicts the public demand for strengthening the aged care workforce to improve quality and bring together partnerships between the health, education, and training sectors (). Prospective and proactive approaches for contemporary curriculum design of PCW pre-service education is an essential quality improvement (

      Commonwealth of Australia. (2021). Australian government response to the final report of the royal commission into aged care quality and safety. Canberra Retrieved from https://www.health.gov.au/sites/default/files/documents/2021/05/australian-government-response-to-the-final-report-of-the-royal-commission-into-aged-care-quality-and-safety.pdf

      ). Moreover, recognising the valuable role of PCWs in delivering safe and quality care in RACFs must be a priority (

      Commonwealth of Australia. (2021). Australian government response to the final report of the royal commission into aged care quality and safety. Canberra Retrieved from https://www.health.gov.au/sites/default/files/documents/2021/05/australian-government-response-to-the-final-report-of-the-royal-commission-into-aged-care-quality-and-safety.pdf

      ). Thus, examining the quality of their curriculum and the educational providers is paramount to ensuring the PCW preparedness for practice (

      Commonwealth of Australia. (2021). Australian government response to the final report of the royal commission into aged care quality and safety. Canberra Retrieved from https://www.health.gov.au/sites/default/files/documents/2021/05/australian-government-response-to-the-final-report-of-the-royal-commission-into-aged-care-quality-and-safety.pdf

      ).
      No assumptions can, nor should be made about the preservice preparation of the PCW workforce. And there is no greater need, since the COVID-19 pandemic, that the quality of PCW education should be guaranteed. For example, all health personnel should understand and practice infection control principles (

      Aged Care Quality and Safety Commission. (2018). Guidance and resources for providers to support the aged care quality standards. https://www.agedcarequality.gov.au/sites/default/files/media/Guidance_%26_Resource_V11.pdf

      ;

      Australian Skills Quality Authority. (2013). Training for aged and community care in Australia. A national strategic review of registered training organisations offering aged and community care sector training. Retrieved 14 August from https://www.asqa.gov.au/sites/default/files/Strategic_Reviews_2013_Aged_Care_Report.pdf

      ;

      Royal Commission into Aged Care Quality and Safety. (2019b). Interim Report: Negelct. Royal Commission into Aged Care Quality and Safety. Retrieved 13 November from https://agedcare.royalcommission.gov.au/publications/interim-report-volume-1

      ). But online delivery of infection control education cannot guarantee that the principles are understood for application or even that the intended participant completed the education. The rigour and integrity of PCW online learning must be regulated if RACFs are relying on it to educate their largest workforce.
      The Royal Commission's focus has been on technical and organisational problems (

      Royal Commission into Aged Care Quality and Safety. (2019c). Interim report: Neglect. Retrieved 14 August from https://agedcare.royalcommission.gov.au/sites/default/files/2020-02/interim-report-volume-1.pdf

      ). But, these findings confirm larger studies that indicate interpersonal skills are most valued in a PCW by their employer (

      Mavromaras, K., Knight, G., Isherwood, L., Crettenden, A., Flavel, J., & Karmel, T. et al. (2017).The aged care workforce, 2016. 2022(14 August). https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf

      ). By acknowledging the beneficial contributions of the PCW in communicating resident conditions to the RN, deterioration can be recognised and resolved earlier (
      • Shi C.
      • Xu Y.
      • Chen Y.
      • Pu H.
      • Yu Q.
      • Wu X.
      • et al.
      Perceptions and experiences of risk management by managers of residential aged care facilities: A qualitative study from Hunan Province, China.
      ).
      PCW CE is fundamental to meeting the dynamic complexities of care recipients in RACFs (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ;
      • Grealish L.
      • Henderson A.
      • Quero F.
      • Phillips R.
      • Surawski M.
      The significance of 'facilitator as a change agent' - organisational learning culture in aged care home settings.
      ). The PCWs in this study identified and prioritised their learning needs supporting other studies that CE should be designed and delivered to meet emerging learning needs for the topic and delivery style of the participants (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ). For example, reflecting these findings,
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      through surveys and interviews of 51 health care workers in six metropolitan and rural aged care facilities in New South Wales and Western Australia, found that education that is relevant to everyday practice and situated in the workplace was preferred.
      Buddying and practice-based experience with mentors' guidance was also desired over online or paper-based educational resources (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ). Thus, reinforcing the need to avoid relying on online learning. Likewise, and supported by this Queensland-based study individualised CE will improve PCWs impetus to engage in learning (
      • Choy S.
      • Henderson A.
      Preferred strategies for workforce development: Feedback from aged care workers.
      ). So, promoting CE in the aged care industry that involves the PCWs in their education, as demonstrated in this study is progress because PCWs tend to rely on the employer to provide any necessary CE. The consequence of ignoring the contemporaneous education needs of the PCW workforce in their role as primary carers and the RN's informants is that care could be suboptimal.
      The PCWs in this study identified face-to-face delivery as the preferred method of CE delivery but there are limited CE providers. This lack of access to CE providers is a theme highlighted by several commentators in the field of aged care (

      Royal Commission into Aged Care Quality and Safety. (2019b). Interim Report: Negelct. Royal Commission into Aged Care Quality and Safety. Retrieved 13 November from https://agedcare.royalcommission.gov.au/publications/interim-report-volume-1

      ; ). Therefore, employer-driven CE is implemented to address the gap, which adds to RACFs financial burden. This situation is untenable.

      3. Implications for practice

      If the mismatch of PCW pre-service preparation and lack of CE persists, the circumstances in RACFs will not change despite public demands to the contrary.
      Individualising the CE for PCWs to address the educational nuances needed to deliver quality care would be a prospective action to address some of the Royal Commission's concerns. Thus, reducing incongruence between what is required to be a good PCW and what is provided as pre-service education and mandatory workplace training and enabling the workforce to enhance capacity.

      3.1 Limitations

      The study was limited to two RACFs in regional Queensland. Therefore, the findings are not generalisable even though they reflect the themes of other studies. Additionally, the perspective of the RACF residents was not sought in this study. Future research about the knowledge skills and attributes of the ideal PCW should include residents' perspectives because they are the recipients of care.

      3.2 Recommendations

      RTO curricula need to be revitalised and standardised to meet the emerging needs of PCWs rather than retaining historical content. Also, by focussing on the aspirational aspects of PCW practice education, practice, and policy and be primed and agile to deliver contemporary curricula and PCWs for best practice. Meanwhile, resourcing RACFs is essential to improve practice standards. For example, RACFs can socialise PCWs and train them, but funding models must be adjusted to resource these activities. Lastly, regulation of the workforce is needed to establish standards of education and practice (

      Australian College of Nursing (ACN). (2019). Regulation of the Unregulated Health Care Workforce across the Health Care System – A White Paper by ACN 2019. https://www.acn.edu.au/wp-content/uploads/white-paper-regulation-unregulated-health-care-workforce-across-health-care-system.pdf

      ;
      • Graham F.
      • Eaton E.
      • Jeffrey C.
      • Secher-Jorgensen H.
      • Henderson A.
      Specialling” and “Sitters”: What does communication between registered nurses and unregulated workers reveal about care?.
      ).

      4. Conclusion

      PCWs and RACF supervisory staff identified a set of characteristics and factors describing the ‘best’ PCW practice. However, PCWs' practice capability is hindered by gaps in their educational preparation and access to appropriate CE. Therefore, CE is needed for PCWs to reach the aspirational practices identified in the literature, and the public domain. Only when this issue is satisfactorily addressed will the quality-of-care issues raised by the Royal Commission into Aged Care Quality and Safety be minimised.

      Declaration of Competing Interest

      None.

      Funding

      This research was funded by the Central Queensland, Wide Bay, Sunshine Coast PHN.

      Ethical statement

      The authors confirm that this study had ethical approval from the University of Sunshine Coast Human Research Ethics Committee (Approval no: A/16/824), QLD, Australia. The study design and methods adhered to parameters explained in the ethics application. The participants gave informed consent.

      Acknowledgements

      This study was made possible because of research participation by the PCWs and their supervisors. The participants are acknowledged as creating the knowledge generated by this appreciative inquiry.

      Disclosures

      This study was approved by the University of Sunshine Coast Human Research Ethics Committee (Approval no: A/16/824), funded by PHN Central Queensland, Wide Bay, Sunshine Coast, and supported by the host facilities. There are no conflicts of interest for any of the authors.

      Financial Disclosure

      Nil.

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