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The Aged Care Sector: breaking the rules well

Friday, 7 June 2019  | Karly Michelle Edgar

The imago Dei or image of God is the beautiful and foundational understanding of how we as Christians are called to interact with other members of humanity

So God created human beings in his own image, in the image of God he created them. (Genesis 1:27)

While we are not identical to the triune God, we are similar to God. Our reflection of God is held in our very essence of being created in the image of, and by, God, and we cannot lose it. We do not acquire the image of God when we reach some point of faith, although we may develop our likeness to Christ over our time of faith. Imago Dei should be the foundational structure on which we build all of our understanding about, and communication with, others.

Without exception, the imago Dei offers dignity to all. Respect and dignity are easy to offer to those who are well, productive, active and similar to ourselves, and to those of whom it might be said that they are ‘pulling their weight’. But when offering dignity requires effort, its importance can, unfortunately, lag behind a whole host of other things.

This article emerges out of my frustration with an underlying lack of dignity and respect in the treatment of those living within aged care facilities. I am not referring to the terrible and outright instances of abuse by staff that have already come to light during the Royal Commission and that require a great deal of attention, but rather to a pervasive and underlying missing link in the expectations of how jobs are carried out, and the training process of staff that influences the expectation of what offering respect and dignity look like within aged care.

I recently re-trained and began working as a lifestyle assistant[1] in an aged and disability care facility and so I come to this as a new member of the sector. I recognise that I have much yet to learn. These are some thoughts I have from still being a relative ‘outsider’. I have completed multiple higher education degrees and VET (Vocation Education and Training) certificates, have lectured in the tertiary system and am about to begin teaching in the VET sector (in leisure and health). All of these influence how I view this issue.

The VET Sector

While there are a number of issues that could be addressed with regard to aged care (expectations of management, more money, more staff, more training etc.), I would like to focus on the impact of the training of VET sector workers. The model used within the VET sector to train the majority of aged care workers, specifically PCAs (Personal Care Assistants), nurses and lifestyle staff, is competency-based training. It teaches what to do and how to do particular skills. It does not encourage significant reflection on why we are doing what we do or how to think about the broader issues.

This means we are not encouraging workers to develop their ability to break the rules well. This is not rule-breaking for the sake of rule-breaking, or laziness, but rule-breaking because sometimes rules are outdated and need to be questioned and re-evaluated. Instead, we have a sector that cares for very vulnerable people by continuing to be primarily focused on a ‘cure’ model for people who most likely require as much ‘care’ as ‘cure’. Aged care is not a health industry where we expect people to make a ‘full recovery’ (although improvements are frequently made). Elderly people may require significant and complex medical attention, but being elderly is also their life. They still need to be able to live their life in a way that gives them dignity and respect.

Encouraging thoughtfulness and consideration about why and how we do what we do could be instrumental in advocating for the recognition of the imago Dei in all people and, in particular, in the training of workers for the aged care sector.

Aged care facility staff

Within a regular aged care facility there is a wide variety of workers, such as managers, nurses, PCAs, lifestyle staff, laundry staff, maintenance staff, administrators, cooks and cleaners.[2] For the purposes of this article, I am primarily considering three positions - nurses, PCAs and lifestyle staff - as they have the most constant day-to-day contact with residents. All the points I make here can also relate to management, however they often enter the sector via a path other than VET training and many do not have any specific training or experience in aged care (or dementia), which is an issue in itself that I will not address in this article.

It is important to acknowledge that this is a sector broadly populated by low-paying positions. Raising incomes may have a big impact on the commitment workers have to employers and those they care for. An increase in proportion of staff (nurses, PCAs and lifestyle workers) to residents would also make a big impact on the quality of care that can be offered. The enemy of care is being rushed.

Breaking the rules well

As mentioned above, only a small portion of VET sector training explores why things are done the way they are done or the implications for how we do what we do.

I understand the competency focus. We need to know how to do certain skills well. In carpentry it is good to learn how to correctly use the tools when sawing wood. In nursing it is good to learn how to give medication correctly. Similarly, in PCA work it is good to learn how to do manual handling correctly. In all of these skills, following the rules allows you to do a good and safe job without losing a finger, handing out the wrong medication or people being dropped when assisting them. These competencies need to be learnt and then carefully followed.

There are times, however, when the ability to break the rules well can be just as important. One class in my Cert IV in Leisure and Health training highlighted this. We were asked to practice communication within the team. We were given a fictional scenario about a woman who was having an affair. She snuck out one night to go to the house of the man she was having an affair with, was kicked out by him, couldn’t find transportation, had to walk home in the middle of the night and was raped.

Our task was to personally list the various people in the scenario who were responsible for her rape in order of responsibility. I filled in number 1 with the person who raped her and left it at that. The person next to me saw this and said, ‘you have to fill out all the numbers’. I said I wasn’t going to because no one else was responsible. She filled out a few more spaces because they were the rules of the exercise, but interestingly not all of them, just the top 3. Our next task, in small groups, was to come to a group consensus on the list. Everyone else, bar the ex-copper who also had only listed one person, had listed numerous people.

What concerned me the most was that we did not actually spend any time in class discussing the ethics of victim-blaming, or consent, or the value of life, or anything else like that, because this was a class about team communication. And the ex-copper and I were the only two students to ‘break the rules’ and question the aim of the exercise.

The importance of encouraging people to continually think about why we are doing what we are doing can be just as important as teaching a skill where the rules must be followed. Encouraging thoughtfulness in why things are done this way, how things are done and, in general, how to think about an issue develops our ability to assess when we may or may not consider breaking the rules well. Ideally it would also encourage everyone in caring roles, even those who may not have an understanding of the imago Dei, to give considered thought to their own understanding of what care and respect for others mean and how this might effect their work.

In my experience, those in care positions do not treat people without consideration because they are being deliberately cruel. Rather, I think dignity is not given because staff are rushed and are under pressure, because dignity has not been highlighted as important in their training, because they do not have the time to be thoughtful about what they are doing, because they feel insecure in their jobs and because they simply must get task done and there are literal boxes that must get ticked. This is a pressure I see every day in my work. The focus in training is on getting the job done because this is what is expected by the industry, not on how getting the job done affects the resident. An example a manager gave recently is of someone who brought in a resume looking for a PCA job. She came back to see why she had not been given an interview and in conversation gave as her best quality the ability to give five showers in one hour. Having a numerical basis as your best quality denies the value that needs to be given to individual people – how much dignity is there in being given a shower where the focus is on getting to the next person? This allows no consideration for the individual needs, physical and psychological, of people when they are in such vulnerable position as requiring assistance when having shower. And yet this is the focus that the job hunter’s training had clearly highlighted.

Another example is the lack of expectation of dementia training for nurses and PCA staff (this also applies to management), despite the fact that ‘more than 50% of residents in Australian residential aged care facilities have dementia’.[3] Dementia training is more common within leisure and health training, but while this is a good thing, it is concerning that the (trained[4]) lifestyle staff in many facilities may have the most official training in dementia care of all the staff. (I recognise that some nurses may have done specialised training, but not all. My understanding is that PCA courses in general do very little specialised training. Without a doubt this influences the carer’s understanding of dementia behavior.) One exception to this is the University of Tasmania, which is now offering a free online course called ‘Understanding Dementia MOOC’,[5] which more workers are starting to do.


What all of this means is that we end up with almost an entire sector of workers who are not in a financial position to resign if they, or their residents, are not being treated with respect, because they fear they might not be able to find another job. They may also believe that this lack of respect is the same everywhere, therefore there is no point in changing jobs. This is also a sector where an entire group of workers have been trained only to follow the rules and get the job done, and that has not widely encouraged (or acted upon) suggestions for breaking the rules well (i.e. improvements). Why would anyone continue to make suggestions for improvements if they are not confident that they will be taken seriously, or if they can do so without fear of losing their job?

I recognise there are no simple solutions. Rather, this is more of a call to modify our approach to aged care, something that hopefully the current Royal Commission will help bring about. For it is by our care for those who are vulnerable and cannot demand respect for themselves that we have the opportunity to fully demonstrate our understanding of the imago Dei. This sector needs people who can think deeply about the value of human life and about how to demonstrate respect in everything they do: from the way people are spoken to and the way they are assisted in living, to the expectations we do or do not place on how they live and the time that is given to assist them. It needs people who can question why tasks are done a certain way and then, ideally, suggest improvements if needed. Because sometimes the most respect we can offer someone is to break the rules well for them.

Karly Michelle Edgar is a visual artist, trained in theatre, currently working as a lifestyle assistant in the aged care sector with an interest in dementia care. Her current project is the ‘One a Week Psalms Project’. More at www.karlymichelle.com.

[1] I did a Cert IV in Leisure and Health.

[2] This does not take into account those who provide particular medical care who generally are not employees of the facility such as physiotherapists, doctors, podiatrists etc.

[4] Not yet a requirement for gaining a lifestyle position.

[5]https://www.utas.edu.au/wicking/understanding-dementia. This is a very good course and I encourage anyone with any connection to those with dementia, personally or professionally, to do this.

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