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Aged care does not need change, it urgently requires transformation. It’s like an old house that is beyond renovating, so it will be easier and more cost effective to knock it down and start again from a stronger foundation.
As I was starting my journey in nursing thirty years ago, person centred dementia care and learning culture were hot topics and the attention of much research. Peter Senge introduced concepts like team learning, shared vision and systems thinking as part of the development of learning culture, which led to what became called learning organisations (Senge 1990). Around the same time Tom Kitwood brought us Person Centred Dementia Care (Kitwood 1997).
In my view, since the 1990s, both person centred care (PCC) and learning culture have been considered as ‘done.’ What I mean by that is that everyone says they have a learning culture and all providers claim to provide this thing called PCC. In reality both are lauded as if they are the default in aged care organisations. Actually, these organisations are like the Emperor showing off his ‘new clothes.’ (Anderson 1837). They are a disingenuous fairytale and it’s beyond time for aged care providers, the Emperors in their corporate ivory towers, to look at themselves in the mirror!
"It is conceivable that most of the advances that have been made in recent years might be obliterated, and the state of affairs in 2010 might be as bad as it was in 1970, except that it would be varnished by eloquent mission statements and masked by fine buildings and glossy brochures."
A quarter century on and we have plenty of glossy brochures and nice hotel-like buildings in which we segregate people from their community and lock many up, for spurious reasons. The term PCC itself has fallen into such ubiquitous use it is rendered meaningless. Indeed, David Sheard (a guest speaker at OTD meeting 4) said the term has been “hijacked” and that we should stop talking about care to people and value support for strengths remaining. We should stop educating about what dementia is, remove the ‘us and them,’ the transactional, task-oriented approach and move towards support built on emotional intelligence. Effectively we need to return to the authenticity of Kitwood’s notion of ‘a moral education.’(Sheard 2024).
This correlates to calls to hire people for attitude and then mentor or coach them, which was a thought reiterated by Dr Rodney Jilek in OTD Meeting 7, and considered one of the successes of Community Home Australia. He said this is important in harnessing the skills of culturally diverse team members, often taught to not use their inherent cultural propensity for caring in other organisations (Jilek 2024).
Sheard cautioned OTD2030 that it is very difficult to start conversations about failed systems and change when so many people in aged care are working tirelessly and passionately every day to support people with dementia (Sheard 2024). It is important OTD2030 recognises this and adopts an egoless, no blame approach emphasising the failure of the system is not a failure of many people involved within it, and we need to keep moving forward together in the face of negativity and resistance to change. Those people, including many of you reading this, will be frustrated that you know what is needed and many of the solutions, and have been working at these exact things, too often in isolation, and perhaps have felt like with one hand tied behind your back? OTD2030 is a safe space to acknowledge your commitment and help you effect change in your setting. This is another important element of a learning culture. At the least OTD2030 can help you begin conversations about opening doors, both figurative and literal in your setting by 2030.
In 2024 then, people with dementia in long term care remain misunderstood and so, like things we don’t understand, we hide them away and segregate them in locked units. These are some times erroneously called memory support units (MSUs), even though not all forms of dementia involve memory loss. Let’s be honest, there is not much memory support going on and the environment is wholly counter-productive to person centred support. People with dementia who are locked in together with other people are continuously in the fight or flight response. Their sympathetic autonomic nervous systems are constantly telling them they are in danger, and perception is their reality. Environmental seclusion and restraint using drugs to somehow try to ‘manage’ this so-called behaviour (which is a natural reaction to the situation) will only add to the anxiety and agitation and create a vicious downward cycle. This is what I call the Cycle of Unmet Needs and is the opposite of best practice (Page 2023). True support in a community using emotional intelligence and a relationship-based approach may not completely eliminate all distress but is shown to significantly reduce it. In Allen Power’s words at OTD Meeting 5, it “turns down the boiling the kettle,” so that when incidents do arise they are more easily resolved by the team (Power 2024).
Learning culture is not about more courses or how great the learning management system is in recording compliance. It is not about the quantum of learning but the impact it has on support and life quality. He suggests 3 vital ideas that resonate strongly with aged care:
Culture is everything! We cannot expect our teams to be emotionally intelligent and build meaningful relationships with residents if we don’t role model this and provide meaningful roles and locus of control for our team members; all our team members. Without a learning culture there cannot be PCC, and the truth is most organisations delude themselves they have both and wonder why they have a revolving door of people coming in then leaving! Residents come second; team members must come first. While this is not a novel idea, it has not been the norm in aged care. This must change.
Residents come second; team members must come first. While this is not a novel idea, it has not been the norm in aged care. This must change.
OTD2030 meetings showcase some of the most innovative ideas from around the globe so we all have rapid access to knowledge we might want to try in context. We gather and synthesise as much as we can, our monthly meetings have generated great insights and we thank the amazing guest speakers for their time and passion. Between each meeting we have recently launched Keys to the Doors meetings which unpack the issues around a chosen topic and explore what is working well, what the barriers are, and how we can work collaboratively to provide solutions. So, part movement, part resource: A Comm-Unity of best practice! And, importantly, a genuine learning culture which is the foundation for relationship-based, emotionally intelligent, person-centred support. All organisations would do well to borrow and adapt whatever they can from OTD2030 and the wealth of knowledge its members and supporters are only too happy to share.
