The Royal Commission into Aged Care Quality and Safety delivered its final report in early March 2021. Although none of the findings were particularly surprising, the report was highly critical of past and current practices. There have been so many reports – over so many years – of substandard care for older Australians that we are no longer taken aback by each new revelation.
Indeed, if we are shocked and outraged, it is mostly because little has changed since the last enquiry. As the report’s Executive Summary noted, “The same issues have arisen repeatedly in these reviews without being resolved.”
- The report’s recommendations
- What is a clinical learning environment?
- The Best Practice Clinical Learning Environment initiative (BPCLE Framework)
- The quality of the learning environment is closely related to the quality of the care environment
- Implementing the BPCLE Framework in aged care would bring many benefits
The report’s recommendations
The Royal Commission identified numerous systemic problems in the aged care system and made nearly 150 recommendations. Most of these relate to how aged care is funded, governed and regulated.
However, the Commissioners also noted that “Inadequate staffing levels, skills mix and training are principal causes of substandard care in the current system”. Chapter 12 of the report specifically examines the aged care workforce, delivering 13 recommendations.
Although this represents less than ten per cent of the report’s 148 recommendations, how these are addressed may be essential to whether the aged care system improves or not. Specifically, improving the quality of the education and training for the workforce – particularly work-based placements in aged care contexts – is likely to be a leading indicator for improvements to the delivery of aged care services.
My views on this issue have been shaped by more than 12 years spent working on improving clinical learning environments for health professionals.
What is a clinical learning environment?
For those who may be unfamiliar with this, a “clinical learning environment” is any care delivery setting that provides a “placement” or “rotation” or “fieldwork” for a learner. In some sectors, this is called “work-based learning” or “work-based experiential learning”. Placements can be for a few hours, days or weeks, up to many months at a time.
We usually think of students enrolled in university or Vocational Education & Training (VET) courses when we think of clinical placements and clinical education. But it is not just undergraduate or entry-to-practice level learners that undertake clinical education. Qualified health professionals completing internships, postgraduate courses or vocational/specialist training, and some continuing professional development (CPD) courses usually include a practice-based component. Indeed, internships and specialist training are almost entirely work-based learning.
Since work-based learning is central to developing the knowledge, skills and expertise of health professionals, it is not surprising that the environment in which this learning occurs is critically important.
The Best Practice Clinical Learning Environment initiative (BPCLE Framework)
In 2008, the Victorian Department of Human Services (now the Department of Health) contracted me to research and then develop a framework to guide the development and maintenance of high-quality learning environments for health professional learners. The resulting framework – the Best Practice Clinical Learning Environment (BPCLE) Framework – is now used across Victoria. All public hospitals, registered community health services and about 150 community services across the state are using the framework. Several other Australian jurisdictions are just starting to come on board as well.
I have remained involved with the BPCLE initiative since that first project. There were three more projects – to validate the framework, develop resources and establish performance indicators – followed by a pilot implementation project. We worked with 11 organisations across the state for the pilot – including one residential aged care facility – and trialled an implementation process and tools. This led to the development of an online implementation tool, BPCLEtool, which we maintain.
Importantly, this ongoing involvement has given me a front-row seat in observing how the quality of the clinical learning environment reflects what is happening in the organisation more broadly. To understand why this is the case, it helps to know a little bit about the framework.
The BPCLE Framework includes six elements that are the essential underpinnings of a high-quality learning environment. These are:
- An organisational culture that values learning
- Best practice clinical practice
- A positive learning environment
- An effective health service – education provider relationship
- Effective communication processes
- Appropriate resources and facilities
As you can see from the list of BPCLE elements, there is considerable overlap between the things that contribute to a great learning environment and the things that are likely to be important to delivering high-quality services.
For example, an organisational culture that values learning will value “formal” learning that involves students and supervisors/educators and value “informal” learning that encourages managers and staff to reflect on and learn from routine practice to enable continuous quality improvement. Likewise, best practice clinical practice is important to ensure safe and high-quality care for patients and model best practice to learners. A positive learning environment that is welcoming and safe for students will also be an environment that is welcoming and safe for staff. And, of course, effective communication processes underpin all activities in any organisation.
One of the most interesting things I observed about organisations that have implemented the BPCLE Framework is that it has only been through assessing the quality of their learning environment that they became aware of these issues that are fundamental to the quality of their healthcare services as well.
This is why I believe that addressing the quality of learning environments in aged care settings could be a great place to start for organisations seeking to improve aged care service delivery quality. And this is important because it’s not entirely clear how the Royal Commission report will help individual aged care organisations improve their services at the coalface.
Reports from reviews don’t always help individual organisations improve
We have seen many instances where Royal Commissions or other reviews have produced large numbers of recommendations, many of which relate to governance and regulation issues. What usually happens is that governments – at state or federal level – set up all kinds of agencies, statutory bodies, task forces, frameworks and standards to improve governance and regulation. We end up with a system that is very good at talking about what should be done and very good at identifying organisations that don’t measure up against the standards. But that system is quite poor at helping organisations with the practical steps of improving what they do.
On the other hand, when health services implement the BPCLE Framework, they have structured conversations about the practical things they need to have, to achieve the objectives for each of the six elements of the framework. These structured conversations – involving managers and frontline staff – provide a strong foundation for improvement.
Implementing the BPCLE Framework in aged care would bring many benefits
If aged care organisations were to implement the BPCLE Framework, those same conversations would help them identify where there are issues that impact the quality of the learning environment and the quality of the care environment. And as I mentioned earlier, we already know that aged care organisations can successfully use the BPCLE Framework, based on the pilot project conducted several years ago.
There’s an important benefit to taking what appears to be an indirect approach to improving aged care quality. The Royal Commission’s recommendations about improving the skills and training of the aged care workforce cannot be successfully implemented if aged care organisations cannot provide high-quality learning environments.
And this is not only true for professionals who are specifically and exclusively working in aged care. This is equally true for professionals who occasionally work with aged care recipients but must receive high-quality learning opportunities in senior care settings as part of their broader education and training.
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With the Royal Commission identifying the need for a “paradigm shift” in how the aged care system operates, perhaps this is also the opportunity to shift the paradigm as we think about the best way to approach this task. Instead of seeing education and training as a secondary add-on to the “core activities” of delivering care, there could be significant benefits to placing education and training front and centre in our efforts to improve the system.
Because when we create excellent environments in which to train a high quality aged care workforce, we are also creating exceptional environments for attracting and retaining staff and, most importantly, ideal environments for the delivery of care. And fortunately, a best practice framework that can be used for this purpose already exists.