Workforce training needs to address social and emotional wellbeing in home-based Aboriginal and Torres Strait Islander aged care
Adriana Parrella A B * , Jonathon Zagler
A B , Matilda D’Antoine A , Tina Brodie A B , Kate Smith C , Aunty Martha Watts D , Tameeka Ieremia E , Graham Aitken E , Alex Brown F G and Odette Pearson A B
A
B
C
D
E
F
G
Abstract
To explore the training needs of the home care workforce in supporting the social and emotional wellbeing (SEWB) of Aboriginal and Torres Strait Islander peoples receiving aged care services through the Home Care Package (HCP) Program.
A mixed-methods design including (1) a focus group and interview with coordinators of HCP Program services for Aboriginal and Torres Strait Islander peoples across metropolitan and rural South Australia in April and June 2022, and (2) a desktop review of training, professional development opportunities and resources for existing and pre-entry workforce addressing the SEWB of Aboriginal and Torres Strait Islander peoples in aged care across the Vocational Education Training and higher education sectors in South Australia, the Australian Indigenous HealthInfoNet, the Department of Health and Aged Care website and aged care email alerts between December 2021 and September 2022.
Five themes representing workforce training needs were identified: cultural safety, trauma-informed care, case management, compliance with funding rules and preferred formats for training. The desktop review identified a paucity of formal training, professional development and resources within the context of addressing the SEWB of Aboriginal and Torres Strait Islander peoples in aged care.
These findings suggest that ongoing practice-based professional development learning opportunities are needed within organisations to enhance peer-learning and support. These need to be available together with dedicated formal training programs and practical resources on meeting Aboriginal and Torres Strait Islander peoples’ SEWB in aged care.
Keywords: Aboriginal and Torres Strait Islander peoples, aged care, education and training, equity, Indigenous health, social and emotional wellbeing, workforce.
Introduction
The aged care workforce is one of the fastest growing sectors in Australia with approximately 370,000 workers across diverse care settings and is projected to grow further as the Australian population continues to age.1 A skilled workforce is fundamental to delivering quality care; however, the Royal Commission into Aged Care Quality and Safety (Aged Care Royal Commission) found inadequate training is common across the sector, including training that incorporates the needs of Aboriginal and Torres Strait Islander peoples.2 Workforce training and education is a shared responsibility between government and industry, and aged care providers are mandated under the Aged Care Act 1997 to ensure workforce meet consumers’ individual care needs.3 Building workforce capability is a key action arising from the Aged Care Royal Commission (2021).4 The Australian Government’s 2022–23 October Budget begins to implement the policy platform of reforms within the sector.5
Social and emotional wellbeing (SEWB) is the foundation of physical and mental health for Aboriginal and Torres Strait Islander peoples, embedded within a holistic definition of health.6,7 For Aboriginal and Torres Strait Islander peoples, SEWB includes culturally defined roles and relationships within families and communities, spiritual connections to Country and ancestors, and recognises the interplay of these with experiences of grief and trauma.6,7 Older Aboriginal and Torres Strait Islander peoples have identified that SEWB is influenced by several factors including learning in cultural ways, fulfilling cultural obligations, experiences of loss, grief, trauma and cultural disconnection,8 and that a greater understanding of SEWB within aged care is required.9 Furthermore, for older Aboriginal peoples, ‘having a good spirit and life’ is supported by a relational model of care called ‘Good Spirit, Good Life’ (GSGL).10 The GSGL outlines a range of interconnected factors including Country, community, health, services and supports.10 Older Aboriginal peoples with strong connections to the GSGL factors are less likely to experience depression and anxiety.11 Further testing of the GSGL in remote populations and with older Torres Strait Islander peoples is in progress.11
Grief and trauma continue to impact communities today, stemming from Australia’s colonial policies and practices.12 Aboriginal and Torres Strait Islander peoples experience institutional racism, high rates of chronic disease and premature loss of life, and ongoing impacts from the forcible removal of children from their families and lands, known as Stolen Generation survivors.7 A growing number of ageing Aboriginal and Torres Strait Islander peoples are accessing services each year, which as of 2023 will increase further with the inclusion of Stolen Generation survivors who are now all aged 50 years and over and eligible to receive aged care.13 It is crucial that workforce can respond to their unique SEWB needs, given that Stolen Generation survivors are more likely to experience adverse health-related, SEWB and socioeconomic outcomes than Aboriginal and Torres Strait Islander peoples who are not of the Stolen Generation.14 For Aboriginal and Torres Strait Islander peoples, the ongoing impacts of intergenerational trauma are evident in multiple ways, and it is now widely understood that these experiences can shape the relationship between individuals and service providers.15–18
Improving workforce understandings of Aboriginal and Torres Strait Islander peoples’ culture and the components that support SEWB is likely to support quality of care.19 There is a growing understanding of the needs of Aboriginal and Torres Strait Islander peoples within aged care.9,20–28 Providing care to Aboriginal and Torres Strait Islander peoples requires a unique set of skills, knowledge and attributes.20,21,25 However, a lack of workforce training can exacerbate the impact of poor health outcomes.22,25–27
While Aboriginal and Torres Strait Islander peoples are increasingly accessing care across community, home-based and permanent residential care settings, the majority of this increase is occurring within home-based aged care.29 The Home Care Package (HCP) Program, administered through the Commonwealth Department of Health and Aged Care, is the major program to access comprehensive home-based aged care.30 The HCP Program operates through four levels of funding from low- to high-level needs, aimed at accommodating access to services from low-level support through to high-level complex care support needs. As of 31 December 2022, an estimated 565 Aboriginal and Torres Strait Islander peoples were receiving a HCP in South Australia.31
This research aimed to explore how services funded under the HCP Program support SEWB for Aboriginal and Torres Strait Islander peoples and workforce training needs from the perspectives and experiences of the aged care workforce providing service coordination through three stages: (1) to understand what is required to support SEWB from the perspective of clients receiving a HCP; (2) to inform service responses and training required for the HCP workforce to meet these SEWB needs; and (3) to identify improvements required in the HCP Program to meet SEWB needs. This paper presents findings relating to the second stage of the research, workforce training needs.
Methods
Ethics and governance
Approval to conduct this research was granted by the Australian Institute of Aboriginal and Torres Strait Islander Studies (#EO279‐20210726) and the Aboriginal Health Research Ethics Committee (#04‐21‐971) following the South Australian Aboriginal Health Research Accord32,33 and relevant health and medical research guidelines.34 A study advisory group (SAG) comprising a majority of Aboriginal and/or Torres Strait Islander peoples and a Chief Investigator committee provided oversight of the study conduct. To address the potential for conflict of interest with regards to the dual role of investigator and Chief Executive Officer of the participating aged care organisation, the role of the SAG involved greater oversight and influence over the research activities. The SAG was involved in designing the interview guide questions, scope of the training review, and the interpretation and dissemination of research findings.
Research design
The research was proposed by the Chief Executive Officer (CEO) of Aboriginal Community Services (ACS), a community-controlled organisation that provides services to over 600 Aboriginal and Torres Strait Islander peoples across residential, community and home-based aged care settings in South Australia,35 and was collaboratively designed by ACS and Wardliparingga based on identified service delivery challenges in meeting Aboriginal and Torres Strait Islander peoples’ SEWB and workforce needs within the HCP Program. The study methods included a focus group, interview and a desktop review. Research activities were informed by Gee et al.’s SEWB framework7 and Smith et al.’s GSGL model.10
Focus group and interview
Following a purposive sampling strategy,36 all HCP Program coordinators employed by ACS were invited to participate in a focus group via an email invitation from the CEO. The email included a detailed study information statement outlining the purpose, research activities and a consent form. Informed consent was confirmed by participants’ willingness to attend the focus group and verifying their understanding of the study purpose at the beginning of the focus group. An interview was scheduled for coordinators who were unable to attend the focus group. As per informed consent protocol, participants signed a consent form prior to the interview and were explained the purpose of the research prior to interview start.
A topic and interview guide were used to facilitate discussion relating to training needs and awareness of resources, professional development and training programs (Table 1). The focus group, held in April 2022, was facilitated by both Aboriginal and/or Torres Strait Islander researchers (OP, MD) and non-Indigenous researchers (AP, JZ). At the commencement of the focus group, the SEWB7 and GSGL10 models were presented to the participants to support the subsequent discussion. The focus group included whole group discussion and a breakout session where participants were divided into two groups and recorded written responses to the topic questions onto butcher’s paper. This was followed by a roundtable discussion to further explore responses from the breakout session. An interview for coordinators who could not attend the focus group was held in June 2022, facilitated by JZ and MD. With participant consent, the interview and the focus group roundtable discussion were audio-recorded and transcribed verbatim.
| Topic | Questions | |
|---|---|---|
| Training, resources and professional development needs to support the social and emotional wellbeing of HCP clients | What training, resources or professional development opportunities have helped you support the SEWB of your clients? | |
| What training, resources or professional development opportunities would you like to see provided to you to support the SEWB of your clients? | ||
| How have/would these types of training help you to support your clients’ SEWB? |
The transcribed audio data was de-identified and written responses were scanned and imported into NVivo 20 for analyses.37 An inductive thematic analysis was undertaken to identify emergent themes.38 Primary coding was completed by JZ and the data were validated by the research team. The SAG met four times during data analysis, providing input and interpretation on the themes. To ensure validity of the findings, all participants were asked to provide comment on the summary results at a feedback session at the organisation in February 2023, facilitated by OP, AP and JZ.
Desktop review
To provide context to the qualitative findings, we conducted a desktop review of formal training, resources and professional development opportunities available to pre-entry and existing workforce relevant to working in Aboriginal and Torres Strait Islander aged care (Table 2). Four sources were reviewed using a combination of search terms: ‘Aboriginal and Torres Strait Islander’, ‘social and emotional wellbeing’, ‘older people’ or ‘aged care.’
| Source | Provider | Title | Delivery | Aboriginal and Torres Strait Islander-specific or partial A | Target group | |
|---|---|---|---|---|---|---|
| Department of Health and Aged Care | Department of Health and Aged Care | Improving outcomes for Aboriginal and Torres Strait Islander peoples in aged care | Webinar | Yes | Not specified | |
| Department of Health and Aged Care | Department of Health and Aged Care | Coronavirus disease 2019 (COVID-19) Grief and Trauma Support Services for Aboriginal and Torres Strait Islander peoples | Brochure | Yes | Not specified | |
| Department of Health and Aged Care Email Alerts | Department of Health and Aged Care | COVID-19 Aged Care Grief and Trauma Support Resources | Resource | Partial A | Not specified | |
| Australian Indigenous HealthInfoNet | Aboriginal Health and Medical Council of New South Wales | Wellbeing for Elders during COVID-19 | Booklet | Yes | Not specified | |
| Australian Indigenous HealthInfoNet | Anglicare, Northern Territory | Cup of Tea | Audiovisual | Yes | Not specified | |
| Australian Indigenous HealthInfoNet | Menzies School of Health Research | Yarning about mental health | Flipchart | Yes | Not specified | |
| Australian Indigenous HealthInfoNet | Aboriginal Ageing Well Research, University of Western Australia | Good Spirit, Good Life Package | Training and assessment package | Yes | Not specified | |
| Vocational Education Training | ||||||
| Aboriginal Health Council of South Australia | Aboriginal Health Council of South Australia | Aboriginal and/or Torres Strait Islander Aged Care Skillset | Skillset | Yes | Aboriginal and/or Torres Strait Islander Health Workers | |
| Nunkuwarrin Yunti | Nunkuwarrin Yunti | Diploma of Narrative Approaches for Aboriginal People (Counselling Group and Community Work) | Diploma | Yes | Aboriginal and Torres Strait Islander workers employed in SEWB roles | |
| Nunkuwarrin Yunti | Nunkuwarrin Yunti | Certificate IV in Stolen Generations Family Research and Case Management | Certificate IV | Yes | People who work in Link Up organisations, or similar organisations, who provide a range of services to members of the Stolen Generations, their families, foster and adoptive families | |
| TAFE SA | TAFE SA | Certificate III in Individual Support (Ageing and Disability) | Certificate III | Not specified | Support work | |
| TAFE SA | TAFE SA | Certificate III in Individual Support (Ageing) | Certificate III | Not specified | Support work | |
| TAFE SA | TAFE SA | Certificate II, III, IV in Community Service | Certificate II, III, IV | Partial A | Support work | |
The websites of four South Australian Registered Training Organisations (RTOs), including TAFE SA, the major provider of VET sector qualifications and three Aboriginal community-controlled organisations that are RTOs.
Descriptions of undergraduate and postgraduate programs on the websites of the three public universities in South Australia.
The ‘Your Aged Care Update’ email alerts from the Department of Health and Aged Care were reviewed as these are widespread within the sector. We also reviewed the ‘Aboriginal and Torres Strait Islander Health’ and ‘Aged care’ sections under the ‘Resources’ tab of The Department of Health and Aged Care website.
Results
Focus group and interview
In total, seven HCP Program coordinators providing client care management across metropolitan (n = 5) and rural (n = 2) South Australia participated in the research. Three coordinators identified as Aboriginal and/or Torres Strait Islander. Each participant reported a range of prior experience across aged care, disability and community services with both Aboriginal and Torres Strait Islander and non-Indigenous populations and qualifications, including undergraduate degrees in Social Work, Nursing and Psychology, Certificate IIIs in Community Services and Aged Care, and Diplomas in Enrolled Nursing.
We identified five themes that represented the training needs with regards to meeting the SEWB of Aboriginal and Torres Strait Islander peoples receiving a HCP: (1) cultural safety, (2) trauma-informed care, (3) case management, (4) compliance with funding rules, and (5) training delivery modes. Illustrative quotes for each theme are presented in Table 3.
| Theme | Illustrative quotes | |
|---|---|---|
| Cultural safety | ‘The trauma and understanding that and the trust and … why there’s been breakdowns and why it’s so hard to recover that … it would give people a better understanding of the history and that would help us better communicate with our Elders, how to better understand their needs (Participant 2) | |
| ‘I guess the first thing is about understanding – to understand where Aboriginal people were, what has been endured and where Aboriginal people are now, and that’s a bit of a process to get people through that, to understand that with any real empathy or any real understanding of it. So yeah, it’s an eye-opener for people. I think it’s really important that people understand that, because a lot of people come with their own preconceived ideas about Aboriginal people and try and do it to challenge that preconceived idea is difficult. But if you can do it successfully, then that’s all you can really ask for, and get people to look at things differently’ (Participant 6) | ||
| Trauma-informed care | ‘A lot of our clients have a lot of similar traumas, like Stolen Generations, things like that. That sort of catered training, specifically for those things that are afflicting our clients everyday would be very beneficial’ (Participant 3) | |
| ‘…and it’s as simple as the damage that was done to this person carries on to their children out of fears and so forth – you know, it’s fear … Once the trust is broken, it’s very hard to regain that and that generational trauma has been going for hundreds of years, so yeah, it was very informative. I really enjoyed it, so I would recommend doing it.’ (Participant 2) | ||
| Case management | ‘Especially if you’ve not done it before. If you’re coming in new to this – absolutely no experience with anything – then you’ve got to have some [case management] training…’ (Participant 1). | |
| ‘Case management training, as well, in general I think, always benefits everyone…I personally felt that I needed more training, case management training … While I’m familiar – I’ve grown up with similar – similar to our clients, I feel like the case management stuff I still have to learn quite a bit. That made me take a step back and kind of re-evaluate…’ (Participant 3) | ||
| Compliance with funding rules | ‘The My Aged Care Portal has a lot of resources on there. Unfortunately, you’d spend a month going through them all finding out what was relevant to you.’ (Participant 7). | |
| ‘Yeah, I read it when it first came out. Then I’m like, let’s just hope this never comes out … Every time someone brought up the Support at Home, I got anxiety. And the thought process of what we are going to have to face in the future and the crap that’s going to come with it. I was just like, no. It gives me anxiety just thinking about it … then you think to introduce this [new program] and we’re going to have to try and explain [to the Elders] – while figuring it out ourselves – a whole new program’ (Participant 2) | ||
| Training delivery modes | ‘You can’t relate to the facilitator of the training. It’s way too cold and impersonal training that way I think. You can’t be spontaneous in your questions … Whereas if you’re in a face-to-face situation, you can get things out better … I don’t know who in the room is resistant to the training, how to reframe what I’m going to say, to be able to reach certain people in the room, so I’m not a great fan of online training’ (Participant 6) |
Participants described the value of cultural safety training in gaining an in-depth understanding of Aboriginal and/or Torres Strait Islander culture, cultural practices and kinship systems. They believed training should include content relating to Australia’s history of colonisation, intergenerational trauma, and the differences in health and care needs compared to non-Indigenous people. For example, health disparities, including the earlier onset of dementia and other age-related health conditions in Aboriginal and Torres Strait Islander peoples than non-Indigenous people. Effective cultural safety training would promote empathy and challenge preconceived biases and should be mandatory across the sector, including for aged care assessors. All participants viewed aged care assessments for Aboriginal and Torres Strait Islander peoples as culturally unsafe and believed that their clients would receive an appropriate level of HCP funding if aged care assessors had received cultural safety training.
Recognising intergenerational trauma in clients, families and communities was seen as integral to supporting SEWB. Trauma-informed care training was seen as critical to service coordination for survivors of the Stolen Generations due to their additional care needs, and would equip workers with necessary knowledge to appropriately support and care for their clients. Although familiar with the term, most participants expressed a lack of understanding of trauma-informed care when commencing their role. While trauma-informed care training had been completed by some, these were not Aboriginal and/or Torres Strait Islander-specific. The intrinsic link between trauma-informed care and cultural safety training was recognised, reflecting that to work in a culturally safe way, the workforce must be trauma-informed.
Emphasising a complex client caseload, participants expressed a need for training in case management. Effective case management ensured that clients with complex trauma, disability and co-morbidity would receive the necessary services and facilitate navigating relevant services and supports available through the HCP funding. Case management training would also help workers to build skills in advocacy and empathy.
The need for training on funding guidelines was identified. Changes were made frequently to funding guidelines, yet participants often discovered these through conversations with their colleagues rather than formal sources. Information disseminated by the Department of Health and Aged Care was described as insufficient and hard to locate. Not having the most up-to-date information had negative consequences on the client, particularly if service inclusion or exclusion criteria changed. Furthermore, participants expressed their hope that they would receive appropriate training before, and during, the rollout of the new Support at Home Program, which at the time of conducting the interviews was due to commence in 2024.
Participants spoke of the value of ‘learning on the job’ from more experienced colleagues and by sharing strategies, particularly in relation to the HCP funding rules. However, they believed that on-the-job learning should be supplemented with additional formal training programs. All participants valued formal group training with their colleagues who brought multidisciplinary perspectives, experience and reflections that supported learning. There was consensus that training should occur on-site within their organisation as the additional time commitment required for training off-site was a barrier. Additionally, participants preferred face-to-face delivery, rather than online, to facilitate collaboration and a more personalised experience. Participants also highlighted that training, such as cultural safety and trauma-informed care, should be continuous.
Discussion
This paper explored training needs in meeting the SEWB of Aboriginal and Torres Strait Islander peoples receiving HCP services and existing training within the aged care sector. To our knowledge, this is the first study conducted with workforce relating to the SEWB of Aboriginal and Torres Strait Islander peoples receiving home-based aged care.
Key workforce training needs required to meet the SEWB of Aboriginal and Torres Strait Islander peoples in aged care include cultural safety, trauma-informed care, case management and compliance with program funding rules. The desktop review found minimal training, resources and professional development opportunities that centred on Aboriginal and Torres Strait Islander people in aged care, let alone supporting the SEWB of this population group.
Our findings are consistent with the Aged Care Royal Commissions’ findings which suggest inadequate training was being provided throughout diverse care settings.2 The intrinsic link between cultural safety and trauma-informed care as identified within workforce submissions to the Aged Care Royal Commission16,18 and the broader literature39,40 was similarly identified in this study. Trauma-informed care is vital in achieving cultural safety, yet it is overlooked in current training programs.16,18,39 Recommendation 48 proposed that by 1 July 2022, the Commonwealth should require the aged care workforce undertake regular cultural training that included both cultural safety and trauma-informed service delivery.41 Despite the Commonwealth of Australia accepting this recommendation,42 our research reinforces that aged care organisations and workforce face significant challenges in achieving this, including a lack of training that centres on cultural needs, time constraints and delivery modes.20,23,24,26,27,42 Given the low proportion of Aboriginal and/or Torres Strait Islander workforce, with only an estimated 2% employed in aged care,43 it is crucial that there is sufficient training for all workforce in meeting SEWB. To achieve this, a commitment to developing a culturally safe workforce through policy, service design, leadership and ongoing training is required.25
The Australian Government is currently undertaking significant reforms to improve the safety and quality of care provided to older Australians, including initiatives to build the aged care workforce to lift the profile of and attract more workers to the sector, and introducing a new home-based aged care system.44 This research reinforces the need to adequately support workforce caring for Aboriginal and Torres Strait Islander peoples within the new Support at Home Program. As part of these reforms, A$5.3 million has been committed to develop high-quality cultural safety, trauma and healing-informed care training to improve quality, build trust, and meet increased demand of aged care for Aboriginal and Torres Strait Islander peoples.45 Reflecting previous literature,9,23 the findings of this study highlight an urgent need to partner with the aged care sector to develop both professional development resources and accredited qualifications which are centred upon the voices, needs and experiences of older Aboriginal and Torres Strait Islander peoples.
Strengths and limitations
By triangulating the qualitative findings with the desktop review results, we have developed a comprehensive understanding of the training needs of HCP service coordinators and existing formal training, resources and professional development opportunities. Having participants endorse the research findings allows for confidence in the validity of the findings. There are, however, some limitations to the study. We did not include interviews with personal care workers, who comprise the largest proportion of the direct care workforce (>75%) with the most contact with people in care. Future research should involve personal care workers to explore training needs. A limitation of the desktop review was the exclusion of in-house training that may be available within aged care organisations or private consultancy-developed and delivered training programs. Furthermore, the review findings relied on an explicit description of the training, resource or professional development activity to ascertain whether SEWB was covered.
Conclusion
The Australian aged care system is at a critical juncture whereby current Government reforms can hinder, harm or improve consumer access, experience and outcomes of care. The workforce is the most valuable asset in ensuring these reforms benefit consumers and as such, workforce development must continue to be a priority within the sector. At the same time, there is a critical need for relevant education and training across VET and higher education to build the necessary competencies required of those entering, or currently working within the Aboriginal and Torres Strait Islander aged care sector. Training curricula must include learning and insights into Aboriginal and Torres Strait Islander culture, health and SEWB needs, and the structural drivers of inequity burdened by this population.
Data availability
The data that supports this study cannot be publicly shared due to ethical or privacy reasons.
Conflicts of interest
Graham Aitken is the Chief Executive Officer of Aboriginal Community Services and Chief Investigator on this project. To mitigate this potential conflict of interest, he was not involved in data collection or analysis. Odette Pearson is an Associate Editor of Australian Health Review. To mitigate this potential conflict of interest, she was blinded from the review process and was not involved at any stage in the editing of this manuscript.
Declaration of funding
This work was supported by the Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) under Research Exchange Grant #OG00094.
Acknowledgements
The authors would like to acknowledge and pay their respects to the traditional owners of the lands on which this research was conducted. We extend our gratitude to the study participants for sharing their experiences, the participating aged care organisation, and the study advisory group who provided governance and advice.
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