From 1 July – after a somewhat hurried and harried introduction – interRAI will be the mandatory clinical assessment tool for nurses to use in residential aged care facilities nationwide. FIONA CASSIE catches up with some nursing leaders as facilities head down the home straight in a race to meet the deadline to train nurses in an already time and resource-stretched sector.
Getting enough nurses to be proficient with the new electronic interRAI tool by the Government’s 1 July deadline has been a tight race. Some facilities have crossed the finish line early; others will make it after hard slog, and some are in panic mode, with nurse turnover undermining their best efforts to be prepared.
Training courses are being run right up to and beyond 1 July to ensure nurses are competent in the clinical assessment tool – a 53-hour process that is costly both in time and resources. Concerns about lack of government support for its own project prompted a backlash from the aged care sector during contract talks last year, leading to a post-budget, pre-election funding boost for ongoing interRAI support, which starts from 1 July this year. (See timeline sidebar for details of interRAI funding.)
The Ministry of Health reports that 2,302 registered nurses had reached interRAI competency as at 21 May and it expected to exceed the project target of 2,370 and have 2,500 RNs trained by July.
It appears the problem a number of facilities face is not getting nurses interRAI trained – but retaining them, says aged care nurse practitioner Dr Michal Boyd.
Boyd was the lead researcher for an initial demonstration trial of interRAI in residential aged care in Waitemata and Bay of Plenty DHBs back in 2008. She has always believed the standardised interRAI assessment tool could bring rewards, as long as effort was put in to making the electronic tool user-friendly for time-pressured nurses.
“They have succeeded in training staff in residential aged care for interRAI, that is true,” says Boyd. “And they have succeeded in people doing interRAI in residential aged care, but at different levels depending on the facility and how up to speed they are.”
She says a major dilemma for facilities with interRAI is the huge turnover of nursing staff. “I was talking to one facility manager who said she has trained five nurses in interRAI and only one of them still remains at the facility.” Boyd says high turnover is now an ongoing issue as residential aged care is a relatively low-paid sector and if nurses get an opportunity for higher pay or better shifts they will take it.
Staff turnover of interRAI-trained nurses has hit Metlifecare’s eight facilities hard, says Amanda Iavarone, an experienced aged care nurse who is Metlifecare’s clinical quality and risk manager. Asked whether she thinks all their facilities are ready for the 1 July deadline, she replies: “Not at all, in fact there is a lot of panic.”
She says all of its facilities have lost interRAI-trained staff and had to start over and train more, with the result being in early June they had 14 of the 35 interRAI-competent RNs that they required.
Iavarone said Metlifecare was one of the first providers to get on board with interRAI and the initial response had been positive. “This has changed now…”
Hilda Johnson-Bogaerts, an experienced aged care sector who is general manager of residential and community care for the Selwyn Foundation’s 10 facilities, said it also had had to train”a few more nurses than initially envisaged” because of staff turnover.
However, it had also been able to recruit some trained interRAI nurses and had been able to meet the ratio of interRAI-competent RNs set by the DHB. “Which I’m confident will be sufficient.” She says it had initially thought that all its primary nurses with a care-planning caseload needed to be interRAI proficient, but after gaining more experience with interRAI, that was no longer the goal.
“We may have interRAI-trained nurses preparing the assessments for the primary nurses, who can then use the information to further work on their residents’ care plans.”
Sylvia Meijer, an older adult nurse practitioner, says most of the facilities she works with in Horowhenua have the majority of RNs trained and appear to have systems in place to ensure they meet the deadline.
|Amanda Lavarone||Hilda Johnson
|Michal Boyd||Sylvia Meijer|
Audit and hardware
Early in the interRAI journey much of the frustrations were IT-based in a largely low-tech health sector – and the length of time interRAI assessments take.
Johnson-Bogaerts says all Selwyn facilities now have Wi-Fi internet access and at least one COW (computer on wheels) but government funding had not been enough to cover the hardware or the backfill cost to cover training and ongoing increased demand on staff time.
Iavarone says Metlifecare facilities are using desktop PCs to carry out interRAI and thinks the government investment in hardware was “enough”. But she says a lot of the RNs “aren’t very computer savvy”, seeing hands-on care as their priority, and find interRAI assessments take a very long time.
Meijer says there was initial reluctance by some nurses because of the IT requirements of interRAI and she still hears occasional comments by nurses about the time interRAI assessments take. Nurses also talk about finding it hard to concentrate on completing assessments, she says, because facility computers are often in a busy office, leading to many interruptions.
Boyd says another conundrum for facilities has been that auditors have not recognised interRAI data for certification and spot audit purposes; so facilities already using interRAI have had to double-up and continue with traditional assessment reporting as well as interRAI. (N.B. after 1 July 2015 auditors will officially begin considering how facilities are using interRAI assessments to inform care planning).
Meijer agrees, saying most facilities she deals with still have separate care plans and IT compatibility with organisational policy sees some facilities continue to simultaneously operate an electronic and paper system.
Next step: using interRAI for care planning
Boyd says the next step, now that interRAI training has been established, is to really focus on using interRAI assessment findings to inform care planning.
Iavarone says currently nursing staff often view interRAI as too time-consuming and tedious and don’t always see the big picture of what interRAI can offer.
“In theory, interRAI is excellent, and of course in time when everyone is trained and faster at doing the assessments then things will run more smoothly,” says Iavarone. “In reality, there are many RNs who are struggling with this, those older RNs who aren’t tech savvy, or those with English as a second language – often both. So far there isn’t a great benefit for our residents that we have found.”
Meijer says interRAI is helpful in her NP role as it provides more detailed information on residents that is used as a basis to discuss care with the client and/or staff. She has noticed some variability in interRAI skills among nursing staff, with some RNs more “confident and competent” to do assessments and others needing additional teaching. “Assessments in general should be person-focused, but as a starting point, interRAI is helpful to have a level of consistency and rigour throughout the country,” she says, about the now-mandatory tool.
Johnson-Bogaerts says Selwyn nurses also initially felt that the increased time spent on interRAI assessment was taking them away from actual ‘hands-on’ caring for residents.
“Now that they have more experience in using the tool, there is greater understanding of how the evidence-based interRAI assessments contribute to improved care planning and, ultimately, to improved care,” says Johnson-Bogaerts.
“InterRAI enables nurses to quickly focus on health issues and plan care interventions to improve or prevent the issue from getting worse.”
Nonetheless, she expects there to be increased pressure on nurses’ time for a period post-1 July as they work to ensure all existing long-term residents have an interRAI assessment.
With the finishing line in sight, it may still be some time before the country’s residential aged care facilities can catch their collective breath and decide whether they’ve won the race.
TIMELINE for interRAI
2008: Pilots using interRAI assessment tool in residential aged care facilities are held in Canterbury, Waitemata and Bay of Plenty DHBs.
2011: The Government allocates more than $10 million over four years towards nurse training, a software licence and funding for at least one laptop or computer to implement interRAI in facilities. Forty facilities are selected as ‘early adopters’ in the planned four-year national rollout across the about 700 facilities nationwide.
2012: From June all DHBs are using a community version of interRAI for assessing older people living in their homes who may need home-based support services or a place in residential aged care.
In October the Government announces that from July 2015 using the interRAI Long Term Care Facilities (LTCF) assessment to inform care planning will be mandatory in all aged residential care facilities in
The NZ Aged Care Association criticises the Government for implementing interRAI too quickly, investing too little money in training and making it mandatory.
In late 2012 the Ministry of Health sets up a project training team to fast-track the training of one RN per 15 facility beds (training process takes 53 hours per nurse).
2013: In April the Government announces an extra $1.5 million towards the cost of interRAI implementation. DHBs report facilities making slow progress hampered by IT infrastructure issues and the cost and time required for nurse training.
2014: In June the Government announces a post-budget grant of $4.5 million a year for four years from 1 July 2015 to provide “ongoing support and training for nurses and rest homes”. The announcement follows concerns about interRAI raised by the aged care sector during a pre-election contract dispute.
The Ministry reports by November 2014 that 1,706 nurses in 580 facilities have been trained to competency level in interRAI; this had risen to 2,302 RNs by 21 May 2015 and it was predicted that by July this year 2,500 nurses would be competent with interRAI (the initial target was 2,370).
What is interRAI?
The interRAI assessment tools were developed by a network of researchers from over 30 countries making up the interRAI collaborative.
The aim of the tools’ standardised questionnaires and algorithms are to promote evidence-based clinical practice and policy to improve health care for the elderly, frail or disabled. The tools use a common language to assess the health and needs of people in community care or residential care including their medical, rehabilitation and support needs.
The electronic tool, which can be used on a tablet or laptop, uses standardised data collection so statistical trends can be gathered on a facility-by-facility, regional or national level.
New Zealand is the first country in the world to have a national implementation of the tool.
*interRAI stands for international Resident Assessment Instrument.
interRAI Long Term Care Facilities (LTCF) requirements from 1 July
- Aged care residential care facilities must use the interRAI LTCF assessment to inform their care planning.
- The first interRAI LTCF assessment of a resident should be completed by an interRAI competent RN within 21 days of admission. (N.B. the interRAI home care assessment tool is used by the DHB to assess the older person’s eligibility for residential aged care and results made available to the facility).
- The interRAI LTCF tool is then to be used for all residents’ ongoing six-monthly reassessments. It is a full clinical assessment tool that covers areas including pain, falls or pressure injury risk, behaviour, body mass index, communication and cognitive performance.
- The assessment triggers clinical assessment protocols (CAPs) that identify possible solutions, risks and potential for improvement that can be used to inform RN care planning.
- If there is a significant change in a resident’s health status, interRAI tools are used to reassess whether the resident is eligible for a hospital-level bed and/or extra funding.
- Auditors undertaking certification or surveillance (spot) audits will be looking at how facilities use interRAI assessments to inform their care planning.
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