L4 Early Professional Experience_PEOLC Introduction to clinical placement

Overview

This lecture introduces the ELM2 Early Professional Experience (EPE) clinical placement in residential aged care facilities (RACFs). It sets the demographic and clinical context of aged care in Aotearoa New Zealand, describes the healthcare assistant (HCA) role students will shadow, explains the purpose and structure of the placement as experiential learning, and covers the logistics, professional expectations and assessment/terms requirements students must meet.

Context of Care in Aotearoa NZ

• NZ has an aging population, driven by lower birth rates and increased life expectancy.
• By 2051, 25% of the NZ population will be aged >65 years, up from 15.2% in 2018 (stats.govt.nz; www.ehinz.ac.nz).
• Multimorbidity is common as people age, putting them at risk of polypharmacy, confusion and falls.
• Frailty and complexity of residents in RACFs is increasing.
• RACFs are major providers of primary palliative care.
• Complexity of care need at first assessment in permanent aged care residents has risen over time: the proportion of residents classed “High” complexity rose from roughly 12% (2009) to roughly 53-60% (2016-2018), with “Nil” and “Low” complexity proportions shrinking correspondingly (GEN Aged Care Data 2018).

The Changing Nature of Death

• Historically, people tended to die at the end of the first decade following retirement, “fairly worn out, but quite happy”; researchers call this the Third Age.
• People may now live an extra decade, two, or even three beyond that, typically with “withering health and independence” following some kind of accident (usually a fall), often followed by hospitalisation or care lasting weeks to months. This later period is the Fourth Age.
• The Fourth Age is characterised by frailty, possible double incontinence, and severe compromise of sight, taste, hearing and orientation in time and space, alongside significant physical and emotional pain.
• Framing question raised: what does palliative care look like when a person is 90, frail and has dementia?

Dementia in NZ

• Almost 100,000 people are living with dementia in NZ currently, projected to increase to 170,000 by 2050 due to the aging population (infographic gives more granular projections: 69,713 in 2020, 99,245 in 2030, 135,470 in 2040, 167,483 in 2050).
• 1 in 4 people will die with dementia.
• Dementia is approximately 30% more common in women than men.
• Unpaid carers provide over 1 million hours of care per week (infographic: 52.7 million hours per year, valued at $1.19 billion/year).
• Residential care for people with dementia costs approximately $1.21billionperyear;totaldementiacarecostisprojectedtorisefrom$2.46 billion to $5.92 billion.
• There is inequity in dementia care across NZ ethnic groups, and dementia is increasing faster in Māori, Pacific and Asian peoples. Care cost per person by ethnicity and care type (Community Care / Aged Residential Care): European $17,820/$12,600; Māori $2,710/$3,270; Pacific $3,570/$12,450; Asian $1,810/$8,280.
• Priority areas identified: research into true rates of dementia in Aotearoa NZ, culturally appropriate care that maximises quality of life, and development of a National Dementia Plan for Aotearoa NZ.

Levels of Aged Residential Care

Note the distinction between “resident” (aged care) and “patient” (hospital) terminology.

• Rest Home (RH): residential care for older people who need assistance with some daily tasks but retain some independence.
• Dementia care (DM): specialised care provided in a secure unit.
• Hospital (H): the highest level of aged residential care, for residents with significant disabilities and medical needs.
• Psycho-geriatric hospital (PG): secure residential care for older people with psychiatric disorders who require specialist support.

The Role of the Healthcare Assistant (HCA)

• HCAs deliver the majority of care for residents, under the supervision of a licensee or registered nurse (RN), including care for residents with complex needs.
• No formal qualifications are legally required, but most employers prefer a qualification such as the NZ Certificate in Health & Wellbeing (level 2 or 3).
• HCAs rely on instinct, experience, support from other staff, and organisational policies to guide their practice.
• HCAs describe their work as emotionally significant and demanding: they build deep, long-term knowledge of residents and their families (likened to the role of a priest, as confidences are shared with them), and describe the work as “very hard, very heavy, difficult, stressful and emotionally draining.”

Purpose of Clinical Placement and Student Role

Purpose of the placement:

• Gain confidence in early professional interactions with patients/residents.
• Learn to be professional within someone’s personal space.
• Put theory into practice (aged care, palliative care, professionalism, emotional intelligence, resilience and self-care).
• Begin to consider what practising medicine involves and what kind of doctor the student wants to be.
• Framed as pushing students out of their “comfort zone” into “challenge.”

What students will actually do (assistant caregiver role):

• Work in a team with other health professionals providing personal care (washing, showering, toileting, mobilising).
• Make beds, tidy resident rooms, serve meals and drinks, and feed residents who need assistance.
• Observe medication rounds, wound care, GP rounds, and nursing assessments.
• Participate in social, diversional and recreational activities.
• Talk with staff, residents and their family/whānau.
• Conduct a formal resident interview.

What this is intended to develop:

• Clinical, communication and teamwork skills.
• Ability to provide personal care in a professional, dignity-enhancing manner.
• Ability to identify, manage and reflect on personal responses.
• Understanding of the doctor-patient relationship, learned via the parallel student-resident relationship.
• Understanding of the roles of other healthcare providers.

Student reflections (before/after placement) describe common initial nervousness and uncertainty about the value of a non-clinical role, followed afterwards by a strengthened commitment to healthcare, reframed motivation (service to others rather than status), and recognition that first-hand immersion teaches things a lecture cannot, such as the lived experience of the doctor-patient relationship.

Approach to Experiential Learning

• Learn by doing.
• Reflective practice.
• Emotional intelligence: consider one’s own perspective as well as those of others (e.g. resident, staff, whānau).
• Metacognition, structured as five questions: What do I know? What do I need to know? How will I learn this? How am I tracking? What did I learn?
• Placement is framed as an opportunity to integrate learning and apply theory to practice, drawing on Clinical Skills, Integrated Cases, and block and vertical modules.
• With permission, students may read residents’ medical records to identify: what medical conditions the resident has; what physical signs and symptoms they have (e.g. heart failure and swollen ankles, Parkinson’s tremor); what medications they are on; and, if applicable, what type of dementia they have and how it affects them.

Placement Timeline and Logistics

Sequence of placement components:

1. Tutorials 1-3 (all streams), after which streams A and B do the clinical placement while streams C and D do Unit 4 (and vice versa).
2. Compulsory orientation session at the RACF.
3. Complete 20 hours of clinical work over 5 weeks, on weekends, or in the student’s hometown over the mid-year break.
4. Complete the Resident Interview.
5. Attend the guided reflection session.
6. Debrief tutorial and presentations.
7. Reflective essay due 7pm Sunday 21st September (later slide gives the essay deadline as Sunday 22nd September; both dates as stated in the transcript).

Shift preferencing and location:

• Dunedin placements: shift date/time preferencing opens in Sonia, week of May 12-16 for streams A & B, week of June 9-13 for streams C & D. Students should consider preferred location and other commitments (AM vs PM shifts, weekdays vs weekends) before selecting shifts.
• Out-of-town placements: students are notified if confirmed; some facilities’ confirmations are still pending. Contact epe@otago.ac.nz with queries.
• Once shifts are confirmed with the facility manager, students must not change them.

If unwell:

• Stay away from placement if sick.
• Notify the facility manager, the EPE tutor, and elm.admin@otago.ac.nz and epe@otago.ac.nz, and reschedule the shift(s).
• Wear a mask as required.
• If a household member tests positive for COVID-19, advise the facility manager and follow their guidance.

Professional Expectations

• Be prepared, be proactive and get involved.
• Be professional in all interactions with staff, residents and their whānau.
• Use initiative: ask staff how you can help.
• Avoid doing anything you have not been trained to do; ask for help or supervision instead.
• Take an interest in residents as individuals.
• Protect the confidentiality of staff and residents at all times.
• Uphold dignity, respect and compassion as core values.
• Follow all health and safety and infection control procedures, e.g. safe lifting, handwashing, masks and gloves, fire and security procedures.

Assessment and Terms Requirements

Terms requirements have two components:

1. Satisfactory completion of the EPE clinical placement, comprising:
   • Completing 20 hours as an assistant caregiver in a RACF.
   • Professional behaviour, with no reported concerns.
   • Completion of the resident interview.
   • Prompt submission of all paperwork (Attendance Log, Clinical Placement feedback form).
   • Tutorial group presentation giving a brief summary of the placement and resident interview.
2. Satisfactory completion of the reflective essay.

Resident interview:

• An in-depth interview with one resident, to understand who they are as a person, the events that have shaped their narrative, their perspectives on life, and their expectations of healthcare.
• Students ask a staff member to help identify a suitable resident, explain the purpose (coursework) and use (group presentation), and gain verbal consent before proceeding.
• Findings are shared in a tutorial group presentation.

Placement paperwork/forms:

• Student Attendance Record: signed by the supervisor (unit nurse manager, facility manager, or another supervisory person) at the end of each shift; satisfactory performance recorded here is a terms requirement. Covers the orientation session and weeks 1-5, plus a section for the meeting with the EPE tutor. Pages are handed to the EPE tutor at the follow-up tutorial.
• Learning Log: a shift-by-shift record of activities performed and independent learning tasks arising from them (e.g. personal care given, procedures observed, follow-up reading identified such as researching a condition or medication seen on shift).
• RCF Assessment Form: completed on the student’s last shift by the supervisor or HCA they worked with. Includes a global evaluation (Unsatisfactory/Satisfactory), free-text feedback on strengths and areas for improvement, and a rated table (Not Observed/Unsatisfactory/Satisfactory/Excellent) across categories: enthusiasm, motivation and preparedness for work; dress, attendance and punctuality; teamwork; relationships with residents (caring, empathy, respect, confidentiality); awareness of limitations in knowledge/skills and response to feedback; and the learning log.

Reflective essay:

• 1500-2000 words, uploaded to Moodle.
• Students choose one of two topics: (1) what they learned from the clinical placement and how it will influence their future care of older people as a tākuta/doctor, or (2) what they learned from their most significant learning experience in ELM2 and how it will influence their future practice as a tākuta/doctor.

Self-test

1. Distinguish the “Third Age” from the “Fourth Age” of death, as described in the lecture.
2. What proportion of the NZ population is projected to be aged over 65 by 2051, and what was the figure in 2018?
3. List the four levels of aged residential care described in the lecture, with one distinguishing feature of each.
4. Describe the trend in complexity of care need among residents entering permanent aged care between 2009 and 2018.
5. What proportion of people will die with dementia, according to the lecture?
6. Describe the inequity in dementia care costs across ethnic groups in NZ, as shown in the lecture’s infographic.
7. Describe the role of the Healthcare Assistant (HCA) in a RACF, including supervision and qualification requirements.
8. List at least four activities a student will undertake as part of the assistant caregiver role during placement.
9. Describe the five metacognitive questions used as part of the experiential learning approach.
10. A student is unsure whether they are allowed to help a resident with a task they have not been trained to do. According to the professional expectations covered, what should they do?
11. What are the two components of satisfactory Terms Requirements for the EPE placement?
12. Describe the purpose and process of the Resident Interview, including how consent is obtained.
13. Name the three placement paperwork/assessment items completed during or at the end of a shift, and briefly state what each records.
14. A student in placement becomes unwell. Describe the steps they should take according to the lecture.
15. Explain how the resident interview and student-resident relationship are intended to help a student learn about the doctor-patient relationship.

Answers

Reveal answers

1. The Third Age is the traditional pattern of dying around the end of the first decade after retirement, “fairly worn out but quite happy.” The Fourth Age is a later period some people now live into, an extra one to three decades beyond that, marked by “withering health and independence” often triggered by an accident such as a fall, and characterised by frailty, possible double incontinence, and severely compromised sight, taste, hearing, orientation, and significant physical and emotional pain.
2. 25% by 2051, up from 15.2% in 2018.
3. Rest Home (RH): assistance with some daily tasks, resident retains some independence. Dementia care (DM): specialised care in a secure unit. Hospital (H): highest level of care, for significant disabilities and medical needs. Psycho-geriatric hospital (PG): secure care for older people with psychiatric disorders requiring specialist support.
4. The proportion of residents classed as “High” complexity of care need at first assessment rose from roughly 12% in 2009 to roughly 53-60% by 2016-2018, while “Nil” and “Low” complexity proportions shrank correspondingly; residents entering aged residential care have become progressively more complex.
5. 1 in 4 people.
6. Care cost per person differs substantially by ethnicity and care type: European $17,820(CommunityCare)/$12,600 (Aged Residential Care); Māori $2,710/$3,270; Pacific $3,570/$12,450; Asian $1,810/$8,280. The lecture notes explicit inequity in dementia care across ethnic groups, with dementia increasing faster in Māori, Pacific and Asian peoples.
7. HCAs deliver the majority of resident care, including for residents with complex needs, under the supervision of a licensee or RN. No formal qualification is legally required, though most employers prefer one (e.g. NZ Certificate in Health & Wellbeing level 2 or 3). HCAs draw on instinct, experience, colleague support and organisational policy to guide their work.
8. Any four of: providing personal care (washing, showering, toileting, mobilising) as part of a team; making beds, tidying rooms, serving meals/drinks, feeding residents who need assistance; observing medication rounds, wound care, GP rounds, nursing assessments; participating in social/diversional/recreational activities; talking with staff, residents and whānau; conducting the formal resident interview.
9. What do I know? What do I need to know? How will I learn this? How am I tracking? What did I learn?
10. Avoid doing anything they have not been trained to do, and ask for help or supervision instead.
11. (1) Satisfactory completion of the EPE clinical placement (20 hours as assistant caregiver, professional behaviour with no reported concerns, resident interview, prompt paperwork submission, tutorial group presentation), and (2) satisfactory completion of the reflective essay.
12. The student conducts an in-depth interview with one resident to understand who they are as a person, the events that shaped their narrative, their perspectives on life, and their expectations of healthcare. A staff member helps identify a suitable resident; the student explains that it is coursework and that the information will be used in a group presentation, and gains verbal consent before proceeding.
13. Student Attendance Record (signed by the supervisor at the end of each shift, confirming satisfactory performance); Learning Log (records activities performed each shift and resulting independent learning tasks); RCF Assessment Form (completed by the supervisor/HCA on the student’s last shift, giving a global evaluation and rated feedback across categories such as enthusiasm, professionalism, teamwork and relationships with residents).
14. Stay away from placement; notify the facility manager, EPE tutor, elm.admin@otago.ac.nz and epe@otago.ac.nz, and reschedule the shift(s); wear a mask as required; if a household member tests positive for COVID-19, advise the facility manager and follow their guidance.
15. Students are not treating or diagnosing patients, but instead build a relationship with a resident directly, similarly to how a doctor builds a relationship with a patient, through personal care, conversation, and the formal interview. This first-hand, immersive experience is intended to teach the doctor-patient relationship in a way lectures and tutorials alone cannot.