Dr. Christine Clark is the CEO and Founder of Kalandra Education Group, based in New Zealand. The tertiary institute is dedicated to helping health care assistants improve the lives of older adults through training – both traditional and innovative.
Kalandra’s offerings are often based on gaps in the knowledge of health care assistants, and Christine is keen to talk about how care requirements of the next generation of elders will be vastly different from those of the current generation.
In this conversation Christine challenges the audience to put themselves in the shoes of health care assistants, and consider how environmental, workload and policy factors impact on their working lives and their ability to provide quality care for care recipients.
It’s a thought provoking and at times emotionally charged conversation, and Christine speaks plainly and clearly about the issues she feels must be addressed.
Ash de Neef: Christine, thank you so much for joining us today.
Dr. Christine Clark: Oh, you’re very welcome.
Ash de Neef: Can we start with a bit about yourself and the work that you do?
Dr. Christine Clark: Yeah, I’m a registered nurse by trade and I’m a doctor by qualification, not the MD. But I established Kalandra, which is a private training organisation several years ago in response to needs I saw in aged care.
So the care was good, but the were different gaps and both my parents were in aged care and my doctorate was in aged care. So these gaps became more and more obvious. And so that was explored during the doctorate.
Ash de Neef: And what were some of these gaps?
Dr. Christine Clark: The older people aren’t the compliant people that we knew years ago. They expect far more in their care that they are much more discerning consumers. They expect a higher level of service, and this is the average person, and this is pretty much worldwide. And we don’t actually make allowances for that.
We will develop villages for them, which have got the chandeliers and the beautiful spa pools but that appears to be tokenism that appears to be “okay, let’s develop these gorgeous places and we’re going to charge you hundreds of thousands of dollars more to live there.”
But the average consumer – you know, I’m quickly getting there. And I want to know that if I’ve had a stroke, I can go to someone for a massage, cause I like massages. But I need to know that they can actually understand I’m going to need positioning slightly differently. I need to understand that the person who’s doing my facial can comprehend that the skin is ageing and they really shouldn’t try and tear it off with wax. But we’re not addressing those needs.
So even in our dementia care, we aren’t addressing the fact that we’re very stereotypical of our care with dementia. And it’s only the few radical organisations, which are beginning to look at what else we can offer. 20% of the world is aged and we are not addressing that at all.
Ash de Neef: Do you think these shifting expectations of older adults is just a result of adjusting to a new lifestyle or are there other elements at play here as well?
Dr. Christine Clark: I think that they just, over the period of years, become a lot more demanding and that’s not in a negative way at all. And they’re expecting more. They’ve got more disposable income. I’m talking about the New Zealand and Australia and European type thing, not the third world.
And those needs, I don’t think they’re aware yet. I don’t think the older person is aware that they can actually ask for people to be skilled in something other than the purple hair dye. Or the rinse.
I don’t think they realise that this can actually happen, that they can expect to be – well pre-COVID – they could have been taken on tours on the most beautiful of boats. And have fantastic care, which is addressed to their needs and that the ageing person. Yes. We’ve got longevity going on more than ever before.
There’s a lot of 80 year olds in this world now, but the average person is actually quite fit and we stereotype type them as being the older person who’s got limited mobility, limited cognitive functions. And, everyone seems to think that aged people are about to kick the bucket.
And that’s not how it is at all, and we’re not addressing it.
Ash de Neef: A good way to establish what Kalandra does is to look at what’s the sort of bog standard framework in New Zealand. What training is required, what’s mandatory? And what does Kalandra provider that’s extra?
Dr. Christine Clark: So in New Zealand our training starts at level two. That is the very basic foundation training, which will get someone to be a reasonably safe caregiver. So we’re talking about healthcare assistants or they call them clinical assistants. So just the basic in the old days they were called, nursing assistants.
Then we have our level three, which is a little bit more intense and a little bit more skill based and a little bit of effects and professionalism added into it.
And then there’s level four, which is your, almost your team leader type role and under Kalandra, we specialise that role into someone that either offers mental health, has mental health knowledge or has a reasonably good level of dementia care knowledge.
In New Zealand we went through the pay parity thing in 2017 and that rocked the world, I think. Where the government, all of a sudden, almost overnight said, “okay, we recognise the health care system has been very much underpaid and undervalued. So we’re going to increase the page hugely.”
But this happened overnight basically. And they said in the pay parity act that if you had been working as a health care assistant up to eight years, you were regarded as a level two. This is with no qualifications. And if you’ve been working up to 12 years, now that’s a significant time, you regarded as a level three.
And if you were 12 years plus, which is a lifetime for a lot of people in work to be in one job you were regarded as a level four. You didn’t need training, but we do have those trainings available. And, in fact the pay in July for a level four is going to be $27 an hour. That’s pretty significant money.
Then you can do level five. It’s not recognised under pay parity. So you do that just as a team leader or to improve your CV. Our internationally qualified nurses, it doesn’t matter where you come from including Australia, unless you’ve done our cultural papers you are only regarded as a level three.
So that’s a slap in the face for registered nurses. And once you’ve done your cultural papers or you’ve done the level four you can be paid as a level four, but I probably shouldn’t be saying this. We do not treat out international qualified nurses with the respect that they deserve, but under that pay parity, at least they’re getting pretty good money.
Ash de Neef: Do you think that the future of training carers and healthcare assistants is to be more specialised or more general or some combination?
Dr. Christine Clark: It may be more specialty orientated. It may be. We need people with knowledge of dementia. Absolutely. And that’s one of our many requirements that people work in dementia they must have a couple of our unit standards within a few months of working in that area.
But I’m thinking that our care is going to deteriorate. The opportunity for caring is not going to be there. And that actually, that really worries me.
One of the things organisations did with the pay parity, cause they didn’t want to pay the increased money, was they went through and they looked at some of the nonclinical jobs that the healthcare assistant was doing. For example, putting out the meal trays, they removed that out of their role, which is not a bad thing. And they created another person, another role.
And so the healthcare assistant became more clinically focused, more task focused. And one of the things I worry about is that over a period of time – because of time pressure that they are under, because they’re expected to cope with so many clients that – that the role has become going to become very task focussed.
And they’re not going to have time to provide the caring that the older person needs. And they’re not gonna have time to sit on that bed and give them the hug that they need. They shouldn’t be sitting on the bed anyway. They need to be able to give someone a hug when they need a hug. When I did my doctorate, what I realised was that when people first became a health assistant, they went into, I call it a protective mode where they offered task focused care.
They were just trying to protect their job and their income. And so therefore they were focusing on just making the bed well showering the person. They weren’t able to cope with actually adding in that extra hug, the touch or the make-up on the person .Or give them a shave that they wanted desperately. They could only cope with what absolutely had to do.
And I’m really worried that with the increased number of clients are going to get with the cost saving, which is occurring, that the person’s going to come more task focused.
But when they get past that, they actually then start to learn how to balance their workload really well. And then when they’ve learned how to balance it, that’s when they become engaging. And so you’ve got this amazing person who can work their time, manage their time incredibly well, teach others, work with families, do counselling, go and find the resources they need.
Because they’ve learned how to balance everything and they get support. Hopefully there is support of their colleagues and their employers.
And that’s when they become that really rich caring person who does all that engagement. That’s the person we need, but that comes with employer support. So let’s go for the engaged person.
Ash de Neef: What does it take to, to find these engaged people? Is it just a matter of time in the system with the correct support or is there something about the recruitment?
Dr. Christine Clark: It is time. Because I did actually come across quite a few people who didn’t want to be healthcare assistants, but had worked in the area long enough that they had learned to love it. And to become comfortable, they need that time, but they need that support.
One of the things that they would say to me when they first came into a unit or first became a healthcare assistant was under this protecting thing that if they saw the nurse or they saw the boss walk past, they would actually physically hide. They were so worried about protecting their job. They didn’t care if they’re doing a good job. They would hide.
And things like if resources were short and they wanted to wear gloves, for example, and they were told they couldn’t cause they were too expensive, believe it or not, they would hide those gloves so that no one would know they were wearing gloves. And they wouldn’t do anything with gloves on until people we’re not around them. That’s just how bad it was for them.
So we need them to be safe. And then once they got past that, they were then working out how to balance everything and not be so scared. Then they would engage and provide that time for the caring. Really interesting.
Ash de Neef: That’s interesting that’s linked to the pay parity act, that what’s ostensibly an act to compensate people for their work more fairly may result in a changing standard of care.
Dr. Christine Clark: Yeah. And that’s because, in the past, I might’ve employed two people to look after 16 clients, which eight clients per person is pretty reasonable in the aged care place. Under the pay parity because of the increase in pay, they cut back on staff.
And so they employed this person to put out the tray tables and to tidy up afterwards and they cut back on the number of healthcare assistants. And so they were incredibly time stressed, very, very time stressed. So they are expected to do more. Not all places I’m generalising, but they are expected to do more.
Ash de Neef: How do you think that the workload of care assistance can be reduced without affecting the quality of care or, resulting to cost saving measures?
Dr. Christine Clark: Every single piece of literature you read, they talk about time. The time management, how they are time, poor. Resource poor. So if we were to be sensible and streamlined the caring, and it’s really hard because when you talk about patient or person centered care, you talk about responding to the care that person needs.
So if they don’t want to get up at seven o’clock in the morning and have their shower and be ready for breakfast at eight, like a lot of places demand. We need to respect that and we’re meant to say, “okay, I’ll come back to you. And I will help you shower at whatever time it is that you want.” There is increasing the load on the caregiver.
So we need to work out a system where we can respect what the person needs. Put it number one, but still be really clear at manipulating our time. So there’s a huge amount of time wasted in finding resources.
Some of these beautiful villages. We talk about some of these beautiful hospitals, which are being built, they have not been designed by the person that works in them. One I saw was built around a beautiful quadrangle, looked fantastic. So we had four pieces of this ward, all individual rooms, beautiful. And the linen was in the furthest corner. And so no matter where you went, you were walking half of that building just about to get a sheet.
Ash de Neef: Yeah.
Dr. Christine Clark: And because it was beautiful, you weren’t allowed to have the old-fashioned linen trolleys in the corridors. You couldn’t do that. And the drug room was right on the other side. So you couldn’t go and get the medication acquired and then get the sheet that you needed all at once. So why don’t they first of all, ask people who know what is required before they design these places? Put in quite a few different areas for them to go and get resources, so in other words, have a lot of resources available.
But during my study, I found that the health assistant was having to go into other units or other wards and basically steal pads and sheets and socks, stuff like this, and hide them from the other healthcare assistants so that they could actually manage to give them to their clients.
And they spent a lot of time actually trying to find things. It was so much wasted time. So let’s be sensible about this and actually have some resources and put them in good locations, have actual nurses helping design facilities so that we can look at some time frame.
How about when you’ve got these large facilities giving the staff, some little tiny motorised scooter that they could go from one end to the other end when they need to? Or put those little conveyor belts through, that you have in the airports to speed up their walking. Or to limit the amount of energy they’re expending, use technology more efficiently.
And I know that some places, when a call bell goes, it’ll buzz on a person’s phone and alert them and still the person having to rush out to the corridor to see where the bell is sounding. Some of my research mentioned distractions. That the caregiver actually is distracted from their work at least once a minute, every single minute they are interrupted.
How can they focus when this is happening? And a lot of those distractions of verbal or bells, buzzers demands on them. And so we need to minimise those distractions because that’s time wasted. So what technology can we use, which is going to make that easier?
But remember, a lot of the caregivers are middle-aged and they don’t like technology. So how about we train them in how technology can be friendly and how about we make the technology really easy? So all they have to do is push a button to see where that bell is going. Or if the bell is not answered within two three minutes. It goes down to the next phone.
And I know that some systems over here are actually using that, but it’s more as a, “okay, if the health care assistants are answering within x number of minutes, it’s going to go to the supervisor and they’re going to get told off.” Not, “why haven’t they answered, how can we help them?” Does that make 0sense?
Ash de Neef: Yeah. It’s interesting that what you didn’t say was you didn’t say anything about the specific tasks that are required of care assistants, but you did say environmental factors and using technology and more creative ways.
It sounds and correct me if I’m wrong, but it sounds like you think that the role of the carer as it is at the moment is probably appropriate, but that we can shape the factors around it to help that be more effective.
Dr. Christine Clark: I know that we are going to become more robotic focused. I know that we are using things like drying tubes a lot more. There’s nothing wrong with that. That will speed up the process and sometimes make life more comfortable for our clients.
What I did find was that there’s no real boundaries to this role. And there is actually – I called it the blue domain. That a lot of these healthcare assistants are working in an area which is not defined. And it’s deliberately not defined because if you define it, then someone can come along and say, are you’re working outside of your role.
In New Zealand, we only have a role defined by their employment contracts, their job descriptions. And by the qualifications, no one is going to actually say you shouldn’t actually be doing this.
The union sort of say, you shouldn’t be doing it, but nothing really happens. And so this blue domain, especially for that international qualified nursed – she’s a pseudo registered nurse. We exploit them and I’m going to get rapped over the knuckles for saying this i’m sure, but we do. And you do in Australia as well.
We by default use their knowledge and their skills they have as a international qualified nurse in the aged care environment. And when the registered nurse who’s meant to be doing it is not available, usually international qualified nurse or the very senior HCA steps up and fills that gap. Because if they don’t, whatever it is, is not going to be done.
Unfortunately if you’re on a work visa, It’s very easy to very quietly say, l”ook, you really want us to agree to your work visa. You really want us to sign for it for you next time to apply for it. So therefore you really need to be a very good worker for us.”
And they feel quite oppressed. And feel that they have to do these things, which they feel that probably shouldn’t be doing. There’s a lot of stuff that they have to do. They do it very well. I’m not saying our clients are in danger. I am saying that we are ethically and morally wrong in what we are doing with them.
So the role of the caregiver yeah. I love the caring they give. I love the fact that sometimes they’ve got time to give that hug, and to sit with someone and cry. And I love the fact that they can sometimes have time to grieve. But I do see the role changing and I’m really worried that, that beautiful caring is what is going to be sacrificed. Putting someone in a drying tube is not the same as actually drying someone.
Ash de Neef: So you’ve mentioned a few times there the exploitation of overseas qualified nurses and let’s just dig into that. What do you think, what are the changes that would be needed to be made to alleviate that exploitation?
Is there some sort of external auditing that needs to go on? What do you think the solution is there?
Dr. Christine Clark: Around the world. A lot of people have been talking about it. There’s been a lot of inquiries all over the world as to the role of the health care assistant. And predominantly these inquiries are triggered by abuse, deaths and different areas.
There’s been huge inquiries in the UK over the years. There’s been big inquiries and well they’re still going on in Australia, massive ones in New Zealand. And still it goes on and they talk about legislation and regulation and some people want it and some people don’t want it.
There are about, I think it’s 27 countries, which actually have a regulation or legislation defining the role. And it defines a role which is really task orientated. You can do this, and this, and it never mentions anything about the empathy and the caring.
I’d like to actually be quite radical. And I’d like to be able to say, “how about we recognise the internationally qualified nurse as a qualified nurse?” That each country has some sort of bridging program, and actually allows them to operate at the level they should be at.
New Zealand, used to do it with doctors, had a bridging program, and then we stopped it. Why don’t we? And perhaps we say it’s aged care only because aged care is so very short of international qualified nurses.
And how about we go one stage beyond that and we say, okay, most of the world is desperately short of caregivers and aged care. And there are a few countries which have a lot of people that can actually train and export to fill these gaps. Why don’t we come up with a qualification, which was pretty generic, which most of the world actually likes. And we actually teach that to reasonably young people and these young people with these new skills caring skills can then go and do the OE in almost any country in the world
And they can actually earn reasonable money and look after older people and experience the world at the same time. Now, my God, nannies used to do that. And bartenders used to do that. Why can’t healthcare assistants do that?
And so I could learn as a healthcare assistant in New Zealand, how anywhere in the world would like their older people to be taught. Within reason you might have to do some cultural papers somewhere along the line.
And I could go to Ireland and work for a year and then I could cross the ditch and I could go somewhere else. We could make that attractive to youth. And then how about we come even more dramatic here and we actually say you do that.
And you work as a healthcare assistant in your own country, or internationally say for two or three years. And, Oh my God, we might actually give you some credit towards a nursing program or a physio program or something.
And put you on your way and along another pathway, that could be quite interesting. But no, our professions are quite arrogant and snobby and this probably wouldn’t work. It would be nice if it could.
Ash de Neef: It highlights like the fragmentation internationally and in the way that care qualifications are presented and the requirements of them. And also the kind of lack of pathway, as you said. That perhaps one way to get more people engaged in care work is to say, “this will contribute to a further qualification. You can test this out. This could be a way into a different career.”
But I could see for some people it might be seen at the moment as a one-stop destination. There’s no where to go beyond aged care.
Dr. Christine Clark: Yeah, we have that in New Zealand because it would be very difficult for a healthcare assistant to actually get into nursing because they haven’t got the sciences that are required.
They could perhaps get into the diploma level, but not the registered level maybe, but probably not. There’s quite an arrogance through all of our different healthcare professionals, all the councils, we’re desperate for registered nurses. We’re desperate for the healthcare assistance and yet we don’t actually do a hell of a lot to attract them.
Ash de Neef: Yeah. That’s a challenge the world over I’m. Sure.
Dr. Christine Clark: A few years ago, Korea put out a call for farm laborers to come in and look after the older people, you know farm laborers. And New Zealand, our government actually said that the people that were no longer picking Kiwi fruit could look after older people.
And they were prepared to do a two day training course. How absolutely disgraceful was that? What a disrespect to our older people.
Ash de Neef: So circling right back to the start. And you’re talking about the shifting landscape. I know there is an ageing population problem in most countries and Australia and New Zealand are no exceptions to this.
What can healthcare assistants and carers do to prepare for the future?
Dr. Christine Clark: If you were going to be sensible and were career driven, you would probably think, “okay, how can I be different? What else can I add? What can I do on my CV, which is going to impress people?” same as if you want to be a fireman now or into the armed forces.
Now, how can I look different to anybody else? And if I was that person, I would be looking and thinking, “okay, I’m going to add in some extra information on dementia.” Which is very freely available. At least the knowledge, especially from Australia, amazing research done out of Australia.
I would be looking at experience in palliative care because our aged care facilities are palliative care – now they are almost hospice.
I would be looking at can I do some massage for the older person? What can I learn about beauty therapy for the older person? What can I learn about exercise related to the older person? Can I do some counseling courses? Probably not, because there’s not really a lot of counseling courses.
I’ll tell you something. We developed a graduate diploma, level seven counseling for the older person, and we took it to NZQA and you know what they see said to me, “why would an older person need counseling?” And I just said, “are you kiding?” This is one person very high up in NZQA. “Why wouldn’t they need counseling?”
And we fought so hard to get that through. And we couldn’t, and it’s currently being taught in Singapore. Why wouldn’t they need counseling?
But as this caregiver, as this really intelligent caregiver, empathetic caregiver, I’d be looking at what else can I add to my abilities? It’s going to make you really attractive. Not because there’s a hundred people applying for the job, but because I want to be exceptional.
Ash de Neef: So what are you excited for in the coming years within, within aged care?
Dr. Christine Clark: I’m really trusting that the whole ethics and professionalism will win, and that our health assistants are going to have the most amazing role defined clearly for them so they’re safe.
But that role will encompass things like knowing how to massage someone, knowing how to spend more time in caring for this person.
That I’m really hoping that they won’t cut back the numbers of people and that these people will give their opportunity to actually be care assistants and they’ll have amazing registered nurses or similar who will supervise them and train them and support them.
So I’m hoping that we will develop a generic qualification, which will be recognised around the world. And our young people will want to do this career because it’s going to open the world to them. COVID willing and other pandemics willing of course. But, to use this as the way of exploring internationally would be amazing.
Imagine the skills they could bring back to us and the experience they could bring back to us. It’d be fantastic. So this is what I’m hoping for.
Ash de Neef: Yeah. That’s great. And I would really tap into the Aussie and Kiwi love of traveling and probably snag a few younger people into the industry.
Dr. Christine Clark: Yes. That’s the idea, it’s one of the most complex roles. Probably anywhere in the world because you’re dealing with people, multiple people, multiple illnesses, multiple diseases. They’ve got family tensions and the tensions of getting older and dying. It’s huge.
And this poor person. So often they just dump them there with very little support because they don’t need it because they could be a farm laborer or kiwi fruit picker to be able to look after old people.
Ash de Neef: Christine, thanks so much for your time today. This has been fun. People can find more about Kalandra at your website. Can you remind us of your website please?
Dr. Christine Clark: Yeah it’s just www.kalandra.ac.nz. Just Google Kalandra.
Ash de Neef: Awesome. Thank you again for your time.
Dr. Christine Clark: Thank you, Ash. It was fun.