Clinical governance supports aged care organisations to deliver high-quality care and services to achieve good health and wellbeing outcomes through positive care experiences. [1] Although there is no ‘one-size fits all’ approach to clinical governance, [1] the Aged Care Quality and Safety Commission (ACQSC) suggests six core, interrelated elements to clinical governance which together promote optimal health and wellbeing outcomes for people receiving aged care services. [2] Governing bodies should consider each of these and set up systems to manage, operationalise, and monitor success against them. One of these elements is the combination of communication and relationships. The other core elements are covered in detail in our clinical governance themes.
Why are communication and relationships important to clinical governance?
Aged care recipients often have multiple, complex medical and personal care needs, especially those who are older, living with dementia, or approaching the end of life. [3] They, therefore, require the services of a team of care providers, including personal care workers, nurses, doctors, and allied health professionals. For care to be safe and effective, it is important that all members of the care team have the same understanding of the person’s current health needs and preferences for care. This relies on staff establishing effective communication and positive relationships with the older person and their families and clearly documenting important information in an accessible care plan. A high-quality care plan supports all team members to work towards achieving the same care goals. [4]
At times, the needs of those living in residential aged care may often exceed the skills or resources of the residential care team, necessitating a transfer to an emergency department and perhaps a hospital admission. It is important at these times that information about the person’s health and care needs flows smoothly and in a timely manner between the aged care facility, hospital service, and back again. [5] Ensuring older people receive coordinated, continuous care across different care providers and settings is a crucial, yet often challenging, objective of aged care clinical governance. [2] Instances of inadequate documentation, record keeping, and information sharing continue to be reported, putting the health and safety of care recipients at risk. [6] Good clinical governance is therefore reliant on structured, formal communication mechanisms and constructive working partnerships between professional groups operating both within and external to the aged care service. [2]
Communication, relationships, and the regulation of Australian aged care
The importance of communication and relationships in delivering safe, effective care to aged care recipients is emphasised throughout the current (2019) Aged Care Quality Standards. [7] In communicating with care recipients, the Standards require care staff to:
- Communicate their decisions with, and provide current, accurate, and timely information to care recipients in a clear, easy to understand way (1(3)(c); 1(3)(e))
- Effectively communicate the outcomes of all assessment and planning to the care recipient. This may be documented in a care services plan that is made accessible to the care recipient (2(3)(d))
- Document and communicate to the care recipient their condition, needs, and preferences, and share this with others who also have responsibility for that person’s care (3(3)(e); 4(3)(d))
- Encourage and support care recipients, their families, friends, and carers to provide feedback and make complaints (6(3)(b)), enabling them to feel safe in doing so and to know that appropriate action will be taken (6(1))
- Demonstrate they use an open disclosure process when things go wrong (6(3)(c); 8(3)(e))
- Build relationships of trust with care recipients (7(3)(a))
- Be kind, caring and respectful, considering identity, culture and diversity when communicating with care recipients (7(3)(b)). [7]
The Revised Aged Care Quality Standards (2023) strengthen guidance on how staff should communicate with care recipients by including considerations of diversity and people with communication difficulties. These Standards direct aged care providers to:
- Implement a system that identifies and assists care recipients needing support with decision-making to participate in the decisions that affect their lives, and all communication relating to agreements (e.g., this may require providing translation or interpreting services) (Actions 1.3 and 1.4)
- Understand how diversity (including those at higher risk of harm) must be acknowledged when offering services, and ensure communication and services meet care recipients’ needs (Action 2.1.4)
- Ensure they practice open disclosure with care recipients, their families, and carers when things go wrong (Action 2.3.5)
- Ensure there are strategies in place to support the workforce to understand different communication needs when caring for people living with dementia, or who otherwise have difficulty communicating. Strategies should highlight the importance of both verbal and non-verbal communication in providing care (Action 3.2.9). [8]
The Revised Quality Standards also set out communication requirements for effective information sharing between members of the care team. They include directives to:
- Implement systems to capture information about the care recipient and communicate this in a timely manner to ensure situations do not escalate – e.g., what the needs, goals and preferences of the older person are (especially when these change), risks that emerge or incidents, and handover instructions between members of the workforce (Action 3.3.2)
- Communicate transition plans to and from the aged care provider with the care recipient and other providers of care and services (Action 3.4.3)
- Ensure all clinical governance priorities and strategic directions are communicated effectively to workers and care recipients as part of their duty of care (Action 5.1.1)
- Have processes that communicate between care recipients and/or their representatives, care workers and others, information regarding an individual’s end-of-life care preferences including the place they wish to receive care (Action 5.7.3). [8]
The Code of Conduct for Aged Care adds further support to both the current and revised Quality Standards in describing how the aged care workforce should communicate with care recipients. The Code sets out the expectations that staff will:
- Communicate with care recipients in a clear, easy to understand way that enables the care recipient to exercise choice (Element A)
- Use assistive tools or interpreters, for instance, to overcome any barriers to communication with care recipients (Element A)
- Treat care recipients with dignity and respect in all communication (Element B)
- Encourage communication of preferences by care recipients to show how they want their care, support, and services to be delivered (Element B). [9]
Components of effective communication and relationships for clinical governance
The aged care leadership team might develop a strategy for strengthening internal communication processes between staff and care recipients, as well as between all members of a person’s care team, including visiting health professionals such as general practitioners, subcontracted staff, and external care organisations. This strategy should be developed in consultation with all care providers and aged care recipients, documented in the clinical governance framework, and regularly reviewed.
Systematic, structured approaches for communicating with, and receiving information from, staff about individuals and their needs, as well as risks, incidents, and feedback are vital for effective clinical governance and good care outcomes. In communicating to staff, the organisation's leadership team might consider:
- Using structured documents such as flowcharts, protocols, and templates to instruct or update staff on policies or processes relating to the delivery of care [7]
- Using structured approaches to facilitate the sharing of high-quality information about care recipients between staff, especially those working different shifts [8]
- Approaches to sharing information about end-of-life care preferences. [8]
Continuity of care is associated with better health outcomes for care recipients. [10] The organisational leadership should, therefore, develop structured communication templates, protocols, and agreements that support open and efficient communication and constructive relationships between staff and visiting clinicians or external healthcare organisations. [11] This may help prevent communication failures leading to errors, missed care, inappropriate treatment, and poor care outcomes. [4] Agreements might cover how care decisions are documented and shared with the care team, standing orders for individual care recipients, and protocols for contacting the clinician after-hours or in emergencies. [12] Visiting health professionals should also have easy access to the care recipient’s care plan for safe and efficient information sharing.
Communication is also central to the partnership between care recipients and aged care staff. [7] Adverse events (or ‘incidents’) will inevitably occur within aged care settings. When they do, open disclosure processes should be followed in communicating with the person affected and their families or representatives. [13] Open disclosure involves expressing regret (using the word ‘sorry’), and openly and honestly discussing what happened, the consequences, and steps to be taken to ensure a similar incident does not happen again. [7] Open disclosure should also allow the care recipient and/or their family to ask questions and air their concerns.
What might effective communication and relationships look like?
People working within an aged care organisation with strong systems for communication and establishing and maintaining relationships are more likely to agree that their workplace:
- Has good record-keeping systems to support clinical quality and safety
- Has effective staff communication processes in place for clear and effective handovers between shifts
- Uses structured processes and templates to share information when consumers are transferred to or from external healthcare providers
- Provides staff and visiting health professionals with ready access to the information they need about each person to provide appropriate care (e.g., care plans and advance care plans)
- Encourages effective relationships with visiting health professionals and external providers
- Is mindful and considerate of the diverse backgrounds of care recipients or any factors impacting their ability to communicate, such as cognitive or hearing impairments
- Uses an open disclosure process when communicating with care recipients and their support people about incidents (and near misses) that affect them
- Fosters a culture that allows staff to feel ‘psychologically safe’ when raising concerns [14]
- Provides training to staff on how to tailor communication to the care recipient’s needs and backgrounds. [7, 8]
Additionally, in organisations with effective communication, care recipients are more likely to say they:
- Have trusting, respectful, and caring relationships with staff members
- Are communicated with in a clear, easy to understand way
- Can access communication tools such as translator services when needed
- Are encouraged to be involved in all discussions that affect them, and any meetings regarding their care
- Feel supported to communicate feedback on service quality or report an omission of care without fear of reprisal. [7, 9]
