Cultures of aged care delivery: Qualitative content analysis of Australia's Royal Commission into Aged Care Quality and Safety

Abstract

Objectives

Organisational culture is increasingly recognised as influencing the quality of care provided to patients and residents of aged care, both in research and in policy. For example, investigations into quality and safety issues in health care frequently highlight cultural problems, but often without adequate theorisation of culture. This study aimed at identifying how cultures of care delivery are considered in the final report of the Royal Commission into Aged Care Quality and Safety, and its subsequent implications.

Methods

A documentary analysis was performed on the five volumes of the final report using qualitative content analysis.

Results

Of 211 references to culture, the majority focussed on organisational culture (n = 155), followed by the sector's culture (n = 26), the culture of the agencies involved in managing aged care (n = 21) and the national culture relating to the treatment of older people (n = 8). These cultures were discussed in five ways: (1) highlighting poor culture as a problem (n = 56); (2) showcasing the style of culture that should be aspired to (n = 45); (3) reinforcing the importance of culture (n = 38); (4) making attributions about factors contributing to culture (n = 33); and (5) discussing the need for culture change (n = 30).

Conclusions

The Royal Commission's findings emphasise the importance of care culture and the need for change but provided limited guidance on how this should be achieved, or culture conceptualised.

Practice impact.

The final report of the Royal Commission into Aged Care Quality and Safety recognised the importance of culture in the delivery of high‐quality care to older people but provided limited guidance on changing it. Providers wanting to improve their culture might partner with researchers who can provide theoretical and methodological expertise to facilitate understanding of its evaluation and achievement.

1. INTRODUCTION

Organisational culture, the shared values, attitudes, beliefs and norms of behaviour of a group of people within a workplace, has become an important topic in health care over the past two decades. ¹ , ² A positive culture characterised by open communication, teamwork, and engaged leadership is associated with reduced mortality, falls, hospital‐acquired infections and increased patient satisfaction. ³ Residential aged care facilities (RACFs) with a safety culture tend to have fewer health care deficiencies and complaints, higher quality ratings, lower use of physical restraints and deliver person‐centred care. ⁴ , ⁵ , ⁶

The importance of culture is increasingly recognised in policy: National Safety and Quality Standards for health service organisations and the Aged Care Quality Standards both include the promotion of a culture of safety and quality. ⁷ , ⁸ Findings of the recent Australian Royal Commission into Aged Care Quality and Safety (RCAC) ⁹ provide a further opportunity to examine the degree to which ideas about culture have been adopted to understand quality issues in RACFs. In this regard, Mannion and Davies ² argue ‘culture is often identified as the primary culprit in healthcare scandals… (but) such simplistic diagnoses and prescriptions lack depth and specificity’. Informed by this conjecture, this brief report aimed at:

1. identifying the types of care culture in the final report;

2. analysing how these care cultures are deployed; and

3. consider the implications of how culture is theorised.

2. METHODS

The five volumes of the RCAC ¹⁰ were exported to NVivo. ¹¹ Mentions of ‘culture’ and its stemmed words (e.g. ‘cultural’) were segmented using text search. While extracts about the cultural background of older people in care (e.g. Aboriginal and Torres Strait Islander peoples) were excluded, several types of culture related to aged care delivery were inductively categorised (e.g. organisational, sector). Further inductive coding was used to classify how these cultures were being referred to (e.g. culture as problem); during this process, subcategories were developed to classify recurrent types of content within a category. To ensure a systematic process, coding rules were developed and a subset of segments were coded a second time 2 months later by the first author (i.e. double coding). ¹² Codes were also confirmed with other members of the research team, and any instances of uncertainty were resolved through discussion. The qualitative content analysis was summarised descriptively as frequencies, category descriptions and illustrative quotes, with a matrix coding table created in NVivo to highlight variability in category distribution by type of care culture.

3. RESULTS

Of 659 references to culture, 211 (32%) were about aged care delivery, which were categorised into five levels as summarised in Table 1. These care cultures were deployed in five different ways.

TABLE 1.

Types and levels of care culture referenced in the documents

Type of culture	Number (%)	Description	Extract
Organisational culture	155 (73)	The culture of aged care providers and aged care facilities	‘Providers need to shoulder some of the responsibility for the systemic problems of the aged care system. Specifically, providers have not focussed sufficiently on the provision of high quality and safe care, on older people's wellbeing, on service innovation and excellence, on listening to older people and hearing their complaints, on effective clinical governance of their services, and on workforce leadership, development, skills and culture’. (Final Report 1) ‘Culture is the key determinant of an organisation's performance and ability to meet its objectives. Organisational culture must make the wellbeing of those receiving care paramount in aged care’. (Final Report 3b)
Sector culture	26 (12)	The culture of the aged care sector or system as a whole	‘We recommend a series of reforms that should make the aged care system more open, transparent and accountable. This will require an investment in transparency and culture change that favours open access to information over secrecy, and continuous improvement over denial’. (Final Report 1) ‘When I informed my In‐Charge that I had been assaulted by a resident, the In‐Charge shrugged their shoulders and said “That's dementia”. This has happened on different occasions; I think there's an overriding culture in aged care of simply shrugging it off’. (Final Report 2)
Culture of government bodies	21 (10)	The cultures of the various government departments and regulatory bodies responsible for managing aged care in Australia	‘A competent, vigorous and well‐resourced regulator is critical to the success of any regulatory regime. The systemic failures we have identified in the aged care system raise concerns about the capability, leadership and culture of the regulator’. (Final Report 1) ‘In the new aged care system, the Department will need to be a proactive system leader that drives reform of the sector. This will necessarily involve cultural change. I am therefore proposing an explicit and stronger role for the Department in governance of the aged care system and the establishment of an Office of Aged Care’. (Final Report 1)
National culture	8 (4)	Societal attitudes and values towards older people, particularly around respect	‘Inextricably linked to all of these concepts is the question of whether Australia has a national culture of respect for ageing and older people. Attitudes towards ageing and older people can affect the care that is provided to them’. (Final Report 4a) ‘[Name], a personal care worker, called for a complete cultural change to aged care in Australia and for a shift to valuing older people. She said it should not be a matter of: “Well, we'll just stick them over there where we can't see them and we won't worry about that because it's all a bit yucky when people get old and, you know, they're just not themselves anymore.” (86) The need for education to create deep change in community attitudes towards older people was emphasised’. (Final Report 4a)
Professional culture	1 (<1)	The professional culture of medicine	‘In his statement, Professor Poulos identified a number of “professional cultural and systemic barriers” which affect access to specialist medical care in residential aged care’. (Final Report 4b)

‘Highlighting culture as a problem in aged care’ (n = 56) involved positioning culture as negatively affecting the quality and safety of care provided to older people, expressed in language such as ‘poor workplace culture has also contributed to poor care’ and ‘cultural failings’. It was often mobilised in relation to organisational culture, including naming specific providers or facilities. In some instances, processes or strategies that indicated poor culture were referenced: ‘Poor complaint handling and a lack of open disclosure can be a reflection of the poor culture of an approved provider, or a particular service’ (Final 1). Such words assume tangible work practices are the manifestation of culture.

Second, ‘showcasing cultural values to aspire to or avoid’ (n = 45) included references to the style of culture that should be encouraged or, equally revealingly, avoided. Idealised cultures broadly fell into two subcategories, appreciating older people (e.g. ‘national culture of respect for ageing and older persons’) or focussing on quality improvement (e.g. ‘culture of continuous improvement and striving for excellence’). By contrast, cultures to be addressed or avoided were those that lacked a focus on quality (e.g. ‘incurious “tick‐a‐box” regulatory culture’) or where aged care was ‘a money‐making exercise’.

The third most frequently used was language ‘reinforcing the importance of culture’ (n = 38). These references were frequently explicit, for example:

‘We [the Royal Commissioners] both understand the importance of leadership and culture to the delivery of high quality and safe aged care’ (Final 1). This rhetoric sought to emphasise the degree to which organisational culture differentiated facilities, in that it was integral to their providing high‐quality care and was a necessary foundation for, for example, ‘workforce development and growth’ (Final 3a). The importance of culture was also sometimes implied, such as in a suggestion of the need to consider, address or measure organisational culture: ‘Risk management systems… should also include measures to identify emerging problems with organisational culture’ (Final 3b).

While some of the previous categories focussed more on outcomes of culture, ‘making attributions about factors contributing to culture’ (n = 33) involved highlighting a range of features that (were assumed to) affect culture. Leadership was the most frequently cited (n = 19) of these, present in statements such as the ‘values and behaviour of people in these senior positions have a significant impact on workplace culture and the quality of care that is delivered’ (Final 2). Other recurrent contributors to culture were governance (n = 6) and staffing and workforce issues (n = 5); for the latter, specific processes believed to shape culture included rostering people consistently and recruiting new staff members based on congruent values.

Finally, ‘discussing culture change’ (n = 30) was often a general call for a need for culture change to support or drive more concrete changes within a level of the aged care system:

In the new aged care system, the Department will need to be a proactive system leader that drives ongoing reform of the sector and nurtures its numerous components in a coordinated and purposeful way. This will necessarily involve cultural change. (Final 3a)

In some references, there was information about strategies or processes that might be used to change culture, but these were infrequent and lacked detail, for example, ‘[Name of witness] explained that regulatory compliance “drives cultural change, both within society and institutions”’ (Final 4C).

While most ways of deploying culture were used across the types of care culture, there was variability in their degree of representation. Organisational culture was most frequently discussed in relation to culture as problem (30%) or to reiterate the importance of culture (23%). Meanwhile, the culture of government bodies was more often referred to when mentioning the need for culture change (47%), and the broader sectoral culture was typically discussed in the context of aspirations for culture (34%). This information is summarised in the heat‐mapped cross‐tabulation in Table 2.

TABLE 2.

Differences in the way culture were deployed for each type/level of culture ^a

	Organisational culture, n (%)	Sector culture, n (%)	Culture of government bodies, n (%)	National culture, n (%)
Culture as a problem	42 (30)	3 (10)	3 (18)	2 (20)
Aspirations for culture	28 (20)	10 (34)	5 (29)	2 (20)
Importance of culture	33 (23)	4 (14)	0	1 (10)
Factors contributing to culture	29 (21)	4 (14)	1 (6)	0
Need for culture change	9 (6)	8 (28)	8 (47)	5 (50)

^a Heat mapped—Red indicates low or no mention, yellow indicates some mention (approximately 20%), green shows frequent mention (approximately 50%) in that way for each of the care culture types/levels.

4. DISCUSSION

This analysis of the final report of Australia's RCAC found that culture referred to various aspects of the aged care delivery system. The term culture was used most frequently to highlight its importance in care delivery and link it, particularly the organisational culture of providers, to problems in the quality and safety of aged care. Despite this, discussion of a need for culture change in the documents analysed provided little guidance on how change should be achieved. ² That culture was most frequently discussed as a problem of organisations, while culture change was considered in relation to sectoral and regulatory levels, implies a top‐down expectation for achieving this culture change that is underpinned by somewhat simplistic assumptions of ‘cultural uniformity’. ¹³

The RCAC's Final Report includes numerous recommendations for improving Australia's aged care system through legislation, regulation and workforce arrangements. To paraphrase Davies et al., ¹ it is unclear whether discussion of ‘cultural transformation’ within these documents is a separate, real thing to be achieved by addressing norms, values, beliefs and behaviours directly, is something that will flow from more tangible structural changes, or whether it is just a shorthand for them. Cassie and Cassie ¹⁴ have also highlighted how discussion of culture in nursing homes frequently involves rhetoric about ‘culture change’, but with variable definitions of what culture is, if it is defined at all. Without such guidance, aged care providers are left with little support on where to begin in understanding and improving their cultures, though research in this area is expanding. ¹⁵ Rather than taking for granted a concept such as culture, policymakers, regulators and providers should engage with theories for its conceptualisation and methodologies for its assessment, to support both a greater understanding of the phenomenon and the capacity to evaluate any such change in it.

While consensus on these issues is still somewhat elusive in academia, ¹ the work of Edgar Schein has become particularly influential. ¹⁶ He defines organisational culture as involving shared basic assumptions that are developed or discovered by a group to cope with both ‘external adaptation and internal integration’. ¹⁷ Following on from this last point, an organisation's culture reflects what the group has learned in relation to challenges, such as a recent national inquiry, major reform, workforce issues ¹⁸ and a pandemic. ¹⁹ Moreover, culture change need not be treated as a separate activity to understanding the current state of culture, but as the natural extension of such work ²⁰ , ²¹ ; a first step in culture change, and therefore improvement in the care delivered to older people, is more richly understanding the cultures within facilities at this critical juncture.

5. CONCLUSIONS

Inductive qualitative content analysis was used to examine the types of care culture referred to, and the ways they were discussed, in the final report of the RCAC. The final report comprises eight influential policy documents developed from many public inquiries, witness testimonies, submissions and commissioned research that captured numerous issues in Australia's aged care sector. Although the documents clearly recognise the importance of culture, further guidance is needed on how the culture of the aged care system, and within RACFs, can move towards a greater focus on quality and respecting older people.

FUNDING INFORMATION

This work was supported by a National Health and Medical Research Council Investigator Grant awarded to KC (grant number 2007765).

CONFLICTS OF INTEREST STATEMENT

No conflicts of interest declared.

Churruca K, Long JC, Ellis LA, Saba M, Braithwaite J. Cultures of aged care delivery: Qualitative content analysis of Australia's Royal Commission into Aged Care Quality and Safety. Australas J Ageing. 2023;42:417‐422. doi: 10.1111/ajag.13175

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available in Royal Commission into Aged Care Quality and Safety at https://agedcare.royalcommission.gov.au/. These data were derived from the following resources available in the public domain: Final Report, https://agedcare.royalcommission.gov.au/publications/final‐report.