It Depends on What the Meaning of the Word ‘Person’ Is: Using a Human Rights-Based Approach to Training Aged-Care Workers in Person-Centred Care

Abstract

Aged-care services are in crisis through a combination of rising demand and increasing costs. Quality of care is often reported to be insufficient. Medical science has increased lifespans but the overmedicalisation of aged care may affect the financial sustainability and quality of care. Person-centred care was developed as a solution and is generally interpreted as being concerned with consumer choice. This study presents a human rights-based approach to a code of conduct for aged-care consumers and workers to ensure autonomy and participation in aged-care communities, which are fundamental to person-centred care. A test–retest cohort study was used to investigate the impact of a training module about a human rights-based code of conduct on the perspectives of new aged-care workers (n = 11) on a case scenario involving conflicting care priorities. Qualitative content analysis was used to categorise and count the participants’ responses. The analysis found that prior to training the majority of participants were focused on a medical and risk reduction model of care. After the training participants had a more expansive understanding of care needs and recognised the importance of client empowerment to enable clients to participate in decisions affecting their care. The results support the implementation of a human rights-based approach to worker training and client care; such an approach is consistent with person-centred care.

1. Introduction

The great marvel of our world in recent decades is the significant increase in life expectancy. A baby born in 2020 in Australia, Belgium, or Canada (for example) can expect to live at least 20 years longer than if it had been born in 1920 [1]. This is a global phenomenon, though it must be acknowledged that disparities exist between people with higher socioeconomic status disproportionately favoured [2]. Much of this change is attributed to advances in medical sciences with the advent of effective control of infectious diseases, better infant and mother care, and improved management of cardiovascular disease [3]. Medical science has been so effective in prolonging life that diseases generally associated with aging, such as dementia, are increasingly frequent causes of death [3]. The positive impact of medical science on life expectancy may result in seeing ageing as a “condition” to be “treated”. Over the last 30 years, it has been observed that a medically focused approach (“medicalisation” or “overmedicalisation”) to aged care may have unintended consequences; perhaps undermining the wellbeing of people receiving aged care. Overmedicalisation may also be impacting the sustainability of the sector [4,5,6].

This study aimed to determine whether an approach to aged care using a human rights-based code of conduct could be used to change the perspectives of new aged-care workers to think in categories beyond risk and medical care. We wanted to find out whether workers who were new to the sector took a “medical” approach to their work, and whether human rights training would expand their horizons. A human rights approach to aged care emphasises the importance of client participation, agency and empowerment. Knowledge of human rights is essential in those countries that have chosen to implement human rights into domestic law [7], and even in a country like Australia that has not done so, the legislation on aged care acknowledges the importance of client human rights. In our opinion, a best practice approach acknowledges and respects the human rights of all participants; clients and workers.

The response from governments to increases in life expectancy tends to focus on increased resourcing of aged care, and increased investment on staff with medical/health-based training. For example, the USA is expected to increase its spending on aged care from 1.3% of gross domestic product to 3.9% between 2013 and 2050 [8]. This increase in spending is required during a period in which the size of the taxpaying workforce is expected to shrink, making this financial burden unsustainable without fundamental reform of the revenue base [9]. In Australia, the crisis in quality of aged care was documented in great detail by the Royal Commission into Aged Care Quality and Safety [10]. High rates of turnover and difficulty attracting workers points to an unsustainable sector and significant challenges maintaining care standards. Over 50% of employees in the sector are intending to leave their organisation or at risk of doing so [11].

Globally, aged care tends to be a highly regulated environment, grounded in the principle that clients may be vulnerable and they require support and high quality medical care [12]. These are important goals of aged care, and although people typically require increasing medical care as they age, and such care can promote longevity [13], a model of aged care that places too much emphasis on medical care and inadequate focus on the important psychological and social dimensions of aging may be harmful [4]. We need to avoid an approach that sees a disproportionate amount of resources spent on medical objectives that can lead to a “warehousing” approach to aged care in which medical directives and avoidance of risk supersede other important objectives, such as how the impact of a medical focus may impact a person’s wellbeing, participation, agency, and empowerment in their relationships and community [14].

Kitwood’s [14] concept of “person-centred care” arose from his work in dementia care and is widely considered best practice in aged care more generally. At the heart of person-centred care is the view that dementia or (as can be applied to our discussion) ageing is not a medical condition or just a biological state but has psychological and social dimensions, and that proper care involves a focus on the well-being of the whole person with dementia. Critically, the person at the centre is not merely an autonomous individual but exists in community and through social connections [14]. These connections mean that the relationship between the worker and consumer of aged care is not unidirectional but should be seen as a collaboration between people. In other words, aged care should be more than a carer providing medical based care that meets the minimum expectations of a regulatory framework.

A brief survey of policies on aged care in Western democracies shows that the terminology “person-centred care” is frequently used in describing the preferred approach to aged care. For example, in the United Kingdom, the Care Quality Commission regulates aged-care services. Regulation 9 is “Person-centred Care” and person-centred care is indicated by the delivery of care and treatment services that are “appropriate, meet their needs and reflect their preferences” [15] (pp. 38). In Australia, residential aged-care services are to be person-centred, defined as follows: “Care and services are developed with, and tailored to, the older person, taking into account their needs, goals and preferences” [16] (pp. 6). These services are regulated by the Australian Government Department of Health and Aged Care according to the Star Rating System. All but one of the criteria relate to medical care and physical safety [17,18]. Similarly, in the United States, the star rating systems used by Medicare and Medicaid include measures of client safety and staff ratios but nothing about interpersonal relationships, autonomy, or staff experience [19]. These regulatory settings can allow aged-care providers to fail to meet fundamentals of person-centred care with minimal impact on their ratings.

In their work on the relational care framework, Tieu and Matthews [20] observed that person-centred care has devolved from Kitwood’s [14] original theoretical construct into “autonomy and self-determination in the context of individualism and consumerism” (p. 88). The view of the recipient of aged care as only a consumer of services carries the danger that a person is reduced to a list of tasks to be completed rather than a person collaborating in their care [15]. This misalignment in the regulation of person-centred care may help explain, at least in part, some of the poor experiences of residents in aged care. For instance, in the Australian context, the Royal Commission into Aged Care Quality and Safety (in a report simply and forcefully titled “Neglect”) reported that as many as one in three consumers of residential aged care received substandard care [10]. The Royal Commission found a wide variety of substandard care activities and omissions, but emphasised the need to avoid a task-based work approach that did not consider the rights of the individual client [10]. The report was consistent with the findings of the observational study by Eggenberger et al. [21], who reported that people living in aged care received, on average, two minutes of conversation per day from staff that was not directly related to care tasks such as toileting. Aged-care expenditure is growing, but enlarged spending is not producing a system that meets community expectations that dignity will be recognised and supported.

Regulatory settings can also be a contributing factor to the poor experiences of workers, who are also entitled to the human right of dignity [7]. Person-centred care is meant to focus on the relationships of the person receiving aged care (including the worker providing care [14,20]). However, regulations claiming person-centred care have focused on tasks to be completed by aged-care workers rather than the relationships between workers and clients. Responsibility for the health and welfare of people in aged care falls on aged-care workers. But care work without dignity for workers and clients is dehumanising and disempowering [22] and clashes with the reasons why people want to work in aged care (i.e., perceptions of autonomous and challenging work, but with the opportunity to build quality connections with consumers, conferring dignity [23]).

A new approach is needed. Green and colleagues [15] have suggested that an alternative to the view of aged care residents as consumers is to emphasise the personhood of clients and their relationship with the community in which they live. This perspective places less emphasis on consumption of services and greater emphasis on cooperation and collaboration within the aged-care community (including residents, workers, and families etc [15]). A code of conduct for aged care in a framework emphasising our common humanity, which supports dignity and the best principles of person-centred care, is needed. Accordingly, we support a framework deploying a human rights-based approach (HRBA) based on the United Declaration of Human Rights [24] which affirms the dignity and value of the person (Article 1) and that all people have rights and responsibilities within a community (Article 29 [24]). The human right to health stated in the International Covenant on Economic, Social and Cultural Rights is important, as is the United Nations Principles for Older Persons, guaranteeing rights of self-fulfilment and dignity [25,26]. In addition, the World Report on Aging and Health, the World Health Organization [27] adopts a HRBA. Since many countries have signed these instruments, the human rights they recognise could and should apply to all services regulated by governments [28].

These instruments are relatively long, so a summary is helpful. The Australian Human Rights Commission has recognised that a HRBA is based on five principles: (i) participation, (ii) accountability, (iii) non-discrimination and equality, (iv) empowerment, and (v) equality [28]. Participation involves active, free, and meaningful involvement in decisions affecting human rights, with accessible information. Accountability requires monitoring of compliance with human rights standards and providing remedies for breaches. Non-discrimination and equality focus on eliminating all forms of discrimination and prioritizing marginalized groups. Empowerment ensures individuals and communities understand and exercise their rights. Legality ensures that laws recognize and enforce human rights. Together, these five principles form the acronym PANEL (and will be referred to as the “PANEL principles” in this document). A HRBA based on the PANEL principles provides a framework to integrate human rights into policies and practices, advancing dignity for all. Such a framework is consistent with person-centred care in that individual choices and preferences are protected in the context of their relationships with the people in their community (aged-care workers, families etc.). The PANEL principles neglect neither risk nor care and legal requirements but these are addressed by “L” legislation. The potential benefit of a HRBA is that the emphasis on aged care moves from regulation of behaviours to the human, lived experience of care and community. Such an approach takes into consideration the rights of both the resident and worker to empower both to work together in community. In providing a better balance of rights and moderating the focus on regulation of medical care, a HRBA to aged-care services is likely to provide higher quality experience in aged care for the consumer and worker.

Providers of aged care are required to comply with regulations regarding treatment of residents and the training of workers to provide this care (for example, see section 18.2 of the United Kingdom’s Health and Social Care Act [29]). Regulation, therefore, influences worker training which, in turn, influences the experience of residents in the aged care setting. Changing the regulation of aged care is challenging and can take many years as it involves the changing of laws and the updating of associated policies and processes. Working with care providers to change training curricula to meet government and community aspirations while adopting what the literature suggests to be best practice may provide a realistic option to promote rapid changes in worker behaviour.

The following qualitative study explores the development of a human rights-based code of conduct using the PANEL principles in the aged-care sector and its implementation in the training of new aged-care staff. The study employed co-design in working with aged care providers to develop a human rights-based code of conduct and training module. We present a model for aged-care providers, workers, and consumers based not on a medical model but an HRBA where the rights of the parties involved in aged care (the consumer of services, the service provider, and the aged-care worker) are considered. This study aimed to determine whether a human rights-based code of conduct could be used to change the perspectives of new aged care workers to broaden their horizons beyond thinking about aged care focused on risk and medical care; and how an HRBA could help them solve common problems in aged care.

2. Materials and Methods

A test–retest cohort study (with no control group) was used to investigate the use of the human rights-based code of conduct training module and its impact on workers’ consideration of consumers. This study received ethical approval from the Australian Catholic University Human Research Ethics Committee (Project 2024-3501E).

2.1. Development of the Human Rights-Based Code of Conduct Training

The co-design group included the human resource/people and culture managers of aged-care providers involved in this study. The co-design process was conducted over four sessions. In session one, partner provider organisations shared the values held by their organisations as published on their website. Following this session, authors L.B. and H.O. grouped these values into four suggested categories. In the second co-design session, members discussed the groupings of values and agreed upon the final groupings and named the values shared by all partner providers. The final list was “compassion”, “dignity”, “excellence”, “flourishing”, “justice”, and “respect”. In the third co-design session, the partner providers met with a human rights lawyer who explained the PANEL principles of human rights. The lawyer facilitated a discussion about how each of the PANEL principles could relate to (i) each of the shared values of the provider organisation and (ii) the perspectives of consumers and aged-care workers. The perspectives of both consumers and workers were considered, as a central concept of person-centred care includes relationships within the community [14], and the core community of consumers was aged-care workers. A definition for each of the PANEL principles was then agreed upon by the group, for each of the shared values. The product of this discussion was the human rights-based code-of-conduct matrix (see

Table 1. Human rights-based code-of-conduct matrix.

	Values
Principles	Compassion	Dignity	Excellence	Flourishing	Justice	Respect
Participation	Effective compassion requires carers/clients/providers to enable participation through listening and dialogue.	Promoting and achieving dignity for clients and workers requires participation in care decisions and practices.	Excellent services and workplaces are participatory practices that focus on the achievement of service and workplace excellence.	For clients and workers to flourish, they need to be able to participate in the decision that affect them.	True justice requires the participation of people in the decisions that affect them.	A respectful environment reflects participatory values and practices.
Accountability	We are all accountable for our behaviours and should demonstrate compassion as providers, carers and clients.	Clients and workers are entitled to care and a workplace that reflects high standards, where people are accountable for their actions and behaviour.	Care practices and workplaces strive for excellence by monitoring compliance with human rights principles.	For clients and workers to flourish, services and practices need to be accountable for the achievement of human rights.	Accountability = justice	To achieve accountability, you need to have core practices and a workplace that are respectful.
Non-discrimination and equality	To be compassionate, we need to accept and celebrate difference and diversity, and treat people with equality; equally where this is appropriate and differently where this is appropriate.	dignity requires recognition, acceptance and celebration of every client and every worker.	Excellent services and workplaces do not tolerate unlawful discrimination, strive to treat people equally, and recognise appropriate differences.	For clients and workers to flourish, they need to be treated equally (which includes being treated differently where appropriate).	Non-discrimination and equality, to be achieved, requires a system that realises justice	Non-discrimination/equality reflects the value of respect
Empowerment	To be compassionate, we need to empower our clients and workers to feel heard, and we need to be curious about what their wants and needs.	dignity in care practice and the workplace requires the empowerment of clients to have their reasonable wants and needs met, and a safe workplace committed to the realisation of dignity for all.	To achieve excellence, you need to empower clients and workers to maintain or change practices if necessary.	For clients and workers to flourish, they need to be empowered to participate in the decision that affect them and to have opportunities to see their decisions and preferences realised in maintained or changed practices.	A justice system empowers clients and workers to address and redress wrongs and problems	The empowerment of respect underpins the value of compassion
Legality	Compassion is an implicit value in the principles of Human Rights that apply to all of us.	Dignity is reflected in relevant human rights principles, which should underpin care practices and safe and healthy workplaces.	An excellence service blends human rights principles and care/workplace practices seamlessly and properly.	For clients and workers to flourish, human rights principles need to be reflected and realised in care practices and approaches.	A legal system/procedure/process is at its best when it achieves justice.	Human rights principles enforceable by law reflect the value of respect.

).

Following the finalisation of the HRBA code of conduct matrix, the provider partners met to co-design the training module. Authors K.F. and E.C. provided an information session on the development of curriculum (constructive alignment [30]). According to this information, the group developed learning outcomes, a plan for learning activities and a plan for assessment of the learning outcomes. The training module was prepared for delivery at an aged-care induction workshop.

2.2. Participants

Thirteen participants who were attending a half-day induction to the care workforce training session were invited to participate. Of this group, 11 participants were consented and included in the study (2 of the 13 attendees declined to participate). The attendees of the workshop were job seekers looking for employment in the aged and disability care industry and included university students recruited through advertisement and people referred through an employment agency. The age range of the group was 20–70 years.

2.3. Procedure

The half-day induction workshop included the following training modules (in the following order): human rights-based code of conduct, a day in the life of a care worker, communication with people with communication disabilities, and self-care. The pre- and post-test assessments for the human rights-based code of conduct module were developed in Qualtrics. Prior to the beginning of the human rights-based code of conduct module, a QR code was presented on screen for participants to access the participant consent and information. After providing consent, participants were required to enter a code (a pet’s name and their birth month) to allow matching of pre- and post-test responses. The assessment consisted of a care scenario taken from the Aged Care Quality and Safety Commission [31] “Code of conduct for aged care: Case studies for workers and providers” followed by three questions requiring free form responses. The case scenario and questions are presented in Figure 1.

2.4. Data Analysis

The participants’ responses to the three assessment questions pre and post participation in the training module were analysed using deductive qualitative content analysis with an unconstrained coding matrix, as described by Elo and Kyngäs [32]. The coding matrix was developed prior to analysis of the data using the co-designed human rights code of conduct. Responses that did not match the coding matrix were coded using inductive coding methods. This open coding process involved creating categories and abstracting the data from the pre and post-test responses to the three assessment questions. To ensure the analysis was trustworthy and rigorous, two team members conducted the inductive and deductive content analysis independently (K.F. and E.C.). The two team members then met to compare their coding and consult to resolve differences. Direct quotes from participants for each code are listed in

Table 2. Unconstrained codes with examples.

Question	All Unconstrained Codes	Example Quote
What values, principles, rules or laws explain why Slava’s Wheelie Walker was taken away?	Risk of harm	“As the issue is potentially a health risk hazard the service manager decision is correct.”
	Legality	“Legal risk”
	Code of conduct	“Code of conduct: organisation felt it necessary”
	Quality Care	“Felt it was excellent care”
	Safety	“It’s a safety hazard and concern”
	Duty of Care	“Organization has duty of care”
	Policies	“There is a policy in place that providers remove a risk to Slava’s health”
What values, principles rules or laws might be broken by taking away Slava’s Wheelie Walker?	Independence	“Takes away her independence”
	Negligence	“Negligence”
	Trust	“Loss of trust with worker/organisation”
	Freedom	“Freedom”
	Elder abuse	“Elder abuse”
	Restrictive practice	“They might have broken the law because what they did is restrictive practice”
Imagine that you are working with Slava as a care worker: What would you do in this situation? What values, principles, rules or laws would support your actions?	Intervention plan for mobility	“I would provide a bell she can use to call assistance whenever she needed walker”
	Explain situation to client	“I would try my best to make her understand about the situation”
	Escalate/consult with supervisor	“Report to the manager”
	Follow rules	“I would follow rules given to me by my employer”
	Consult with client	“I would consult with Slava first and ask what does she want to happen”
	Risk assessment	“Suggest to the manager to do a falls risk assessment”
	Consult allied health	“Suggest to manager to refer Slava to allied health professionals who could assess her house and help reduce falls”

, with standard punctuation for clarity, to illustrate each category. These quotes have been labelled with participant numbers.

3. Results

Coded responses with counts of frequency of response and be found in

Table 3. Results of Content Analysis of Training Responses (numbers in parentheses indicate frequency of code use across participants’ responses).

Question	Trial	Principles	Values	Others
What values, principles, rules or laws explain why Slava’s Wheelie Walker was taken away?	Pre	Accountability (8) Legality (1)		Risk of harm (9) Duty of care (2) Agency policies (1) Safety (2)
	Post	Accountability (8) Legality (6)	Excellence (1)	Risk of harm (3) Code of conduct (1) Duty of care (3)
What values, principles rules or laws might be broken by taking away Slava’s Wheelie Walker?	Pre	Empowerment (1) Legality (1) Accountability (2)	Compassion (1) Dignity (1)	Independence (6) Negligence (1) Freedom (2) Duty of care (1) Elder abuse (1)
	Post	Participation (3) Empowerment (5) Legality (1)	Dignity (8) Respect (6) Compassion (3) Flourishing (1)	Independence (1) Trust (2) Restrictive practice (1) Duty of care (1)
Imagine that you are working with Slava as a care worker: What would you do in this situation? What values, principles, rules or laws would support your actions?	Pre	Legality (1) Participation (1)	Compassion (1)	Intervention plan for mobility (6) Explain situation to client (3) Consult with supervisor/escalate (1) Follow rules (3) Consult with client (2) Risk assessment (1) Consult allied health (1)
	Post	Empowerment (4) Accountability (3) Participation (2) Legality (2)	Respect (4) Excellence (1) Compassion (3) Dignity (1)	Intervention plan for mobility (3) Explain situation to client (2) Consult with supervisor/escalate (4) Follow rules (3) Consult with client (1) Risk assessment (1) Consult allied health (2) Trust (2)

. In the pre-testing phase, the majority of the responses were coded from the unconstrained codes (42 unconstrained code responses versus 15 matrix code responses). The majority of the post-test responses could be coded with the code matrix (28 unconstrained code responses versus 62 responses matric code responses). The following analysis considers each assessment question and the range and frequency of responses pre- and post-test.

In response to the question, “What values, principles, rules or laws explain why Slava’s Wheelie Walker was taken away?”, in the pre-test assessment, the majority of responses were coded as unconstrained codes (14/23 identified codes) and the minority of responses related to the HRBA “principles” from the coding matrix (9/23 identified codes). No responses could be coded as any of the “values” from the coding matrix. The most frequent and majority response related to the code “risk of harm” with most participants explaining that the reason Slava’s Wheelie walker was removed was that continued use of Slava’s wheelie walker might result in injury to Slava. In the post-test phase, the majority of responses related to “principles and “values” (15/22 identified codes) from the coding matrix and only 7 unconstrained codes were identified. Most responses referred to the HRBA values of accountability and legality to describe that aged care workers have a responsibility to Slava for her health and well-being and that laws are in place relating to this responsibility.

In response to question 2, “What values, principles rules or laws might be broken by taking away Slava’s Wheelie Walker?”, the majority of the responses in the pretest assessment could be coded with unconstrained codes (11/17 identified codes). Only six responses related to HRBA principles codes and no responses related to principles or values codes from the coding matrix. The modal code was “independence” with six participants indicating that the removal of Slava’s wheelie walker would be problematic due to it impinging on her right to independence. Another two participants responded similarly that such action towards Slava would be detrimental due to restricting her right to freedom. At post-test, the participants provided more content rich responses with 32 codable statements produced across the 11 participants. The majority of responses related to HRBA principles (9/32 codes) and values (18/31 codes) from the coding matrix and only five statements related to unconstrained codes. The majority of statements related to the codes “dignity” and “respect and empowerment” combined, meaning that the majority of participants could identify the violation of these values and principles in the event of removing a wheelie walker against the wishes of a consumer.

The final question was, “Imagine that you are working with Slava as a care worker: What would you do in this situation? What values, principles, rules or laws would support your actions?” In pretest assessment, almost all statements in the responses related to unconstrained codes (17/20 codes used) and only one statement made in response to the question related to a code from the coding matrix. The most common course of action related to providing an intervention plan to assist Slava with her mobility (6/20 codes used). Such responses included “teaching [Slava] to walk safely” and asking “Slava to call for assistance when walking”. The next most common courses of action suggested related to the codes “explain the situation to the client” and “follow the rules”. These codes relate to the participants suggesting that their role as a carer is to “help Slava understand the situation” and “follow rules given to me by my employer”. Only one response suggested values, principles, rules or laws to support their plan. At post-test, the participants gave more statements in their responses such that 36 statements could be coded across the 11 participants’ responses. Most responses related to the HRBA principles and values (20/36) with the most common responses stating the importance of empowering Slava and showing respect for her wishes. For example, one participant planned to “be compassionate towards [Slava’s] request and help her by providing her with the wheelie walker”.

4. Discussion

This study aimed to determine whether a human rights-based code of conduct could change the perspectives of new aged-care workers We wanted to encourage them to use a HRBA framework in solving common problems in aged care; to think about aged care holisitically, beyond merely calibrating risk, applying regulations, and focusing on medical care. We hypothesised that a HRBA would confer dignity, fostering better quality interactions between consumers of aged care and aged care workers, and thereby improve the quality of aged care. A test–retest design with a qualitative content analysis was used to examine worker responses to a case scenario before and after a training session of a human rights-based code of conduct. The main finding of this study was that following training, responses conformed to the developed HRBA code of conduct than prior to training. Moreover, prior to training, participants responses to the scenario frequently related to a desire to reduce risk or provide medical interventions. Following training, the count of responses increased and the majority of responses were related to PANEL principles and the values of the code of conduct, which are fundamental to person-centred care and human rights such as the dignity of the individual.

What do the results indicate about our theoretical constructs of aged care? What are the implications for training of aged-care workers? What impact could a HRBA have in aged care on the quality and sustainability of the sector?

The most striking difference between the pre- and post-test analysis was the shift in both the conformity of the responses to the HRBA Code of Conduct and the quality of the responses. The finding that people change responses and can give more detailed answers to questions following a training module is not surprising. What was of interest was how the pre-training responses conformed with widespread but problematic views on aged care (i.e., the focus is reducing risk and prioritising physical health) and that training can change hearts and minds to a position that is more consistent with authentic person-centred care. The modal responses to all three questions pre-training related to risk reduction and intervening to change the client “Slava”. Question 1 related to explaining why Slava’s wheelie walker should be removed and the modal response related to risk reduction. Question 3 asked for suggestion actions to address this situation and the modal responses related to therapies to improve Slava’s mobility or compliance with the decision to remove her wheelie walker. Pre-training, participants provided the least amount of content in response to question 2 (what values, laws, or principles would be broken …?) suggesting that such a pattern is consistent with the current aged-care regulatory settings where medical interventions and risk reduction are prioritised over consideration of how restrictive practice might diminish the dignity of the person receiving aged-care services. The data from pre-training suggested that the default position is one of technical risk reduction and a focus on medical care which is consistent with the warehousing view of aged care, risk is to be minimised, and so is autonomy [14].

At post-test, the majority of the responses given related to the Human Rights-Based code of conduct, and a greater number and range of responses were given. The participant’s responses included concerns over health and safety (described in terms of accountability and responsibility) but also included empowerment and participation of Slava. In response to question 2, the majority participants at post-test were aware that Slava’s right to empowerment and participation would be breached by removing her wheelie walker; these responses were not present at pre-test. This pattern of responses at post-test is more consistent with person-centred care than that observed in pre-test. This result suggests that aged care workers can be trained to balance considerations for their responsibilities for the health and safety of a recipient of aged care with their right to participation in community and to be empowered. Using a human rights-based code of conduct could thus be used to promote principles of person-centred care and improve service quality vices.

The human rights-based code of conduct matrix developed for this study was based on the PANEL principles; however, it was paired with the values of the aged care provider organisations engaged with this study. The values agreed upon by the providers were compassion, dignity, excellence, flourishing, justice, and respect. The PANEL principles are intended to be universal for application across all government and private services [26] and therefore, it could be expected that the values espoused by the care providers would be compatible and easily intersect with the PANEL principles. It is possible that a different human rights code of conduct could be developed to suit the values held by other benevolent organisations. However, little variation would be expected in the values of aged care organisations as they are generally regulated to promote person-centred care and therefore values such as dignity and respect for recipients of care would be required. Given the importance of relationships in authentic person-centred care and that community in aged care involves both recipients of care and workers [15], consideration of the interests of both of these groups is encouraged in the human rights-based code of conduct. One of the key contributors to the unsustainable state of aged care is the shortage of workers and high worker turnover [27]. A code of conduct that considers the rights of both recipients of care and workers may help improve the working environment and attractiveness of the aged care sector.

The main impetus for developing and investigating the training of a human rights-based code of conduct with new aged-care workers is the need to work towards sustainable and quality aged care. Aged care in its current state is unlikely to be financially viable into the future [8]; the workforce required to deliver aged care is not sustainable [27] and quality of care in the aged-care sector is below community expectations [10]. Potential drivers of this problematic current state are the regulatory environment that does not encourage person-centred care but a focus on medical care and risk reduction. Potential workers are attracted to aged care due to the perception of autonomy in clinical work and the opportunity to have meaningful interactions with consumers [23,33]. However, work focused on risk reduction rather than consumer interaction may be responsible for workers leaving the profession [33]. An HRBA code of conduct using the PANEL principles has the potential to restore the principles of person-centred care as human rights seek to protect participant autonomy and participation in community whilst maintaining quality medical care. The data from the present study showed that it is possible for workers to consider both person-centred care and medical care.

Limitations and Future Directions

This study presents evidence to support the use of a human rights-based code of conduct to improve the ability of aged-care workers to consider aspects of care beyond medical care and risk reduction. Although it is hoped that this work provides evidence that training can help improve the quality and sustainability of aged care by helping workers better approximate authentic person-centred care, this study is a modest first step towards this end. Firstly, this study was a qualitative study which included a small number of participants with no control group. Secondly, the data collected in this study were responses to questions in a case scenario. Carryover of the training into the clinical environment and the long-term effects were not observed. Thirdly, the human rights-based code of conduct was developed by aged care providers working with researchers. A code of conduct which aims to protect the rights of recipients of aged care and workers would benefit from further consultation with the parties to which the code relates. This study therefore provides a platform for a range of future research including replication with larger numbers of workers and follow-up with workers and recipients of aged care.

In order to determine whether the trained code of conduct is applied in practice and whether it is effective in improving the quality of care in the aged care environment, future studies would need to occur in residential or community care settings. It is recommended that such work commence with the inclusion of recipients of aged-care services and workers in codesigning any changes to the human rights-based code of conduct. Future studies with larger numbers would afford the opportunity to include a control group, test long-term follow-up and use quantitative methods with inferential statistics. Larger quantitative studies with experimental designs could include more objective measures than those used in qualitative research, such as environmental analysis, to measure the impact of the introduction of a human rights-based code of conduct in aged-care settings on both worker and resident well-being. An additional benefit of sufficiently powered quantitative research with an experimental design would be the generalisability of the results beyond the sample studied.

5. Conclusions

A human rights-based-code of conduct can be used to enable new aged-care workers to consider a range of concepts necessary to enable quality care in aged care. With the provision of aged care being a major challenge for societies now and into the future, it is crucial that stakeholders act with haste to deliver aged-care services that address the social dimensions of ageing and provide a meaningful work environment focussed on care and not risk and regulation. As we look towards a future of 100-year lifespans, may we marvel at medical science whilst we work towards a sustainable future that provides quality healthcare whilst empowering women and our most vulnerable workers.