Getting to Know the Person 11.1: Elyce Green

This is the Getting to Know the Person podcast. In this podcast we chat with the people who have expertise and wisdom about healthy ageing and aged care. Some of these people have acquired and accumulated their knowledge through lived experience. Some have studied and done research to gain their experience. Some have both. It is our privilege to share these conversations with you in the hope that by getting to know the person, you can engage and understand older people and their experience of ageing.

This series of podcasts are conversations with the people who wrote chapters in the second edition of Healthy Ageing and Aged Care for Oxford University Press Australia. We hope you enjoy getting to know these interesting authors as people.

Denise

Hi, I'm Denise Winkler, one of the editors of healthy ageing and aged care, and in this podcast, I have a conversation with Elyce Green, one of the authors of Chapter Eleven, ‘Older people in acute care’. Welcome, Elyce.

Elyce

Thank you very much.

Denise

Okay. Let's get to know you by having you tell us your story. Tell us about yourself and what made you interested in and knowledgeable about acute care?

Elyce

Yes, so I guess my interest in working with older people in acute care really started back when I was at university. So I was studying nursing and paramedics, and I remember I went on a clinical placement in residential aged care, actually. And, you know, kind of the hard thing about being on a placement in residential aged care is that there's so few registered nurses working there that, you know, they don't have a lot of time to work with you and teach you as a student sometimes. So I spent a lot of time following around the enrolled nurses and helping the residents with their activities of daily living. And I don't know why, but this one particular incident really still sticks out for me. Even, you know, that was probably 15 years ago now.

I met this older lady who lived in the residential aged care facility, and she was lovely, and after a few days she became confused. She became agitated and she kept injuring herself and getting skin tears on her walker, which obviously was, you know, really significant for her. Her family was getting really upset by her behavior. This is obviously not an uncommon thing to happen in working with the older person. But for me, you know, I was young, I was keen. I was enthusiastic and I was thinking, ‘Oh my goodness,’ you know, for such a dramatic change to happen in someone. What's going on? So having all this time on my hands and of course, being a super keen student nurse, I thought, all right, let's start looking at, you know, the reasons why this lady might be confused.

Funnily enough, I was talking to an intensive care specialist a couple of years ago, and he said to me, ‘Elyce there’s five Ps that are the reasons why older people can be confused and they’re pee, poo, pain, pus or pills.’ And it's funny now thinking back to what I was looking at as a student then because it really was covering those things, you know, looking at the urine, looking at constipation, her pain levels. Pus is obviously about infection, and pills is looking at polypharmacy. So it's a nice little capsule that I've always remembered that since.

But anyway, obviously I took that on and I started looking into all these things and you know, it came down to it, it was just a UTI that she had, which really is quite a simple thing, and we treated it quite easily and she went back to baseline and she was, you know, very grateful. And looking back on it, she'd known that she was confused and doing all these things, but obviously that had such a significant impact on her quality of life, just having that urinary tract infection. And, you know, thinking back about that now, I don't know, like a part of me thinks it was such a simple thing, and it certainly wasn't something that needed me to diagnose it. But I think it really showed to me a couple of things about working with older people. The first being how extremely complex health care can be working with an older person. They have really, really, you know, they can have really complex need, lots of co-morbidities, but also they don't present the way that other people or younger people present when they're unwell.

And I think the other thing it showed to me was, you know, even as this keen little student nurse, I could have such an impact on her life, you know, from doing something so simple and just looking into it. And I guess that's why it just it was a pivotal moment for me, I think, and it made me really interested in working with older people. And I think that, you know, that kind of thing is what's continued to keep me interested in this space, as you know. Well, that was 15 years ago, and I've worked across lots of different acute care, subacute and even community settings now, and I've been blessed to work with some really, really intelligent people. But, you know, I've always found that working with older people, there's always something new to learn. And it's definitely not always something you can learn from a textbook. There's always, you know, funny little things that come out that you think, ‘Oh, wow, I never would have known that otherwise.’ So I just find it really interesting. And I think that working with older people is something that you can just always continue learning. So that's probably what's kept me interested, I think.

Denise

Yeah, great. Thanks so much for sharing that pivotal moment with your personal experience and your key learnings of that working with older people is complex. They have a complex presentation and that each person can have a huge impact no matter what their level of education or knowledge. And thanks for that little, that little extra. I'm sure our listeners will be madly going, ‘Oh, what were those five Ps again?’

Elyce

I still use it today.

Denise

So maybe I'll get you to write those in the chat and we'll get Matt to add them to the show notes.

Elyce

Yes. Sure, that's OK.

Denise

We’ll do that later. Let's go on to my first question then, now that we're getting to know you and your lively personality. So what is one concept, idea or main point in your chapter that you're most passionate about?

Elyce

So hard to whittle it down to one but can I tell you there's a few. And I think they've probably all come from different reasons and from working in different areas throughout my career. And I think the first thing would have to be pain assessment in the older person. And I think that is something, my first year when I was nursing, I think that was in about 2007 or 2008, I remember working on this medical ward and we had a fair few people who were older people who were admitted, who had a diagnosis of dementia, as well as some other underlying acute condition. Quite often it would be broken bones and things like that, after falls. And I remember getting so frustrated because they weren't verbalizing that they had pain, they would very rarely get analgesia. And it was something it really just … it really gave me a big gripe and I thought, ‘Oh my God’, you know.

And by this time, I'd met Maree Bernoth. She was part of my life. She taught me in my undergraduate studies, and she said to me, ‘Elyce, you should do your honours.’ And I was like, ‘Honours, what is that, research? I have no idea how to do it.’ And she, you know, as Maree does, talked me into it. And I ended up doing a study that looked at basically the incidence of pain or analgesia that was given to people with the diagnosis of dementia compared to people who didn't have a diagnosis of dementia when they had broken bones, so in people with fractures, and found that unsurprisingly, they were getting a lot less analgesia. So yeah, I know. And not shocking at all. But you know what it's like in the world of academia and health. Things don't actually happen unless you've published about them and it’s written down somewhere.

So we published that study, and I ended up doing some education with my colleagues on the Abbey Pain Scale, which is looking at assessing pain in people who can't verbalize. So that was something for me that I think made me quite passionate about pain other than the fact that pain again, is such a complex thing.

And when you look at older people, you know, more than two thirds of them have chronic pain as well as, then they come into acute care. They quite often have an acute reason for pain as well. So you've got kind of this, you know, double edged sword going on of what you need to treat and look at. So pain assessment is something that I'm really, really passionate about. The other thing, if I can have two.

Denise

You can. I allow it.

Elyce

Thank you. Would definitely have to be inappropriate transfer to acute care. And I mean that, you know, in looking at the older person who lives at home who gets transferred to acute care when they probably don't need to, and also people who live in residential aged care facilities who get transferred.

This is a really, really complex issue, and it's particularly come to the forefront of my mind. Last year during COVID, I worked for a critical care advisory line, who we also did the patient flow for the area, and what we found was that in a lot of instances, particularly with residential aged care, when someone got sick in the aged care, they were just getting sent to the hospital because it was like that. You know, sometimes it was they didn't have the staff to look after someone who had acute care needs, sometimes it was that they didn't know how to. And sometimes I just think it was the culture of, well, that's just what we do. And I mean, yeah, we know and we wrote about this in the book chapter that, you know, often, and I mean, don't get me wrong, sometimes it is appropriate, of course, for them to go to acute care, but often it's not. And also often it's not what the older person wants.

Denise

Exactly

Elyce

Yeah. And like where did we get that we forget to ask them what they want, you know. Or even talk to their family. So that's something that I'm really passionate about. I think because it's kind of, you know, two issues. One is that we really need to involve the older person in decisions about their care and what they want and where they want to go. And I think it's also really important that we, as health care professionals, educate ourselves and also, you know, make sure that we have the capacity and the skills to look after people to make sure that they can stay at home when they are able to. And I’m really, really passionate about advocating for that locally. But you know, yeah, as I said before, it's a really complex issue, but that's certainly something that I'm really passionate about.

Denise

Yeah. Well, those are two really, really big issues. And having lived … you're talking about my life in the past year because I dealt with those, both of those issues with my mom who had a huge surgery and then the pain assessment and the inappropriate transfer to acute care. Not necessarily against her wishes, but in this COVID time I don't think that anybody really explained to her that once she went, the family, us, weren't going to be allowed to see her.

Elyce

Yeah, yeah.

Denise

And ten days, two weeks later when we did, wow, she was a mess, a mental health mess. And we had gotten to have a few phone calls with her but, you know, she just kept saying, ‘I never would have done this if I would have known that I wouldn't get to see you. I just want to come home. Please get me out of here. Let me come home.’ We're like, ‘Well, then you have to go to rehab.’ And she just kept saying, ‘I never would have agreed to this if I would have known. I just never would have agreed.’ And so, yeah, my life is this past year, my personal lived experience is really echoing these two things. So thank you for sharing those.

Elyce

Yeah, I think it's something that you know, we can be unfortunately really good at as health professionals is. It's not that we are often lying to the person, but sometimes it's easier to present them with, oh well, if you go to the emergency department, you can have X, Y and Z and come home. But that is very rarely what does happen and we need to be really careful about, you know, being honest with people about what will happen. And you know, you might lie in ED for four to six to twelve hours. And you know, it's not the, you know, the gold standard or the cure all just to send someone to ED and think that this is going to be fixed.

Denise

Correct. Yeah. And you're going to have to have another COVID test before you even get into the ED and then tested every day while you're there. And there was that, huh. But yes, those are really two strong, passionate things to be brought to everybody's attention. And thank you for that.

So now onto my next question is what resource has been the most influential to your thinking or your understanding about pain assessment or inappropriate transfer to acute care?

Elyce

I think to be honest, and I mean, this is applicable to everything I know about health care full stop, I think the greatest resource that I've ever had access to is people. I think that, you know, and this is particularly in terms of working with older people, but also just in general. I have learned, you know, there's a lot you can learn from textbooks and, you know, Denise, that I'm very passionate about research. I love doing research. I love reading research. But you know, the things that you learn often are the way that people apply those things that you read in research or textbooks and you get that from people.

And I've had a lot of really, I would say, really powerful and passionate people in my lives. And, you know, Associate Professor Maree Bernoth is certainly one. Professor Paul Finucane is another. He's a geriatrician, and I also have to give a shout out to Bridget Honan, who co-authored this chapter with me because she is just so extremely passionate about best practice in working with older people, particularly in the emergency department. So Bridget is not only an emergency consultant, she also does research. I've really, really enjoyed writing this chapter with her because I think, you know again, we both brought two completely different backgrounds to this, and we learned a lot from each other throughout the whole experience. So that's been unbelievable for me throughout my whole career.

But the other side of it is, I have learned so much from older people themselves, you know, working with older people throughout my whole life. I just, you will never, ever learn more about someone's health than from that person themself and more about what their needs and what that disease means to them. And you know, I think in particular about my two grandmothers, Betty and Margaret, who you know and as you know, Denise, my nan Margaret passed away three years ago now, but I learned so much about her from health and even just being on the other side of the fence and being on the consumer side of health with her. You know, there's lots of lots of different things I think about.

Like, you know, Nan had stage three bowel cancer and we used to go and visit the renal consultant and he'd say, ‘Oh, Margaret, you know, you're looking well today,’ you know, kind of implying considering how ill you were, and she'd say to him, ‘Well, why shouldn't I? I'm not sick.’ Right. You know, having stage three cancer, like, you know, she had metastasized cancer nearly everywhere by then, but she wasn't sick because she felt well, you know, and it meant something completely different to her. And she was really offended every time he would say, ‘Oh, you know, you're looking okay considering your scans’ and all that kind of thing.

I also think about her, I was thinking, you know, in preparing for this podcast, I remember one day she had to have a procedure and the anesthetist said to her, ‘Oh, you know, Margaret, if you die on the table, you want us to bring you back, don't you? You know, we'll pump your chest and we'll bring you back.’ I was sitting beside her thinking, hey, this is very condescending thinking that she doesn't know what CPR is, because of course she does, and her and I had had a big conversation, but also the fact that he was kind of misrepresenting to her what the outcomes of CPR might be for an 80-something year old woman with several co-morbidities.

Denise

And broken ribs.

Elyce

Yeah, exactly. Exactly. And she was saying to him, ‘No, I don't. I don't want it.’ And he was saying, ‘Yeah, you do. Yeah, you do.’ And I thought, you know, this is her choice, not yours. Anyway, you know, some people might think as I was sitting there beside her did I have to step in and advocate for her but if you knew anything about my grandmother, she did not need me to advocate for her and she put him in his place.

Yes, you know those are just some of the little lessons you get along the way. And now, I guess in particular after that, because I'm an intensive care nurse, you know, primarily by trade and we have lots of conversations with people about CPR and things like that and sitting in that room with my Nan I learned more about how to have that conversation than what I've learned from any other health professional in the world. So, you know, I think that just comes back to the, its experiences, but it's always the people. The people are your best resource and has by far been who I've learned from the whole way through, and I'm so grateful for it.

Denise

Yes. And it's that the people part of research, the qualitative research that we do that I think is so powerful. You can crunch all the numbers you want but when you hear people say what they're feeling and experiencing that, and that's what this book is about, people. Yeah, that's great.

Elyce

And it's what health is about, isn't it? You know, at the end of the day, clinical, you know, is what it's all about the people. You know, that's why we're here. That's what I always think at the end of the day, that's why we go to work. That's why we educate. We research, we work, you know, in hospitals, it's for people. So, you know, yeah.

Denise

It's people learning how to work with people from people.

Elyce

Yeah, it's a good way to look at it.

Denise

That's our ethos anyway.

So now let's get out the crystal ball and gaze into the future, shall we? A little bit. So what topic or what didn't you include in your chapter that's on the leading edge that you would like to have written about? And maybe you'll have enough research? Or what do you see in the future about acute care and older people?

Elyce

To be honest, what I see or I guess what I selfishly would like to see in the future is, I guess, a shift in the culture or the way we discuss or talk about aged care in general, if you know what I mean. So, you know, it's not so much about, as we've just been discussing, it's not so much about clinical advances. And you know, there are many of those. But I think what we really need to start thinking about and talking about is the way society views working with older people.

My current job, I work a lot looking at health professionals’ recruitment and retention, and we see a lot, you know, with students coming through in the health professions, this whole idea you know, I couldn't count the amount of times I've been told by a student, ‘I don't want to go on an aged care placement because I don't want to work in aged care when I graduate.’ And I think it does not matter where you work, you will be working with older people. But also, where did we get this idea that it was somehow, you know, a lesser form of health care? You know, and it makes me sad, to be honest, because if anything, you know, as I've told you, it's the most complex type of health care, but also it's something that is so rewarding and something that we can constantly learn from. You know, and I just think it's so sad that people do say that to me.

So I think and I guess in the times that we're at at the moment, you know, coming off the back of the royal commission and things like that, I think that we're going to start having these conversations now. And I know there certainly are some champions in this area, and I have to again say Maree Bernoth is 100% one. Because this whole idea of working with older people in health care has also been transferred to working with older people in health education. And I really love that idea. I love that the idea of bringing in an older person to teach health professionals about health.

Denise

Because it’s their health.

Elyce

Yeah, 100%. Because I mean, as I've told you, I've been working in health for 15 years and the best lessons I've gotten have been off older people. So, you know, why would we not include them in that education? So I guess for me, what I would love to see in the future is, you know, every aged care subject that we run at university, we should be inviting older people in to talk about health and what it means to them and how it affects them. And I know that that is starting to happen, but it's certainly something that I would like to see a lot more of. And I guess that's something that I would particularly like to invest some time in in the future in getting some more of that happening. And certainly, I've got some great role models like yourself and Maree who were at the forefront of that kind of thing that I would love to follow with.

Denise

Awesome. I agree. And this podcast is part of that. And this book is part of that, and the other side projects that we're always working on. And I do think that the media part is helping, will help broaden that. It's lovely to have a person face to face. But I do think that unfortunately in our ongoing pandemic, that people are a little bit leery of meeting face to face with older people because they don't want to put them in danger. However, at the same time, the older person needs contact with people. Yeah, and for mental health and other reasons. So that's why I keep hoping we're going to get that worked out. But yeah, I just keep hoping at this point in time.

Elyce

That's right. And I mean, it's forever evolving, isn't it? You know, my grandmother, Betty, who is still alive, she's 86 now, and she got a phone last year. And, you know, I've just had a little boy and we text photos and she calls me off her mobile and all kinds of things now. So I mean, it's becoming a more common part of life, isn't it?

Denise

It is. It is. It's not as good as being face to face, though.

Elyce

No, it's not. It's not. Don't worry, Nan would be the first to tell you that.

Denise

Yeah, exactly. Well, good. Thank you, Elyce, for sharing your insights relating to Chapter Ten. The listeners and readers of this chapter will benefit from what you've shared about being passionate about pain assessment and inappropriate transfer to acute care and listening to the older people to learn many, many things.

As you've used many examples of story in this podcast and really so we can work together on, all together, our listeners and everyone who's already in the health professions and training future health professionals, that the culture does need to shift from aged care being a lesser form of medicine or at the end of life, then those people aren’t worthy of being cared for as well as humans at the first part of life, starting out life. So thank you for sharing those ideas with us.

And now for the fun part. This is like a game show, it’s sort of called the Lightning Round. I'm going to ask you nine quick questions that I want you to answer with the first thing that comes to your mind. Do you want to play this game?

Elyce

Yes, sure.

Denise

Okay. Fill in the blank. Healthy ageing looks like …

Elyce

My nan in her garden.

Denise

Beautiful. What age do you feel like you are right now?

Elyce

21. I don't look it though.

Denise

We didn't ask looks. You said feel, I said feel. Tell me your favorite meal.

Elyce

Potato, any kind.

Denise

Tell us about the best book you've ever read.

Elyce

Oh, it would have to be Fall of Giants by Ken Follett, historical fiction. Amazing. Yeah.

Denise

Good one. So this is probably going to be an easy one. Tell us about a most significant life event.

Elyce

Well, as you know, Denise, I gave birth to my first little baby boy this year, four months ago, and I think that that has undeniably been a life changer for me in a very good way. Yeah.

Denise

Good. You're not alone in that one. What's your healthiest habit?

Elyce

Oh, I don't know why but reading comes to mind. I guess because it helps my mental health.

Denise

Yes. Yes. Yeah, good one. Tell us about a joyful moment.

Elyce

It's very simple, but there's nothing more joyful to me than having a beer with my husband on a Friday night.

Denise

Oh yeah.

Elyce

Simple things.

Denise

Yes. Perfect. Tell me, what age do you hope to live to?

Elyce

As long as I feel well.

Denise

Hmmm. Last question, what's the best part of your day?

Elyce

When my husband gets home from work by far, and I think anyone who's got a four-month-old could relate to that.

Denise

Or children of any age, during lockdown. Oh, that's perfect.

Thank you, Elyce, for letting us know who you are as a person. This will be fun for our listeners and readers to connect with you. We appreciate your time and energy. And thank you to Bridget Honan, who is your co-author, for putting together words and stories and information that all of us can learn about in Chapter Eleven, ‘Older people in acute care’. Thanks, Elyce.

Elyce

Thanks very much, Denise.