More than 170,000 older Australians live in aged care homes. Of those, 83% are classified as requiring high care. An estimated 60% of “high care” residents have dementia, 40-80% have chronic pain, 50% have urinary incontinence, 45% have a sleep disorder and 30-40% have depression.
The management of these complex conditions, and combinations of conditions, requires the skill of experienced registered nurses, supported by doctors and allied health providers such as psychologists and physiotherapists.
But nursing home providers looking to cut costs are bypassing registered nurses and employing less-skilled personal care attendants (PCAs) who aren’t adequately trained for the job.
Federal legislation is urgently required to ensure that, at a minimum, aged care homes have one registered nurse on site at all times.
Skills and training
Registered nurses are trained to assess, monitor and manage complex medical conditions; personal care attendants are not.
Registered nurses complete a three-year bachelor degree at university and enrolled nurses complete an 18-month diploma. Both are registered with the Nursing and Midwifery Board of Australia and must meet registration standards in order to practise.
PCAs have a Certificate 3 in aged care, which can be completed in five weeks. No registration body oversees PCAs.
Registered and enrolled nurses working in aged care homes have expertise in administering medication, controlling infection, ensuring residents are receiving adequate nutrition and hydration, managing dementia and other challenging behaviours, and supporting residents in their final months, weeks and days of life.
PCAs are responsible for residents’ personal hygiene, such as washing and toileting. They also provide assistance with meals and help residents move around. When PCAs observe changes in a resident’s behaviour or health, they are trained to report these changes to a registered nurse.
But with no registered nurse on site, elderly residents, particularly those who are uncommunicative, do not receive timely treatment when their condition changes. In some cases, this is a form of neglect.
Why we need nurse-resident ratios
According to the Aged Care Act (1997), providers must:
maintain an adequate number of appropriately skilled staff to ensure that the care needs of care recipients are met.
But unlike childcare centres, hospitals and schools, there is no federal legislative requirement for aged care homes in Australia to have staff-to-resident ratios or skill prerequisites.
In contrast, the Victorian government recently introduced the Safe Patient Care Act, which prescribes ratios of registered nurses for a small number of publicly owned aged care homes in the state.
On the morning shift, one registered nurse is required for every seven residents; in the afternoon, one registered nurse for every eight residents; and on the night shift, one registered nurse for every 15 residents.
When enough registered nurses are on duty in aged care homes, residents have better outcomes. They have fewer pressure ulcers, lower rates of urinary tract infections and are less likely to lose weight.
Most importantly, care from registered nurses results in fewer residents being transferred to hospital.
But the Victorian legislation covers just 30 or so state-owned aged care homes, not the 2,600 or so other facilities around the country.
Over the past decade, there has been a marked shift in the composition of the residential aged care workforce.
Registered and enrolled nurses now account for less than 27% of this workforce, while personal care attendants (PCAs) make up 68%. Much of the hands-on care that registered and enrolled nurses once provided is now being provided by PCAs.
This shift coincides with the increased number of privately owned aged care homes.
Managers who are under pressure to meet their profit targets do so by employing cheaper and less-skilled PCAs rather than registered and enrolled nurses. A grade 5 registered nurse costs about twice as much as a PCA: A$42 per hour compared with A$22 per hour.
Time for action
The federal government’s current inquiry into Australia’s aged care workforce received 73 submissions from staff and relatives who are concerned about standards of care. These submissions describe many aged care homes employing an inadequate number of registered nurses.
According to submission 55:
Registered nurses are often required to look after more than 100 residents.
Other submissions have highlighted inadequate personal care, neglect and negligence.
The care of vulnerable older people is too important to be left in the hands of providers seeking to maximise profits. The federal government must require nursing homes to roster on one registered nurse at all times.
It should also follow Victoria’s lead and implement appropriate nurse-resident ratios.
First published in The Conversation on 13 September 2016