People are marching in the streets demanding better care for older Australians in aged care homes after increasing media reports of neglect, abuse and negligence.
If we want to improve the situation for residents, we need more registered nurses in aged care homes. When registered nurses are on duty, residents have better health outcomes, a higher quality of life and fewer hospital admissions.
When I worked as a critical care nurse in hospitals, there was a one-to-one ratio of registered nurses to patients. Some days were busy, others were not. However, because society values “saving lives”, legislation ensures every intensive care unit is well staffed.
There are also mandated ratios in childcare centres because society values the safety and welfare of children. Yet we don’t take the same approach when it comes to aged care homes.
Is this because we don’t value older people?
‘Flexibility’ not the answer
The 2011 Productivity Commission Report Caring for Older Australians described staffing ratios as “a fairly blunt instrument for ensuring quality care because of the heterogeneous and ever-changing care needs of aged care recipients.”
Yet this “blunt instrument” delivers results in hospitals where patients have “ever-changing needs”.
To date, protests and petitions to boost staffing ratios have failed. Mandated nurse-to-resident ratios are opposed by Ken Wyatt, Minister for Aged Care, and the peak bodies representing for-profit and non-for profit aged care homes. They argue mandated ratios would increase costs and limit flexibility.
But the current “flexible staffing” approach leaves the decision whether to have a registered nurse on duty at the discretion of the provider/manager. Evidence suggests some managers do not employ additional staff when care needs increase.
The following example illustrates why staffing levels should not be decided entirely by managers.
I witnessed an elderly woman die in excruciating pain because no-one on the night shift was qualified to administer the prescribed morphine.
My friend was so traumatised by the situation, she could not remain at her mother’s bedside to hold her hand.
Nurses improve health
Although the needs of older people in aged care homes are variable, over 80 per cent of residents have high care needs. The staffing profile of aged care homes today does not reflect the resident profile. If it did, we would have seen a large increase in the number of registered nurses.
Instead, the number of registered nurses has decreased while the number of less-skilled personal care attendants has risen substantially. Registered nurses now account for less than 15 per cent of the workforce, while personal care attendants make up 72 per cent.
Overseas studies show the ratio of registered nurses-to-residents has a positive impact on the standards of care in an aged care home. This research demonstrates that staffing levels and skills are the most critical determinants of care in an aged care home.
Whether residents’ care needs are due to cognitive decline, incontinence or chronic pain, residents invariably benefit from having registered nurses on duty.
Tax dollars for nurses not managers
Although aged care homes are not funded to provide hospital-level care, the government subsidy of around $230 a day for each resident should be tied to direct care for residents, not profits for providers. However, StewartBrown’s Aged Care Performance Survey indicates the top 25 per cent of aged care homes made a profit of $18,285 per resident per year.
Although additional staff will increase operating costs, it is alarmist to state that some aged care homes, particularly those in rural and remote areas, will be forced to close. The worst-case scenario is that governments may need to assist some aged care homes to remain viable.
In Victoria, many rural aged care homes are owned by the government. In 2016, the Safe Patient Care Act was introduced, This Act prescribes ratios of registered nurses for the 181 publicly-owned aged care homes.
Cate Carnell pointed out on ABC’s The Drum that the abuse at Oakden Older Persons Mental Health Service occurred despite a high ratio of registered nurses. However, the Independent Commissioner Against Corruption‘s investigation into Oakden described poor systems, unacceptable work practices and poor workplace culture. The Commissioner found relatives’ concerns fell on deaf ears.
Public right to know
Australia needs to establish minimum staffing levels based on research and expert opinion.
In the meantime, aged care homes should be required to publish their direct care staffing rosters online. This would enable people to make informed decisions about the standards of care in each aged care home.
First published in ABC online on 3 June 2018