Implementing mandated minimum staffing levels and skills mix in aged care is not the sole indicator of a quality system yet one undoubtedly cannot be achieved without taking the action.
That was the key message from Australian Nursing and Midwifery Federation (ANMF) Federal Secretary Annie Butler as she took the stand at the Royal Commission into Aged Care Quality and Safety to deliver evidence on day three of public hearings held in Adelaide this week.
Counsel assisting the Royal Commission, Paul Bolster, opened questioning by asking Ms Butler about the barriers that stop nurses remaining in aged care and whether remuneration was a major hurdle.
“What we hear most often from our members now is the increasing pressure they’re experiencing with workloads,” Ms Butler said.
“Many of them across the country describe their workloads now as unsafe. They’re untenable. They report to us that that’s why they’re increasingly leaving the sector.
“Remuneration is a barrier definitely when you’re trying to recruit into the sector and when you’ve got the public system, the private system, a whole range of other systems that are offering more attractive pay, but also more attractive conditions and a whole range of more attractive, both professional opportunities and supports.”
ANMF National Aged Care Survey 2016
Mr Bolster highlighted the ANMF’s 2016 National Aged Care Survey, labelling it “quite confronting when you read it”.
He drew attention to testimony from the survey, including an experienced registered nurse who left the aged care sector following escalating staff cuts who said – “I am saddened and disillusioned with aged care and fear for our vulnerable residents and standard of care they are going to receive.”
Another account raised involved one registered nurse caring for 60 residents.
“Well, unfortunately that’s not the most extreme,” Ms Butler said when asked if the ratio was typical.
Further feedback from the survey singled out by Mr Bolster concerned an Assistant in Nursing (AIN) having only 15 minutes with each patient in the morning and being expected to shower, dress and attend to the needs of high care dementia patients.
“This is a story that we hear all the time,” Ms Butler said.
“Just again and again and again, and people are time clocked, you’ve got six minutes to do each shower.”
Mr Bolster pinpointed other evidence from the survey detailing an extreme case where nursing home staff did not attend to an elderly stroke patient who ended up with a catheter “tunnelling into his penis”.
Ms Butler told the Commission missed care does happen and acknowledged handover as one of the greatest areas of concern.
“It’s one of the areas that tends to get missed and sometimes is not even allowed,” she said.
“We don’t know whether there’s always an RN on duty. We saw in another example, is there one on night shift? We don’t know what the ratios are. We don’t know what the facility’s practices are in allowing proper handover and detailed clinical information.”
National Aged Care Staffing and Skills Mix Project Report 2016
Mr Bolster moved onto the ANMF commissioned National Aged Care Staffing and Skills Mix Project Report 2016, carried out by Flinders University and the University of South Australia, which details an evidence based staffing methodology to ensure all assessed care needs for each nursing home resident are met.
He underlined several resident profiles featured in the report in a bid to examine care needs and how they should be determined.
Ms Butler said the analysis, the only one of its kind covering this topic, aimed to set the minimum care requirements.
“We’re saying in the absence of anything else this is an evidence-based staffing methodology which would allow facilities to staff appropriately to ensure all care needs are met.”
Ms Butler raised the problematic issue of missed care and how many nurses and carers simply don’t have enough time to carry out their complex roles.
“What happens is that there’s – particularly nurses – and it’s not unique to high pressure situations in the aged care sector – but they will ration, they will ration care and so they will pay attention to the absolute “must dos”. So many of the other things that are significant and important end up getting missed.”
The Royal Commission heard the project’s results, which included a MISSCARE survey of more than 3,000 nurses and carers from the aged care sector, for the first time in Australia established a baseline for what the amount of care should be.
Results showed significant gaps across the sector, including just 8.2% of participants reporting that they always had adequate staffing.
The Royal Commission was also told a final Delphi survey found 94% of experts agreed that a staffing methodology needed to be built around assessing and meeting the assessed needs of residents for morning, afternoon and night shifts.
Referring to the key findings of the study, Mr Bolster acknowledged the minimum staffing ratios proposed in the report, specifically that residential aged care residents on average require 4 hours and 18 minutes of care per day, and a skills mix of 30% RNs, 20% ENs and 50% PCA’s.
Financial and Cost Benefit Implications of the Recommendations of the National Aged Care Staffing and Skills Mix Final Report
Mr Bolster pointed to the ANMF commissioning Flinders University to undertake an independent economic analysis of its 2016 aged care staffing report.
Findings from the economic analysis showed implementing minimum staffing hours outweigh the costs and warn there would be significant costs in not implementing the report’s recommendations.
Ms Butler said while the study found it would cost $5.3 billion to fully implement the increased staffing and skills mix requirements, this would be offset in a number of other areas such as hospital avoidance, productivity gains and losing fewer of the workforce.
Ms Butler argued adequate staffing and the right people to deliver proper care could reduce mortality, enhance a patient’s life and experience and lead to better health outcomes.
The role of nurses in aged care
Mr Bolster made special mention of testimony heard by the Royal Commission on Tuesday by COTA Australia chief executive Ian Yates commenting on the role of nurses in service delivery in residential aged care.
Mr Yates was asked about staff ratios and how they have changed between qualified and enrolled nursing staff and other personal care staff in recent years.
“I mean, is everything that a nurse used to do have to be done by a nurse?” Mr Yates posed.
“But sometimes the strong command culture of nursing historically and I recognise that that has also been addressed has meant that in terms of things like consumer-directed care, consumer-centric practice that there has been more resistance from nurses and nurse administrators than there have been to others whose experience might be, for example, in the hospitality industry.”
Questioned by Mr Bolster about the comments, Ms Butler said they demonstrated a significant lack of understanding of the nursing profession.
“What’s unfortunate I think with this is I would like to know what evidence that comment is based on,” Ms Butler said.
“To me it seems solely opinion. There is a confusion for someone – he’s not in a position to understand what nursing is, what nursing care is. Nursing care encompasses the whole of the sorts of things that we’re talking about.”
Ms Butler also provided a witness statement to the Royal Commission, highlighting how the ANMF over many years has drawn attention to systemic problems in the aged care system led by chronic understaffing.
Other issues covered include inappropriate regulation, insufficient response to the changing needs of the nation’s elderly population and a lack of transparency and accountability across the sector.
She outlined how Australians receiving residential aged care, as well as their families and the community, deserve safe quality care, suggesting it can be met by adequate numbers of appropriately skilled staff.
Extensive research shows mandated minimum staffing levels and skill mixes are fundamental, Ms Butler states, with the ANMF having developed an evidence-based staffing methodology that if implemented will deliver safe, best practice care in residential aged care facilities meeting the expectations of the community.
The methodology recommends aged care residents require an average of 4 hours and eighteen minutes of care per day, delivered by a skills mix of 30% registered nurses, 20% enrolled nurses and 50% personal care workers.
The witness statement also points out current regulation and funding remains problematic, with the Aged Care Act 1997 creating ambiguity surrounding the responsibility providers have in terms of staffing.
“The funding and regulatory regime applying to the system must be directed to ensuring that adequate numbers of appropriately qualified staff, in accordance with an evidence-based staffing model, are available to deliver care,” the statement reads.
The ANMF plans to provide a further statement to the Royal Commission in due course where it will expand on issues including difficulties attracting and retaining appropriately qualified staff, low pay across the sector, inadequate career opportunities, stressful working conditions and poor management practices.