Mandated minimum staffing levels and skills mix key to delivering quality aged care, new paper argues

In a new paper, my colleagues Annie Butler (ANMF Federal Secretary) and Casey Marnie from the Federal Office Research Unit and I argue that mandated minimum staffing levels and skills mix are the foundation for delivering safe, quality care in nursing homes.


While other factors such as increased education and training are important, providing quality and respectful care requires having at least the right number of the right kinds of staff to carry out the work.

We say that without a mandated minimum staffing level and skills mix across all nursing homes, vulnerable older people will continue to suffer neglect.

Published in the world’s top nursing journal, the International Journal of Nursing Studies this month, the paper discusses and brings together three separate but related tools for:

  • determining appropriate nursing home staffing levels and skills mix;
  • determining the funding required for staff to deliver care; and
  • publicly rating and reporting the suitability of staffing levels and skills mix.

Each of these tools has featured prominently in the evidence before, and Final Report, of the recently concluded Royal Commission into Aged Care Quality and Safety.

As has been noted by the Commissioners, aged care is a large and complex system. To help untangle some of these complexities, the paper explores how the three tools can work together.

Each tool has been developed for a specific and different purpose. But when used together, each tool could support the delivery of holistic, dignified aged care underpinned by appropriately funded safe staffing levels and skills mix that is transparently rated and reported to the public.

The paper argues that the keystone for the system to work effectively and safely is mandated staffing levels and skills mix.

Although the delivery of dignified and holistic care goes beyond simply having enough people, even the most competent and committed aged care worker is going to struggle when they simply don’t have the time or support from other staff.

The first tool (a tool for determining staffing levels and skills mix) examined in the paper looks to determine what best-practice care looks like and the amount of time and skill mix of staff required to deliver it.

Presented to the Commission by the ANMF, but first reported in 2016, findings of a ‘time-in-motion’ staffing and skills mix study found the time taken to deliver best-practice care to the average nursing home resident (not each, but the average) requires 4.3 resident care hours per day, delivered by a skills mix of 30 %  registered nurses (RNs), 20 % enrolled nurses (ENs), and 50 % personal care workers (PCWs).

When implemented by a nursing home, this staffing level and skill mix create an environment that allows each resident to receive best-practice care.

Of course, the delivery of care costs money, and so it is crucial that funding received by a nursing home covers the cost of providing the care residents require. As the second tool presented, the paper discusses a new funding instrument known as the Australian National Aged Care Classification (AN-ACC) model. This tool has been proposed as a replacement to the existing Aged Care Funding Instrument (ACFI).

The paper argues that if a person requires a certain level of care, but funding is insufficient to pay for it, then they may not receive the care they need. Conversely, if nursing homes receive excess funding (eg. by inaccurately classifying a resident as having greater need for care than they do in reality), there is a risk that they may not use the funds efficiently or appropriately.

When a resident’s care needs and funding requirements are assessed by the nursing home providing their care, nursing homes may classify a resident as requiring more funding than is actually necessary.

In answer to these issues, AN-ACC relies on the periodic and independent external assessment of residents; the nursing home assesses the resident to determine their care plan.

External, independent assessors assess the resident to determine how much funding the nursing home should receive. The AN-ACC tool places each resident into one of 13 categories that reflect their care needs. Across each category, around 50% of the funds go towards care that is ‘shared’.

For example, to cover the costs of care shared by residents, such as communal dining, an additional variable portion of ‘individual’ funding provides funding that is allocated to each resident depending on the extent of their individual care needs.

Those with greater care needs attract more funding compared with those with lower needs. An actual dollar value for how much it costs to provide care would then be determined by an independent pricing authority similar to the National Hospital Pricing Authority.

Overall, this approach to funding would make sure the funds received by nursing homes not only covers the cost of a case-mix of resident care, but efficiently meets the cost of delivering the care they need. This goes some way towards addressing the issues that currently exist under the use of the ACFI, which is by many accounts no longer fit for purpose.

The paper notes however that determining the amount of funding required to pay for care relative to residents’ care needs cannot define what staffing levels and skills mix are necessary. Put simply, knowing how much funding is required doesn’t tell you how many or what sort of staff a provider needs to employ to deliver the care.

Finally, the paper highlights that, given the complexity of the aged care system and the vulnerability of those who rely on it, it is of particular importance to include a third tool that ensures the transparency and accountability of nursing homes. In discussing staffing, it is suggested this requirement for transparency can be met by having facilities publicly report their staffing levels and skills mixes.

One method put forward to the Commissioners is the United States’ Nursing Home Compare System, which allocates star ratings to each nursing home, including a rating for staffing levels and skills mix.

A rating for staffing is awarded, depending on how many minutes of RN care time, and how many minutes of care time in total (including minutes provided by other care staff including ENs and PCWs) a facility provides per resident per day.

Although this kind of reporting may indicate how a facility does staff, it is neither designed to provide nursing homes with an indication of how a facility should be staffed, nor ensure they are staffing to a particular level.

Quite simply, it is a rating system, not a staffing tool. If a similar tool is used in Australia, the paper argues that it should measure and report staffing concerning what should be provided to ensure best practice.

According to the US tool, five-star care is best practice, but most Australian nursing homes provide less than adequate care (less than three stars).

The paper argues that Australia should aim for best practice care rather than aiming for three or four stars based on a US system.

With all of these tools working together, the paper suggests a staffing tool should be used for making staffing decisions that ensure best-practice care can be provided, a funding instrument should be used to guide how the care provided to residents should be funded and to what level, and a rating system should be used to report publicly how well nursing homes are staffed in relation to mandated minimum standards for staffing levels and skills mix.

As has clearly been evidenced by the Commission, Australian aged care requires significant reform, and each of these elements makes a unique contribution. However, as the paper finds, it is still only mandatory staffing levels and skill mixes that will ensure the right number of people are available at a given time to meet the care needs of residents in a nursing home.

Without a requirement to provide a certain number of suitably trained staff, there is ultimately no guarantee that even the most competent aged care workers will be supported enough to do their job.

“Ultimately, we suggest that any reforms in aged care designed to support the delivery of safe, quality, respectful care must be underpinned by having at least the right number of the right staff to do the work. Without this, older people in nursing homes with insufficient staffing levels and skills mixes will continue to suffer the same neglect they have for far too long.”

Access the full paper here – https://doi.org/10.1016/j.ijnurstu.2021.103943

Authors
Micah D J Peters PhD and Mr Casey Marnie are in the National Policy Research Unit, Australian Nursing & Midwifery Federation (Federal Office).
Both are based at the University of South Australia, Clinical and Health Sciences, Rosemary Bryant AO Research Centre.

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