Despite several years of the ANMF’s calling on governments to urgently improve staffing levels and skills mix in nursing homes, two years into the SARS-CoV-2/COVID-19 pandemic Australia finds itself at a readily foreseeable crisis point with the Prime Minister announcing that up to 1,700 Australian Defence Force personnel will be deployed to support the foundering aged care sector due to a staffing crisis.

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While this drastic action is almost certainly warranted for a sector facing dire staff shortages and where almost half of all nursing homes are experiencing an outbreak, this crisis could have been significantly diminished or even avoided in many circumstances had the Commonwealth Government heeded the ANMF’s warnings before and during the earlier months of the pandemic.

With the defence force and private hospitals now propping up a devastated nursing home sector with many thousands of staff off sick or isolating as close contacts, the Australian Government is urging us to focus less on those who have lost their lives in insufferable loneliness and neglect and consider these deaths as imminent and unavoidable. To quote the aged care minister during 2 February 2022’s Senate Committee Inquiry on COVID-19; “I think the sector is performing extremely well”. Here, we argue that had the government acted on the ANMF’s recommendations regarding implementing safe staffing levels and skills mixes along with a raft of the Royal Commission into Aged Care Quality and Safety’s recommendations, the situation in nursing homes today could be quite different.

Accepting the unacceptable

With almost half of all nursing homes grappling with active outbreaks in January, almost half of all COVID-19 deaths in aged care occurred in the two months of 2022; around 7% of the total duration of the pandemic. The Prime Minister recently remarked that over 60% of these lost lives were older people receiving palliative care and that most of the other lost lives were people with multiple conditions. This could be interpreted as highlighting that these older people – people’s mothers, fathers, and family members – were simply about to die anyway and we should focus instead on the lives that have been saved.

This perspective probably comes as small comfort to those who lost much loved family and friends living in nursing homes; people who account for around two thirds of all Australian COVID-19-related deaths.

COVID-19 has significantly added to the risk and burden in Australia’s nursing homes.

Figures released on 8 March show that the 859 deaths reported in 2022 account for 47% of all Australian COVID-19 nursing home deaths since the start of the pandemic and over 15.5% of all Australian COVID-19 deaths to date.

This, in just over two months of the 26 months pandemic. Deaths related to COVID-19 in aged care were and are avoidable, but it is not solely these deaths that cause so much impact on residents, families, and staff. The pandemic and ongoing staff shortages have impacted both those with and without COVID-19 outbreaks. With nursing homes facing crisis-level staff shortages, there are many heart-wrenching stories of loved ones dying alone, in soiled beds, hungry, thirsty, without family, and without the care they need and deserve.

Around 3,178 (1.3%) nursing home residents are assessed as requiring palliative care, however this is likely to significantly under report the actual number of people who require or receive palliative care due to the fact that the Aged Care Funding Instrument (ACFI) only captures end of life palliative care within the last week of life. Almost everyone living in nursing homes has some need for complex healthcare, activities of daily living, and cognition and behaviour, with over half of all residents having high needs for care in at least one of these domains.

Implying that people who receive palliative care or those who have complex healthcare needs are less worthy of our attention significantly diminishes the worth of many older Australians and their families.

Suggesting that these deaths were somehow imminent and therefore able to be passed over also suggests that these older Australians and their families would be somehow more able to accept and comfort themselves with the notion that their passing was unavoidable.

Palliative care, even when it is in the last days before the end of life, is about supporting a person to live comfortably, with as little pain and discomfort as possible and to ensure that families and loved ones can also be supported and cope during this difficult time. Palliative care can last for many months or years when a person’s primary treatment goal is optimisation of quality of life rather than ‘cure’.

This highlights too, that the pandemic and strain on the aged care workforce isn’t just impacting people who die with COVID-19 but everyone in aged care, receiving palliative care or not, as well as their families who want to be with them in the last hours, days, weeks, or months of life.

To return to the notion that the current crisis must inadvertently result in unavoidable death and suffering for nursing home residents and their families begs the question does our government and its leaders really care about older Australians?

Australian nursing homes need safe staffing levels and skills mix

Based on a study by the Australian Health Services Research Institute (AHSRI),¹ in 2020 the Royal Commission into Aged Care Quality and Safety recommended that from 1 July 2022 on average, the average nursing home resident should receive at least 200 minutes of care per day including 40 minutes from registered nurses (RN) as well as 16 hour per day RN presence.² This minimum requirement would then increase from 1 July 2024 to at least 215 minutes of care per resident per day including at least 44 minutes from RNs and 24/7 RN presence.

The Commonwealth Government did not agree to deliver on either of these recommendations. Instead, the government postponed implementation of the minimum of 200 minutes including 40 minutes of RN time and 16 hour per day nurse presence to 1 October 2023 and refused to commit to increasing these minimum standards or requiring 24/7 RN presence.³

The ANMF and others have been vocal for many years regarding the need to ensure 24/7 RN presence and that on average, residents receive 258 minutes of care per day including 77 minutes from RNs, 52 minutes from enrolled nurses (EN), and 129 minutes from personal care workers (PCWs).⁴ Had the Commonwealth Government listened and acted sooner, the crisis facing so many nursing home residents, staff, and families would have been much reduced.

Milestones missed – the implementation plan explained

The ANMF’s staffing and skills mix implementation plan would enable Australian nursing homes to provide safe, quality care to aged care residents now and in the future. Adopting the ANMF’s implementation plan would not only ensure that Australian nursing home residents receive safe, quality care more quickly it will also guarantee better working conditions and therefore improved attraction and retention of nursing home staff.

Of course, the plan could not be implemented in isolation, which is why the ANMF has also called for greater transparency and accountability in the use of funding and improved wages and conditions for all staff. These preconditions have been known for many years, but the government inactivity has simply kicked the can down the road to the point of catastrophe.

Had the government acted to implement our plan when first recommended, the picture in aged care right now might be quite different. Had reforms been implemented that allowed for a sufficiently sized and skilled workforce, workers would have more time to spend with residents separated from their family through isolation requirements, and more time to support residents to maintain contact with family and friends through digital link-up.

Further, with less residents to care for per staff member, the extra time required for staff to ensure infection control procedures are followed could be accommodated. Assisting a person with their basic hygiene needs such as showering and toileting is considerably more time consuming when needing to ensure facilities are wiped down and sterilised between use.

A process that was repeatedly raised by staff as being inadequate due to time constraints even prior to the pandemic.

The gradual implementation of these reforms would also allow for other necessary reforms such as better pay and conditions and a new Aged Care Act to be put in place. The staffing levels and skills mixes below are calculated across the facility, not by individual units or wings. This would give nursing homes the flexibility needed to respond to varying care needs of the residents. Toward the end of the implementation period (2025-2026), reassessment must occur to ensure that any future adjustments to minimum standards for nursing home staffing levels and skills mix will continue to provide safe, quality care for residents.

If the government were to follow our recommendation along with the other recommendations of the Royal Commission, from 1 July 2022 – 31 December 2022 (Stage 1), the implementation plan would have each nursing home ensure an average of 200 minutes of nursing and personal care per day per resident including 60 minutes of care from RNs, 40 minutes from ENs, and 100 minutes from personal care workers, as well as 24-hour on-site registered nurse cover with a minimum of one registered nurse per shift. This would help improve care and dignity for many residents and greatly improve the working conditions of many staff.

Conclusion

The government must admit that its refusal to act to reform aged care over many years has cost lives and significantly and detrimentally impacted on the lives of hundreds of thousands of nursing home residents and families. While it is now too late for too many older Australians, immediate action is urgently required to ensure that we have the world-class aged care system all Australians deserve.

It has been just over two years since the beginning of the COVID-19 pandemic and a year since the release of the Royal Commission’s final report. Before both of these milestones, many reports over the years described and reported on an aged care sector beset by significant and widespread problems; not least a workforce with an insufficient size and skills mix to provide safe, dignified care to vulnerable residents with complex health and personal care needs. The suggestion that many of those who have lost their lives with COVID-19 has been (and will be) unavoidable, inevitable, and therefore could not have been helped both denigrates the value of these older Australians and the lives of the families and loved ones they have left behind. Many of whom could not have been together in the last precious moments and also who have experienced two years of isolation and restrictions.

While planning for, managing, and recovering from a global pandemic is anything but simple, we argue that certain aspects are certainly clear-cut. Australian nursing homes need safe staffing levels and skills mixes to provide safe, dignified, effective care. They needed this before, and now they need this more than ever.

References

1. Eagar K, Westera A, Snoek M, Kobel C, Loggie C, Gordon R. How Australian residential aged care staffing levels compare with international and national benchmarks. Centre for Health Service Development [Online]. Wollongong: Australian Health Services Research Institute (AHSRI), University of Wollongong. 2019. Available: https://agedcare.royalcommission.gov.au/sites/default/files/2019-12/research-paper-1.pdf (Accessed 18 Nov 2021).

2. Royal Commission into Aged Care Quality and Safety. Final Report: Care, Dignity and Respect [Online]. Canberra: Commonwealth of Australia. 2020. Available: https://agedcare.royalcommission.gov.au/publications/final-report (Accessed 18 Nov 2021).

3. Australian Government Department of Health. 2021. Australian Government Response to the Final Report of the Royal Commission into Aged Care Quality and Safety [Online]. Canberra: Commonwealth of Australia. 2021. Available: https://www.health.gov.au/resources/publications/australian-government-response-to-the-final-report-of-the-royal-commission-into-aged-care-quality-and-safety (Accessed 18 Nov 2021).

4. Willis E, Price K, Bonner R, Henderson J, Gibson T, Hurley J, Blackman I, Toffoli L and Currie T (2016) Meeting residents’ care needs: A study of the requirement for nursing and personal care staff. Australian Nursing and Midwifery Federation.

Authors:
Micah DJ Peters PhD and Casey Marnie are at the National Policy Research Unit (Federal Office), Australian Nursing and Midwifery Federation (ANMF) and University of South Australia, Clinical and Health Sciences, Rosemary Bryant AO Research Centre