Chapter 7 - Aged care nursing

The Association is of the view that the aged care sector is in dire need of increased numbers of enrolled and registered nurses if they are to reach an adequate standard of nursing care. Recipients of that care would have the opportunity to experience health gains and as a consequence, the quality of life of those residents would also improve. No longer would we have to hear of elderly Australians dying from opportunistic infections because of neglect arising from care worker ignorance.[1]

7.1        The Committee received much evidence detailing the acute shortage of nurses in the aged care sector. Concerns were voiced about the impact of the shortage on quality of care, particularly for residents of aged care facilities.

7.2        The aged care sector is the second largest employer of nursing staff after the acute care hospital sector. Approximately 20% of Australians aged over seventy use aged care services with more than half of this group accessing Home and Community Care Services. The remainder are cared for in nursing homes (5%), hostels (3.7%) or through Community Aged Care Packages (0.2%).[2]

7.3        The profile of residents in the aged care facilities has changed over the last few years with an increasing number of older clients with higher levels of dependency. The Australian Institute of Health and Welfare (AIHW) has provided an overview of the main characteristics of residential aged care:

• nearly half of those residents in aged care homes at 30 June 2000 were aged 85 or over;
• about 62% of residents fell into high-care categories (Resident Classification Scale (RCS) 1 to 4) and 38% into low-care categories (RCS 5 to 8);
• the lowest level of care (RCS 8) contained about 2% of residents on 30 June 2000;
• between 1998 and 2000 dependency levels increased with the proportion of residents classified as high care (RCS 1 to 4) rising from 57.8% to 61.8%, while those classified as low care (RCS 5 to 8) falling from 42.2% to 38.3%; and
• newly admitted resident tended to have marginally higher dependency levels, overall, than did current residents.[3]

7.4        The Australian Nursing Homes and Extended Care Association (ANHECA) NSW also pointed to an increasing acuity of residents. It reported that at December 2001 there were 806 residents classified at category 1, the highest level of need in hostels and nursing homes, which ‘was up from 620 some nine months earlier, and there were 23 153 in nursing homes, up from a previous figure of 20 890’.[4]

Aged care nursing staff

7.5        The rise in acuity levels of residents reflects government policy which focuses on allowing aged care residents, with increasingly high levels of need, to remain within the one facility. At the same time, a greater proportion of care for people, who would otherwise be eligible for low-care residential support, is being provided in their homes. The AIHW noted ‘available residential care places have thus been targeted to a progressively more dependent group of people’.[5] Witnesses also noted that changes to hospital practices such as early discharge of patients back to residential facilities have added to rising resident acuity.

7.6        Nursing staff may now be caring for acutely ill residents requiring more intensive levels of care such as palliative care and post-operative care. Registered nursing staff may be administering Schedule 8 drugs and providing care for residents with tracheotomies and those in need of subcutaneous infusion or dialysis. In addition, early hospital discharge results in rising acuity of those cared for in the community and extends the length of time of care.[6]

7.7        Against this background of rising acuity levels of residents, evidence pointed to a number of major trends in the workforce employed in the aged care sector: there is an acute shortage of registered nurses; the number of enrolled nurses in the sector has decreased; and the number of unregulated workers has increased. The ANF (SA Branch) noted:

...in aged care, we have an almost total conflict between the growth in patient requirements for care in that sector and a reduction, if anything, in terms of nurses involved. For example, in South Australia in low care, the number of people in hostels requiring a nursing home level of care has grown from 18 per cent of residents in March 2000 to 24 per cent in March 2001. In nursing homes, the top two categories of care have grown from 65 per cent to 76 per cent of the resident population over that same year. But at the same time, we had actually a small reduction in registered nurses and enrolled nurses in employment in aged care facilities – a complete reversal of the actual trend.[7]

7.8        As with the nurse workforce generally, it is difficult to identify the extent of the shortages in the aged care sector. Employment statistics indicate trends in the aged care nursing workforce. AIHW data indicated that in 1997, a total of 35 294 nurses were employed in geriatric and gerontology nursing, 6 040 fewer than in 1994. Although the total numbers decreased, the proportion who were RNs increased from 54.8% in 1994 to 58.4% in 1997, reflecting a greater decrease in the number of ENs in aged care from 18 671 in 1994 to 14 632 in 1997. The AIHW also noted that the average age of RNs in aged care (43.5 years) is greater than nurses in general.[8]

7.9        Evidence from the QNU also pointed to a decrease in employment of both RNs and ENs in aged care in Queensland between 1997 and 1999. As with the national trend, the decrease was greater for ENs.

	ENs employed in aged care in Queensland	RNs employed in aged care in Queensland
1997	1 401 (22.7% of ENs)	3 419 (11.8% of RNs)
1999	1 142 (18.3% of ENs)	3 332 (11.2% of RNs)

Source: Queensland Nurses Council, Workforce Characteristics: Nurses Re-registered in Queensland 1996,1997, 1999.

7.10      Aged and Community Services Australia noted that in Victoria there were as many as 4 500 vacant shifts in residential care homes per fortnight.[9] The Victorian Department of Human Services has undertaken an analysis of the Victorian aged care workforce. The preliminary findings of this study anticipate a shortfall of 7 000 nurses by 2004 in residential and sub acute services.[10]

7.11      Other evidence also provided trends in employment in the aged care sector. The Tasmanian Branch of the HACSU stated that since the mid 1990s there had been a decline of over 26 per cent in the number of nurses employed in the aged care sector in that State.[11] The ANF (Victoria) stated that in Victoria ‘for the most part we have an average of one division 1 nurse, a registered nurse, to 45 high-care patients. You would not want to try it. It is quite devastating’.[12] Australian Catholic University indicated that it was not unusual for one registered nurse to be responsible for up to 100 residents.[13]

7.12      In some areas the shortage is more acute, for example, the ANF (NT Branch) described the situation in the Northern Territory as being at ‘crisis point’ with many registered nurses obliged to work considerable amounts of rostered overtime to keep nursing homes operational.[14]

7.13      The prevalence of the substitution of qualified nurses, in particular ENs, with unqualified personnel was of particular concern to many witnesses. Witnesses stated that it is difficult to obtain current data on the number of unqualified workers employed to perform nursing work in the aged care sector. This is due to the use of different nomenclature for unqualified workers performing nursing work, the variety of their work roles and the time lag in data collection and analysis.[15] However, some evidence was provided that indicated the extent of substitution in the aged care sector, for example, the NSW Nurses’ Association stated that the ratio of unqualified workers to registered nurses is now 5:1.[16]

7.14      The ANF (SA Branch) also pointed to the increase of unqualified staff delivering aged care packages for people living at home:

There are over 3,000 full-time equivalent personal care workers and 3,000 full-time equivalent nursing and personal care staff in aged care in the state, so a good 50 per cent of the work force falls into that unlicensed care worker category. Within community aged care packages, that proportion is significantly higher. So almost all the care packages are being delivered by unqualified or unlicensed personnel, mostly with completely inadequate supervision of their care by registered nurses, to the point where a number of the aged care providers in this state just will not get into the business of aged care packages, because they are not satisfied that they are actually able to give the quality of care program that would be required if they go into it with the current level of funding and with the current arrangements.[17]

7.15      The shortages of nursing staff in the aged care sector adversely affects the care provided to residents. The QNU stated that the nursing skill mix and staffing levels in many hostels are failing to match the acuity levels of residents.[18] With continued shortfalls in staffing requirements, precious resources are spent in constantly trying to recruit staff and orientate new staff. Organisations may have to engage expensive agency nurses to fill gaps. As a result, ageing residents have to cope with a constantly changing workforce and may be unable to develop relationships with staff. This affects both resident care and resident satisfaction and quality of life.[19] The use of agency staff is also expensive. The ANF concluded that the growing nursing shortage has the potential to compromise government policy on nursing home accreditation and its legislative commitments to quality of care for residents.[20]

7.16      Evidence was received that recruitment and retention of nursing staff in the aged care sector reflected similar difficulties as nursing generally with a number of aged care specific problems which are related to:

• remuneration;
• increased workloads due to increases in dependency of clients in care;
• increased workloads related to increasing client numbers and demand in acute and community-based services;
• increased workloads related to documentation and external validation required by the Commonwealth Government relating to the Resident Classification Scale;
• increased use of unqualified workers;
• lack of career prospects;
• poor image of nursing in aged care;
• lack of re-entry programs in aged care; and
• the size of the residential care units.[21]

Implications of RCS funding

7.17      Submissions argued that funding for aged care needs to be sufficient to ensure that the appropriate number of qualified staff are employed in the aged care sector.[22] The Committee received many comments critical of present funding mechanisms through the Resident Classification Scale (RCS). It was argued that the RCS funding tool does not acknowledge the increased level of care required by residents who are chronically ill including those who have been discharged early from hospital with complex needs. The ANF stated that ‘as a result, we cannot employ more qualified people because the money is not there’.[23]

7.18      Queensland Health stated that the Commonwealth funds aged care for outcomes and does not stipulate inputs. It is for individual facilities to determine the inputs that the facility requires to achieve the desired outcomes for it to reach the standards set out in the Aged Care Act. Queensland Health noted that this ‘has the potential for facilities to reduce RNs and/or employ more unregulated workers’.[24]

7.19      The NSW Nurses’ Association argued that the funding model created a further problem: the RCS creates a financial disincentive for admitting residents with low care needs. This raises the aggregated acuity level of aged care residents ‘to the point where they are more realistically regarded as patients because they are more ill or frail than they are well and require far more than hygiene, nutritional assistance and custodial supervision’.[25]

7.20      The level of documentation required by accreditation and the RCS model also drew considerable criticism. Witnesses frequently commented on the time required to complete documentation, with one suggesting that it was not uncommon for registered nurses to work for two hours per shift on documentation.[26] Nurses argued that this prevented staff from actual delivery of care which is their primary role.

7.21      The ANF stated that there was a large amount of repetitive documentation being required to validate a RCS claim. Further, that the RCS has been in use for some time and that the number of questions could be reduced: ‘it is a funding tool and it has 20 questions. Statistically it should be possible to reduce the number of questions so that the RCS becomes a funding tool and does not become a pseudo care plan.’[27] The ANF also noted that the Department of Health and Aged Care had considered the level of documentation but indicated:

They said, ‘Yes, it is possible’, but they were reluctant at that time to reduce the number of questions for two reasons: one was that they did not want to introduce more change into the system and, secondly, they thought they were collecting a lot of valuable data that they might want to use at some stage. I do not think those reasons are good enough now...

You have a care plan. At the moment, because you are doing so much documentation for the RCS, it is almost being used as a pseudo care plan which it was never meant to be and it is not designed to be. It does not pick up all aspects of care. So it is your care plan which is your legal tool. The RCS is a funding tool and should be limited to that.[28]

7.22      Aged and Community Care Services Tasmania indicated that a survey of 25 per cent of aged care providers ‘found that there was probably an extra $4 million of time spent completing just the RCS requirements in excess of normal documentation requirements. This time could have been better spent perhaps in providing direct resident care.’[29]

Remuneration in aged care sector

7.23      Disparity between rates of pay for aged care nurses and acute care nurses was raised frequently in evidence and was seen as a major reason for staff attrition in the aged care sector. Wage disparities also exist between the public and private sector and are causing nurses to leave private aged care facilities. The ANF noted that the disparity in some states is as high as a twenty per cent. This translates to a difference of between $65.00 and $155.00 per week between aged care and public sector wage rates.[30]

7.24      The difference in pay rates varies across the States and Territories. For example, in Tasmania aged care nurses are paid 15 per cent less than those in acute care.[31] In Western Australia, aged care nurses are about 28 per cent behind acute sector nurses.[32] In Victoria, the difference between the public and private sector for registered nurses division 2 (Enrolled Nurses) is now $4.74 per hour.[33]

7.25      The Victorian Council of Peak Nursing Organisations indicated that nurses in aged care in Victoria ‘work under a separate award, an aged care award, which is negotiated on the basis of what those facilities are funded by the Commonwealth government.’[34] Some organisations paid above the award to keep staff, but others, particularly the for-profit sector did not.[35]

7.26      The need to provide wage parity was viewed as one of the most significant mechanisms to improve recruitment and retention in the aged care sector. The Nurses Board of Victoria stated that until the anomalies in wages are addressed ‘other strategies will be less effective in drawing nurses to the area’.[36] The ANF proposed that the gap in wages between nurses working in the aged care sector and nurses working in the public sector be closed and mechanisms be developed to fund ongoing wage parity.[37]

Use of unregulated workers in aged care

7.27      The increased use of unqualified and unregulated workers in aged care was criticised in evidence. The ANF stated that in its view ‘employers are substituting nursing positions with unlicensed workers citing current shortages as their rationale and yet they are doing little to reverse the exit of educated and experienced nurses from the aged care sector’.[38]

7.28      The impact of the use of unqualified workers on the skilled workforce was highlighted. With larger numbers of unqualified workers, there is a need to exert stringent supervision and control over employee activities through routines and procedures if the legal duty of care of the organisation is to be met. The NSW Nurses’ Association stated that in such circumstances, routine can undermine the attractiveness of this type of nursing. RNs may also have to provide training to unqualified workers before work can be delegated.[39] This increases the workload of RNs and adds to the level of stress in the workplace. As UnitingCare stated:

This is a self-perpetuating, downward spiral: non-registered staff are employed because registered staff are not available, increasing the pressures on the registered staff, which adds to the sector’s general inability to recruit and retain nurses in aged care.[40]

7.29      Enrolled nurses also expressed concern about the use of unqualified workers, stating that they were made to feel a ‘lesser being’ as they were precluded from undertaking some duties by their enrolment provisions which unqualified workers are asked to do. The National Enrolled Nurses Association stated that they have become the ‘lesser option when it comes to employment’.[41]

Specialist education

7.30      In order to recruit and retain nurses in aged care, specialised education was seen as essential. The Queensland Nursing Council indicated that only 2 per cent of Australian nursing students were attracted to aged care although it currently accounts for 28.5 per cent of nurse employment.[42] Witnesses argued that there is poor identification and valuing of aged care nursing in the undergraduate courses.[43] This reinforces the low status of aged care as a potential area of specialty and is exacerbated by the lack of clinical placements.

7.31      The ANF noted that aged care is a specialist area of nursing with its own discrete body of knowledge which is constantly growing. However, there is a lack of postgraduate courses, for example, it was stated that the University of Tasmania has not offered postgraduate gerontology studies for some time.[44] The ANF also pointed to a shortage of gerontic specific education courses at Graduate Certificate level in external and distance modes offered at a reasonable cost. The need for a review of educational and professional development needs was seen as particularly important because of the changing context of aged care health delivery and the need to ensure that quality care for older people using aged care services is maintained. ANHECA also noted that education and development opportunities are an enormous incentive for nurses to stay in the profession.[45]

7.32      Poor access to refresher/re-entry programs was also seen as a disincentive for nursing staff to move into the aged care sector. The Victorian Government has addressed this by offering refresher, re-entry and supervised practice programs for nurses through public sector facilities with a residential aged care focus. However, it was noted that there are limitations for the non-public residential aged care sector (ie. private and not-for-profit providers) to provide such programs due to their inability to offer all the components of the accredited course and a lack of approved clinical supervisors in the sector.[46] Queensland Health suggested that to overcome problems in this area, the Commonwealth fund re-entry and refresher programs in aged care.[47]

7.33      Other staffing issues raised included a lack of positive promotion of aged care nursing and a prevailing view that it is a low status occupation with unchallenging, unrewarding work and a place where nurses lose their clinical skills. It was argued that this is a major contributor to the difficulties experienced in recruiting and retaining nursing staff. Witnesses stated that the nursing profession was poorly articulating the value of aged care nursing. As a result, specialist aged care nursing is not being widely recognised and valued inside and outside the profession. Frontier Services noted that the Commonwealth had provided ‘funding only for policing in aged care, reinforcing the notion that the industry is unprofessional and needs to be carefully monitored’.[48]

7.34      A further issue raised was the high rates of occupational injury, particularly in relation to manual handling injuries. Nursing homes still experience higher worker’s compensation claims rates than hospitals, including psychiatric hospitals. The rate for nursing homes is 72 per cent higher than the all-industries average. Nursing homes average workers’ compensation cost per occurrence is $8 330 per claim, which is 13 per cent higher than for hospitals and 37 per cent higher than for psychiatric hospitals. Claims are predominantly related to manual handling.[49]

Administration of medication

7.35      The issue of administration of medication, particularly by enrolled nurses, in aged care was raised in evidence. Many residents of nursing homes have complex needs with complex pharmacology requirements. The Working Group on Aged Care Worker Qualifications has undertaken a review of the current role of enrolled nurses in the aged care sector. As part of that review, the Working Group examined options for the administration of medications in aged care. It reported broad support for an enhanced scope of practice for enrolled nurses up to and including S4 medication administration provided there is appropriate education and supervision in a nationally consistent framework.[50] Stakeholders will consider the findings of the review later in the year.

7.36      ANHECA supported an expanded role for enrolled nurses, believing that they are under-utilised in the aged care sector largely because of limitations placed on their practice by current legislation. ANHECA supported post enrolment education and training for enrolled nurses to increase their scope of practice to administering up to and including Schedule 4 medications, under the indirect supervision of a registered nurse.[51] Catholic Care of the Aged voiced concern, stating that such a move may lead to the number of registered nurses working in nursing homes being further reduced and that there may not be enough enrolled nurses to take on this role.[52]

Commonwealth Government programs

7.37      The Department of Health and Aged Care stated that the Commonwealth ‘is assisting and providing leadership to support the industry in a number of ways, and has committed resources for initiatives to help promote the aged care nursing workforce and lift its profile and professionalism, to assist with the retention of the existing workforce and to attract new entrants to that workforce’. The Commonwealth has introduced initiatives such as Awards for Excellence in staff development which the Department stated would enhance the professional profile and image of aged care as a discipline.

7.38      The Department commissioned a report on recruitment and retention of nurses in residential aged care on behalf of the Aged Care Workforce Committee.[53] The report investigated reasons for nursing attrition in aged care; factors to encourage nurses to return to aged care; strategies the aged care sector might implement to attract nurses; and the influence appropriate re-entry courses might have on the sector’s ability to attract nurses to the profession. Twenty recommendations were made in the report covering re-entry programs, wage parity, postgraduate programs, skills mix, national education and training, and improving the image of aged care nursing.

7.39      The Department noted that aged care workforce issues are monitored and considered by the Aged Care Workforce Committee, a high level advisory committee made up of representatives of the aged care industry, academia, nursing organisations and carer and consumer groups, and a representative of State and Territory Governments. This Committee is considering the link between quality care and an appropriate skilled workforce, including nursing staff.

7.40      Under the Minister for Aged Care’s National Compliance and Accreditation Forum, two working groups are addressing workforce issues. One is looking at a Code of Ethics and Guide to Ethical Conduct for Commonwealth Residential Aged Care. This will be a voluntary and self-regulated code within the industry. The second group is the Aged Care Worker Qualifications Working Group which, as noted above, has reviewed the role of enrolled nurses in aged care.

7.41      In the 2002-03 Budget, the Commonwealth provided an additional $26.3 million over four years to fund up to 250 aged care scholarships, valued at up to $10 000 per year, for students in undergraduate, postgraduate or re-entry nursing studies at rural and regional university campuses. Universities will be responsible for marketing the scholarships and will be expected to make additional nursing places available. Funding of $21.2 million over four years is to be provided so that personal care staff in smaller, less viable aged care homes can undertake a range of accredited courses related to geriatric care. Upgrading the skills of personal care workers will enable facilities to free registered nurses to concentrate on clinical work rather than general personal care.[54]

7.42      The Budget also provided for increased subsidies for residential aged care of $211.1 million. The additional funding will allow providers of aged care to attract and retain more aged care nurses by offering them pay rates closer to those of nurses in the public hospital sector.[55]

Conclusion

7.43      In its submission, the Department of Health and Aged Care stated that in the aged care sector ‘a strong, well-trained and qualified nursing workforce is essential for the delivery of quality aged care whether in residential or community settings’.[56] The Committee agrees with the Department’s view, however, evidence indicates that delivery of quality aged care is under threat. The Committee considers that the threat comes from the retreat of qualified nurses, both RNs and ENs, from aged care and the increased employment of unqualified staff. This results in staff with skills mix which is at best variable and in some instances not up to standard. The qualified nurses remaining in the aged care workforce are left to care for sicker clients and to supervise increased numbers of unqualified workers. Clients and their families also have expectations that there will be expanded use of new technology and greater levels of intervention. At the same time workloads have increased due to the massive amount of repetitive documentation required by government.

7.44      The Committee considers that the shortage of qualified staff has now reached a crisis point. The Committee’s recommendations, together with those of the Final Report on Recruitment and Retention of Nurses in Residential Aged Care, provide strategies for resolving the crisis in the aged care sector. However, there will be no resolution without national leadership, without the involvement of all stakeholders including employers and without implementation of solutions already identified. There needs to be a concerted and sustained effort to act and ensure that all those in the aged care sector receive the quality of care that the Australian community expects to be available and that aged care nurses receive working conditions, remuneration and recognition commensurate with their training and professionalism.

Recommendation 68: That the Commonwealth review the level of documentation required under the RCS tool to relieve the paperwork burden on aged care nurses.

Recommendation 69: That the outcomes of reviews and research be used to establish appropriate benchmarks for resources and skills mix in aged care nursing so as to support improved care for residents, workforce management, organisational outcomes and best practice and that Commonwealth funding guidelines be reviewed in light of this research.

Recommendation 70: That universities review the content and quality of clinical placements and experiences of students in aged care in their undergraduate courses and that clinical placements include a range of aged care settings.

Recommendation 71: That universities review and develop postgraduate programs and courses, including the provision of courses by distance education, appropriate for the aged care sector.

Recommendation 72: That the Commonwealth fund the expansion of re-entry/refresher programs specifically targeted at aged care nurses.

Recommendation 73: That the Commonwealth provide additional funding to implement wage parity between aged care and acute care nurses in each State and Territory.

Recommendation 74: That strategies be implemented to improve the image of aged care nursing.

Recommendation 75: That the Commonwealth take measures to reduce occupational injuries to nurses working in aged care, including the introduction of ‘no lift’ programs across the aged care sector in conjunction with the provision of up to date safe lifting devices that are readily available for staff use and are regularly maintained.

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