Our ailing aged care system shows you can't skimp on nursing care

Staff shortages and a lack of training have once again emerged as key issues underpinning the nation’s aged care crisis, as the aged care royal commission hears testimony in Perth.

Registered nurse Noleen Hausler shared the experience of her 98-year-old father, Clarence, who was force-fed, assaulted and had a serviette held over his nose by a carer who was later convicted of aggravated assault.

Aside from this criminal behaviour, Ms Hausler said the standards at her father’s aged care facility declined after a new operator reduced staffing levels and employed carers with little training. Call bells went unanswered, she said, and incontinence pads were rationed.

Ms Hausler has called for increased ratios of registered nurses in aged care facilities, and better training and registration for carers.

Under-staffing and inadequate training have long been problems in Australia’s aged care facilities, with aged care facilities employing fewer registered and enrolled nurses and more carers who have lower levels of training.

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Who does what in aged care?

A registered nurse (RN) provides nursing leadership and clinical supervision in aged care facilities. They are skilled clinicians who can respond to medical emergencies and are qualified to carry out assessments.

Registered nurses undergo three years of undergraduate study at university and are registered with the Australian Health Practitioner Regulation Agency (AHPRA) in order to practise in health care setting across Australia.

An enrolled nurse (EN) conducts observations and assessments, and collaborates with and seeks assistance from the registered nurse in charge. Enrolled nurses are registered with AHPRA and undergo an 18-month diploma of nursing at TAFE.

Finally, care workers form the bulk of the aged care workforce and perform tasks such as showering, dressing and feeding residents. Titles for carers vary and include assistant in nursing, personal care worker, personal care attendant, and aged care worker, to name a few.

Care workers are required to complete a certificate III-level course, which can take up to six or seven months, but don’t require registration.

Carers cost less than nurses

There is no clear legislation requiring a certain number of registered nurses, enrolled nurses and carers to be on duty at certain point in time. The Aged Care Act 1997 is open to interpretation, so aged care providers are largely free to set their own staffing levels.

As a result, in recent years aged care operators have recruited proportionally fewer registered and enrolled nurses and increasing numbers of unregulated carers.

The changing make up of the aged care workforce is mainly influenced by economic advantage: hiring carers is cheaper than hiring registered or enrolled nurses.

It can also be difficult to find enough nurses. Nurse retention in aged care has been a major challenge for the industry because aged care providers often pay lower wages than hospitals.

But nursing care is worth the investment

Research shows having a greater number of registered nurses increases patients’ well-being and safety. Better staffing levels allow nurses to spend more time caring for residents and reduces the likelihood that vital information is overlooked.

Adequately staffing aged care facilities has economic benefits by reducing staff turnover related to burnout and job dissatisfaction.

Employing skilled registered nurses in aged care facilities can also save the health system money by reducing the number of costly hospital admissions that arise because residents can’t be adequately cared for in their aged care facility.

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Aged care residents often have mental health issues, face cognitive decline or dementia, take multiple medications each day, are physically frail, and often have multiple chronic conditions such as heart disease, diabetes, cancer, arthritis or asthma.

But it’s difficult to meet the needs of these patients with the current aged care staffing and skill levels.

More than 50% of the residents in a residential aged care facilities have some form of dementia, for example, yet more than 50% of aged care workers have no dementia training.

Substituting registered nurses with lesser skilled carers has meant tasks such as medication management have been assigned to carers in some aged care facilities, despite this being a high-risk task that requires a high level of skill and experience.

What are the solutions?

Carers currently make up around 70% of the aged care workforce. We need to reset aged care staffing levels and ensure we have the right skill sets, which industry bodies suggest is: 30% registered nurses, 20% enrolled nurses and 50% care workers.

It’s also time to professionalise caring roles with better regulation and the introduction of carer registration.

Registration would clarify carers’ roles and allow only the delegation of tasks which are deemed safe for carers to carry out within their scope of practice. It would also ensure minimum training standards are met and that quality and safety is maintained.

The aim is not to vilify carers, who are the backbone of our aged care system, but rather to highlight the need for the right level of training, education and support to strengthen the aged care workforce and complement the care provided by registered and enrolled nurses.

Finally, we also need to increase the number of registered and enrolled nurses in the aged care workforce with guided pathways to attract and retain nurses. Well-structured graduate nurse programs, for instance, can provide support and guidance to the graduates who are considering a career in aged care.

Read more: Don't wait for a crisis – start planning your aged care now