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Residential aged care staffing in australia

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Residential aged care staffing in australia

  1. 1. A study into Residential Aged Care Staffing in Australia Report April 2018 Dr Rodney Jilek Principal Advisor Aged Care Consulting & Advisory Services Sydney, Australia
  2. 2. Contents Contents............................................................................................................................................................................2 The Study - Methodology..................................................................................................................................................5 Results - Demographics.....................................................................................................................................................5 Staffing – Registered Nurses.............................................................................................................................................8 Staffing – Aged Care Worker / AIN / PCA........................................................................................................................13 Staffing – Recreational Activities Staff............................................................................................................................17 Staffing - Physiotherapy..................................................................................................................................................20 Staffing – Education........................................................................................................................................................22 Conclusions .....................................................................................................................................................................23 Limitations of the Study..................................................................................................................................................24 Additional Comments .....................................................................................................................................................25
  3. 3. Introduction Staffing levels in Australian residential aged care services have long been a topic of debate, with significant differences of opinion held by government, providers, staff, unions and consumer groups. Staffing levels, mix and quality are all intrinsically linked with funding. The funding of aged care staffing has changed considerably over the years. Those of you who have been in the industry for a long time with remember the days of CAM / SAM funding, where a provider was given a pot of money to spend on staffing and care related expenses and then required to prove they used the money they received for the purpose for which it was received. A novel reconciliation approach which was successful most of the time, except when the provider made up employees to ‘ghost’ rosters. At least one was infamously jailed in NSW for commonwealth fraud. Through a succession of care funding tools, the commonwealth has sought to control the cost blow out for taxpayers as the cost of providing aged care services to older Australians increased into the tens of billions of dollars. The difficulty today is that there appears to be a significant incongruence between in the level of staffing expected by residents (and more specifically their families) and the funding provided for “care” via the Aged Care Funding Instrument or ACFI, which pays for this staffing (amongst a range of other care related items). This is further complicated by the ever-increasing wage expectations of Australian workers. Even at current staffing rates, where the numbers are generally reported to be below expectation, the wages contribute between 60% and 80% of a provider’s total income and are constantly rising through annual enterprise agreement pay rises and external market pressures to attract and retain quality staff. We now see differences of up to $20 an hour between the gazetted national award rates and those in enterprise agreements negotiated by unions, with many aged care providers forced to pay even higher rates to secure staff in an increasingly competitive market. Aged care struggles to compete with the public hospital system (which is also heavily government funded) because rates of pay are significantly higher and mandated patient to staff ratios are as low as 1:4. In the last few years, we now see one of three things occurring in the Australian aged care system: (a) Staff are being reduced to directly reduce wages costs and improve profitability. (b) Particularly in the home care sector, new entrants are subcontracting staff so they are required to cover their own workers compensation and liability insurances and effectively charge rates less than standard EBA rates paid by established aged care providers. I expect this will also flow on to residential services in the future if this is seen as a successful strategy in home care. (c) Providers financial viability is decreasing rapidly resulting in consolidation of the market. With the major nursing and health unions commencing their latest campaigns to establish staff to resident ratios into Aged Care (as they have successfully done in the public hospital system), and while I hold the belief that mandatory staffing ratios in isolation are not the answer to aged care’s clinical woes, I thought it an opportune time to explore what staffing levels actually were and how this compared to expectation. I have long held the view that government will only introduce mandatory staffing levels as a very last resort (they have been fighting it for about 20 years already) because they cannot afford to fund the levels expected by unions and consumers and if they set the benchmark too low, they will be ridiculed by everyone and be directly blamed for any future problems related to poor staffing.
  4. 4. And while successive commonwealth governments have attempted to ensure older Australians are provided with high quality care, their attempts at dealing with the looming workforce catastrophe have been feeble at best. While the Aged Care Act 1997 stipulates that a provider must ensure There are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives There are no objective levels to compare one service to another or guidance for providers or accreditation assessors to determine what is an acceptable level. The current system of regulation is completely subjective. The fall-back position has therefore become: Government – it is up to providers to determine what is the appropriate level of staff (even though they are the regulator and put the measures into place) Unions – there are not enough staff Consumers – there are not enough staff Staff – there are not enough staff Providers – our staffing meets ‘industry averages’ or is ‘based on the needs of our residents’ Given the Aged Care Funding Instrument is an activity based funding tool which supposedly measures resident acuity, one would suggest it was possible for the government to articulate staffing need using the same, except of course if: (a) the money provided wasn’t enough to pay for the recommended staffing levels or (b) the recommended numbers were too low to provide the care. It is clear that new, more cost-effective care alternatives must be explored that both meet the funding available and the expectations of the community. Unfortunately, it is also clear that both measures are moving in polar opposite directions as expectation increases and funding sources dry up. This issue is more than just increasing efficiency or changing the delivery point of care. It’s also not just about increasing funding endlessly. It’s not about having endless reviews that never eventuate to anything or shuffling the deckchairs in government departments to give the perception that something new is happening. It’s certainly not about blaming other political parties and state governments when a facility that you fund, accredit and regulate fails under your nose and you failed to act. It is about clarifying and understanding expectation, quantifying the resources necessary to meet that expectation and laying it all out on the table so people can make informed decisions. What do we want, can we afford it, and if we can’t, what is an alternative we can afford? Now that would be a very courageous decision indeed Minister, as Sir Humphrey Appleby would say. This study has been completed independent of provider groups, unions, advocacy groups and government and I thank each of the participants for their time.
  5. 5. The Study - Methodology The study was conducted through online questionnaire utilising the LinkedIn networking platform drawing participants from the authors network of nearly 10,000 contacts and their subsequent contacts. Questionnaires were completed between 15 April 2018 and 25 April 2018. The LinkedIn article and questionnaire was viewed 8,097 times with a total of 3,152 questionnaires completed during this period. Results - Demographics (a) Participant Employment / Reason for Aged Care Exposure (b) Location of Participant Two percent of participants were not located within Australia so if the purpose of this report, their responses have not been included. One participant chose not to disclose their location.
  6. 6. (c) Size of the Aged Care Home they work in or visit (d) Location of the Aged Care Home 63% 16% 12% 8% Capital City Large regional centre (+ 30,000 pop) Medium regional centre (10,000- 30,000 pop) Small regional town (less than 10,000 pop)
  7. 7. Is the Aged Care Home … Participants were able to select as many answers applicable to their home.
  8. 8. Staffing – Registered Nurses Does the home have a Registered Nurse rostered 24 hours a day? Do YOU THINK the aged care home should have a Registered Nurse rostered 24 hours a day? Yes, 98% No, 2%
  9. 9. How many residents does a Registered Nurse oversee on the morning shift? How many residents DO YOU THINK a Registered Nurse should oversee on the morning shift? Less than 20 21-30 31-40 41-50 51-60 61-80 80+ 4% 17% 19% 23% 10% 10% 16%
  10. 10. How many residents does a Registered Nurse oversee on the afternoon shift? How many residents DO YOU THINK a Registered Nurse should oversee on the afternoon shift?
  11. 11. How many residents does a Registered Nurse oversee on the night shift? How many residents DO YOU THINK a Registered Nurse should oversee on the night shift? Less than 20 21-30 31-40 41-50 51-60 61-80 80+ 6% 3% 3% 9% 10% 14% 55%
  12. 12. Does the Registered Nurse also oversee a co-located retirement village? In one case, a participant provided information that she was responsible for the management of a 50 bed secure dementia specific unit as well as managing adverse events across the co-located 150 unit retirement village.
  13. 13. Staffing – Aged Care Worker / AIN / PCA How many residents does an Aged Care Worker / PCA / AIN provide care to on the morning shift? How many residents DO YOU THINK an Aged Care Worker / PCA / AIN should provide care to on the morning shift? Less than 5 6 7 8 9 10 11 12 13 14 15+ 25% 36% 12% 9% 1% 12% 1% 1% 1% 0% 2%
  14. 14. How many residents does an Aged Care Worker / PCA / AIN provide care to on the afternoon shift? How many residents DO YOU THINK an Aged Care Worker / PCA / AIN should provide care to on the afternoon shift?
  15. 15. How many residents does an Aged Care Worker / PCA / AIN provide care to on the night shift? How many residents DO YOU THINK an Aged Care Worker / PCA / AIN should provide care to on the night shift?
  16. 16. Are the care staff numbers the same on weekends as they are during the week?
  17. 17. Staffing – Recreational Activities Staff Does the aged care home employ lifestyle and activity staff? Are activity and lifestyle staff available 7 days per week?
  18. 18. DO YOU THINK lifestyle and activity staff should be available 7 days per week? How many activities or lifestyle staff are employed Monday to Friday?
  19. 19. How many activities or lifestyle staff are employed on weekends?
  20. 20. Staffing - Physiotherapy Does the aged care home employ a physiotherapy assistant? How many physiotherapy assistants are employed?
  21. 21. Is the physiotherapy assistant position …
  22. 22. Staffing – Education Does the aged care home employ a nurse educator or education coordinator? Is the education position …
  23. 23. If you needed attention or care, how long DO YOU THINK it is acceptable to wait? While the number of staff cannot be directly linked to the provision of higher quality care, it would be interesting to further explore the notion of acceptable wait times through a time and motion study. This may prove to be a more reliable variable to use when considering if staffing levels are appropriate or not. Conclusions It is obvious that staffing ratios are not the be all and end all when it comes to quality care provision. It was never the intention of this study to suggest or test this hypothesis. The study has however highlighted: • There is significant incongruence between reported actual staffing numbers provided and those expected by the participant group. • The results of actual staffing can be described as ‘scatter gun’ with no real “industry average” across the direct staff. • Similarly, in many areas, respondent expectations are spread across the spectrum with no clear “expected average” being identifiable. • Perceptions around acceptable waiting times for care may be a valuable variable for providers to consider when planning staffing rosters. • Education appears to be a relatively low priority based upon availability of education staff with over 50% of participants suggesting their organisation does not employ an educator at all. • While only 4% of participants suggested activity officers were not employed in their home at all, over 50% reported that no activities staff were rostered on weekends which could suggest that these tasks are added to the care staff role during these periods. Almost 90% of participants indicated they believed activity staff should be available on weekends.
  24. 24. Limitations of the Study • The study was conducted solely on an online business social media platform so therefore limited the breadth of potential respondents. • The participants were untargeted and unvetted, so in theory, a single participant could have responded multiple times. • While the study was conducted independently, there was no stopping particular interest groups from promoting the survey and thus skewing the results. • The study did not explore the employment of enrolled nurses. In NSW, Enrolled Nurse numbers have been traditionally very small (unlike other states such as Victoria) and these numbers appear to be shrinking as providers opt for certificate III and IV staff who do not have registration and scope of practice restrictions imposed by AHPRA (like Enrolled Nurses) and can practice without the direct supervision of a Registered Nurse.
  25. 25. Additional Comments Participants were asked if they would like to make any additional comments. While the vast majority did not, the responses that were recorded are provided here. • Average funding per day is under $200 prpd. The public hospitals are discharging residents to age care much sicker with acute care needs. They get funded $1200 a day, so level and quality of RNs are not funded or available to provide acute medical care. • Public holidays are reduced hrs for recreation staff • RN now not providing medications AIN trained staff with little or no skills in observation recognizing resident changes. Facilities reviewing ACFI before accepting new residents - Refused If ACFI low • Ratios are rubbish. Staff numbers should be sufficient to provide safe quality care for the resident cohort based on their actual care needs. That is what funding pays for and that should be what is on the ground. If care needs increase then staffing should increase and vice versa. There is no one size fits all solution. But I have seen what you have posted as your staffing levels and I am surprised you can stay afloat financially. But small homes that put all profits back into the home and don’t do acquisitions or refurbs can afford to do that. But that is not the real world, because progress costs profits. • Not enough respite beds 4 week minimum stay for respite • Staff training -staff who have English as 2nd language family children do parents on line learning- Not good enough • With lifestyle, please ensure there is 7 day a week service and not 9-4, but coverage until 6/7 pm to allow for evening programs and dementia specific programs, increased leisure and social engagement leads to increase interaction, fun, choice, better quality of life, choice, better sleep, and minimises falls, behaviours of concern, absconding.... • We need more RNs to meet the increasing acuity of the residents and more care staff to meet the new car standards and requirements of the residents. • Agency staff should be trained as a carer not a 3yr RN student with NO experience. Need better in- house supervision to ensure policies, procedures and care plans are being followed. • It takes the carers a long time to answer call bells to take my mother to the toilet. They always tell her she had to wait or they’re busy or short staffed. • This home I’m currently working in is better staffed than ones I’ve previously worked in. • Aged care needs staff to resident ratio to provide better care and the care they deserve. • Aged Care Hones are severely understaffed - there is never enough time to undertake basic duties - even in the better places - and this is one of them - residents deserve better quality care. • Every aged care hone needs a chaplain / pastoral carer. • Ask the Govt to fund the sector better and the staff will be afforded and delivered! • Our Aged deserve much better care than they are getting and where I work they are paying a premium.
  26. 26. • Numbers of staff are being reduced at an alarming rate, the accreditation agency should check rosters and numbers of staff at each visit. • Care staff numbers do not reflect residents needs and as a result residents go without or become frustrated and angry. Care staff get burnt out and their mental and physical health suffers. The industry needs better funding. • It’s not just the staff ratios. Its pay rates and casualisation. No full-time jobs and few part-time. Very hard on workers. • Staff are worked until they drop and when someone is off sick they are rarely replaced. • Being a lecturer in aged care, Cert 111 students often discuss issues working in the area including lack of staff, that they are requested to work more hours than their contracted hours. • I am approached by care managers advising of vacancies which they are unable to fill. Being in a rural area seems to make filling vacancies more difficult. • Education is covered by the clinical manager who oversees 3 separate sites (135 residents and as many staff). A full time physiotherapist is employed and they assess pain for massages, R/V post falls and attend mobility assessments. • I have since resigned from XXXXX as an EN due to unnecessary deaths, we had as many as 20 in a very short time. Most of these were overnight and were not dealt with appropriately. We had an RN grad who was very inexperienced and prompted and carried constantly by the ENs. The manager disregarded our concerns and stated that the only problem was the ENs bullying the RN!! The frustration was overwhelming and I still grieve over so many unnecessary deaths...I never once met or was spoken to by a single member of management ever! I haven’t as yet gone back to nursing as really miss it, I relish the role as an advocate and may try that route. • Caring is more than giving pills. Residents are not plants to feed, water and protect from the outside but that is what staffing to numbers to prevent disaster is. We need better measures of care. When facilities fail now they are failing in the most basic care. We need to raise our ‘acceptable ‘standards above maintaining bodily functions and really provide care of human beings. My local facility is good but staff are straining with new reductions. They can’t dispense liquid oral medication as it doesn’t come in a Webster pack- they carefully crush medication but it isn’t the same- gritty chocolate syrup that is bitter is not the same as liquid paracetamol and screwed up residents faces speak for the non-verbal. • Workload for carers is too heavy and is getting more demanding, new carers not trained properly (2 week placements is outrageous) the pay is the same as a check out girl! • More experienced carers leaving as it’s not caring anymore but hoping to get residents "ready" in time. Residents don't want to ring the bell as they know you are busy and will help themselves with often results in falls 🙁 been a carer for 30 plus years and it saddens me to see that there is not enough time to give proper care anymore and not enough good carers to employ. • At this time no education assist is available. • Aged care is def understaffed in my opinion on all levels. • The Facility I work for, has finally, after months of increased work load, and pushing by staff, employed 2x 4hr PCA’s to help alleviate the problems associated with the increasing needs of the current residents in situ. • The PCA’s are taking time off for stress related illnesses, and the facility is using more Agency as current staff are becoming fatigued. • The stresses of being a PCA are not just physical. They’re Emotional and Psychological too.
  27. 27. • As our homes become filled with High(er)-Care residents, the challenges escalate. • The educator has no education qualifications. The education is also the resident liaison selling beds and will drop education responsibilities if resident liaison takes priority. The entire set up is so disrespectful to nurses. • Also need Mandatory NUM for each 30+ bed home and Quality Manager part-time. • I have had my mother in respite for the first time ever. Over the 2 weeks she was there I think she had a shower once. The staff never came near her, made medication errors and the one main thing they needed to do was care for her skin due to the severe eczema that she gets and they didn't do this very well. I often could never find a staff member when I visited in the evenings. The tragic thing about this is the lack of respite beds for people like my Mum, so even though the place was JUST satisfactory I will probably have to use it again for respite because there is nowhere else nearby. • Many staff not adequately skilled in appropriate responses when addressing the needs of people with dementia. • Please help our residents achieve better care and happiness. • The time for ratios is now. • Carers have more and more roles placed on them as well as administration of care. e.g. serving meals, medication administration, cleaning.... • Staff levels are low and this needs to change. • Staffing levels need to be determined according to resident needs and not purely based on resident numbers. Funding needs to reflect the actual cost of providing care. The current funding model does not reflect the cost of delivering care or the extra staff numbers demanded by interested parties not prepared to pay. • Don't forget to factor in Enrolled Nurses in the skills mix ratios above. Also, the level of skill and knowledge (in my experience aged care nurses are often deskilled and this is a major contributor to poor outcomes for residents not just staff/resident ratios) • The registered staff employed are only new grads, English 2nd language. No experience. AINs large majority English 2nd language. Very little experience. Cert 3 that does not give the staff all required in aged care. No educators, management too busy with budgets, complaints, ACFI, assessments, accreditation to give any education or supervision. • Not always about ratios it is about skill mix, acuity levels, built environment etc • The communication skills of some of some of the care workers were very poor. Care workers are not registered with any peak organisation or regulatory body and when working as agency staff are serially unaccountable. • The whole industry needs an overhaul. Ratios should be mandated and spot checks should be carried out without prior notice. Homes where carers are expected to clean, cook and care for residents should not be allowed. There should be higher ratios for residents who suffer from dementia. • Watching my Mother pass recently in a Facility where staff had good intentions that were eroded into complacency has made me fearful of my pending geriatric treatment. And serious consideration of Assisted Suicide options. • Good to have a law for maximum number of residents for an RN to look after.
  28. 28. • If staff were allocated smaller ratios of residents to care for, the interactions between staff and residents would be more meaningful, personal, less like a Drive-Through, enable the build up of trust with both residents and their families who entrust staff, and allow true relationships to develop with residents. I am a firm believer that we can learn more from the elderly than what we could from almost any other sector of society. Such relationships are almost impossible to develop when the interactions are so rushed. • Staff ratios are a generic measure & the right ratio depends upon the Resident mix at the facility, as well as the support from all Stakeholders. We have so many brilliant RN’s, PCA’s, FM’s & support staff who put their heart & soul into caring for our Residents. • The media coverage regarding Aged Care sector has focused too much on the 1% of poor examples. • The industry funding model needs to be fair & sustainable. Encouraging investment in staff & facilities with reasonable ROI based upon the risks & scrutiny should be seen positively rather than with short sighted scepticism. • Rosters need to be regulated too much staff fatigue staff left to work short shifts and not compensated for extra work load pay is ridiculous. • This survey assumes a very institutional structure. I have visited many homes but I think Hammond Care have by far the best model in the cottage model. It is not normal to live with a registered nurse but timely access to good advice is important. Sadly, not all GPs or nurses have skills or interests in older people. • Average funding per day is under $200 prpd. The public hospitals are discharging residents to age care much sicker with acute care needs. They get funded $1200 a day, so level and quality of RNs are not funded or available to provide acute medical care. • 120 bed home. 1 RN each shift. Night duty 1 RN/5 PCA'S. Residents may have to wait more than 30 minutes for pain medication if RN busy. This is count clearly unacceptable. • Ratios may not necessarily equate to better care. I believe appropriate skill mix and better trained staff will assist our homes. • A lot is talked about ratio, in my view “ratio“ is subjective to this discussion. I say that because, complexity of residents, skill and knowledge base of staff largely determines the service delivery. Having an acceptable ratio or in that matter even is not the answer when you employ low skill and poor knowledge base staff. Having competent, effective and attenuative staff is the answer. Pay them well, engage with staff the same way you engage with clients and share the profits..... be it by monetary or recognition. Good luck. • Ratios are important for aged care. For too long have I seen poor outcomes that could have been avoided if we had more staffing. • More staff with better understanding of the comorbidities if old age. Motor Neuron disease mimics dementia in many ways and is often mistaken causing a lot if distress to my family member. Nurses and Aides need to remember that these are PEOPLE who had meaningful lives before HAVING to come into an aged care facility through no other choice. • After this survey can we do one on the regulation of care workers. Also you say the ANMF are running a campaign on this. They’ve been talking about it for years!! • Stop reducing staff numbers overnight. • No showers for Night duty staff as this is a safety issue.
  29. 29. • Have more experienced staff overnight as PCA, I will be asked to take casual as I have said I am only available to work Friday and Saturday night duty as I educate new PCA for the industry through the week and have no other available time To give to the organization, after 37 years in the industry I will be asked to leave or take another shift. • Minimum ratios should be 1 carer to 6 patients in the AM shift, 1 carer to 7 patients in the afternoon and 1 to 15 patients overnight with and RN in charge at all times. • Along with care training I would like to see care professionals obtain emotional intelligence and humanity training • We have 66 residents, the RN overseas all residents as well as having medication rounds and having a full task list to undertake. • The care workers hit the floor running and don’t stop. • Ratios do not equal quality care. Funding is limited and lifestyle should be the job of everyone. • Registered nurses on our morning and afternoon shifts are each supported by an enrolled nurse. • I will euthanize myself before subjecting myself to the horror that is aged care. I have worked in aged care for ten years and have had to leave as my conscience was making it unbearable and soul destroying. • Staffing must be linked to ACFI and acuity not just determined by number of residents. • I like being busy but sometimes I just can't get to people that need my help quickly enough because in with someone else that needs my help. • Mandatory staff ratios are essential to ensuring quality care, although that alone Will not dic existing care deficits. • The ratios need to be the same 7 days per week. RN should be in charge each shift and be onsite. • I don’t believe a set nurse resident ratio provides better care but I do believe more Registered Nurses are required to oversee good quality care. Hours per resident per day should be mandated according to ACFI classification. • Much depends on the level of care needed by clients as Nursing home as many clients who could live at home under a package care package. While no responses were changed, some provider names were removed so that individual providers were not identified.

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