The staffing crisis in aged care and some possible solutions

Residents are dying as increasing numbers of aged care residents contract Covid Omicron

2 years on from the onset of the Covid pandemic residents are dying in their hundreds as announced in the daily news with deaths occurring in all east coast states, in remote first nations communities and sporadic outbreaks in Western Australia, South Australia, and the Northern Territory. Over January 2022 there were more deaths in Aged Care than for the whole of 2020-21. For all the lockdowns, isolation, and reported hundreds of millions of dollars spent on the personal protective equipment (PPE) national stockpile the outbreaks continue to spread.

Aged care is once again front-page news with hundreds of electronic media and current affairs hours devoted to the causes. Thousands of words examining blame, omissions, and failures are dissected in print and social media. Despite the unofficial Federal Election campaign openings via National press Club addresses by Anthony Albanese last week and PM Scott Morrison today there remains a reluctance to examine root and branch cause; workforce, workforce, and workforce issues.

The aged care workforce has been deskilled and attrition rates are rising despite the predicted demographic needs

Aged Care has evolved as a federal government responsibility over time since the birth of the Australian federation. Acute healthcare is mainly delivered by the States and Territories with some community services delivered by local government.

Australia did not have a national institute of Demographic Studies until 1974. By the mid-1990’s the then Liberal government recognised that the Baby Boomer generation, those born after WW2, were projected to live longer than previous cohorts and would require a greater expenditure of gross national product (GNP) to support their care in old age. It was decided by Cabinet that the formulae for funding should change to a privatisation model with an accommodation bond required of care recipients via a means test and augmented by monthly fees to supplement federally funded basic fees.

Private investor companies were encouraged to invest in modern buildings to provide for increasing residential care demand. Market forces and competition were promoted as being the forces that would provide high standards of care delivery. The government resolved to take a hands-off approach with infrequent inspections of care standards to allow providers to develop business models which allowed efficiency and productivity gains to increase profits.

The result was that the cost of skilled staffing was the first to be trimmed in an industry that is labour intensive. When the 1997 Aged Care Act was enacted Registered Nurses made up some 21% of the workforce, Enrolled nurses 29% of the workforce while unregistered personal care workers some 50%. Care recipients were overall younger, and fewer were needing high care. With the introduction of “ageing in place” longer-term residents increasingly required more care which was at times not reflected in the Aged Care Funding Instrument (ACFI).

By 2018 the average admission age of males was 82+ years and females 85+ years. As age at admission increased so did the care needs, co-morbidities including cognitive decline and dementia incidence which is estimated at some 68% plus. In the interim, the workforce composition had changed to 11% RN’s, 17 % EN’s, and up to 70% carer staff. Of these many were from non-English speaking backgrounds with poor understanding and health literacy. 29% had no formal training while others had only very basic Certificate 3 personal care training.

The 2018 Aged Care Workforce Study showed that poor job satisfaction, heavy workloads and lack of workplace support had resulted in a 28% pa staff attrition rate.

Registered nurses’ pay and career structure awards had not kept up with awards in the Primary care, private acute, and public hospital sector so as older nurses retired it became increasingly difficult to fill the fewer advertised positions. Similarly, enrolled nurses gravitated to the acute sector so became increasingly difficult to recruit and retain.

Nurses are required to be nationally registered by AHPRA, are required to show evidence of ongoing education and competency, and are required to have personal indemnity insurance against possible malpractice. Despite nursing professional organisations and unions lobbying to have care workers similarly registered, industry lobbying to the federal government produced only a rebranding of aged care and insistence that “residential care” did not require professional training.

Federal Minister for Aged Care Services Bronwyn Bishop warned Cabinet that recognising the care workforce as a “third level of nursing” would be a major on-cost which would discourage private providers from investing and thus modernising the sector. Her successor, liberal aged care minister, Christopher Pyne completed the rebranding of aged care in the public mind by insisting in 2006 that residential care facilities were the resident’s “home” and therefore there was no need to have qualified nurses present to deliver care and assessments 24 hours a day. 

The fact that increasingly older residents died within weeks to months of admission seemed totally irrelevant. As one lone backbencher is recorded in Hansard as saying in 1997 “One would think Nursing Homes have disappeared from the face of the earth”

By 2010 a comprehensive report produced by major non-profit provider Catholic Care found that 63% of residents died in aged care within 6 months of admission. Such persons were either precipitously transferred to regional hospitals when there was a sudden deterioration in their health status or were offered little in the way of end-of-life care because of a lack of knowledge by facility staff. Few received optimal palliative care unless fortunate enough to be transferred to a major hospital with dedicated palliative care beds. Referrals to community palliative care in-reach services were a rare occurrence.

The 2020 Covid pandemic created havoc in residential Aged Care as evidenced by initial outbreaks in NSW and Victorian private aged care homes.

Staff who coped poorly with outbreaks of gastroenteritis and influenza were caught totally unschooled and unprepared for the killer Covid-19 pandemic for which there was no vaccination, no treatment, and no prevention except disciplined use of social distancing, isolation, PPE, and stringent infection control.

When Senator Colbeck’s department contacted the 2600 odd residential care facilities in Australia, 93% stated they had infection control policies in place and were prepared for outbreaks. The reality was that few had supplies of masks, let alone fitted masks, protective gowns, and gloves. Infection control principles were not understood, therefore unable to be put into practice. Community suppliers sent their PPE on private jets to China while aged care facilities were unable to get supplies privately or from the national stockpile which was being sent to acute care facilities.

State health departments stepped in to enforce isolation, furlough workers who had been in contact with infectious patients, and called in government contractors who were to supply replacement staff trained in infection control. These replacement staff had no understanding of aged care practices or experience of working with frail aged and dementia patients. Many refused to come back for more than one or two shifts. Patients died of dehydration, neglect, lack of medication and care as well as Covid infection.

2 years on many aged care residential facilities cannot fill shifts on a daily basis. The burden placed on those who do arrive for their shift is immense. Carer staff often on zero-hours contracts are working 12-hour or longer shifts just to provide basic care. Dressings are left unattended, medications are administered late. Carers are reporting that many are resigning or considering resigning when they find alternate employment.

Even the Royal Commission Report stopped short of recommendations that mandated having Registered Nurses onsite 24 hours a day. Enrolled nurses have left to work in Covid testing stations, RN’s have found well-paid positions in primary care, hospitals, and vaccination centres.

There are insufficient nursing staff to take care of pain management, diabetes management, and often complex symptom management of palliative care patients.

The solutions

Fair wages and funding

• Registered Nurses: Wage parity with nurses of similar experience and training working in acute care, primary care, and public hospitals.
• Immediate federal Government support for the Wage Case before Fair Work Australia for a 20% increase in carer wages which are currently only $22.00 per hour.
• Fund Allied health staff and recreation therapists to improve quality of residents lives.

Career pathways and training

• Establish a career structure in aged care to train new leaders to mentor nursing and carer teams in aged care. Subsidise or waive education fees for the advanced certificate or Masters degree studies for a five-year period while the aged care system is rebuilt.
• Support/expand the 10-year nurse practitioner program to increase availability of expert nursing knowledge especially in rural and remote areas.
• Establish or re-establish the Advanced Certificate in Palliative Care to provide expertise in end-of-life and palliative care in residential and community care.
• Offer advanced training or conversion to Bachelor of Science in Nursing (BSN) nursing degrees to enrolled nurses.
• Work with Nursing professional groups and unions to redesign workplace practices and provide training in patient handling, occupational health and safety, infection control.
• Expand TAFE Enrolled Nurse Diploma courses. Such training courses already have qualified nurse teaching staff, training laboratories and contacts with hospital and care facilities to provide course practicum.
• Establish a national register of carers with practitioner body AHPRA with harmonised, nationwide primary registration criteria and yearly registration requiring ongoing retraining in infection control. OHS, Manual handling, dementia care, behaviour modification training and basic palliative care awareness.
• Establish a career structure for carer staff with incremental pay scales to reflect years of experience and ongoing training in dementia care, palliative care and mental health studies.
• Establish scholarships for experienced personal care staff to study nursing.
• Liaise with professional bodies such as the College of Nursing Australia to develop gerontology nursing courses and other Aged Care Specific training modules.
• Increase funding to eminent research universities such as the University of Tasmania Wicking Centre (UTAS) to provide widely available short courses for carers and aged care nurses to improve their knowledge and practice of dementia care and cognitive impairment. As these courses already exist they could be rapidly increased based on current courses and utilising current staffing.
• Fund University nursing schools to set up training units in gerontology and make a practicum rotation to accredited aged care residential facilities and community care services a compulsory part of BSN training to give trainee nurses exposure to working in aged care.
• Fund palliative care as a basic unit of training in the BSN (baccalaureate of nursing degree) for registered nurses in training.

Many of these programs could be established in 12-18 months and would go a long way to stop staff attrition, encourage recruitment and reward hard-working existing dedicated staff.

Back-up the workforce

• Establish a publicly funded, American style “travelling nurse” corps to to provide annual leave and contracted term staff replacement for rural and remote aged care services.
• Establish state-based surge workforce units to provide infection control back-up staff where there are Covid or other infectious disease outbreaks. Such staff could be utilised to train facility staff on infection control and prevention. Similar units could be used for dementia support and behavioural modification training.
• Employ more administration staff to free RN’s and care staff from administration and IT tasks.

The current reform process is too provider and industry-centric

Post Royal Commission the federal government has commenced a 5 year, 5 Pillars Plan of Reform which is to culminate in a New Aged Care Act in 2023. The Aged Care Quality Standards have been revised and work is in progress to assist providers to embed new reporting systems to improve care standards and adherence to best practice. In 2021, the first year post-Royal Commission, a new Serious Incident Response Scheme has been implemented to monitor the incidence of assault, neglect, sexual assault, and inappropriate restraint of care recipients.

Many members of the public, stakeholders, elder care recipients, their significant others, and eldercare activists fear that the current reform process is too provider and industry-centric.

Although the federal health department has some 70 teams of public servants and consultant groups working on the 5 Pillars Reforms the department and aged care ministry have been slow to set up the community consultant groups recommended by the Royal Commission’s final report.

Both the Council of Elders and The National Advisory Council were selected a full 6 months after the recommended date of appointment which was 1^st July 2021.

The National Advisory Council was finally appointed in November 2021 and The Council of Elders was announced on 23rd December 2021. This leaves the community observer to wonder how much weight the input from these bodies will have on reform processes being driven by economic considerations and budgetary constraints.

Let us hope that greater public awareness and the scrutiny of an election year concentrates the resolve of all concerned.