Submission to the Aged Care Workforce Taskforce’s Aged Care Workforce Strategy

Recommendation 1: That the Aged Care Workforce Strategy recognises the Australian Government’s central role in the operation of the aged care sector.

Recommendation 2: That the Australian Government introduce mandatory minimum staff-to-resident ratios for all direct care roles, including nursing, personal care and allied health staff.

Recommendation 3: That aged care providers be required to publish the staff-to-resident ratios they operate under via My Aged Care so that this information can be accessed by the public.

Recommendation 4: That mandatory staff-to-resident ratios also specify the number of care recipients an RN, EN and PCA/AIN can reasonably be expected to care for at one time and the level of supervision required to do so.

Recommendation 5: That residential aged care facilities looking after residents with high care needs should be required to have at least one Registered Nurse on site at all times.

Recommendation 6: That pay levels are increased for all types of aged care workers and incentives should be offered to attract workers to rural and regional facilities.

CPSA welcomes the opportunity to provide input to the Aged Care Workforce Taskforce’s development of an Aged Care Workforce Strategy. CPSA represents pensioners of all ages and low income retirees. As such, CPSA is interested in ensuring that the aged care system is able to deliver high quality care and support to all those who need it, regardless of their geographical location and their capacity to pay.

CPSA is concerned with the current availability of high quality, person-centred aged care, which maximises the autonomy and dignity of recipients. This submission focuses on how staff working conditions influence the quality of care they are able to deliver in residential aged care and subsequently the workforce provisions needed to ensure that older Australians receive high quality aged care in residential facilities. CPSA’s priorities are to ensure that all residential aged care facilities are required to have a Registered Nurse on duty at all times and to see the introduction of mandatory staff–to-resident ratios and staffing skill mixes.

Why does an aged care workforce strategy matter? What practical difference do you hope a strategy will make? How do you think a strategy can contribute to meeting future needs in aged care?

The aged care industry, particularly the residential sector, is responsible for ensuring safe and adequate care to some of the most vulnerable people in society. However, the volume of aged care abuse stories documented by the media, at inquiry hearings, in submissions and divulged by whistle blowers over the last year reflect a systemic failure of the industry’s capacity to fulfil this role. In light of an increasingly market based aged care system and the pressures of an ageing population, the importance of a workforce strategy that maps out a consistent and coordinated approach to the aged care workforce cannot be overstated.

The current lack of aged care workforce regulation suggests that the responsibility for the aged care workforce rests primarily in the hands of providers and that they must take the lead in developing their own workforce strategies. CPSA rejects this position and argues that the Australian Government is the only appropriate authority to take charge. Government stewardship in the area of the aged care workforce is required in order to ensure that the short to medium term financial pressures faced by aged care providers do not undermine the longer term sustainability of the sector as a whole and quality of care provided. Outsourcing leadership and strategic direction has had a disastrous effect on the quality of care available to older Australians, not least of which is because staff working conditions are intimately linked to the quality of care they are able to deliver to residents.

Without a coordinated strategy placing the Australian Government in a central role, our aged care system will not be able to make the adjustments necessary to meet growing demand. As the body overseeing funding, accreditation and regulation, the Australian Government retains control over the aged care sector. Accordingly, it is the only player with the authority and oversight necessary to drive the changes needed for the aged care sector to manage growing demand for high quality care. These changes cannot be left to the market, because the market for aged care is necessarily competitive and competitive conditions are not always conducive to the delivery of universal quality care.

That the Aged Care Workforce Strategy recognises the Australian Government’s central role in the operation of the aged care sector.

Tell us what is working well in the aged care workforce (across the industry, at provider or service level or through place-based initiatives) and where future opportunities lie.

Future opportunities for the aged care sector are discussed later in this submission.

Tell us what you see as the changes on the horizon that aged care needs to be ready for, and how you think the workforce strategy can contribute to meeting these future needs?

The aged care sector has experienced significant changes and will continue to in coming years. The Future of Australia’s aged care sector workforce report documented changes ranging from the ageing of the Australian population and the corresponding ageing of the workforce, the increased use of technology in service delivery, the increased complexity of health needs of individuals entering into aged care, and the shift in policy approaches to aged care.1 All these developments are placing significant pressure on the aged care workforce and need to be considered in the strategy.

To ensure that the growth in demand for aged care, potential shortages of the workforce and increased complexity of residents’ needs don’t negatively impact the quality of care received by aged care recipients, the strategy must respond to the issue of inadequate staffing. Due to the scale of this issue, CPSA is of the view that a number of regulations around staffing in residential aged care are necessary to address future conditions. More detail about this recommendation is provided below.

What areas of knowledge, skills and capability need to be strengthened within the aged care workforce?

CPSA doesn’t have anything to contribute on this topic.

What do you think is needed to improve and better equip the workforce to meet individual needs and expectations? What is needed for leadership, mindset and accountability to innovate and extend new ways of working tailored to the needs of older people who use aged care services, their families, carers and communities?

The Australian Government’s ageing in place policy has meant that people have increasingly been able to fulfil their desire to live independently for longer. This also means that those who enter residential aged care have increasingly complex and acute care needs. In 2004-05, 62.9% of people in residential care were classified as having high care needs2 and in 2016 this had increased to 92% of residents.3 Providing quality care for people with complex needs takes more time and a broader range of skilled professionals.

Aged care workers have repeatedly reported that they are not able to spend the appropriate amount of time delivering quality care to residents. A study found that residents living in Australian nursing homes received an average of 2 hours and 50 minutes of direct care per day, but that at a minimum they required at least 4 hours and 18 minutes of care per day.4 A discussion paper released by the Department of Health estimated that the prevalence of pressure sores among aged care residents was between 26% and 42%.5 Additionally a recent study estimated that there has been a 400% increase in premature deaths among nursing home residents since 2000.6 These figures are completely unacceptable and represent some of the ways that residential aged care is systemically failing to meet the needs of residents. This clearly highlights the need for a national policy framework to equip the workforce with adequate staffing levels and correct skill mixes to improve the quality of care received by residents and meet their increasingly complex needs.

CPSA notes that constituents are almost always shocked to learn that there are no mandatory staff-to-resident ratios in residential aged care. Adequate staffing levels are crucial to improving care and quality of life outcomes for residents in nursing homes. But because staffing is by far the greatest cost for aged care providers, without mandated ratios they have little incentive to ensure that staffing levels are adequate. Providers instead opt to maintain a flexible workforce so that staff can be hired and fired according to competitive market conditions. The accreditation system only stipulates that homes have a ‘sufficient’ number of staff on duty to deliver care; however the assessment of ‘sufficient’ staffing levels is not directly linked to the care needs of recipients.

In practice, this means workers in the aged care sector are under increasing pressure to deliver a higher level of care to sicker and sicker residents despite dwindling resources and reduced supervision. Care work is incredibly labour intensive and workers deal with some of the most vulnerable people and regardless of skill or experience. In the end staff can only provide high quality care to a few recipients at any one time. The pressure placed on individual aged care workers to meet the needs of residents is essentially made impossible. To ensure the needs of aged care recipients are met and to ensure the sustainability of the workforce, the Australian Government must mandate minimum staff-to-resident ratio for residential aged care. Staff-to-resident ratios must also apply on overnight and weekend shifts as well as on shifts during normal business hours, as the care needs of care recipients do not change according to the time of day or availability of staff.

Many aged care industry bodies have rejected the call for minimum staff-to-resident ratios on the basis that ratios are a blunt instrument and that they may stifle innovation. CPSA anticipates that these minimum staffing ratios would be flexible, varying with reference to the care needs of residents. Given that ratios are intended as a basic minimum requirement to ensure the safety of residents, it is difficult to see how they could be viewed as an impediment to innovation. It is important that the workforce strategy addresses the adequacy of provider-appointed staffing levels and staff satisfaction as it directly relates to the delivery of quality care.

That the Australian Government introduce mandatory minimum staff-to-resident ratios for all direct care roles, including nursing, personal care and allied health staff.

CPSA understands that implementing mandatory staff-to-resident ratios across the aged care sector will be a significant undertaking that will require careful planning and extensive consultation with clinical experts. Given the importance of staffing models in the delivery of safe care that meets the needs of residents, residential aged care providers must be more transparent about the staffing levels they operate under in the meantime. Currently, there is no way of knowing how each facility is staffed and providers have no obligation to inform prospective residents of actual staffing levels. Transparency on the part of aged care providers is crucial if consumer directed care is to function as intended.

CPSA has heard from many residents and families who have been promised 24 hour access to RNs, only to find that RNs are only rostered on during business hours. In order to address the issue of insufficient staffing and to drive improvements across the residential aged care sector, providers should be required to publish the staffing ratios they operate under via My Aged Care. Given that current staffing levels fall well below community expectations, increasing transparency in and of itself is likely to drive at least some improvement in staffing levels.

That aged care providers be required to publish the staff-to-resident ratios they operate under via My Aged Care so that this information can be accessed by the public.

 

It is not only critical that residential aged care facilities not only employ a sufficient number of workers to care for residents, but that there are sufficient mixes of staff with the qualifications necessary to deliver this care. Another strategy used by aged care providers to manage staffing costs is to adjust the skill mix so that Personal Care Attendants (PCAs) make up a greater proportion of the workforce relative to Enrolled Nurses (ENs), Registered Nurses (RNs) and Allied Health Professionals (AHPs). This practice of deskilling the aged care workforce is widespread. The National Aged Care Workforce Census and Survey (NACWCS) first conducted in 2003 showed that RNs comprised 21% of the workforce, ENs 13%, PCAs 58.5% and AHPs 7.4%. In 2017, RNs comprised just 15% of the residential direct aged care workforce, ENs 10% and AHPs 4.6%, while PCAs grew to 70% of the workforce.7

While the majority of PCAs do hold a tertiary level qualification8, their job is to provide basic personal care and support. RNs as well as ENs practicing within the scope of their training are charged with providing specialised clinical and medical care to aged care recipients. CPSA is concerned about the impact of deskilling of the aged care workforce on the quality of care being delivered. Staffing ratios must also specify the level of supervision required by RNs, ENs and PCAs on each shift, based on the range of tasks each is qualified to carry out and they must be based on the level of care required by care recipients.

CPSA believes it is essential that staff are also adequately supervised and supported to deliver high quality care. Supervision is also necessary to ensure that the few uncommitted workers who do enter the aged care sector for the wrong reasons are quickly identified and removed. Staffing ratios also need to account for the additional supervision and support required by new staff members.

That mandatory staff-to-resident ratios also specify the number of care recipients an RN, EN and PCA/AIN can reasonably be expected to care for at one time and the level of supervision required to do so.

In the aged care sector, RNs perform a central role in coordinating and managing each care recipient’s care plan. Their extensive training and expertise in the management of patients with complex care needs means they can identify and treat issues proactively. This is crucial in the aged care sector, where, unlike in hospitals, there is generally no immediate access to a doctor and where a care recipient’s condition can deteriorate rapidly with little warning. RNs also perform an important leadership and supervisory role, providing care staff with advice to support the delivery of care and acting as a point of escalation when issues arise. Around the clock nursing care is increasingly important given that people are staying at home for longer, meaning that by the time they enter residential aged care their care needs are higher and more complex.

CPSA is concerned about the potential links between the rise in premature deaths of nursing home residents, the rising acuity of residents in terms of their care needs and the declining number of RNs providing direct care. The number of RNs working in residential aged care has declined significantly as a proportion of the overall residential aged care workforce. This decline in RN numbers is even more concerning given that the majority of these RNs now spend less than one third of their time providing direct care.9

CPSA is concerned that without an RN on duty at all times, residents with high care needs do not have access to the level of care they have been assessed as requiring. If there is no RN on duty to provide the care required, then the only option is to transfer the resident to a hospital emergency department. Residential aged care providers who accept residents with high care needs receive funding to provide a high level of care, components of which can only be delivered by an RN. Accordingly, CPSA is of the view that all residential aged care facilities looking after residents with high care needs should be required to have at least one RN on site at all times.

That residential aged care facilities looking after residents with high care needs should be required to have at least one Registered Nurse on site at all times.

What do you think are the key factors the Taskforce needs to consider to attract and retain staff?

CPSA rejects the claim that staff shortages in the aged care sector come about because the work is inherently unattractive or undesirable. The recent NACWCS shows that aged care workers report high levels of job satisfaction in all areas except the time available to them to care for residents and pay.10 Thus, increasing the pay of all types of aged care workers is crucial to attracting more workers to the sector and offering incentives could help with attracting them to locations experiencing staff shortages, including rural and regional facilities.

Subsequent studies have highlighted job satisfaction as the most significant factor influencing worker retention11 and that job satisfaction is maximised when workers are able to provide what they understand to be high quality care.12 The NACWCS results indicate that although aged care workers view themselves as sufficiently skilled to do their job, few feel they have adequate time to spend with each care recipient and frequently report feeling under pressure at work, both of which undermine their capacity to deliver good care. This suggests that issues around the retention of aged care workers do not stem from the work itself being of poor quality, but rather from the conditions under which the work is carried out. Thus efforts to promote the attraction of new workers to the sector and retention of existing workers should be focused on ensuring that working conditions support staff to deliver high quality care.

The delivery of high quality care requires that aged care workers have sufficient time to spend with each care recipient in order to carry out the tasks necessary to fulfil their needs.13 Because care work is inherently labour intensive, any attempt to reduce the amount of time spent caring, or increasing the number of people being cared for by one worker in a given timeframe, will reduce the quality of care being provided. The sorts of workplace provisions that allow aged care workers sufficient time, continuity and autonomy are generally determined by the aged care providers that employ them. However, the operating budgets of these providers and subsequently the workplace provisions they can afford, are largely shaped by the Australian Government through the funding and accreditation process. As stated above CPSA recommends that the Australian Government mandate staffing ratios and skill mixes for the residential sector.

That pay levels are increased for all types of aged care workers and incentives should be offered to attract workers to rural and regional facilities.

What should aged care providers consider with workforce planning?

Issues about workforce size and structure, mix of skill occupations and resident needs are discussed above.