workforce
A job for the royal commission
The impact of poor staffing
levels and private-for-profit
ownership on quality of care.
By Julie Henderson
T
he announcement of a royal
commission into aged care has
brought into focus the staffing
levels and skill mix of residential aged
care facilities.
Demand for aged care services is
increasing due to the ageing of the
Baby Boomer population and post-war
migration, leading to concerns with the
costs of providing aged care services.
To address perceptions of rising costs,
the current federal government has
made changes to aged care funding and
legislation, making it easier for private-
for-profit groups to purchase and manage
residential aged care facilities.
The changes made include increased
user payments to facilities through the
reintroduction of a refundable deposit to
pay accommodation costs, the capacity
to charge for additional services, and
legislative changes to make it easier to
transfer ownership of aged care beds.
These changes, along with guaranteed
funding from the federal government
through ACFI payments, make aged care
attractive for investors.
At the same time, concerns have been
raised about having enough staff to
meet service demand. Currently, care
services in residential aged care are
provided by a combination of nursing
and care worker staff, with the balance
of staffing shifting towards care workers
in the last 10–15 years. Care workers
are cheaper to employ and provide
a means of achieving cost savings
and increasing returns to investors.
Cost savings can also be achieved
by employing fewer staff.
As a consequence, residents are
receiving fewer hours of care. In 2015,
residents in Australian residential aged
care facilities received 39.8 hours of direct
care/fortnight, which averaged up to 2.86
hours/resident per day.
A recent study which used activity
timings for the care tasks required for
residents with a range of diagnoses
determined that between 2.5 and 5 hours
of care were indicated, suggesting that
residents are experiencing shortfalls in the
number of hours of care they receive.
A team from Flinders University and
the University of South Australia recently
conducted a study of nurses’ and care
workers’ perceptions of the level of care
which was missed in residential aged care
and the reasons why care was missed. The
study, which was commissioned by the
ANMF, surveyed 3206 staff working in aged
care settings across Australia, including
aged care wards in public hospitals and
multipurpose services. Missed care for this
study was defined as required resident care
that is omitted (either in part or in whole)
or delayed due to multiple demands and
inadequate staffing and material resources,
and/or communication breakdown.
The central finding was that staff believed
that care was being missed in all facilities,
with higher levels of missed care reported
in facilities which are privately owned.
Unscheduled tasks, such as responding
to call bells and to toileting needs within
five minutes, were most likely to be missed,
although there were deficits in completing
all tasks.
When asked to indicate the reasons why
care was missed, staff in all facilities viewed
too few staff, the complexity of resident
needs, inadequate skill mix of nursing and
care work staff, and unbalanced resident
allocation as the greatest reasons for
missed care.
Government employees reported
significantly lower scores for 16 of the
27 items than staff employed in privately
owned facilities, with staff in private-for-
profit owned facilities rating 14 of the 27
items as being a greater cause of missed
care than staff in other settings. These
differences were most notable in relation
to access to resources.
Staff/resident ratios were also found to be
higher in privately owned facilities, meaning
each staff member was delivering care to
more residents and had less time with each
resident to complete care tasks. There is
also some evidence from responses to
open questions that enrolled nurses were
being replaced by care workers and of
employment of recently graduated registered
nurses over more experienced registered
nurses in private-for-profit facilities.
Given that people are being admitted to
residential aged care when they are frail
and more dependent on services than
previously, and that residential aged care
facilities are dealing with higher proportions
of residents with dementia, staff are dealing
with residents who have more complex
needs and greater need for nursing care.
At the moment, there are no mandated
staffing levels for residential aged care, with
the standards only stipulating that adequate
staffing be provided. This allows residential
aged care facilities to reduce running costs
through cutting staffing levels.
It may be timely, therefore, for the royal
commission to explore the impact of
private-for-profit ownership on quality of
care and to consider the establishment
of mandated staffing levels to ensure
resident safety. ■
Dr Julie Henderson is a research
associate at Flinders University where
she undertakes nursing and public
health research.
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