Ominous shifts

A less-refined workforce is being asked to do more and more in aged care; experts see a bad mix. 

A report revealing the disease mix aged-care workers must treat has experts concerned that issues already bubbling around the nursing workforce in the sector will get worse.

The Patterns in Use of Aged Care: 2002–03 to 2010–11 report, released by the Australian Institute of Health and Welfare (AIHW), highlighted that those who accessed permanent residential aged-care services tended to have higher levels of care needs and greater activity limitations.

Professor Tracey McDonald, fellow of the Australian College of Nursing and RSL LifeCare Chair of Ageing at the Australian Catholic University, said more than 87 per cent of residents are classified as, and funded for, high and complex care needs. At the same time, she said, there is a continued push by business managers in the sector for substitution of RNs with unregistered care assistants.

“Clearly this is not a situation that can continue without having a significant negative impact on the quality of care for residents and increased risk to their safety,” McDonald said. “Care assistants are unable to provide the high level of professional care and supervision that residents with high and complex care needs require.”

Postdoctoral research fellow at Centre for Quality and Patient Safety Research at Deakin University, Dr Joan Ostaszkiewicz, added: “I don’t think we’ve grasped the significance of this major shift. We’re starting to feel it now but of course it’s going to increase. We need to be thinking of the best ways to guarantee quality of care of older people who are presenting with increasingly complex care needs.”

The Patterns of Use report held that the main condition contributing to a need for assistance for about one-fifth of the cohort was dementia. A further 6 per cent had dementia reported as a secondary diagnosis.

One-tenth had musculoskeletal disease as the main cause of care needs. “Cardiovascular problems were also common, and heart disease and CBV problems were each the main health condition for 8 per cent of the cohort,” the report held.

“One of the big issues is the need for the nursing profession to grapple with the fact that we are working alongside, and are responsible for, a workforce that is not nursing, and that we’re responsible overall for the quality they provide,” Ostaszkiewicz said. “It’s absolutely critical that nurses are aware of their scope of practice and their responsibilities around delegation.”

The Nursing and Midwifery Board of Australia has developed a set of principles termed “A national framework for the development of decision-making tools for nursing and midwifery practice” to assist RNs and registered midwives when they make decisions about nursing practice and whether to delegate activities to others.

Ideally, she said, the non-nursing workforce should be regulated to guarantee greater quality of care.

And the need for more staff is growing. McDonald said a larger nurse workforce is needed to meet increasing demand. She said, “With the removal of the dementia supplement for residents who have particularly florid behavioural disturbances comes a further reduction in funding of skilled nurses, who are the only personnel who have the skills and knowledge – and authority – to provide effective quality care.”

On top of this, the rise in use of aged-care services has been faster than population growth. AIHW spokeswoman Pamela Kinnear said this has largely been driven by the use of community-based services designed to help people live independently.

“For the older cohorts in particular, there is a trend towards people combining use of community-based care and respite care prior to entry into permanent residential aged care,” Kinnear said. “This would point to the importance of community-based nursing and the effective complementary use of respite services to enable continued community living where this is appropriate.”

The Patterns in Use report also revealed an increase in the use of aged-care services in the last year of life. “This would imply that nursing and similar professions may be dealing with cohorts with more concentrated needs, including requirements for palliative care,” Kinnear said.

Ostaszkiewicz said the report highlighted that nurses and non-nurses working in aged care need to have specialised knowledge and skills to provide care and to manage residents’ comorbidities – such as diabetes, cardiovascular disease, and musculoskeletal disorders – with confidence.

McDonald added that nurses need to understand the environments they are working in, particularly the drivers of financial management decisions surrounding staff mix compared with the case mix of residents in care.

“Nurses need to provide considered and evidence-based advice to aged-care providers on the risks and benefits of having registered nurses in sufficient numbers and in roles where they can provide nursing support for those who need it,” she explained.

She said the enduring trend of moving RNs into management roles has left essential basic clinical services spread thin and unable to meet demand.

“Nurses need to understand the situation they are in and to provide professional advice to employers about the risks to staff and residents of not having appropriate staffing as required under the Aged Care Act 1997,” she says.

To ensure there is a nursing workforce prepared to meet the demands of the changes to the sector, McDonald said, positive practice environments that support nursing excellence and provide high-quality services are needed.

“They enable and sustain a motivated, well-prepared nurse workforce [and] enable nurses to work within a nursing model of care and to their full scope of practice,” she said. “Such environments are necessary in aged care to attract and retain nurses.”

“The nurse workforce requires opportunities and support for professional development to inform and sustain professional motivation to undertake research and enhance practice development to increase our understanding of care needs, nursing practices and care outcomes,” she said.

Ostaszkiewicz said more education programs are needed to equip healthcare professionals so they can implement systematic approaches to the care of older people, as are partnerships between the aged-care sector and schools of nursing and midwifery within universities.

“We need the aged-care sector to be much more cognisant of the delivery of evidence-based and partnership-centred care and that is best achieved by nurses and allied health professionals] from the university and VET sectors being prepared to engage with the aged-care sector.

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