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Poor staffing contributes to missed care in residential aged care

The recent announcement of a Royal Commission into aged care has brought issues of the staffing levels and skill mix of residential aged care facilities into focus.

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 to 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 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 to 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 multi-purpose 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 that 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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  1. I have own and operated Aged Care facilities for 22 years. I am a Division 1 nurse in Victoria. I strongly disagree with your assumption that missed care is due to poor staffing levels. You have based your opinion on perceptions of staff rather than actual rigorous scientific research. If you really want to find out, come to Victoria and compare the State run Aged Care facilities with staff ratios against for profit aged care facilities without ratios.
    Missed care is due to multiple reasons such as proper systems not in place, lack of supervision by the managers, staff skills(staff who have done short 3 months courses), culture of the organisation and continuing education program of the facility. Staff should be rostered according to the needs of the residents. Not to some formula. Needs of the residents fluctuate and staffing should be utilised accordingly. It is too simple to throw more staff and expect the quality of care to improve. Don’t forget either tax payer or the facility has to pay for staff been on duty when they are not needed.

    • I have to disagree strongly with Ms Desilva, from our experience with our mother and father, both in not-for-profit homes, generally believed to be 2 of the better homes in Adelaide. Mum died 7 years ago, and so I’ll focus on Dad, who is still alive at 95. When he went into the home, 4.5 years ago, there were 4 carers for about 20 residents, plus an RN and an EN. Then the carers got reduced to 3, and a year or so ago, to 2 and a bit – an indeterminate, and slightly variable “bit”. There are 6 residents who need full assistance with eating and drinking – and Dad, for one, is very slow – plus a number of other who need supervision. Yet there are only 3 staff on over the lunch period. How can they meet all those needs. We go in and feed Dad each lunch-time, and we have all had the experience of getting there 10 mins late to find the tray has gone back to the kitchen and be told, “John didn’t want much”. Knowing that he normally eats at least 90% of the 3 course meal, we know that this means that he was being fed too fast, or with a big spoon, or the meal was too hot or too cold, and he resisted. You only have to look at how many meals go back half-eaten to see that there are many residents who are not getting proper nourishment – no matter how many dieticians plan the meals. I could go on about toileting, positioning in the princess chair, but it is obvious that there are not enough carers to actually do the work, let alone interact in a friendly way with residents. All these carers have at least the Level 3 certificate, and nearly all of them are conscientious and caring. There are simply not enough of them.

  2. Great article and so glad a light is being shone on this area.
    Missed care seems to be an overlooked phenomenon in Australia across the healthcare spectrum.

  3. I currently manage a low care facility and in my experience both contributors above raise valid points. It must be remembered that not all facilities are the same, even although they work to the same accreditation standards, and a one size fits all approach to rectifying deficiencies is not the most suitable approach. The issues with some facilities may be a result of poor management practices, procedures not being followed, poor training etc. but as others have pointed out lower than satisfactory staffing numbers contribute to care issues, due to staff on the floor being time poor and too much being expected from too few. Pointing the finger at one or two causes is futile. There is no doubt that there are issues in our industry that need addressing, so let’s not scramble on to the defensive wagon but embrace the investigation. Let’s face it, if a facility is providing the level of service that is expected under the accreditation guidelines they have nothing to worry about.