May 23, 2019

What Is The Appropriate Staffing Level For An Aged Care Facility?

The aged care industry in Australia was definitely not built on the back of clear definitions.

Words like ‘appropriate’ and ‘care’ are extremely broad by themselves, and the term ‘appropriate care’ is almost indefinable without a series of examples and vague assumptions.

While there is absolutely no doubt that the vast majority of aged care workers do their best to provide for their residents, there is also no denying that a significant portion of staff feels overworked and unable to do their job to the best of their abilities due to time constraints.

The Royal Commission has given Australian’s a chance to voice their opinion regarding potential solutions for some of the issues that the industry currently faces, and it’s fair to say that pretty much everyone (except the aged care providers themselves) feels that a current lack of staffing is the biggest issue.

Recently, a number of unfortunate Australian families received a letter from the Department of Health stating that a certain Victorian aged care facility had been sanctioned by the Aged Care Quality and Safety Commission; and that this facility would need to provide an ‘appropriate level of staff’ to ensure that care was meeting Accreditation Standards.

But what is an appropriate level of staff for an aged care facility?

Research that was undertaken by the Australian Nursing and Midwifery Federation (ANMF) shows that the current aged care resident in Australia receives roughly 2.5 hours of care per day and the staffing mix is usually comprised of 70% Personal Care Workers and 15% of both Registered Nurses and Enrolled Nurses.

But according to some, this is simply not good enough.

The ANMF’s research has shown that the average individual living in residential aged care needs 4.3 hours of care per day – which is close to double the amount of care that the average resident currently receives and that the ideal mix of staff for a residential aged care facility is as follows:

  • 30% Registered Nurses
  • 20% Enrolled Nurses
  • 70% Personal Care Workers

That 4.3 hours of care per day equates to approximate ratio’s of:

  • AM shift – in charge RN plus 5-6 EN/PCAs (mathematically it’s about 5.5 – so enables 5 on some days and six on others)
  • PM Shift – in-charge plus five 5-6 EN/PCAs (as above)
  • ND shift – 8 staff (inclusive of in-charge)

Paul Gilbert, Assistant Secretary of the Victorian branch of the ANMF (VB) shared his thoughts with HelloCare on the ramifications of current staffing levels and the need for regulation.

In 2017 BUPA made 23 registered nurses redundant. At the time, Bupa employed 53 Care Managers and 25 Clinical Managers across its 26 aged care facilities in Victoria. It made the decision to abolish those positions, and appoint 55 Clinical Care Managers,” said Paul.

“Interestingly, the result of this restructure would be that 23 existing RN Care Managers and Clinical Managers positions would be made redundant, and since then they have featured strongly in adverse reports, and in many cases have at least temporarily put additional RNs back into the homes in order to avoid ongoing sanction.”

“Staffing levels and skill mix need to be regulated, we have experienced increasing complexity of resident care needs since staffing obligations were abolished in 1997, with a corresponding decrease in care hours and skill mix.”

Whether you agree with the ANMF’s ideal staffing mix and individual care requirements or not, they are actually one of the few parties in the aged care industry that seem to have any sort of an answer to what appropriate staffing levels could be – but they are far from being the only party with an opinion on the matter in general.

Dr. Rodney Jilek has spent a lifetime working within residential aged care facilities and advising aged care providers on how to improve their processes, and he was kind enough to share his thoughts regarding appropriate staffing levels to HelloCare.

“The difficult thing about staff ratios, in general, is that you have to take into consideration- the residents that you have and their specific needs, the building design, the equipment that you have, the technology that you have, and of course the skills of the staff,” said Dr. Jilek.

“The government will probably introduce a mandated staffing ratio but they will make it so low that it will be meaningless, because otherwise, everyone will come out with their excuses like ‘we are in the country, we can’t get any registered nurses’ or ‘we can’t afford it because of this or that reason’ etc.”

“The fact that you can’t simply walk into a facility and instantly know how many staff are needed to meet the needs of every individual makes staffing a very grey area.”

“NSW already has a mandated staff ratio for registered nurses that states that all aged care facilities must have at least one registered nurse 24 hours per day – and this can be appropriate if you run a 20-bed home, but it can be completely inappropriate if you run a 100-bed home, but the 100 bed facility can still claim to meet standards under that blanket ratio.”

Recent negativity has seen those governing the aged care industry take a much more rigid approach in the way that they assess aged care environments and also in what they deem to be appropriate care, but the fact that they are unable to define ratios or staffing mixes has meant that many providers are now playing catch-up and having to deal with the ramifications of not
asking themselves the tough questions.

Left to their own devices, aged care providers have shown that they will not provide appropriate staffing levels, and the responsible Department cannot tell them what appropriate staffing levels are, just that they must have them,” said Paul Gilbert.

Dr. Jilek was also critical of the lack of clarity regarding staff ratios and mixes from the government and the Safety Commission.

“The agency never even used to be pick-up ‘lack of staffing as an issue because it’s so grey of an area, and it’s good that their starting to actually pick that up but the problem is that their having to rely on failures within an aged care facility to let them know that there’s not enough staff,” said Dr. Jilek.

“The sad reality of aged care at the moment is that everything is reactive, there are not enough providers that are being proactive about this stuff and realistically asking themselves if they have enough staff to provide good care, or whether they are expecting their current staff to go beyond the scope of what’s actually reasonable.”

“How many more people will have to suffer before someone says ‘Hey, you know maybe having one registered nurse for 100 people is not appropriate?”

While Dr. Jilek did not offer any thoughts on his personal idea of the ideal staffing mix and ratio, he did share his thoughts on the ANMF’s proposed numbers as well as the ramifications for providers who provide residents with an increased amount of care-time per day.

“They’re not far out (ANMF), but they’re overreaching and these demands are a best-case scenario. A residents hours of care per-day needs to be an amount somewhere between the current standard and what the ANMF is asking. And even if that is the right number, the next question is, is that affordable?” said Dr. Jilek.

“The homes that I’m usually involved with, sit at around 3.5 hours of care per person per day, which is roughly halfway between current figures and the ANMF figure, and you can do a consistent and reasonable job of providing care with that.”

“Companies that do hover around the 3.5 hours a day aren’t making much money though, which is the flipside to that, but sometimes you have to weigh up if you would rather sleep well at night, or you want to make truckloads of money.”

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  1. As per Professor Joseph Ibrahim (see attached podcast) ratios alone will not resolve the current crisis. We need nursing and medical staff who have post graduate training in gerontology and care staff who have additional training in how to care for the older person. The other missing element is appropriate pay! Every current regulation governing aged care is vague and open to interpretation.

    1. Kerrin I agree ratios will not fix the problem. More investment in time and money from the Commonwealth is very much needed. As with qualifications, many of us having been fighting with AHPRA to have gerontological nurses recognised as a specialty area but with no luck. We have been fighting with the universities to legimise aged care education rather than ‘fitting it into the curriculum where they can.

  2. It’s easy to spruke like Dr Jilek but aged care is actually a business that has obligations to its residents, staff and owners.
    To say “can you sleep with yourself” because you need to make a profit is absolutely ignorant and offensive!
    Every business has an acceptable ROI but clowns like this seem to think that this particular business type doesn’t matter. Clearly the Government agrees and refuses to fund appropriately which will see the present scenario that a few are unhappy with deteriorate further. There will be further job cuts in the industry and that will simply be as a result of continuing gross underfunding.

    When outfits like the ANF suggest staffing levels they should cost same and tell the government. Residential care operations have historically staffed at a cost if around 66% of Government funding, at this stage the cost is closer to 85% and homes are running at a loss. Do you not get it??
    It’s absolutely pointless to bang on at operations as they are struggling to survive, there is no way staffing levels will do anything but go down unless a massive injection of money is forthcoming.

    The reason that RN positions are being dropped in favour of Clinical Management is simply due to the amount of paper work required to be compliant! The actual care component of an RN can be in many cases be legally undertaken by an AIN, most medications come in a blister pack, doctors give directions, and the Clinical manager is called off their computer to address issues out of the norm.
    Question.. How many facilities (like suggested) have one RN to a hundred residents? Is that at night when all are asleep? Is that a hostel low care establishment? What is the category mix of the residents and what is the other staffing levels?
    It’s not helpful for these questions to be ignored and dramatised simply to get your name in print and I keep asking this question.. What is an appropriate ROI on a a specialised industry like ours? “pubs and motels etc that deliver insignificant skills return 19-20%, surely an industry with such emotional and complex care obligations should be at 25% ROI so why do some have such high expectations from businesses running at a loss?
    It’s just stupid.

    1. If most aged care facility claimed to be not for profit then why are you asking for 20% profit? From what i can see from you is that money is more important than elderly’s quality of life. And if you work at night, you will know most of the falls happens at night and there are large amount of aged care residents suffer from insomnia, incontinence and pain. Its because of people like you only cares about money that aged care problems have been ignored for decades. Aged care nursing has the highest turnover rate due to poor working environment, little support from management and low pay. Not everyone can afford 1:1 home care and we will all get old one day. And imagine this will be our future life make me feel sick.

  3. Amazing isn’t it? Even Labor never mentioned Aged Care funding of any sort before the election. The “Untouchables.” I work nights and have stayed back half an hour every day and sometimes and often an hour! I have suggested to management that if they would like to agree on paying me just half an hour more a day, but no body has ever responded! It is evident that I finish at these times from my charting and Progress Notes but nobody cares. I will not go home if someone is incontinent and needs a shower 5 minutes before my “official time” of logging off and then I begin/finish my computer work. I’m looking out for my dear Dementia residents but who is looking out for me and so many other in the industry. Shame on everyone involved in the Aged Care Industry and those not wanting to be involved.

    1. Kelly
      All these people who have an ‘opinion’ should spend some time in an aged care facility actually doing the work of a carer or at least shadowing them for some shifts.
      My wife is an aged care worker doing night duty and what she has to physically do and endure, e.g. clean up residents and their beds full of excrement while being verbally abused, physically abused and being spat in the face while dealing with disgusting foul smelling excrement beggars belief.
      Other than the work she & fellow carers endure, the lack of cares mean residents have to wait for attendance after they call for it. The the resident complains to management & the carer gets hauled over the coals for it and are not interested in the reason the resident was not attended to immediately was because they were already attending to another resident with, at times, many other residents waiting as well. So the resident does not get the care required (and they are paying for), the staff are over worked and stressed and get reprimands. No winners here at all.
      Meanwhile, the accountants and management making the staffing & resource determinations are safely tucked away in their warm beds asleep. And getting paid substantially more than the carers on the front line dealing with excrement covered, bad tempered, demented and often aggressive residents.
      All those with an uninformed opinion should remember that they too may one day end up in an aged care facility and get the level (lack of) they consider as currently appropriate and adequate.

      If no aged care worker worked for 24 hours and left management and their facilities to their own devices i am certain the reality of the need for carers would crystallise.

      Society should value and honor individuals like yourself and pay you substantially more than you currently get. Thank you.

  4. Totally agree with Anton. In short, the entire matter is too complicated to cover in a few lines, but: show us the money. The outcome for every care recipient even 10 years ago was better than it can be now. As a provider we would be happy to have mandated ratios, increased numbers of RNs and ENs, increased GP hours/visits, more and improved mandatory education – add anything to the wish list, but it all comes at a cost and who is going to pay? The ANMF? And that statement is not about profits or ROI. Five deficits from six years. The current Government allocated an additional $320m to residential care for payment between 20/03/2019 and 30/06/2019, then what, full stop! That is an acknowledgement that additional funds are needed and costs have increased. BUT – no commitment moving forward – didn’t get a mention in the election. Funds get thrown in all directions except direct care.

  5. Anton Hutchinson, I have heard Dr Jilek speak a number of times on the struggles of aged care providers given the limited funding that is available and I know he has worked for many years trying to provide care with the same limited resources as you describe. He is also a supporter of for profit providers and understands the need for a return on investment. He works closely with several, including my organisation, to assist us to find a balance. When he talks about being able to sleep at night, he usually refers to his own struggles of having to balance the money available with his desire to provide high quality care and keep his residents and staff safe and I think you may have taken this statement out of context. I do not think he, or anyone else is suggesting that as a business you shouldn’t be able to make a profit although I am not sure 25% would pass the pub test in a human services sector. Calling people clowns and ignorant just because they express an opinion that does not fit with yours is not helpful either. We need to be respectful of others thoughts and opinions and accept that maybe they have different experiences to us.I know I have had to look outside my organisation at what is happening more broadly so I can adapt and adjust. My organisation is better for listening to others.

    1. Thanks Stephen, I’ll try to come up with a better adjective to replace clown. Thanks also for reinterpreting Dr Jileks words. I reread his piece, perhaps you might as well.

  6. Its descusting its not a farm or is it i couldnt give a shit about your profit if you carnt provide quality care get out of the business simple. 20 years of staying back worrying about the falls that could have been prevented or the pressure sore or restaint injuries because we are under staff deliberately and lucky to have fuel in the car to get home hope you can sleep because i carnt.

  7. As an RN working in aged care facilities my whole
    Life I have come to the conclusion that not enough money will be profited from the residential homes and it will be the community) that needs to respond.
    Respond by caring for our own family via the CHSP. That is way the way for aged care in the future. “ nursing homes” will become overpriced and
    Redundant ….!more like a small acute care hospital for the aged population needing respite dementia or palliative care. Time
    To rethink how we managed our lives as we and our families age.

  8. It is now Feb 2021. Nothing has changed. I work in a NFP organization and feel they are more interested in the bottom line. To have millions of dollars of assets and so little regard for the suffering care staff that are the glue that holds these places together. I am tired of being told “if you don’t like it, go elsewhere”, rather than deal with staffing ratio’s and other issues. If private companies can run a string of care homes and make money.. Then we know where the funding ends up and it is not in the care staff pocket. At $22 an hour I would rather more staff than a pay rise just so I can do my job better.
    It is nothing short of cruel to expect human beings to work to the point of collapse and still be criticized by management for “not doing their job”. I love my job, it is not just a means to an end. Many things not just funding need to improve. I cant see this happening. Too many put profits before people.

  9. Hi
    I work as pcw. It is shame to see that staffs are been cut. My heart sinks in I want to look after my residents well . The family trust us to look after residents but work load is too high it seems impossible at times i feel helpless. I m so dead when I come home . I want to do my best but lack of staffing and funding limits us all . Some people have no family to visit and have no one to talk to. They are so fragile they take time to stand up and follow simple instructions. How can I rush them if I m late I m told of but why no one seems to care that elderly need more help. I beg the High commission for more staff and fund as we all deserve to be served like home. We want our beautiful residents to be looked after because we love them and they simply deserve the best. Aged care industry is not money making business fancy furniture fancy things in nursing home are not so important as much as nurses carers and management. I have feeling if staff is pressurised funding are cut we see the ageing staff stress depression insomnia all will follow it is a circle. Please please we need staff and fund.

  10. I am a personal care worker in a private nursing home. Our staff to resident ratio is woeful. 1 x EN and 2, sometimes 3 PCW’s per 32 residents on each floor, there are 2 floors with 1xRN covering both floors on afternoon shift. Many employees are leaving because of the stress and poor pay, which is only going to make things worse.

    It is high time the Government did more than pay lip service to this industry. I read recently that the average profit for privately owned nursing homes is 4%. What a lousy return on investment. No wonder they need to cut their running costs.
    I have done my own figures on what the overheads are based on what I’ve seen at work and they are huge.
    It’s a no win situation for the residents, the workers or the owners.

    How many million did it cost for the aged care commission to come up with their latest statistics? and what did it actually achieve? Reading the findings was not at all enlightening and proved nothing that people already working in the industry didn’t already know. What it did prove that they obviously are academics who have little if any experience actually working on the front line.

    I would like to see the balance sheet from all of the nursing homes, both public and private, analysed by the commission before they make any recommendations. The industry needs billions spent on it, not just a few million (chicken feed) when you consider our overseas age budget and money spent on other non essentials e.g. Submarines, overseas junkets, perks for politicians even after they leave the job and the list goes on. Am I angry YES. I love my job and it’s very rewarding to be able to make someone’s day a bit more pleasant. The elderly don’t deserve to be lonely and neglected just because some some government bureaucrat can use a spreadsheet to show there’s a problem but can’t do their homework properly to come up with a workable solution to fix it.

    The comment about not being able to put a blanket time frame on hours of care per resident is very valid. Some residents require very little assistance and some require a lot of time just to do something as simple as having a shower, not to mention those with significant issues who need much more than 2 hours spent with them per day. Unfortunately people in Nursing homes do not get better or easier to look after, they get worse and need even more care.

    Regular assessment for each residents care needs and complexity is needed and funding should be allocated accordingly, with balance sheets showing what that funding is being used for in each nursing home. In short an annual and rigorous audit of the books in addition to accreditation audits by the aged care commission is badly needed with funding being provided based on these figures.

    I just wish the Politicians would get off their Butts and focus on the real issues facing us instead of taking the easy road.

  11. Hi, I’m wondering hoe many nightstaff is appropriate for 86 residents which includes at least 33 dementia residents some of which are aggressive.


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