Nov 15, 2019

Older Australians Deserve Mandated Staffing Ratios in Aged Care Facilities

There were a lot of new ideas and informative debate at yesterday’s Aged Care Reform Conference in Melbourne, but a panel discussion regarding one particular topic highlighted the disconnect between those that work and live in aged care and those that govern it.

From the outside looking in, the idea of mandated staffing ratios in aged care seems like a no-brainer.

Residents and families want it, aged care employees want it, and polls on HelloCare show that an overwhelming percentage of our audience also feel that it is something that would benefit both residents and staff.

Despite all of this though, there is no indication of ratios being mandated on a federal level  – and excuses from the government, providers and peak bodies appear to be thinly veiled.

Yesterday’s panel discussion featured four guest speakers including ANMF Federal Secretary, Annie Butler, Anita Volkert from Occupational Therapy Australia, Professor Christine Sterling from the University of Tasmania, and Geriatric Medicine specialist Dr. Toby Commerford. 

Even though each panel member had their own specific area of expertise, the support for staffing ratios was unanimous and complemented by various insights.

“The ANMF has been calling for mandated minimum staffing levels and skill mixes for years now,” said Annie Butler. 

“We support giving staff the right training and education, but you can be the most highly qualified nurse on the planet with the best attitude and attributes, if you’re responsible for looking after 157 people, it’s not going to matter. Numbers matter.” 

The rest of the panel echoed Annie’s sentiments, and Professor Christine Sterling provided some insight into where she believes the pushback from aged care providers is coming from. 

“I think mandated ratios of the right mix of staff is vital,” said Professor Sterling.

“Obviously, there is more to any improvement than just numbers, but there is a fundamental underpinning that if you don’t have the numbers then all the quality in the world will not compensate.”

“I think that there’s a lot of pushback and qualifying around that is partly underpinned by a concern that some sort of mandated ratio won’t be supported by accompanying funding.”

 “I think the main fear is that the sector will be forced to have a ratio imposed upon them even though many are already losing money.”

Skills mix and education 

At present, 71.5% of the residential aged care workforce is comprised of personal care assistants, who are the lowest paid and least qualified people within the aged care workforce.

The overreliance on PCA’s has increased steadily over the last 15 years while the amount of registered nurses and enrolled nurses in aged care has dropped dramatically over the same time period. 

Currently, Registered Nurses make up 14.9% of the residential aged workforce, while Enrolled Nurses (9.3%), and Allied Health Professionals (1.1%), and Allied Health Assistants (2.9%), make up the rest.

Some may even argue that the current skill mix is being dictated by who costs the least, as opposed to what will deliver the best outcomes. 

According to Dr. Toby Commerford, specialist care services are not represented anywhere near as much as they should be in the aged care space.

“Semantically, if you think of the phrase ‘nursing home,’ there’s very few nurses because there are no ratios, and they’re not necessarily the kind of home that someone wants to go into,” said Dr. Commerford.

“People are coming to residential facilities very unwell, and it’s nuts that the specialists like us that deal with that like us can’t get in, so ratios do matter a lot, but it’s just what you do with it.”

“I feel like we should have around the clock geriatrician input for residents in nursing homes, to the point that we almost start to change the concept of it being a nursing home and becoming a hospice.”

“People are going into homes at the end of their life, they’re not much different from geriatric wards and hospices, so if we changed the semantics around it, and it became funded like hospital then it would be compulsory to have specialists there.”

“The Royal Adelaide Hospital can’t just have no geriatricians. So, if the nursing home down the road was viewed in the same way then that would force specialists into these homes.”

The Cost Of Ratios

Research that was commissioned by the ANMF and conducted by the University of South Australia and Flinders University concluded that the ideal skill mix required for care was starkly different from the mix we most commonly find in aged care homes today.

The research found that a best-case scenario on average would comprise of a workforce made up of 30% registered nurses, 20% enrolled nurses, and 50% personal care workers.

Annie Butler declared that over time, she believes this process would become cost-effective given the amount of money currently being lost to staff turnover and the cost of constant hospitalisations.

Anita Volkert was also critical of the current skill mix in aged care and called for a more proactive approach to addressing the needs of people as they enter old age.

“Yes, numbers definitely do matter but it’s not just a numbers game, you can have as many people working in residential aged care as you like, but unless you have quality engagement, it makes no difference at all,” said Anita.

“If we approach ageing with a more preventative focus and put our staffing resources into wellbeing early in peoples ageing journeys we see quite a cost-benefit down the track, but that requires investment and a skill mix that we currently don’t have at the moment.”

Blunt Instrument?

Over the years we have heard a variety of Ministers and peak body representatives refer to staff ratios as a ‘blunt instrument’ in an attempt to try and convince the masses that having no minimum staff numbers equates to flexibility.

Quite often, questions regarding ratios are met with rhetoric that all aged care facilities are different and that each facility needs the ‘right’ amount of staff to meet the needs of its residents.

While it is true that facilities do need the right amount staff, the fact of the matter is, aged care providers have differing views on what that is, and the Interim Report highlighted that facilities are understaffed and have staff who are overworked.

The other common rebuttal to staffing ratios is switching the focus to the education of aged care staff and upskilling those in carer roles, and some panel members were cautious about where that road may lead.

“One of the things that does concern me is that I keep hearing that we need to increase the training of care workers, which, yes, we do, but sometimes you think, are they going to try and get care workers and train them up to do the same things as a registered nurse?” said Professor Stirling.

“Let’s not allow the current situation to prevent us from seeing (ratios) as a clear need and solution.”

“We all know that people are getting sicker and that there is more acuity, yet over the last decade there has been a decrease in the clinical expertise of the staffing in aged care facilities and in the community sector.”

No money, no problems 

Annie Butler shared the same concerns as Professor Stirling regarding the upskilling of carers as opposed to utilising nurses and specialists, and she was rather forthright when asked about the true reason that we haven’t seen staffing ratios in aged care.

“Money. The pushback purely comes down to money,” said Annie.

“Aged care facilities that are struggling like rural and remote places are not given any money and the big providers pinch in from them, but the bottom line is – the government doesn’t want to fund it.”

“I think most people would pay more tax for better care, but they would some evidence regarding how that money is being spent. And that’s why we need minimum staffing ratios and appropriate skill mix so that people can tie their tax dollars to care.”

“We (ANMF) would also argue that some of our tax dollars now are not going to the best things right now that should be relocated.”

A recent poll conducted by HelloCare showed that the majority of our audience would be willing to pay more taxes if they could be assured that it was being used effectively to provide better care.

Whether or not this is an option that the government has considered remains to be seen. 


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  1. This discussion features those more removed from the reality of operating an aged care facility. Ratios are not the answer and do not work in aged care. They have been implemented in the public aged care sector and do not provide better care. If extended there would not be enough nurses in the industry.
    What is needed in reality is for an enhanced mix of staff including more allied health and lifestyle staff [especially on the weekends and evenings] and some more care staff.
    The majority of aged care homes provide good care every day with the staffing we can afford. In our case we provide a good clinical structure regardless of the cost and then work to maximise revenue to pay for it. The Royal Commission has only interviewed and assessed a small minority of aged care homes with issues and has only visited 0.8% of homes, so cannot see the good care delivered every day by the silent majority.
    The Commissioners want to see more people who live in homes but have failed to achieve this as they have no coordinated program to visit a proper random sample of homes. Our residents may wish to talk with them, but will not do so in a formal hearing or at a Community Forum with the logistics and inconvenience involved.
    Time for the Commissioners and Counsul to visit them in their homes!

  2. Ratios would work but not just during the week also on the weekends and afternoons as the residents’ needs continue after 5 pm when all the manager, RN, admin, hospitality and housekeeping goes home. Ratios would help so much just having an extra person where I work would be wonderful. We have 1 RN for 50 residents not good enough, the RN is exhausted.

  3. Interesting but not surprising that we continue to see panels of “experts” expressing opinions – all of whom have self-interest at the core of their views. The research referred to by Annie Butler requires an additional $5.6bn and this cost magically disappears progressively so the argument goes. It is not just about the numbers it is about what each of these groups actually do. For over 20 years I was responsible for an operation where we had allied health and yes increased education for carers to both provide a career path and improve reporting to the clinicians. Nursing is an hierarchical structure and many RNs want to “manage carers” rather than provide direct care. Their award is abound with references to RN delegations. If the government wants to fund ratios (and good luck with that) there still would need to be a conversation about duties to be performed because if only half of the workforce is carers then the day to day care delivery including ADLs would need to be done by clinicians. From practical experience it just won’t happen and Carer burn out will increase. As for medical support try getting a geriatrician to visit a care centre. Telehealth and related programs are available and then the medical profession doesn’t want to use it as they prefer “their patients” attend their offices for sometimes hours. None of this push is person centred unless the person is the one supposed to be delivering the care.

  4. What about evidence?

    Australia does not collect or publish staffing data or data about failures in care. Why? Well so that there is no evidence that would challenge policy.

    You can track this nonsense back to 1997 and the years afterwards when companies were quite open that they would not invest unless they could control costs, particularly staffing because income was largely fixed and profit came from keeping costs down. Nursing was the biggest. Government obliged and assisted.

    In the USA, where data about outcomes and staffing have been collected and compared for about 30 years, there is a clear relationship between outcomes when compared with staffing numbers and skills up to the minimum numbers that extensive studies showed were necessary. This is ongoing.

    There is also extensive evidence that staffing and outcomes are closely related to the profit focus of the type of provider.

    I have closely examined the large corporate US health care scandals during the 1990s and early 2000s when large numbers of patients were exploited and many harmed – and then the subsequent aged care scandals. I also met with investigators and examined the evidence collected.

    The evidence of systemic problems was clear but the corporate providers and the managers were blind to it and refused to accept what had happened. Even after they paid millions, even billions, in settlements some blamed it on a media beat up. .. The most culpable and in denial refused to change and it happened all over again a few years later.

    These were people who believed in what they were doing and like most who believe deeply they were wilfully blind to what was happening. Isn’t this what we are now seeing in Australia.

    Anyone who has been listening to what nurses at the coalface have been saying over the last 20 years knows that these failures have been far too common throughout that period but anyone who complained was assured that we had a world class system as revealed by the most rigorous regulation in the world. That was B-sh… but they believed it.

    Anyone who now claims that what has been revealed is not real and is not representative of what is happening in far too many nursing homes must do so with real evidence to have any credibility.

    The risks of the 1997 policy changes were recognised and there had been repeated warnings starting in 1993. I was among those who supplied data to government during the 1990s showing what was likely to happen in health and aged care with the policies they planned to pursue. They were resisted and failed to introduce them fully in health care. Aged care was not so lucky. We are now seeing the consequences. There is nothing unexpected about this..

    No one denies that there are some good facilities and that many do the best they can in a system that is deeply flawed and does its best to frustrate them.

    The problem does not lie with individuals but with a belief system. Similar behaviour is readily apparent when we examine the many failed belief systems of the 20th century. This sort of denial is to be expected from those who have done what they believed was good and desirable. It is very difficult for them and we should be sympathetic – but we should be careful not to accept their justifications without clear evidence.

    Staffing rations are essential art least until we change the structure of the system to undo the harm done in 1997.


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