There is a growing acceptance in Australia that greater transparency around staffing numbers will become part of the aged care landscape in the future. The country’s largest peak body for aged care providers has switched its opposition to ratios to support for a new concept: ‘smart ratios’.
The pandemic has exposed the weaknesses in our aged care system, leading to rethinking of past practices and reconsidering of the future.
More than 2,000 aged care residents have contracted COVID-19 and tragically nearly 600 residents have died. Though Australia has done better than some countries in protecting its older citizens, it is still a disaster of immense proportions.
A shortage of aged care staff with in-depth knowledge about infection control weakened Australia’s response to COVID-19.
If Australia had had greater numbers of more-qualified staff working in aged care homes during the crisis, would the outcome have been better?
We have known for a long time that aged care facilities were short staffed and did not have enough highly qualified staff; these inadequacies have had tragic consequences during the pandemic.
In the Royal Commission into Aged Care Quality and Safety’s hearing about the sector’s response to COVID-19, counsels assisting Paul Bolster and Peter Rozen QC wrote of the “deficits flowing from the absence of skills related to infection control” among staff in aged care facilities.
The royal commission’s final report, due in February, is likely to include recommendations relating to staff ratios. They may recommend ratios be mandatory, or that providers reveal greater transparency about staffing numbers and skills, or perhaps the requirements will fall somewhere in between.
In hearings in late February, counsel assisting the royal commission, Peter Rozen QC, recommended that aged care providers “should be required by law to have a minimum ratio of care staff to residents working at all times.
“The ratio should be set at the level that is necessary to provide high quality and safe care to the residents in its facility.”
The pandemic has only made a recommendation along these lines more likely.
HelloCare has reached out to a range of industry peak bodies, leaders and experts and asked if they support mandated staff ratios or greater transparency around worker ratios in aged care facilities, and if their views have altered during the course of the pandemic.
We found there has been some movement on the issue. The industry is taking some tentative steps towards acceptance of staff ratios in aged care.
Here are the comments we received.
Sean Rooney, CEO, of Leading Age Services Australia
Supports ‘smart’ ratios, position updated
“LASA believes that we should be able to design ‘smart’ ratios that are case mix adjusted, aligned to care outcomes, linked to funding, and allow flexibility to adjust to local circumstances, on an ‘if-not-why-not’ basis.
“That means, if the provider’s staffing numbers and skills mix are not consistent with the agreed case mix requirements, then they must detail why not and what is the impact on the care outcomes delivered.
“LASA has long supported increases in overall staffing levels in aged care facilities – our sector tells us they want more staff, who are well-skilled and well-paid. The challenge is that the average provider is struggling to cover their current operating costs.
“LASA has historically had reservations about a simple ‘one size fits all’ ratio because there is a range of factors that influence the best approach to determining the right number and mix of staff in a residential care service, including acuity and care needs of residents, models of care employed, the layout of facilities, the age of facilities, and rural and remote workforce issues.
“There is a diversity of care need scenarios that need to be accounted for in staffing decisions. Operational management within a facility needs to retain some flexibility to make staffing roster decisions relative to changing resident acuity and care needs, consistent with the organisation’s governance and human resourcing requirements, and that meet Aged Care Quality Standards.
“The Productivity Commission in their 2011 ‘Caring for Older Australians’ report described a minimum staff to resident ratio as a blunt instrument. Furthermore, the Aged Care Workforce Taskforce in their ‘A Matter of Care’ report (2018) did not support a mandated minimum staff to resident ratios. They sought to conduct research into flexible models that realised holistic care and quality of life outcomes, rather than a singular focus on clinical outcomes.
“LASA contends our sector needs to have more staff, they need to be more skilled and qualified, and they must be appropriately remunerated.
“The challenge for the sector is how we achieve this.”
Rodney Jilek, managing director, Aged Care Consulting and Advisory Services Australasia, who has been working in Melbourne aged care homes with outbreaks over the last fortnight
Supports staff ratios, in combination with other measures
“While I still believe transparent minimum staffing ratios are one element that is required, COVID-19 in Melbourne has taught us that mix is just as important. If the site doesn’t have appropriate clinical governance frameworks supported by qualified staff it all ends in disaster.”
Joseph Ibrahim, Professor and Head of Health Law and Ageing Research Unit at the Department of Forensic Medicine, Monash University
Supports greater transparency around staffing levels
More transparency around staff ratios “can be done now and should be done immediately as it informs residents and families. They have a right to know.
“It creates the environment for the issue to be closely examined, debated and new ideas
But staffing issues in aged care go “beyond just the numbers”. Professor Ibrahim said we should be training specialist clinicians to care for older Australians.
“We need specifically trained and qualified staff, possibly a new profession for aged care that combines a bit of medicine, nursing, allied health into a specific person.
“Our thinking is so 20th Century and we need to review what residents need, then the skills to deliver that, then staffing levels.”
Mandated staff ratios is a “tough” issue.
“There is substantial variation in the resident’s clinical profile, therefore a ratio may create over and understaffing.
“We do not have a generic model of aged care services. We do not have a clearly stated purpose for an aged care facility: [is it] rehab, chronic disease management, or lifestyle?”
Minister for Aged Care, Richard Colbeck
Does not support staff ratios, position unchanged
“The Royal Commission into Aged Care Quality and Safety is considering key issues around workforce and the Australian Government will respond to its findings when they are delivered in February.
“Commonwealth regulation does not prescribe the qualifications required by staff, nor the number of staff required to be employed by an aged care service, however it does set out instances where a registered nurse is required, for example in assessment and care planning, and in the delivery of complex nursing procedures.
“Providers of residential aged care are required by law to meet Aged Care Quality Standards to ensure quality care and services are provided to all aged care residents regardless of aged care provider type.
“The Quality Standards require organisations to have an effective and competent workforce where each staff member has the appropriate qualifications and knowledge to perform their role.
Aged care homes are expected to consider the different levels of skills and abilities needed to meet residents’ needs.
“Providers are expected to regularly review workforce levels and mix of skills of their staff, and adapt these to respond to the changing needs and situations of care recipients.
Julie Collins, Shadow Minister for Ageing and Seniors
Supports mandated staff ratios, position unchanged
“Labor has been saying for a long time there needs to be more staff and better pay in aged care.
“Outbreaks of COVID-19 in aged care have clearly underscored the need to expand the aged care workforce.
“Sadly the Morrison Government has ignored report after report highlighting this issue.”
Ms Collins pointed out that Opposition Leader Anthony Albany recently committed to introducing “minimum staffing levels” in residential aged care, should the Labor party be elected to power.
Annie Butler, federal secretary, Australian Nursing and Midwifery Federation
Supports mandated staff ratios, position unchanged
“The ANMF has been a strong advocate of the need for mandated staffing ratios in aged care for many years.
“Now, more than ever before, the COVID-19 outbreak and its devastating effects in aged care have demonstrated that mandating staff ratios must be an urgent priority, as part of any lasting reforms of the aged care sector. In fact until this occurs, safe and quality care across the sector cannot be guaranteed. Without mandated staffing ratios at the core, other reforms will continue to fall short.
“The ANMF, and a growing body of research around the world, has produced considerable evidence demonstrating the positive effects of the right number of the right types of staff, i.e. ratios, on the quality of care outcomes as well as evidence of the failures in care attributable to understaffing.
“The consequences of chronic understaffing across the sector, with respect to both insufficient numbers and skills of staff, have been brought into stark relief during the COVID-19 pandemic, with more than two-thirds of all deaths from COVID-19 in Australia occurring in aged care.
“This tragic outcome is one of the worst in the world with regard to those living in nursing homes.
“It’s distressing to consider that much of this suffering could have been prevented had action on staffing been taken earlier.
“In Victoria, privately-run nursing homes, where providers set their own staff ratios based often on cost considerations rather than requirements to meet assessed care needs, have suffered substantially higher rates of COVID-19 than in Government facilities, which have mandated staff ratios. And importantly, mandated numbers of registered nurses on every shift.
“Already, only 6 months into the pandemic American research is indicating the positive relationship between enough registered nurses in aged care and prevention of COVID-19. A Report published by the Journal of the American Medical Association found that in 4,000 nursing homes in eight US states, facilities with greater numbers of nurses experienced fewer cases of COVID-19.
“COVID-19 has only increased our resolve and determination to pursue mandated staff ratios across aged care.
“The pandemic has stretched staff and resources even further and has made obvious to all the importance of having mandated, safe staffing levels and skills mix, to cope with intensified care demands.”
Patricia Sparrow, CEO, Aged and Community Services Australia
Does not support staff ratios or greater transparency, position unchanged
“There’s no doubt that aged care providers need to be able to employ more staff and provide the level of care the community expects.
“The staffing need is not just for more nurses, which staff ratios tend to focus on, but more staff overall, so while staff ratios aren’t necessarily the answer, we do definitely need more staff.
“Putting more staff in aged care homes will not only allow providers to offer a higher level of care, but can also be an economic driver and boost employment as Australia recovers from the coronavirus pandemic.
“Staffing needs to be based on resident needs and service models, and mandated ratios are too blunt a method to achieve that.
“Transparency is really important, but it also has to be meaningful. Potential residents and their friends and families need to be able to compare like for like services with similar resident profiles.
“The COVID-19 pandemic hasn’t changed ACSA’s views on staff ratios, but it has reinforced and further vindicated our view that aged care needs more staff and that requires funding reform and significant investment.”
Nicholas Brown, Acting CEO, The Aged Care Guild
Supports transparency in staff skills and numbers
The quality of care provided in aged care homes should first and foremost be based on the individual care requirements of each resident. There is no doubt the industry needs more workers, particularly as the baby boomer generation enters aged care.
However, rather than focusing only on the number of staff, other areas integral to the delivery of quality care also need to be considered. They include access to timely and high-quality staff training and development processes, recruitment processes that assess not only skillset but consider personal qualities of candidates, availability of end of life care and other specialised programs, as well as other support infrastructure that assist workers to do their job and ensure delivery of consistent, high-quality care.
Additionally, flexibility in numbers is important so that providers are able to adjust staffing rosters according to the needs of their residents and the occupancy levels of each home.
Currently, staff costs represent more than 80 per cent of care expenditure, however Government funding supports have not kept pace with increasing staff costs.
The Aged Care Guild support meaningful transparency. An appropriate, transparent and effective quality and safety system is good for senior Australians, for providers and for Government. We must ensure information is meaningful and gives clarity on the quality of care provided, assisting senior Australians and their families to make informed decisions when it comes to aged care.
The aged care sector is committed to the necessary reform, but we cannot do it alone; real change means necessary and structural reform from Government. This means taking lessons learnt from the Royal Commission and COVID-19 to develop a long-term and consumer-centred plan for reform, to ensure aged care workers are acknowledged and valued and senior Australians receive the quality of care they need and deserve.
Image: Jacob Lund, iStock.
We should not get hung up about staffing ratios in aged care.
For a start, the ratios are meaningless if you do not have well trained people. Simply having extra bodies on a ward is not helpful if they do not know what to do. The ‘what to do’ hopefully means you have people with skills in behaviour management, basic nursing care, good communication skills, able to read and write effectively, plus knowledge of person directed and person involved activities – these are the minimum.
Second, how do you set what the ratios actually are? Do you ‘sum’ the total emotional, social, psychological and physical needs of all the people on a unit, and base your numbers on that? How do you do that?
And what if needs change over time, and in a short time? Carers need regular work. Can you say to them, ‘it’s a quite day today, you don’t need to come in’. And if you set minimum levels, how do you know that facilities will not just adhere to the most minimal staffing – and then you might be back to where you were in the first place.
Ratios are needed, I have been doing extra education at my own cost for years and now with 2 diplomas I have been told it is a pity you are not an RN and the facility I work for have just afternoon shift hours and looking at cutting more to save money
What about ‘smart profits’ ? Can Sean explain where the money goes ? Why is so much money going in without decent care coming out ? Hundreds of Australians have died. This is a slow train crash. Aged care owners living in luxury driving imported cars while our parents are eating sausage rolls and mashed peas. How did this happen ?
There is simply not enough staff to carry out all the daily duties in residential aged care facilities. Perhaps we need a time and motion study. Not having the necessary number of workers to care for the elderly means essential care is missed.
I will start by describing a morning in a RACF that I don’t believe has ever been documented in any detail…just as an example:
The first thing [all] people want to do when they wake up in the morning is to go to the toilet. But there is not enough time for two carers who have arrived on duty at 0700 hours to take 20, 30, 40, residents to the toilet all at the same time.
Many are woken at the crack of dawn (although I do not know why they are woken at all) to be showered. I believe they should be allowed to sleep and wake up naturally. Some can walk, go to the toilet, and wash their hands themselves, but there are many who wear incontinence pads and they need their pads to be changed before breakfast. Many are faecally incontinent and changing pads requires care staff to devote a lot of time to clean them up properly (or even to shower them before breakfast).
Many residents have hearing aids. Care staff has to make sure the aids are clean and batteries are working / changed / tested before they are inserted correctly into residents ears, before breakfast. This can be difficult when residents have dementia because they may become resistive and lash out at care staff (often hurting them).
Dentures must be cleaned and given to residents or put into the mouths of residents who cannot do this for themselves. Most if not all, residents have full or partial sets of dentures and these too have to be inserted before breakfast.
Then there are dependent, immobile, residents who need total assistance from at least two or three care staff using a mechanical lifter after they have had their hearing aids and dentures put in and pad changed. Lifting these residents out of bed and into a wheelchair to push them into the dining room takes time and I repeat, when residents have dementia they may become resistive and lash out at care staff (often hurting them and themselves).
Breakfast may be served at 0730 hours but the kitchen closes at 0830 hours. Many of the 20, 30, 55 residents need their food cut up for them and some need to be fed (if they have lost the use of an arm following a stroke for example). It is completely unrealistic to think that two care staff can safely manage all the tasks I have mentioned for even 10 residents.
This routine of toileting, pad changing and hand washing, is repeated before every meal. Then at night hearing aids and dentures must be removed and cleaned. Toileting, pad changing and hand washing, is repeated.
I am an aged care, wound care, Registered Nurse (RN). I have been in about 300 RACFs and many private homes since 1997 to see residents with wounds and advise on clinical care and infection control. I have watched them working. I have fed residents when I see that two staff simply cannot get around all the residents who need to be fed (and we wonder why some are malnourished).
I have discussed this with RACF managers and Drs in one Division of General Practice… I have expressed my overwhelming concerns to them. I have written to the Royal Commission about staffing levels. I spoke at the Royal Commission hearing in the Darwin Supreme Court last year — on another aged care matter.
I am so frustrated because I feel ‘ratios’ need to be discussed in the context of what care staff must do each shift…they cannot get everything done. Dentures alone can take 20 minutes to remove, clean, re-insert in one resident’s mouth when they have dementia.
The majority of for profit aged care providers already provide enough staff to carry out all the daily duties in residential aged care facilities. Aged care has already had a time and motion study done and it showed that any increase in staff numbers has to be based on the ACTUAL care needs of the resident.
NOT the number of residents Having too many workers to care for the elderly means the essential care is no better just means more staff just standing around in nurses station.
My parents are in aged care and the amount of time I see the care staff just standing around doing nothing is a amazing.
How could any business stay viable with staff having no real care for the job they have taken on.
For many aged care staff its just a job once I have done the necessary cares for a resident ” I’m not hanging around to have a chat with Betty. I’m off to the staff room or nurses station to stand around.”
There is a huge marketing push by the nurses unions who’s ONLY goal in any of this aged care debate is to increase union member numbers. And if that means the union have to run a fake news publicity campaign to achieve that then so be it.
Those nurses union reps need a bonus pay rise as well.
Any care being provided has to be funded correctly if ACFI only states that a resident needs 2 hours of care a day and that’s all the govt funding they are receiving to provide that care how would a aged care provider be able to provide more staff hours with out running at a LOSS.
So please dont listen to the nurses union rubbish, aged care needs staffing based on the actual care needs of the resident. Not some ratio plucked from unions little red book.