Higher acuity, fewer nurses
The declining role of RNs is a critical issue for aged care, the royal commission heard.
Improving the workforce skill mix is the most important issue for the aged care sector over the next 20 years, Professor Deborah Parker of the Australian College of Nursing (ACN) told the royal commission.
Professor Parker, who chairs the ACN’s Ageing Policy Chapter, said the number of registered nurses as a proportion of the whole aged care workforce has fallen from about 21 per cent in 2003 to about 14.9 per cent now – despite an increase in acuity of patients.
Correspondingly, reliance on “unregulated” staff – assistants in nursing, or personal care workers – has increased, she said.
“The enrolled nurses operate under the supervision of the registered nurse but the unregulated worker with a very short certificate training … is not prepared and does not have the level of assessment and planning skills required to meet the needs of the current aged care clients,” she said.
Professor Parker said the quality of training was “quite variable” depending on the provider, the number of hours for training and whether it was done face-to-face or online.
Also, the low number of aged care RNs meant trainees might be supervised by people at the same level as them.
Counsel assisting the commission, Paul Bolster, asked: “It really depends upon the quality of the people they’re placed with?”
“It does, yes,” Prof Parker replied.
She said the declining proportion of RNs was due to several factors, including lower pay than other health sectors, a lack of new graduate programs and the absence of legislation requiring nursing homes to always have an RN on duty.
“You have to have the skill mix required to meet the needs of the residents or the clients. So individual providers will make that decision,” she said.
“One of the reasons it’s hard to attract registered and enrolled nurses to the sector though is because we have a small number of people within those positions.
“So, if I go to work in an acute hospital I will have a level of support that I won’t have necessarily in the aged care industry.”
Catheter ‘tunnelled into penis’
The Royal Commission into Aged Care Quality and Safety heard an alarming account of missed care as described in a recent member survey by the ANMF.
Counsel assisting the commission, Paul Bolster, read from a statement by a former agency nurse who said PCAs (personal care attendants) told her a male resident needed Panadol to sleep every night.
“I asked further and was told the gent was aphasic post-CVA (a stroke victim unable to speak), that is, very vulnerable. And he had a sore penis.
“He was grimacing as I approached. I asked if I might look. He nodded.
“He had a urinary catheter in place. Instead of exiting from the meatus, the glans had a split down the side to the level of the shaft.
“I’m still horrified to this day. The wound was not new. It took time to erode through with pressure from the IDC (indwelling catheter) tunnelling into his penis.
“The GP had not been informed and obviously I faxed them a message there and then for an urgent (urology) review …
“I am blown away the staff did not report the erosion as it was happening; take steps to prevent it.”
Mr Bolster asked ANMF Federal Secretary Annie Butler if there should have been a handover between the hospital and nursing home following the man’s stroke, and an ongoing care plan in place.
She said handovers were one of the biggest concerns of aged care nurses.
“It’s one of the areas that tends to get missed and sometimes is not even allowed,” she said.
“We don’t know whether there’s always an RN on duty … We don’t know what the (staffing) ratios are.
“We don’t know what the facility’s practices are in allowing proper handover and detailed clinical information.”
She said nursing homes ignored health care needs “way too often” and clinical documentation tended to be “very poor across too many aged care facilities”.
Nurses vital to better care – AMA
The Australian Medical Association (AMA) says trained and experienced nurses are “critical” to improving medical care in nursing homes.
The federal president of the AMA, Dr Anthony Bartone, told the royal commission there was an “inappropriately high” level of patient transfer from nursing homes to emergency departments for conditions that could be managed by a GP with good clinical handover to a trained nurse.
He said a 2017 survey showed that AMA members in aged care believed that “having access to suitably trained and experienced nursing and other health professionals is critical to improving access and quality of medical care in residential aged care facilities”.
Dr Bartone said trained nurses were “able to carry out our directions, our functions and we’ve got that communication, coordination and facilitation of that care to be then delivered”.
“(Nurses) then play a very vital role in carrying that out and ensuring it is carried out.”
The availability of a trained nurse allowed for “a continual process of feedback and improvement in terms of the outcome of the care that’s exerted on the patient”.
He said the AMA survey and other “continual and consistent” feedback from GPs suggested a lack of nurses was compromising the handover process.
This not only subjected residents to a lesser standard of care, it also discouraged doctors from visiting facilities “because of that concern, that worry, that issue potentially around being involved in a lesser standard of care”.