Residential Aged Care Facilities (RACF) are homes for the sickest, frailest people in our society and yet the responsibility of their care can fall on unregistered carers with limited skills and knowledge.

I agree with Annette Peters (Lamp, 2017) when she describes the lack of registered nurses in aged care as a huge problem. I was extremely disappointed to hear the NSW’s government’s refusal to support legislation to reinstate the mandatory rostering of Registered Nurses on site in RACFs over the 24 hours.

Being a Nurse Practitioner in Palliative Care, I strive to provide equitable and excellence in end of life care for our elderly citizens in RACFs.  Unfortunately I am confronted with many challenges in providing that care when a RN is not on site. The most obvious barrier to good care is the inability to provide symptom management such as pain, agitation, nausea, vomiting when the dying person needs it. The Government ruling suggests pain only occurs in office hours! Afterhours, the person may wait hours for the on call RN to respond or call the Palliative Care Outreach (PCO) service.  The PCO service has one RN to serve large geographical areas afterhours, so that service is stretched and again the wait may be hours.

It has been known that some facilities overcome this problem by the inappropriate use of infusion pumps using inappropriate medication doses not based on clinical need but based on the absence of an RN to deliver pain relief when needed.

Clinical assessment skills are necessary in order identify problems and avoid unnecessary suffering. Recent cases in which the carer was unable to identify or palpate a full bladder could have been avoided with an RN on site to conduct a clinical assessment. Instead 84 year old “Fred” was very agitated and restless over the weekend. On Monday morning the RN inserted a catheter and 1200mls urine drained.

I have had the pleasure of meeting some very compassionate, kind and amazing carers and AINs in RACF but it is with some sadness that I hear of carers being “multitasked”, working in the laundry or kitchen and being the “nurse” at other times.

I have no statistics to support my observations of the large turnover of RNs in RACF. One facility I visited every day for a week and did not see the same RN twice, quite often agency staff. This inconsistency understandably impacts on patient care.

Discussions with RNs that do work in RACF have described symptoms of stress and burnout. On several occasions I have come across the RN in tears, feeling morally distressed in not being able to give appropriate care. Caring for large numbers of residents, supervising staff, time constraints all take a toll.

I believe it is paramount that the NSW Government overturn their decision and make RN on site 24 hours per day mandatory in all Aged Care Facilities.