Focus group surveys show an inadequate mix of staff  skills adversely affects health care in nursing homes.

Focus groups of nurses have recommended that  baseline nursing and personal care hours received by aged care residents be increased by half an hour per day on average.

Seven focus groups mostly involving registered nurses (RNs)were conducted in different parts of Australia as part of the National Aged Care Staffing and Skills Mix Project.

The aim was to determine the validity of nursing  interventions and timings for six typical resident profiles used as models in the report.

While the resident profiles were not real people, they were based on real-life examples.

Participants in all focus groups recommended that care hours be increased by half an hour per day on average “due to the impact of indirect care services on the delivery of direct nursing care”.

They agreed that aged care facilities were admitting a greater number of residents with more complex needs who had shorter lengths of stay than previously.

Participants associated a low ratio of RNs to assistants in nursing or personal care workers, with poor reporting and delayed management of emerging health issues.

Aged care needs RNs more than ever

The introduction of nurse-to-resident ratios in aged care may make it easier to recruit and retain aged care nurses, providing their ongoing training and clinical supervision needs are met, says clinical nurse consultant Ann Gaffney.

A senior clinician in aged care, Ann took part in focus groups organised to gauge nurses’ views as part of the National Aged Care Staffing and Skills Mix study.

She says aged care recipients experience extremely complex health problems, which require more nursing time.

“Today, the aged have multiple co-morbidities and complex family dynamics. I have worked in many settings and have found the aged care setting to be the one where a high level  of skill is most keenly needed, yet it is not the preferred choice of many nurses.

“In my current organisation, we are striving to address this problem through continuing education, especially in the areas of dementia and mental health care.

“I have been practising since 1975 and I find today’s complex care needs RNs who can perform in advanced practice roles, much more so than in the past.

“As we shift away from task-centred care towards person- centred care, the more ‘invisible, innate’ interpersonal skills  of nurses are required.

“If we fail to use these skills, or do not know how to use them, aged care recipients will suffer.

“Recovery from highly prevalent conditions will be prolonged because we are not picking up on signs and symptoms and intervening early in the illness trajectory.

“It takes nursing skill to recognise and diagnose symptoms so that they can be treated, and to recognise that ‘recovery’ is a concept applicable to aged care as well as to other specialities.

“We are all about promoting the wellness of our care recipients so as to ultimately relieve the pressure on  the system.”

The lack of RNs is unsafe

Participants worked under various staffing models but there was often only one RN to manage large numbers of care workers and residents, irrespective of the size and geographical layout of the facility.

One participant described her work situation:

“I work in a 100-bed facility, in charge of the same situation all  afternoons, and we have 1, 2, 3, 4 ENs that I need to oversee; I have my own floor to look after as well and medications to do. And so I’ve got to do all the DDAs. They are prescribed that we have to have two people to do insulins. So, I’m all over five floors as well as looking after my own floor, as well as staffing, taking outside phone calls, etc., etc. It’s become very untenable actually and quite dangerous, I feel.”

Having insufficient RNs forced nurses to rely on less  qualified staff to report emerging issues with residents.

“This may be problematic if insufficient time is allowed for change of shift reporting or handovers,” the report noted.

“It may also be problematic if the knowledge and skill set of care workers is insufficient to recognise emerging issues and to manage the complexity of having many residents. Some participants identified workload as leading to a task orientation among care workers which may compromise care.”

RNs weighed down by admin load

Participants also agreed the administrative load undertaken by RNs limited their ability to provide direct nursing care.

This was particularly evident after hours and on weekends when other staff, such as reception and diversional therapists, worked reduced hours or not at all.

Many nurses said they were responsible for care delivery in more than one geographically dispersed site, or had to cover care for residents in facilities widely spread out over one level or on multiple floors.

“One consequence of geographical dispersion is remote decision-making, in which the RN is required to make decisions about care without  seeing the resident.”

One nurse “described disciplinary action arising from their refusal to provide pain relief at  a distance”.

Nursing hours also failed to adequately account for time spent in travelling between floors and/ or in fetching equipment at geographically  dispersed facilities.

Participants said the need to provide emotional support and promote social interaction for residents was not sufficiently reflected in the timings and resident care hours per day.

Lack of appropriate resources to provide  optimum care was “a recurring theme across the focus groups”.

This included discussion about inappropriate chairs, and the lack of availability of imprest/stock items and pharmaceuticals. Focus group participants argued that time chasing missing equipment needed to be factored into indirect timings.