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The Aged Care Royal Commission says every residential facility should have a registered nurse on duty at all times by July 2024.

Every residential aged care facility should have at least one registered nurse on site 24 hours a day, the royal commission recommends.

By 1 July 2022, at least one RN should be on site for the morning and afternoon shifts (16 hours per day).

By 1 July 2024, at least one RN should be on site at all times.

“The evidence is compelling that overall staffing levels in aged care are linked to quality of care, and that registered nurse numbers are particularly important,” says the commission’s final report.

NSWNMA General Secretary Brett Holmes points out that the NSWNMA has waged a long campaign to prevent the state government from abolishing a legal requirement to have an RN on duty at all times in aged care facilities.

“The commissioner’s recommendation on RNs in aged care effectively endorses the union’s stand on this issue,” he says.

The royal commission notes that so-called reforms enacted by the Howard government in 1997 allowed providers to cut costs by replacing nursing staff with care workers, resulting in compromised care for residents.

Charles Sturt University Associate Professor Maree Bernoth says the commission’s recommendation is a welcome move away from the trend towards regarding old people as commodities.

Associate Professor Bernoth, who is an RN and NSWNMA member, says RNs were more common in nursing homes before governments shifted the focus to accommodation and lifestyle rather than health care.

“When you’ve got an industry that’s focused mainly on profit, and when that industry has such power over government, (the result has been) the commodifying of older people,” she says.

“The emphasis shifted to making profits and paying shareholder dividends, and not on the person needing care and the staff providing that care.

“Even questioning the need for an RN is beyond my comprehension. It’s a no brainer, really.”

Support by a multi-disciplinary team

Associate Professor Bernoth has worked in residential aged care, palliative care and acute care and has been a senior nurse educator at a number of large aged care facilities.

She welcomes the royal commission’s recommendation that aged care facilities have access to multi-disciplinary outreach services based at local hospitals.

“These would make people like nurse practitioners, allied health practitioners, pharmacists, geriatricians, and palliative care specialists and other specialists, available for older people in nursing homes and at home,” she says.

“That makes my heart sing, because nursing homes would have care workers and RNs being supported by the multi-disciplinary team.

“Unless we break these silos and have institutions working together, we’re going to keep tripping over these issues.”

Associate Professor Bernoth recently gave evidence to an NSW Upper House inquiry into whether there is a need to have an RN on duty at all times in nursing homes.

She told inquiry members that it takes a skilled RN to be able to assess an older person to see if they have a delirium, which is treatable, or dementia.

“The issue there, is that failing to identify and address a delirium can lead to serious illness – sepsis, for example – and death,” she said.

“An untrained person will have difficulty with differentiating between delirium and dementia.”

She told the inquiry that skilled RNs were also needed to communicate effectively with a person with dementia and recognise that “challenging behaviour or an angry outburst could be caused by pain or distress, or an inability to communicate a need, rather than a need to be restrained physically or chemically”.

RN numbers fall

According to royal commission research, RNs comprised 21 per cent of the residential direct care workforce in 2003, but by 2016 this had dropped to around 15 per cent.

The proportion of enrolled nurses also dropped, from 13 per cent to 10 per cent.

Over the same period, the proportion of the residential direct care workforce who were personal care workers/AiNs increased from around 58 per cent to around 70 per cent.

RN’s role in home care

All personal care workers/AiNs providing care in the home should be supervised by an RN or allied health professional, the royal commission recommends.

The commission is not suggesting an RN necessarily accompany the care worker to a client’s home.

It wants care workers to have an RN or other health professional they can go to for advice and support, and who can provide supervision and training.

“As well as helping care workers provide better quality care to people in their homes, supervision protects older people from the risk that they will receive substandard care or, worse, be the subject of abuse or neglect in their home,” the commission says.