Breaking down professional barriers in aged care

If we are serious about ensuring quality care in residential aged care then we have to realise that nurses and care workers cannot do it all, writes Yun-Hee Jeon.

Yun-Hee Jeon
Yun-Hee Jeon

If we are serious about ensuring quality care in residential aged care then we have to realise that nurses and care workers can’t do it all, writes Yun-Hee Jeon.

In Korea we say “it’s like pouring water in a cracked jar”, when describing a helpless and hopeless situation where all the efforts and investments are lost because there is an unresolved fundamental problem. New policies and reforms targeting aged care workforce and care quality issues often remind me of this proverb.

How many times do we hear about the need for better care quality in residential aged care? Evening news and current affairs tell us of nursing home horrors across the nation – medication error, abuse, negligence, inhumane conduct, avoidable death. Sure, these things happen, and one incident is too many, but it’s wrong to depict all residential aged care workers as though they don’t care. Many staff devote their lives to care for those vulnerable older people in residential care. I have seen many occasions where care is genuinely loving and beautiful.

When it comes to sub-standard quality in aged care, we blame a lack of funding and resources – poor skills, inadequate knowledge and a shortage of nursing staff. While important, these are not the real problems. National inquiries, research and reports all outline systemic problems. In response, we have seen a gradual increase in the last decade in funding to train and support aged care staff. We have also seen emerging staffing models in aged care – the introduction of clinical leaders, team leaders, care coordinators, clinical assists. Unfortunately, the overall care quality in residential care has still not improved.


The reasons are multifaceted. The needs of aged care residents are often highly complex. Most of them have a number of medical health conditions as well as physical and functional declines to be addressed. According to the Australian Institute of Health and Welfare, over 75 per cent of residents are 80 years or older, over 50 per cent have dementia, almost 80 per cent have been reported as having mental health conditions, approximately 40 per cent of residents that had been diagnosed with dementia also have a diagnosis of a mental illness, and 87 per cent (almost 9 in 10) of those residents with dementia require high level of care. The mono-disciplinary approach to care that has been accepted as a norm in residential aged care ignores this diversity of needs, as does the lack of timely palliative care in residential facilities. These emerging trends suggest complex situations require complex interventions.

There is strong evidence that medication for behavioural and psychological disturbances is not greatly effective, so it should not be the first line of intervention for such conditions. Instead, we should advocate for psychosocial approaches to care that are tailored to individual needs. These are known to be at least as effective as medications, without the nasty side effects. There is ample evidence that good palliative care requires interdisciplinary approaches and multidisciplinary collaborations.

We have yet to see how this evidence can be realised in residential aged care, where mono-disciplinary work is still the norm. There is an expectation or assumption that when it comes to management of behavioural and psychological disturbances and palliative care, problems can be solved by up-skilling existing nurses and care workers. We see personal care assistants doing what enrolled nurses used to do, and enrolled nurses doing what registered nurses (RNs) used to do. RNs are often swamped with administrative and management work on top of their clinical duties.

We have severe RN workforce shortages. According to the Aged Care Workforce 2012 report, the proportion of RNs in aged care is now less than 15 per cent, and most of the direct care workforce consists of personal care assistants (62 per cent). The proportion of allied health professionals is miniscule (1.7 per cent). Skilled and competent RNs play a critical role in ensuring good clinical care and leadership. Quite understandably, job satisfaction among nurses is closely related to having opportunities to provide quality care and team collaboration. Often we hear that aged care nurses leave their jobs because they don’t feel they can maintain care standards and be good clinicians, as their scope of practice broadens and larger workloads prevent them from providing holistic and humane care.

Interdisciplinary collaboration 

Attempts to resolve poor care quality in residential aged care have largely been confined to modifying the existing workforce, either by providing more education or reshuffling roles. Why are nurses continually expected to expand their scope of practice and provide care that requires specialist attention, when we know too well we need multidisciplinary collaborations?

My concern for the future of our aged care nursing workforce increases as I continue to ascertain our students’ needs and career hopes. They aspire to be clinically and interpersonally competent and confident nurses, working in a complex and often challenging health care environment. Their desire is to make a difference to the health and wellbeing of our community. We teach them about complex health care systems as well as the complex health care needs of our ageing population. We tell them of the importance of collaborative health care practice in a multidisciplinary context. Many universities, including ours, now have interdisciplinary learning opportunities for various health disciplines. Yet in Australian residential aged care, interdisciplinary collaboration is almost non-existent, or at best, ad hoc.

During my visit to a Dutch nursing home last year, I was pleasantly surprised to see how calm their environments were and hear about a low prevalence of behavioural and psychological disturbances in the home. When asked about strategies for such positive outcomes, the managers talked of the importance of multidisciplinary collaboration, especially the role of psychologists who worked closely with nurse managers and care staff to devise the best care plans for the residents with behavioural and psychological disturbances. I have worked collaboratively with psychologists, social workers, occupational therapists, nurses and medical practitioners towards improving dementia care. Multidisciplinary collaboration has been the key to our research success.

If we are serious about ensuring quality care in residential aged care facilities, we have to realise that aged care nurses and care workers can’t do it all. We also need practitioners from across the disciplines, who can contribute specialist expertise. Then, perhaps, we can mend those cracks in the jar before we continue pouring water in it.

Yun-Hee Jeon is an associate professor at Sydney Nursing School, The University of Sydney. 

Tags: education, multidisciplinary, nursing, slider, training, workforce,

8 thoughts on “Breaking down professional barriers in aged care

  1. Good article, workforce issues are so complex and the major issue facing us. This adds a different angle to it.

  2. Unfortunately, Ma’am, you’re part of the problem. The current nursing syllabus churns out under skilled and unprepared ‘trainees’ with little or no clinical expertise (no, standing at the back of a group with your hands in your pockets watching a disinterested RN incorrectly perform a procedure doesn’t count as clinical experience). It’s all too common to meet people with BSc, masters, even PhDs in nursing and related disciplines who have about 15 minutes worth of clinical experience under their belt. ‘Empty Experts’ are everywhere, more focused on increasing their published list than being on the floor.
    External consultants certainly play an important role in aged care, but its far more important to have a competent RN with the expertise to implement early interventions that may well avert the need to call them at all. Most first aid graduates exhibit better assessment skills than our poor graduates possess after three years of developmental psychology, the history of social health and whatever other irrelevant clutter used to fill the degree.
    Instead of complaining that nurses are ‘continually expected to expand their scope of practice…’ (you cant be serious?) perhaps we should revisit the level of our own skills and reduce the need to call for more multidisciplinary interventions. Nurses need to know that ‘calling the doctor’ is not a valid first response to a difficult situation.

  3. I call into question a GP who recently asked me (an aged care worker) about dementia as I mentioned that I work in the age care sector. The GP wanted to know what happens to people as they progress – this GP had absolutely no idea – he mentioned that he only knew about the people he had seen at the begining of dementia – he had no idea about the progression of dementia and how the brain and body functions grow steadily weaker with the disease. Is this the type of GP that we want in this country. In aged care all teams are under stress with staff shortages. There just aren’t enough workers to fill the positions and the workers that give their very best either burn out or come to the realisation that the almightly $ of profit driven companies really means that residents, families and workers really do not have a voice.

  4. Great article Yun-Hee, very well explained to nurses going into the the aged care sector. Sadly thou, no amount of expertise from nurses will solve the every day concerns that are faced by family members placing loved ones in an aged care facility. Patients call bells not answered in a timely manner, unexplained bruising, no water jugs in reach of patients, rooms untidy, patients spoken to with disrespect. Sorry, but the list goes on. (This is a patient and family concern).

    Expertise, knowledge, degree, will not, and does not make a great nurse. What makes a great nurse is one that understands, listens, respects, cares, and seeing each patient as if they were their very own mum, dad, nana, grandpa, sister, brother.

    Nurses are exhausted, have to work daily under extreme and difficult behavioural issues from patients, nurses are emotionally drained from being yelled at. Nurses require continued support from management, but often do not receive. Nurses need on-going training on how to deal with behavioural issues, how to take care of their own well being to be able to deliver care to others. Nurses can only deliver, if they are not forced to perform duties outside their own training.

  5. Administration and management in the aged care facility I work in are bossy, rude and disrespectful to staff. They then go on to empty the same kind of staff, who are then given the extra training. These nurses and PCAs are rewarded for being bossy, swearing etc. They seem to like the ones who suck up to the boss, spend time at the nurses station sucking up to management. The ones who quietly do their work and do the best they can with limited time. The only winners in aged care are those in the upper echelons.

  6. Great article Ms Jeon but your article wont be able to stop the many abuses going on in aged care homes. I am a nursing student and I had the privilege of getting my first work in a nursing home near where I live. I witnessed abuse on my 2nd night’s shift and I reported it to management. Management sent some person to come and interview me on the abuse. Instead of getting to the bottom of the story regarding the report I made, she started accusing me of spending too much time with one aged person who needed help with toileting etc, which by her accussations told me that I am supposed to be hurrying this frail old lady to hurry up with her toileting. Being new to aged care, I had no idea where and what she was getting at, only later I worked it out that she was sent to cover the abuse and that I am only supposed to spend 5 minutes minimum with some aged person doing what I did above. After the interview with this Manager, I came out and tendered my resignation in disgust. So I worked it out that there must more unreported abuse going on in aged care places.

    My Recommendation

    Perhaps the aged care sector needs to be revamped, family members should be made to care for their own parents, grannies etc where it is done with love and genuine care instead of strangers doing it for money only, there is no genuine care and love from these PCAs or nurses. I come from a culture where we look after our aged parents, perhaps Australia should do away with the formal aged care system and start looking after the people who have brought you to birth.

  7. The registered nurse students you are teaching rarely end up in aged care and may end up in aged care as a last resort when they miss out on hospital placements .Staffing in aged care is increasingly being made up of uneducated migrant workers. I work in aged care and I have seen assistant nurses work as a laundry hand in the morning then morph into an assistant nurse for an afternoon shift. Often they will work a morning shift in a nursing home then go on to an afternoon shift at another facility. Often they disappear when their Visa applications fail and they quit.As a registered nurse I already collaborate with a number of professionals so what you see as a solution is already being implemented yet care in nursing homes remains fundamentally flawed. Staff put up with verbal abuse; being physically abused and one male resident tried to put his hand down my pants. You can have “experts” nursing care plans; collaboration and interventions yet the only way they will work is to have adequate experienced staff to implement them. New grads do not have this experience. I am also a PhD candidate yet I see the irony in how academics envision aged care versus working at the coalface.

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