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.
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.