Registered nurses can and should make a difference to the quality of care in residential aged care homes, writes Dr Joan Ostaszkiewicz.

Residential aged care homes must employ more registered nurses (RNs) to work directly with residents if they are serious about improving quality of care. 

Residential aged care homes with higher rates of RNs qualified in ageing or aged care are associated with fewer pressure injuries, lower restraint use, decreased probability of hospitalisation, fewer complaints, decreased incidence of urinary tract infections and decreased mortality, research published in Nursing economic$ in 2015 showed.

Dr Joan Ostaszkiewicz

Despite such evidence, the 2016 National Aged Care Workforce Census and Survey found that RNs represent only 15 per cent of the workforce in Australian residential aged care homes and are thin on the ground.

Registered nurse roles in residential aged care have also changed. Where once they applied their clinical skills to residents’ care, they now find themselves in managerial positions, struggling to provide the necessary clinical oversight, let alone direct care.

Where once they worked at a direct care level with other nurses, they are now responsible for delegating care delivery to an unregulated workforce, yet remain accountable for the quality of care.  Few RNs would want this high-risk situation.

The public should be even more concerned about the potential impact on residents’ health and safety.

A lack of clinical nursing knowledge at a direct care level leaves conditions such as diabetes unmanaged and uncontrolled, increasing residents’ risk of death. 

It means medicines are given without any consideration of whether appropriate or not in any given situation. Side effects of medication regimens are not monitored and responded to quickly. And residents are at risk of developing acute conditions such as delirium, which are not identified or addressed.

An insufficient number of well-educated RNs in residential aged care homes also means that in the context of COVID-19, cross contamination risks are high.

An insufficient number of well-educated RNs in residential aged care homes also means that in the context of COVID-19, cross contamination risks are high.

The nursing profession finds itself caught up in a larger contested debate about the best ways to address the complex care and service needs of older people in residential aged care.

On one side of the debate are advocates of an approach to care that privileges residents social care needs, i.e. their need for social interaction, enabling them to play a fuller part in society. This privileging fails to recognise the complexity of residents’ clinical and healthcare needs.

People who require care in a residential aged care home have high rates of chronic health conditions such as diabetes, Parkinson’s disease, dementia, stroke, heart disease, respiratory disorders, depression, kidney disorders and incontinence.

They are increasingly older, frailer, and have more complex health needs that require multidisciplinary services drawn from across aged, health and disability care.

They are increasingly older, frailer, and have more complex health needs that require multidisciplinary services drawn from across aged, health and disability care.

Almost 40 per cent of aged care residents have between one and three behavioural changes and/or psychological symptoms, the most common being agitation, followed by irritability and anxiety. Twenty-two percent are unable to perform any mobility related tasks, and 50 per cent experience a fall within 12 months.

Moreover, a recent analysis of data from the Australian Institute of Health and Welfare revealed 77 per cent of aged care residents experience more than three episodes daily of urinary incontinence and 34 per cent experience more than four episodes per week of faecal incontinence.

Another poorly known fact is 23 per cent of residents die within one year of admission  and half die within two years or less.  

All of these factors should signal the need for skilled nursing and medical care.

Market-oriented policies have played a crucial role in the evolution, structure and resourcing of aged care. Market interests have successfully sold the lie that residential aged care is a lifestyle choice, where residents are consumers who can access help and services whenever needed in a hotel-like environment.

However, findings from the Royal Commission into Quality and Safety in Aged Care published in its interim report suggest this is far from peoples’ actual experiences. Residential aged care homes are not an accommodation choice. Access is through an assessment process based on a person’s health and welfare needs.

The government has failed to respond to concerns outlined in previous reviews. We now find ourselves in an extraordinarily dangerous situation where the knowledge and skills of the workforce have not kept pace with increasing rates of residents’ clinical and healthcare needs.  

It took a pandemic to uncover the aged care sector’s overreliance on an unregulated workforce not educationally prepared for the complexity of residents’ changing clinical care needs.

It took a pandemic to uncover the aged care sector’s overreliance on an unregulated workforce not educationally prepared for the complexity of residents’ changing clinical care needs.

This is a direct consequence of government policy and inaction. It is not a judgement on the character of personal care workers who, in most cases, are doing the best they can in environments that lack an RN presence and therefore clinical governance.

Caring attitudes, hotel-type service skills and all the good will in the world are no substitute for knowledge that is part of an RN’s education.

Registered Nurses are educated about the ageing process, how to identify signs and symptoms that warrant further attention, how to minimise the risk of falls, pressure injuries, incontinence, delirium, functional decline and prevent the spread of infectious diseases. The prevention and management of these conditions are core competencies for RNs.

In recent years, the nursing profession has had to defend the role of nurses in residential aged care and demonstrate their clinical and cost effectiveness. In the presence of methodological, definitional and cultural challenges and the absence of high quality randomised controlled trials, it has struggled to do this.

Hence, in its submission to the Productivity Commission’s inquiry into the care of older Australians in 2011, the Australian College of Nursing suggested “residents’ quality of care should not be reduced to a simple mathematical ratio of staff to resident being put in place.” This was followed by their white paper in 2016 arguing nurses were essential in health and aged care reform.

Despite this, aged care providers and the government have held firm to the claim there is a lack of hard evidence of an association between staffing and quality of care.

This claim is simply wrong. Quality in aged care is impacted by multiple factors. One is the number of RNs available and their qualifications.

Dr Joan Ostaszkiewicz is director of aged care research at the National Ageing Research Institute.

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4 Comments

  1. Thank you Dr Joan Ostaszkiewicz, at last someone that has honestly told it like it is in the Aged Care environment. Lets get Nurses to gain greater skills, at the moment we can only attract nurses with no experience (they are fabulous by the way but really need mentoring which does not occur) another area to look at is their rate – why are nurses in aged care paid lower than those who work in a hospital? This could be anywhere between $10 – $15 less per hour – why? Is it because Australia does not value its aged population? That’s the message I feel we send out. That is one Step – another then is the need for better educated Care Staff, they try their best but the training environment for this sector is quite frankly a joke. Then lets get onto Lifestyle workers – no funding for this are whereby this is an area quite under resourced and with no funding however forms x3 Standards under the current Quality Agency Standards? I know of x1 Lifestyle person to provide therapeutic activities, plus deal with social / emotional / spiritual / physical etc wellbeing for up to 100 people – you cannot be realistic to say that all can be supported?
    Small steps at a time – lets take this opportunity to overhaul this industry, we are still relying on an approach that is more than 20 years old.

  2. Great article that highlights the main issues including lack of regulated trained nursing staff in aged care. The role of nurses are often at a managing clinical level where they may be responsible for 60 clients or more with complex needs and then provide supervision of unregulated workers. How can they provide proactive person centred clinical care with clients and family whilst be supervising support provided by other workers, as well as being the responsible person for emergency responses? Increasing number of nurses to client ratio without decreasing number of other workers would improve quality of clinical care and overall person centred holistic support.

  3. Dr O makes a very valid point, however we do have the challenge of finding RNs to work the 24/7 needs of RACFs. We should explore the option of “Remote RNs” as an opportunity to make the knowledge and skills available to organisations. We have found the use of remote ICU providers in acute care hospitals to be beneficial. We can leverage that experience in aged care as well.

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