New study calls for improved staffing and skill mix in residential aged care

Nurses should make up half of the care workforce in residential aged care facilities according to first-of-its-kind research into staffing levels and skill mix released today.

Nurses should make up half of the care workforce in residential aged care facilities according to first-of-its-kind research into staffing levels and skill mix released today.

The study by six researchers from Flinders University and the University of South Australia and commissioned by the Australian Nursing and Midwifery Federation (ANMF) found registered nurses should make up 30 per cent of the skill mix in residential care, enrolled nurses 20 per cent and personal care workers the remaining 50 per cent.

They found that residents should receive on average four hours and 18 minutes of care each day, which would represent a significant increase on current direct care provision. Latest industry figures show residents receive on average 2.9 direct care hours, with those in the highest needs category receiving 3.1 care hours.

The elaborate study involved the development of an “evidence-based aged care complexity profile” with indicative care interventions over a 24-hour period, and tested the elements of care associated with various resident profiles through a series of focus groups with aged care nurses.

The new research into skills mix and staffing

It also determined what care interventions were being missed through a survey of 3,200 aged care nurses and care workers, and confirmed the structure of a residential aged care staffing model with 100 facility managers.

The survey found that staffing levels were the most commonly cited reason for missed care in residential facilities.

Just 8 per cent of staff said that staffing needs were always adequate.

When respondents were asked how many residents they were responsible for on their last shift, the mean ratio was one staff to 38 residents, while RNs managed 59 residents on their last shift.

These numbers were significantly lower in government-owned facilities, the study found.

The researchers said the findings demonstrated that all aspects of care were currently missed at least part of the time, with staffing numbers identified as the major causal factor.

They said:

“This is occurring alongside reduced employment of nursing staff and increasing use of PCWs to deliver many aspects of care.”

The reported number of residents cared for on the last shift worked by the respondent was associated with incidents of missed care, with higher resident numbers associated with more missed care.

‘Need for action’

The researchers said that the findings “support the need for action to improve staffing levels and skills mix in residential aged care, following the application and evaluation of the staffing methodology in this report.”

The ANMF said it had provided the report to the chair of the current Senate inquiry into the aged care workforce which it hoped would legislate minimum staffing levels and skills mix in residential care.

The researchers also said the findings would be used to provide the Aged Care Financing Authority with an evidence base “to inform future staffing levels and skills mix in aged care.”

The new study comes a year after a NSW parliamentary inquiry found that current federal laws were not prescriptive enough on staffing requirements in residential aged care (read AAA’s story here).

That inquiry called for staff-to-resident ratios in aged care facilities and the licensing of personal care workers.

Read the report here.

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Tags: anmf, flinders-university, stewart-brown, university-of-south-australia,

18 thoughts on “New study calls for improved staffing and skill mix in residential aged care

  1. Interesting to note that apparently having an activities co-ordinator with an assistant on site to attend to activites, leisure and physical/mental health needs is not important or forgotten.
    How about allied health professionals such as podiatrists, physiotherapists, occupational therapists and psychologists for geriatric mental health?
    They all contribute to the overall physical and mental wellbeing of residents.

  2. When I read the headline of your leading editorial my first question was “Who commissioned the study”? When I read the words “skill mix” I thought the sponsors MUST either be tertiary education institutions or the Nursing Federation”. It came as no surprise therefore to learn that the nursing profession sponsored the study.
    During my many years in marketing and marketing research there was a popular and common saying…. “any survey will give you the answers you want if you ask the right questions…”” There is another saying from The Salesman’s Bible”…..whose bread I eat of him I sing”…. Go Well. Peter Leith.

  3. I agree with the above comment. Residential aged care facilities would also benefit from employing qualified social workers as in USA. Social workers would routinely work with residents, families and staff.

  4. Sadly the issues for staffing and mix have been around for such a long time. Our system or lack of is currently enhancing the issue of elder abuse. It is through much frustration of many Health Professionals, that they can not make change. The federal government need to step up with some laws implemented with staffing numbers and mix. As we enter the “person centred care era” …. we can’t possibly currently provide this. We are not looking at other services either, allied health, geriatricians, alternative therapists etc. this does not even come into scope of an older persons choice. Healthy ageing and a person centred approach we have a long way to go. We are only at step one which is task orientated…we have not stepped out of this box yet.

  5. Agree with most of these comments . what we really need and I have said this for the last 30 years. Is for the government to walk a day in a facility ,not with the bosses , with the care staff, then and only then will things start changing

  6. I applaud the research team for undetaking this study and will review the report in full with interest. My only initial comment for a balanced perspective is that good quality aged care is not always about the numbers or ‘levels’. Whilst these have importance from a resource quantity perspective, I would argue that HOW the available resources are used is actually more significant. This leads to a focus on leadership, management and culture in our aged care settings. Well led, well managed and culturally empowered staff are more effective, more efficient, and provide better service and outcomes for residents & clients (research evidences this also). Additionally, how settings use partnerships and interdisciplinary collaborations for better outcomes is also worthy of study to measure outcomes.
    Hugely encouraging to see this research happening in aged care, thank you.

  7. Peter Leith I am interested in you view in regards to staffing levels. Perhaps this study was comisioned by nurses because they are working at the coal face and understand the challenges aged care staff have in providing person centred care and the stress and disalusionment they experience because they do not feel their efforts are valued. Many experienced and compassionate staff will be lost in future if the issue of too few staff is not addressed.

  8. Skill mix???
    Perhaps the ANMF should have a look at the research and evidence around best practice/ better practice in aged care?

    I have great respect for aged care nurses. Having said that, I also know the value of a committed and competent MULTI-disciplinary workforce. The ANMF doesn’t own aged care – and this ‘study’ is offensive and arrogant.

  9. Nursing and the distribution of skills within nursing is critical because outcomes data, which is not collected in Australia, shows that without an adequate distribution of nursing staff numbers and skills good care becomes impossible.  It is the right mix that matters.  Australia has ignored this data.  We need to find that mix by monitoring the care we give – including the right number of physiotherapists etc.  We should not make the mistake of lumping them together.
    It is to these researchers’ credit that, even though they did not have access to accurate data as they do in other countries, they have arrived at figures that confirm for Australia the validity of the findings made elsewhere – the number of each skill level required for safe care. Our staff are not superhuman and cannot provide the same care in half the time.

    On average the USA has double the number of RN’s and EN’s (or equivalent) to Australia and provides one hour more of nursing per day to each resident.  Little wonder that staff and many residents are so unhappy in Australia where all of the incentives in the system are directed to keeping staffing as low as possible – so ensuring mediocrity and unhappy staff across much of the sector.

    Accurate data as well as total transparency about staffing and failures in care have improved staffing levels in the USA.  Where they have been introduced, minimum staffing levels have improved care.  We do need them, but they are not a panacea and due care must be taken when doing so. 

    We need to resolve the critical nursing staff issue but at the same time we should avoid the mistakes that the USA have made and instead build around that foundation because much more is required.

  10. Who else was going to commission the research? Government can’t run away fast enough when it comes to questions about quality care and Providers hide behind the ineffectual Standards that are more of a desktop audit than ‘in vivo’.

    Perhaps people should read the whole report before questioning the ethics of two respected universities and the professional judgment of over 3,000 aged care workers and more than 100 residential facility managers.

  11. Perhaps Kate, Peter and Michael can show us how to run a facility with a with just a few OTs and a good manager? I’d be interested in learning how to perfect the ‘loaves and fishes’ staffing technique while simultaneously ensuring all the chairs are the correct height.

    Do they really believe we’ve got the staffing levels and skill mix of care personnel just right ? Such myopia ignores our high rates of weight loss, falls, skin tears and pressure injuries; just a few of the recognised consequences of low staffing levels. Challenging reality just to self-promote is ‘offensive and arrogant’

    Just accept the obvious; we’re running too lean.

  12. I think you may have missed my point Dave.

    We need a ‘mix’ of skills, certainly not ALL allied health or ALL nursing or ALL PCWs/AINs. Evidence shows that multidisciplinary teams achieve better outcomes for residents.

    … and your comments about chair heights suggests you have no idea what OTs actually do in residential aged care in some countries and even in some parts of Australia.No self-promotion involved. I’ve given up my dream of working in aged care and moved into a sector where I can do the job I was trained to do.

  13. Our biggest problem in aged care is understaffed facilities.
    Creates depression…imagine waiting to have a shower in the morning…no staff
    Your wheel chair bound…so you have to wait till the next day to get up or if you lucky….you may get a shower after handover
    Quality care???

  14. Why bother with a negative comment if you’re not even working in the sector?

    BTW, I don’t think anyone really knows what an OT does.

  15. Tut, Tut, Tut….So much negativity. In the end there is a perceived bias in the research when funded by the ANMF. Transparent in their disclosure, I can understand why the study was done. Traditionally these facilities are formally called “nursing Homes”.

    The residents you find inside them are mainly the frailing elderly who are in need of quality nursing care. Nursing care is holistic and can come in may models, we perhaps should be focusing on the reality of what a good multidisciplinary healthcare team looks like when it is functioning on a funding model such as the ACFI.

    What are the standards in needed in a particular care model (rehab or hospice?)and what is the skills mix that the staff should have in each level of care. Good Care, costs money. Good care takes time to deliver and time is currency to the worker, provider and the consumer. The big question is, who is going to pay?

    In the end the reality is that there is not enough funding to cover the cost in care needed to meet any standard that may be ideally laid out. We live in a first world country which has numerous barriers to what is needed as an outcome in good care for the frail and vulnerable. Cost is the biggest issue as the taxpayer doesn’t want to pay, the provider does not want to pay and the consumer doesn’t want to pay. There is not enough in medicare and so there will always be a gap.

    I believe and I know from experience that nurses are the best holistic care service that can provide many of the needed skills mix within a “nursing home”. Develop better models of nursing and skills mixes in nursing and many of the perceived problems in this residential care model will disappear. Let the consumer have the most say, and let them pay the bill. The market will drive the need in demand for the right service.

    More nurses are needed ATM in “nursing homes” to cater to the needs of the great and silent generation. More OT’s and allied health are needed for the Boomer market as the education of the LLLB philosophy is rolled out. Build the models that consumers want and have them understand the fee for services.

    In the end there is always the new CDC model, if people really want to stay healthy active and positive in their ageing process. If that ideal life has come to an end than the model of the “nursing home” that has nurses working in it will be a popular choice come the transition towards the quality death in EOL. The cost will still be the issue.


  16. I first worked as an RN in aged care 30 years ago. For 30 high and low care residents we were 3 RNs, 2 ENs and 3 AINs. Funny that this research study has come up with the same suggested skill mix.

    I did all the medications and yes I did my fair share of the showering. Residents were even able to have the option of a relaxing bath.

    During med rounds I could do a quick 2 minute cognitive assessment, spot over sedation or adverse reactions, decide when to withhold a medication and who needed a prompt review of their medication regime or an urgent physical or medical assessment.

    When showering I was able to see pressure areas before they ever became wounds. I could make judgments and take immediate action on who needed additional nutrition or hydration.

    I was able to lead the team in doing the regular turning rounds, promptly, because we had the right number and skill mix of staff.

    Falls rarely happened.

    When doctors came in I was able to give them first hand information on their resident’s presentation and general health, or any possible reasons for deterioration.

    I went home happy in the knowledge that ALL the residents had received the quality care they deserved.

    Hands up all the aged care RNs that can say they do all of the above now?

    I don’t see any hands…

  17. Love your work, Jamie.

    Hands-on, practical and skilled nursing care…how unusual. I have a suspicion the foundation for these skills came from three years of working with real patients and learning from those who do, rather than those who teach. Of course, I could be completely mistaken and your insight actually comes from a 5 week stint as a supernumerary in a rehab ward and writing assignments on early childhood development?

    It’s worth reading Jamie’s piece again. Attention to the fundamentals, being on the floor, prevention rather than reaction, and working as a team.

    The right staffing levels are critical to delivering the best care, but having the right person to lead the team is what makes it work. If you want to know how to recognise a hospital trained nurse, just watch them walk down the corridor…their head continually swings left and right checking every room as they pass by.

  18. Thanks Kylie.

    I take your point about undergraduate placements not teaching the fundamentals.

    What we oldies need to be is good mentors, not only to the students, but to the early-career nurses as well.

    Their technical knowledge may be greater than ours, but it’s up to us to teach them those fundamentals, the hands-on skills and the empathy that will serve them thru their career.

    Show them what it really means to provide quality care to the elderly… and empower them to continually strive for it.

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