Crisis? What crisis?

Crisis is a word all too often thrown around in relation to the aged care industry. Sadly the frequency with which that word is employed has been blunted and its impact on governments and the community alike is diminished. Descriptions of various crises in Residential Aged Care Services (RACS) sink like stones in a pond of Government and communal indifference.

Recently in the study "Australian General Practitioners Attitudes to Residential aged Care Facility Visiting", many General Practitioners reported visits to residents in aged care facilities as a frustrating experience. Putting aside the fact many considered these visits as being poorly remunerated the experience was frustrating as too often they were exercises in "hide and seek: seeking out the patient, the nurse, their notes and medication charts". Given that average number of care hours allocated to residents is in the order of 2.9 per person per day made up of mainly care assistants it is little wonder they are unable to find a nurse.

Worse still governments fail to act in any meaningful way in response to these "crisis" events. At the same time the public is immune to the issues or simply overwhelmed by the litany of disasters associated with the industry charged with the responsibility of caring for our most vulnerable citizens. The only way the government can hope to arrest this series of regrettable events is to mandate national levels of staffing and skill levels.

The industry peak bodies however are on the record as declaring this approach as being a "blunt" instrument, limiting flexibility and responsiveness to changing circumstances. And the Aged Care Act is not helpful in that it does not stipulate staffing levels or qualifications. The Commonwealth's Aged Care Act (1997) requires only that the approved provider 'provide such care and services as are specified in the Quality of Care Principles in respect of aged care,,,, and maintain an adequate number of appropriately skilled staff to ensure that the care needs of care recipients are met' . This vagueness can readily interpreted managerial as "whatever you can get away with".

Staff ratios such as those implemented in Victoria are described by the industry, as mentioned earlier, as a blunt instrument and does not allow for flexibility in the face of a heterogeneous population with changing care needs. The inference is that nursing rosters in aged care are dynamic instruments forever in a state of flux responding to variable care needs in real time. The fact is nursing rosters are relatively static tools. By and large the only movement is downwards in terms of hours and downwards in terms of trained staff. This has been a long term trend in spite of an increase in resident's levels of dependency and need.

Instead of embarking upon a meaningful examination of the root cause or causes of these social crimes of neglect the government has decided to merely rejig its current means of oversight. According to the government it proposes to set up a "powerful new watchdog" as part of an overhaul of the aged care industry. The implication is that increased scrutiny will lead to a commensurate increase in the quality of care. Yet there is no evidence to support such an assumption. Furthermore this announcement has seen little response from the industries peak organisations other than a few benign references to streamlining and associated efficiencies that may arise. You would be forgiven if you think that this initiative was taken subsequent to widespread discussions with the captains of the aged care industry.

The industry is already subject to relatively intense scrutiny by the present Aged Care Standards and Accreditation Agency alongside the Aged Care Complaints scheme. These organisations routinely name and shame poor performers, apply sanctions and install interim administrators where warranted. Too often a facility is sanctioned or threatened with sanctions by the Commonwealth with what reads like endemic cultural failings. Usually subsequent audits declare the facility has redeemed itself. Recurrent organisational failings suggest such cultural redemptions are cosmetic at best.

These measures have not, it seems, seen any long term rise in compliance or standards of care. It is implausible to believe increased oversight will, in isolation, turn things around. Without a serious examination of the reasons underlying continuing problems within the industry we can expect nothing to change.

With that in mind the only explanation put forward regarding continued failings within Residential Aged Care that has any validity is linked to staff levels and skill mix. The average allocation of care hours per resident per day in residential aged care is in the order of 2.9. This allocation is designed to deliver and oversee the delivery of medicines, attend to skin care including the management of wounds both simple and complex, personal hygiene, assistance with eating meals, undertake a variety of complex care procedures, provide palliative care, offer companionship together with psycho-social support to assist in the management of behaviours of concern and the issues that may simply arise from living in a shared and communal setting. One can easily add to that onerous requirement of documentation, complying with various audits linked to continuous improvement, various committee responsibilities, education, liaising with families, assisting visiting medical and allied health practitioners and managing any critical events such as a fall, assault, medical emergency or unexpected death.

The most recent research contends that the average allocation of care hours should be closer to 4.5 hours per resident per day together with a notional allocation of 50% carers, 30% Endorsed Enrolled Nurses (EENs) and 20% Registered Nurses (RNs). At present some jurisdictions already can operate without RNs on duty 24 hours per day. At least one provider is changing its model of care and medication delivery system to the extent carers can deliver the bulk of medication and accordingly have offered redundancy packages to EENs as much of their work can now be taken over by relatively unskilled staff. Nationwide there has been a progressive uplift in the hours of unskilled staff and commensurate drop in the presence of RNS and EENs. Where there are RNs it is not uncommon for that person to be responsible for care outcomes of anything from 50 to 150 residents per shift

None of this is meant to diminish the value of the care offered by carers, who, as a rule provide excellent service. The danger however lies in what they do not know in relation to dealing with a deteriorating resident, responding to changes in condition or a clinical emergency or managing complex behavioural issues.

The paucity of care hours can be demonstrated in a variety of ways – the ongoing saga of episodes of neglect and abuse that appear year in and year out should be enough to prompt the average person to outrage – but it is the more mundane events that perhaps might strike home more personally to the average person whose loved one is in care.

Person Centred care are the new combination of weasel words bandied about by the industry this season. Brochures and internet promotions tell the would-be consumer about care designed around their specific needs. However it is not uncommon, in fact it is the norm, to find the simplest expression of human need, that of personal hygiene, governed not by personal preference or expressed wishes but by the available human resources on any given day.

Assistance with personal hygiene is a fundamental element of aged care. It provides nursing staff the opportunity to engage in social interaction with the resident in the most basic and intimate fashion getting know them and develop a greater understanding of their needs; it also allows an appropriately qualified nurse the opportunity to asses other aspects of a residents needs in terms of failing health, impaired skin integrity and changes in dependence levels. One might expect a flexible and varied set of arrangements to enable these assessments to be undertaken at the same time as meeting a basic human need reflecting the personal wishes of the consumer. What does exist in direct contrast to a flexible and person centred approach is a "shower list", where people are allocated showers on alternate days or less frequently split between evening and morning shifts where by the vast amount of personal care is undertaken by Personal Care Assistants in a militaristic and time pressured way.

Many aged care services had baths installed after the changes to building certification brought in the'90's. An inspection of facilities now will find that these bathrooms have either had the bath removed and or converted into a makeshift store room. Bathing a person takes time, time to fill the bath, time to bathe the individual and then emptying and cleaning the bath. Accordingly they are rarely if ever utilised. This may, on the surface, seem to be a trivial point but it does underline the impact reduced care hours has upon quality of care.

This meagre allocation of personnel in terms of numbers and skill mix has negative impacts in a variety of other areas – there are usually more residents who need assistance to eat ( regrettably referred to as "feeds") than there are staff to help them in a timely manner – cold meals is a common source of complaint in aged care. Similarly there is little time available for meaningful and non-pharmaceutical interventions to manage some behaviours of concern or simply to socialise with the family and residents to foster a well-developed caring relationship. It should come as no surprise that there remains an over dependence on the use of anti-psychotic medication and benzodiazepine derivatives to manage behaviours of concern exhibited by residents especially those suffering with dementia. Human resource and skill allocation limitation does not allow for simple effective nursing interventions to resolve or mitigate these problems.

The truth about aged care is that is becoming more complex over time. Residents are admitted to care with higher levels of acuity later in their lives and with multiple co-morbidities requiring more and better qualified staff. Yet the industry trend is heading in the other direction in terms of staffing numbers and mix at breakneck speed. It is only a matter of time before we see more headlines detailing more crises and, sadly, an inadequate and inappropriate response from both the industry and government.