Want to improve care in nursing homes? Mandate minimum staffing levels

The Royal Commission into aged care has begun its 18-month investigation into the quality and safety of Australia’s residential aged-care system.

Topping the list of priorities is to uncover substandard care, mistreatment and abuse, and to identify the system failures and actions that should be taken in response.

But we don’t need a royal commission to tell us the number-one thing that can improve care in nursing homes: implementing minimum staffing levels.

Based on our research from 2016, the Australian Nursing and Midwifery Federation recommends residents receive 4 hours and 18 minutes of care per day for optimal health and well-being.

It’s also important to get the right mix of staff performing for these hours and minutes. Half of the care should be provided by care workers (who undertake a short TAFE course), 30% by registered nurses (who complete a three-year bachelor degree at university), and 20% by enrolled nurses (who complete an 18-month diploma).

Nurse ratios in hospitals

It’s no surprise nurse shortages affect patient care. Nurse staffing shortfalls in hospitals have been associated with poorer patient outcomes, longer stays in hospital, and a higher risk of death within 30 days of discharge.

Poor staffing causes stress and frustration among nurses, who constantly feel rushed and unable to provide the type of care their patients deserve. This leads to greater job dissatisfaction and burnout.

One way to ensure nurse staffing levels is to implement mandatory nurse-to-patient ratios. California did this in 1999, when it mandated ratios ranging from one nurse to two patients in intensive care, to one nurse to six patients for women who had given birth.

After the ratios were implemented, the nurses’ patient loads decreased and they reported being able to provide better quality care. They also felt more job satisfaction and were less likely to burn out. Importantly, rates of complications and premature death decreased.

Minimum aged-care staffing

Seemingly small tasks in aged care can have a big impact on residents. If they don’t receive adequate assistance at meal times, for instance, they may lose weight and become malnourished. If they’re bed-bound and aren’t moved frequently enough, they’re at risk of developing painful pressure sores.

As with hospital-based care, minimum staffing ensures staff have enough time to complete these important tasks and has been associated with improvements in health outcomes for residents with multiple illnesses.

Missed or delayed care can have an enormous impact on residents. Elien Dumon/

Importantly, increasing direct care hours reduces the use of medication to manage difficult resident behaviour, allowing residents to maintain their independence.

Increasing direct nursing care also decreases the likelihood of residents being transferred to emergency departments, as their symptoms can be managed in the facility.

One key downside, however, is that the introduction of minimum staffing levels can result in a shift away from employment of registered nurses towards staff with less education and skills, as has happened in the United States.

What happens in Australia?

All Australian states and territories have legislation to determine the minimum staffing levels in hospitals to ensure patients receive timely care and close monitoring. But no such legislation exists in the aged-care sector.

The current Australian Aged Care Quality Agency standards say aged-care facilities need to be adequately staffed with appropriately skilled and qualified staff but they don’t specify what constitutes adequate.

In 2015, residents in Australian aged-care facilities received 39.8 hours of direct care per fortnight. This averaged 2.86 hours per resident per day and is significantly below the recommended 4 hours 18 minutes per day.

Our research, commissioned by the Australian Nursing and Midwifery Federation commissioned research, set out to investigate what constitutes safe levels of staffing in residential aged care.

In phase one, we tested six “profiles” for residents requiring between 2.5 and 5 hours of nursing care daily, using the de-identified data of 200 residents. We then recruited experienced registered nurses to time and record what amounted to nearly 2,000 nursing and personal care interactions in hospitals, aged care and rehabilitation facilities.

We ran the six “profiles” made up of timed care activities through seven focus groups of nurses working in aged care to determine the proportion of residents who meet each profile.

Nurses and carers want the time to provide quality care to residents. Alexander Raths/Shutterstock

Overall, we found more than 60% of aged care residents required four or more hours of care per day. This rate is likely to be similar in most aged-care facilities across the country.

The second component of our research involved surveying 3,206 staff working in aged care to determine the amount and types of care missed and the reasons why. This is care missed or delayed because of multiple demands, inadequate staffing and material resources, or communication breakdowns.

Staff believed care was being missed in all facilities, with higher levels of missed care reported in privately owned facilities (both for-profit and not-for-profit).

Unscheduled tasks such as responding to call bells and to toileting needs within five minutes were most likely to be missed – as were the social and behavioural needs of residents.

Complex care activities such as wound care, medication and end-of-life care were less likely to be missed, although there were deficits in some areas.

When asked to indicate the reasons why care was missed, the respondents cited:

having too few staff
the complexity of resident needs (for example, more residents receiving palliative care and with dementia)
inadequate skill mix of nursing and care work staff
unbalanced resident allocation (some staff having heavier workloads than others).

Beware cost saving

Many of the problems in the aged-care sector can be addressed with adequate staffing, and ensuring residents receive, at a minimum, the required 4 hours and 18 minutes of care each day. But staffing hours should not be increased by replacing nursing staff (who have clinical education and skills) with lower-skilled care workers.

Authors

Julie Henderson
Research Associate, Southgate Institute for Health, Society and Equity, Flinders University

Eileen Willis
Emeritus Professor Eileen Willis, Flinders University

Disclosure statement

Julie Henderson received funding from the ANMF to undertake this research

Eileen Willis received funding from the ANMF. She is a life member of the National Tertiary Education Union.

Aged Care – what we need- but will we get it?

A challenge facing the recently announced Royal Commission into Aged Care Quality and Safety will be to define “quality”.

Everyone has their own idea of what quality of care and quality of life in residential aged care may look like. The Conversation asked readers how they would want a loved one to be cared for in a residential aged care facility. What they said was similar to what surveys around the world have consistently found.

Characteristics that often appear as the basis for good quality of life include living in a home-like rather than an institutionalised environment, social connection and access to the outdoors. Good quality of care tends to focus on providing assistance that is timely and appropriate to individual needs.

A bleak view of aged care

A mature judgment to determine good quality requires us to recognise that many people have an instinctive and distressingly bleak view of ageing, disability, dementia and death. Some people express this as death being preferable to living in aged care, as the tweet below shows.

This doesn’t necessarily reflect an objective assessment of the actual care being delivered in residential facilities, but it does speak to the fear of losing independence, autonomy and identity.

In a survey of patients with serious illnesses hospitalised in the US, around 30% of respondents considered life in a nursing home to be a worse fate than death. Bowel and bladder incontinence and being confused all the time were two other states considered worse than death.

Aged care facilities will be the final residence for most before they die. This means the residents’ sense of futility and the notion one is simply waiting to die can and should be addressed.

Loose-leaf tea can make someone feel at home. Matt Seymour/Unsplash

Our reason for being is usually expressed through social connections. This a recurring theme for residents who define quality of care as whether or not residents have friendships and are allowed reciprocity with their caregivers.

A systematic review that drew together a number of studies of quality in aged care found residents were most concerned about the lack of individual autonomy and difficulty in forming relationships when in care.

Good staff

The need for positive social connections for residents extends to the relationships between staff and families. Achieving this requires staff with a positive attitude who work to build trust and involve family in their loved one’s care. They must also engage on issues that have meaning to the individuals.

Good staff should be both technically proficient and, perhaps more importantly, good with people.

Idyllic, or the way it should be?

A home-like setting – which may include having a pet and enjoying time in nature, as the Tweet below describes – may seem idyllic. However, more contemporary models of care are moving towards smaller home-like environments that accommodate fewer people and are more like a household than a large institution.

The ability to relate and personalise care to a small group of 10-12 residents is surely easier than catering to 30-60 residents. Some studies in the US have shown residents in such smaller units have an enhanced quality of life that doesn’t compromise clinical care or running costs.

This cluster-style housing still has limitations that need to be addressed. These include selecting residents who are suitable together and catering for the changing clinical and care needs of each individual.

Pets and the outdoors

Research into the value of pets in aged care has largely focused on the benefits to people living with dementia. Introducing domestic animals, typically dogs, has been shown to have positive effects on social behaviours, physical activity and overall quality of life for residents.

Pets improve quality of life for people living with dementia. from shutterstock.com

Similarly, providing accommodation where the physical environment and building promote engagement in a range of indoor and outdoor activities, and allow for both private and community spaces, is associated with a better quality of life.

Good food

Another major determinant of quality of life in residential aged care is the quality of food. This becomes even more important as people age. Providing high-quality food and enriching meal times is more challenging as many diseases such as dementia and stroke affect older people’s dentition and swallowing.

Aged care services need proactive and innovative approaches to overcome these deficits and better promote general health.

A key feature often overlooked is the cultural significance of food. Providing traditional foods to residents strengthens their feeling of belonging and identity, helping them hold on to their cultural roots and enhance their quality of life.

Safety, dignity, respect and choice

While the focus is often on preventing abuse, neglect and restrictive practices in aged care, the absence of these harmful events doesn’t equate to a positive culture. Residents want and have a right to feel safe, valued, respected and able to express and exercise choice. Positive observation of these rights is essential for quality of life.

Clinical and personal care

Time is a factor in aged care, as staff often don’t have enough time to spend with each resident. A recent ABC Four Corners investigation into quality in aged care found personal care assistants had only six minutes to help residents shower and get dressed. No wonder, then, that staff often don’t have the personal time to be able to spend with residents who need life to be a little slower, as the Facebook comment below shows.

Clinical care is another important aspect of quality aged care. A resident cannot enjoy a good quality of life if their often multiple and chronic conditions such as diabetes, heart failure and arthritis are poorly managed by their doctors and nurses.

Residents in aged care are the same as those who live in the community. They are people with the same needs and wants. The only difference is they need the community to give the time, effort and thought to achieve a better life.

You can’t ‘erase’ bad memories, but you can learn ways to cope with them

The film Eternal Sunshine of the Spotless Mind pitched an interesting premise: what if we could erase unwanted memories that lead to sadness, despair, depression, or anxiety? Might this someday be possible, and do we know enough about how distressing memories are formed, stored, and retrieved to make such a therapy possible?

Cognitive behaviour therapy (CBT) is a common treatment for anxiety disorders. The basic idea of CBT is to change the fear-eliciting thoughts that underlie a client’s anxiety.

Imagine the instance where a person has a dog phobia. They are likely to believe that “all dogs are dangerous”. During CBT, the client is gradually exposed to friendly dogs to cognitively reframe their thoughts or memories into something more realistic – such as the belief “most dogs are friendly”.

CBT is one of the most scientifically supported treatments for anxiety disorders. But unfortunately, a recent US study indicates that in around 50% of patients, old fear memories resurface four years after CBT or drug treatment. Put another way, the old fear memories seem impermeable to erasure through gold-standard therapy or drug treatment.

Eternal Sunshine of the Spotless Mind was an interesting thought experiment into whether it’s better for your well-being to erase painful memories. Focus Features/Anonymous Content/ This Is That Productions/IMDb

Why distressing memories are difficult to ‘erase’

Fear memories are stored in an old part of the brain called the amygdala. The amygdala developed early in our evolutionary history because having a healthy dose of fear keeps us safe from dangerous situations that might reduce our chances of survival.

things are safe sometimes (encountering a lion in a zoo) we also need to be aware they not safe in many other circumstances (meeting a lion in the wild).

This permanent storage of a fear memory explains why relapse occurs. During therapy, a new memory – say, “most dogs are friendly” – is formed. But this new safe memory is bound to a specific context (friendly dog in the therapy room). In that context, the rational part of the brain, the prefrontal cortex, puts a brake on the amygdala and tells it not to retrieve the old fear memory.

The prefrontal cortext can put a brake (blue line) on the amygdala, if it doesn’t want it to retrieve the old memory. from shutterstock.com

But what happens when a patient encounters a new context, such as a dog in a park? By default, the brain retrieves the fear memory that “all dogs are dangerous” in any context, except the one where the new safe memory occurred. That is, old fear memories can be renewed with any change in context.

This default has helped humans survive in dangerous environments throughout our evolutionary history. However, for anxious clients whose fear is unrealistic and excessive, this default to distressing memories is likely one important basis for the high rates of anxiety relapse.

So is erasure ever possible?

There are a few instances that suggest “erasure” is sometimes possible. For example, relapse is not seen early in life with non-human animals. This may be because the brake signals from the prefrontal cortex to the amygdala mature late in development. As there are no brakes, perhaps erasure of fear memories occurs instead.

By extension, this suggests early intervention for anxiety disorder is important as children may be more resilient to relapse. However, the jury is still out on whether erasure of fear memories occurs at all in children and, if so, at what age.

It’s important to expose yourself to your fear in as many different contexts as possible. Marcus Benedix/Unsplash

So, given the high rate of relapse, is there a point to pursuing treatment at all? Absolutely! Having some respite from anxiety allows for significant moments of sunshine and improves quality of life, even if it is not eternal. In these moments, the typically anxious person might attend parties and make new friends or handle a stressful job interview successfully – things they would not have done because of excessive fear

One way to reduce the chances of relapse is to confront irrational fear at every opportunity and create new safe memories in many different contexts. Anticipating contextual factors that are trigger points for relapse, such as changing jobs or relationship break-ups, can also be adaptive. Strategies can then be used to manage the re-emergence of distressing thoughts and memories.

While erasure of negative memories may be the goal of the characters in Eternal Sunshine, the film also emphasises the importance of these memories. When processed rationally, stressful memories motivate us to make better decisions and become resilient. Being able look back on unpleasant memories without excessive distress allows us to move forward with greater wisdom and this is the ultimate goal for all therapeutic frameworks.

Aged care failures show how little we value older people – and those who care for them

Aged Care photo

As the royal commission begins investigating the failures of the residential aged care sector, it is important such a review also considers the broader socio-political factors that have contributed to this crisis.

The commission needs to go beyond the institutional problems at individual aged care facilities, as these are a symptom of a much broader rejection of ageing in society and marginalisation of older people.

Negative stereotyping of older people is reinforced in the media, and this both informs and reflects societal attitudes. In Western society especially, we fear dependency, invisibility and dying. Aged care is a silo of these fears. And until it affects us personally, we ignore it.

How older people are marginalised in society

We have an expiry date in our society. This is not the date we die, but a time when our skills and knowledge are no longer considered to be valid or useful. Our value is largely determined by our economic contributions to society. But for many older people, this is difficult to demonstrate because they’re no longer in the workforce.

The economic impact of societal rejection of ageing is significant. Modelling by Price Waterhouse Cooper indicates that Australia’s gross domestic product would increase by almost 5% if people were supported to work longer. And data from the Australian Bureau of Statistics reveal that many Australians would like to retire later if they could.

Yet, there is evidence that older people are routinely denied work. In 2016, Age Discrimination Commissioner Susan Ryan said there was an urgent need to “tackle the discrimination that forces people out of work years before they want to leave”.

While older people should be supported to work longer if they wish, over half of Australians between the ages of 65 and 80 report a moderate or severe disability, resulting in greater dependency. A 2017 study of late-life dependency published in The Lancet found that, on average, older people will require 24-hour care for 1.3 to 1.9 years of their lives.

However, it is important that older people are not considered redundant in their societal role when dependency increases.

Aged care workers are also undervalued

Residential aged care facilities fulfil an essential role in our society. Yet, our recent ethnographic study in two residential aged care facilities in Victoria shows how this role has been compromised by an under-skilled, under-valued and overworked aged care workforce.

Older people were exposed to a revolving door of anonymous workers, significantly reducing opportunities for teamwork and fostering relationships between staff and residents. In one of the not-for-profit facilities, a single registered nurse was responsible for the care of 73 residents. This contributed to the delegation of an increasing range of tasks to unregistered personal care assistants with minimal training and delays in recognising signs of health deterioration among residents.

A reliance on general practitioners also increased the likelihood of hospital transfer. And hospital transfers can sometimes prove harmful, with previous studies showing that the noisy, fast-paced environment, bright lights and anonymous faces can have a negative impact on residents, particularly those with dementia.

Within the healthcare sector, aged care has the lowest status of all specialty areas amongst nurses and doctors. Recruiting appropriately qualified and skilled people to work in aged care is thus a constant challenge. Australia is expected to increasingly rely on imported labour to staff its aged care sector in the near future.

Ways to fix the system

Encouraging more healthcare professionals to enter the aged care sector will require a multi-pronged approach, starting with finding ways to engender more professional respect for those working in the field.

Greater emphasis also needs to be placed on improving the gerontological expertise of aged care workers. This can be strengthened by prioritising aged care in medical school education and recognising “nursing home” care as a specialist medical area. It is also imperative that personal care assistants receive greater recognition of their roles and duties.

Registration of personal care assistants as third-tier health care professionals is well overdue to ensure better oversight of their training and scope of their practice.

We also need to recognise the importance of human connection in residential aged care facilities. This requires strategies to build better relationships between residents and staff, and developing a formula for more accurate staffing allocations that reflect the real time commitments involved in aged care.

Who bears the ultimate responsibility?

It’s not enough to be shocked by the aged care scandals uncovered by the media and the decision to appoint a royal commission to investigate. We must also make older people, their contributions and end-of-life needs more visible. Increased funding and oversight will only come when we collectively say it’s important.

It is incumbent on us to ensure that residential aged care facilities do not operate as holding bays for the silenced, or wastelands for the discarded, where the occupants are expected to demand nothing and be as little cost to society as possible.

We have an opportunity to reconstruct the delivery of residential aged care. Let’s begin with the end in mind: a society that not only values older people, but values the resources required to provide the care they need and deserve.

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Mental health help in Australia is a joke

GPs struggle in a system ill-equipped to deal with mental health

I sat in the waiting room staring at my hands, willing them to stop shaking. Anxiety was a fighter jet, roaring through my cells, dropping grenades from head to toe.

When the doctor called my name I shuffled after her, a shrunken version of a self I no longer recognised. Fixing her eyes on a computer screen, she hammered the keys and asked me to explain why I was there.

Our complex emotional pain is being treated with six-minute medicine by time-poor GPs, says Jill Stark.

Photo: Christopher Nielsen

When I told her I was experiencing what felt like an acute recurrence of the depression and anxiety I’d grappled with since I was a teenager she pushed a sheet of paper across the desk and I began to tick boxes.

During the last 30 days, how often did you feel hopeless? … During the last 30 days, how often did you feel so nervous that nothing could calm you down? … How often did you feel so sad nothing could cheer you up?

Ten questions, scored from one to five, with one being ‘none of the time’ and five ‘all of the time’. Under 20 is well. Over 30 is a severe mental-health disorder.

“You got 25, which means you’re only mild to moderately depressed, so there’s not much to worry about,” she said, reaching for the prescription pad before asking if I was suicidal.

I thought about it for a while and said no. “Good. These ones aren’t prescribed very often these days because they’re much easier to overdose on. But you’re not suicidal, so that’s fine.”

Less than fifteen minutes after I sat down I stood on the street weeping. I had no support, no plan for how I was going to make it through the day, armed only with the knowledge that should I want my kill myself the drugs I’d been prescribed were well-equipped for the job.

I wish this was an isolated experience. But since documenting my mental health battles in my recent memoir Happy Never After, I’ve been inundated with messages from people across Australia telling similar stories.

Our complex emotional pain is being treated with six-minute medicine by time-poor GPs struggling to meet demand in a system woefully ill-equipped to deal with the mental health challenges of modern life.

It was revealed in recent days that GP waiting rooms are crammed full of patients with psychological problems.

Research released by the Royal Australian College of General Practitioners found that 62 per cent of people visiting a doctor are presenting with mental health problems – significantly more than any other medical condition.

College president-elect Dr Harry Nespolon said doctors are in an impossible situation, forced to either charge patients for more time to manage these complex problems or wear the out-of-pocket costs themselves.

“As access to psychologists and psychiatrists can be restrictive, to say the least, GPs must not only work as the frontline of support – but as the entire support model, something which is currently not supported by patient Medicare rebates,” he said.

How much longer can we continue like this? When will we stop treating emotional health as the poor cousin to physical health?

We are in the grip of a mental health crisis. We have the highest Australian youth suicide rate in a decade. More people are depressed, anxious and medicated than at any other time in our history. If trends continue, clinical depression will be the second most disabling condition behind heart disease by 2020.

Raising awareness is not enough. The time for wristbands and hashtags has passed. We have learned to ask R U OK but when the answer is ‘no’, too often there is nowhere to go.

Our Medicare system needs to better reflect the times we live in and the health problems we face. Doctors need the financial support to offer longer consultations for patients with complex psychological needs.

And as a matter of urgency, we must stop rationing psychological services to ten subsidised sessions per year.

When I was at my lowest point, I saw my psychologist twice week just to keep my head above water. I raced through my Medicare sessions in five weeks.

At almost $200 per hour, I then had to raise almost $400 a week just to stay in therapy and out of hospital.

There are few other areas of healthcare where we place such arbitrary limits on a patient’s ability to recover.

Through life’s lottery I was fortunate enough to have a supportive employer, and family who could afford to fund my therapy. Without their assistance I honestly don’t think I’d be alive.

Not everyone is so lucky. Many people are no longer here because they couldn’t afford their mental illness. It’s a devastating indictment on a system that is fundamentally broken.

We must demand better. The chances of surviving our emotional pain should not be determined by the balance of our bank accounts.

Lifeline: 13 11 14

Jill Stark is a Melbourne journalist and author of Happy Never After