Staffing of nursing homes has been a key concern among those looking at nursing home care, those who have suffered from failures in care and in the broader seniors community. Minimum staffing levels have been called for by nurses and by groups in the community, including Aged Care Crisis.
When the new Victorian Labor Government decided to introduce mandated minimum staffing ratios in its publicly owned and operated nursing homes, I was fascinated by the outbreak of self-serving nonsense by the industry. To them, this looked like a foot in the door.
Those who think you don't need nurses
A US conman whose personality and successful market strategies brought him enormous success and credibility as an authority, visited Australia in 1997. From his lofty office on top of the luxury company headquarters in the USA he claimed that there was lots of fat in the system and insisted that you did not need highly trained staff to wipe bottoms. This was so attractive to the budget conscious in the USA and Australia that they have been unable to acknowledge their gullibility in the face of mounting evidence and unhappiness.
The 'myths' about staffing
National Seniors expressed the perception of many staff, of those who had fallen foul of the system and of those who had studied it.
Michael O'Neill from National Seniors:
- - - it comes very much back to resourcing levels, to staffing levels and then within staffing levels the number of registered nurses, the qualifications of the staff there.
Source: Aged care under strain ABC 7.30 Report, 14 Sep 2010
The aged care peaks responded to Victoria's plans in impose mandatory staff levels by claiming that there is no evidence that ratios result in better quality care: They have saying this so forcefully and with such authority that those who think otherwise seem to lack credibility.
LASA Vic CEO Trevor Carr says his main objection to the policy is it lacks an evidence base.
"The real issue that nobody ever seems to ever want to talk about is there is absolutely no evidence whatsoever that suggests that having the ratios in place in the public sector provides a higher or a better living environment for the residents of those care facilities," Carr tells AAA.
This view is shared by Aged and Community Services Australia (ACSA) manager government relations and policy Heather Witham, speaking on behalf of ACS Victoria.
"There are accreditation guidelines and we are assessed for whether we have adequate staffing at that time," Witham tells AAA.
The report concludes that, based on the literature review, there is little evidence to sustain an argument in favour of ratios and instead calls for staffing methodologies that take account of a broad range of variables and contexts.
She (Professor Rhonda Nay) says there is little good to say about nurse-to-resident ratios. "The evidence shows that the quality of care and staffing is far more important than the quantity of nurses," Nay tells AAA.
However, Carr describes Labor's position as an ideological response that is at odds with the former Liberal government.
- - - "It really should be left to each individual agency to determine whether or not they can viably, sustainably and strategically be involved in the delivery of these services rather than it being a government policy."
Source: Victorian Govt committed to mandating staff and keeping beds Australian Ageing Agenda, 20 Mar 2015
Victorian Department of Health Report, Innovative workforce responses to a changing aged care environment 2011
In the article above, the industry based their objection to staff/patient ratios on the 2011 Victorian Department of Health Report, Innovative workforce responses to a changing aged care environment which it claimed, also emphasised the lack of evidence. The report did say “in reviewing the literature on ratios, little evidence could be found to sustain an argument in favour of them at this time. The report was advised by Professor Nay. But Baldwin reviewing multiple studies from the USA have shown a very convincing link between the number of staff and the number of failures in care as well a link between the focus on profits and the number of staff.
Perhaps it is the use of the word ratios that limited the literature search and is causing confusion. The number of staff is a crude figure in a complex environment but as the figures from the USA show it is very revealing of what is happening in the sector. At the very least we do need to know what it is and ensure that there are 'enough'. You can then build on that with other data.
The issue become clear when we look at that report.
Having ‘enough’ RNs is indisputable, however, how many is enough remains a matter of debate and the determination of staffing should take account of resident mix, environmental design, staff expertise, model of care and other contextual factors that influence care.
What is clear is that ratios are a very blunt instrument and improving care outcomes for residents and staff satisfaction requires more sophisticated decision making.
It has been demonstrated that a more diverse skill mix could achieve quality outcomes, higher overall staffing levels and staff satisfaction.
The key word here is “enough” and the Victorian public system has always been well staffed so probably has enough. I also think there is much less disagreement here than the critics suggested. The report is promoting the Eden model of care and there is little arguments about what it says. It indicates in its conclusion that what is proposed would need “higher overall staffing levels”. It collects the sort of data that will permit this. It has recognised the problem but its attempts to address them have not worked.
The report focuses on skill mix and structure needed to meet the different requirements. Although many US facilities are still a long way behind in sufficient numbers, the USA has succeeded in slightly improving them. It too is now looking closely at the skills mix needed, the minimum number of each type of staff below which facilities should not fall, and when more than the minimum of each is required.
What this reports says: It is worth looking more closely at the Victorian report which presses for a “skill mix and staffing levels based on a range of considerations including resident dependency, staff experience and context”. The focus is on person centred and not task centred care. It is clear from the report and what it advises that including person centred requires more time and so more staff than we currently have in many facilities.
System changes are required to demonstrate to staff that the organisation is genuinely committed to person-centred care
The information from our consultations was consistent with the literature and indicates that staffing decisions are best based upon a combination of variables, including resident dependency mix, available skill mix, approaches to care, organisational configuration and environmental factors.
The report sets out principles:
The proposed staffing principles are based on teams and are not task oriented. - - The team includes staff with a mix of skills - - The team approach is resident (not task) focused and aims for continuity of care and development of expertise. - - enhanced level of responsibility and professionalism - - an increased emphasis on support, training and development within the facility and an expansion in appropriate external training options. - - - participatory management styles, which are central to the model.
It then goes on to look at responsibilities for clinical leadership, team leadership, management, personal care, lifestyle coordination/community liaison, hotel services and maintenance services. There is little to argue about here but it is worth noting some.
The clinical leadership responsibilities - - - maintain knowledge and skills - - - ensure initial assessments are completed - - - educate and support - - - maintain and communicate best practice - - - liaison and consultation (care team and residents families) - - collect and analyse data - - - links with educational providers - - monitor the implementation of the clinical plan
Team leadership - - assist with development and monitoring of policies and procedures
Management - - - manage human resources - - security and emergency procedures - - - coordinate ACFI timing schedules and collaborate with clinical staff - - lead strategic planning
Lifestyle coordination/community liaison - - - responsibilities of this role are considered crucial to the development of wellbeing and quality of life - - - integrate the community into the life of the RACF - - - create meaning and purpose in the day for an older person - - give attention to self-esteem, worth and dignity until the end of life - - Human interaction ... hinges upon the creativity of the staff - - involvement of families and the external community within the RACF - - involvement of residents within the external community,
Conclusion - - a balance between clinical and social models of care - - Evidence has been provided of quality outcomes being achieved with a broader skill mix than is currently used. It has been demonstrated that a more diverse skill mix could achieve quality outcomes, higher overall staffing levels and staff satisfaction.
There is not much to really disagree with here. The industry is being opportunistic in using this report to justify their position. They know that few will go and search for the original article.
- Innovative workforce responses to a changing aged care environment Victorian Dept Health 2011
If we look at the many reports in the 19 Years of Care section and particularly at the comments of staff and families on the web page Those who know it is very clear that what this report advocates is not happening in a large number of facilities and that is because there are simply not "enough" staff to start with. They don’t have the time to do any of this and only survive by being task focused.
If the industry were implementing these recommendations and if they were transparent about staffing and failures in care in doing so then minimum staff levels would not be required, but the evidence from the USA shows that when there are insufficient staff then requiring more staff improves care. We need to decide what enough is and require that, not as an end point but as a beginning - the minimum.
Compatible with the proposed hub: What this report suggests is not a top/down model. It advocates "participatory management styles, which are central to the model". It is clear that staff but particularly clinical staff will be contributing. Clinical staff will have input into financial decisions. We should also note that the report included structures to “collect and analyse data” and the integration of the community. There is nothing here that is not entirely compatible with the proposed Community Aged Care Hub and which would not be facilitated by the involvement of this hub.
What has been happening to aged care training
Recent scandals: The exposure of the scandals involved the privatisation of TAFE courses in 2015/16 included aged care training. Large numbers of certificates were revoked because aged care and other workers had not received adequate training. I wrote about this on the web page Contracting government services to the market.
But those who saw what was happening had been complaining for years but no one was listening. Way back in 2011 Bxxxxx, a strong critic of what has happened to aged care wrote about the financial pressures that led to it.
No one listeing in 2011: By 2011 Mxxxx Bxxxxx had over 20 years experience in aged care in a diversity of roles including RN, educator, researcher and academic. She had been involved in the development of the Certificate III Aged Care Work in the mid-1990s. She indicated that “There were stringent guidelines for the RTO delivering the qualification and standards set for those who could teach the program”.
She indicated that “I have observed the deterioration of a once substantive qualification into a meaningless piece of paper”. This was “related to the demand for aged care workers and the focus on the fiscal rather than on the person – the person being both the person receiving the education and the person who is the potential recipient of care.”
Bxxxxx described the multiple factors that had led to a situation where poorly trained and clinically inexperienced staff were being funnelled into the system by the providers who were able to do this at minimum cost. “When RTOs are vying for contracts with aged care facilities, it is the lower cost and the shorter training time that is most important."
The culture: Bxxxxx confirms my own assessment of the dysfunctional culture that develops in market driven facilities. Her research “exposed the level of bullying between aged care workers when a different approach to skills development was introduced” and “articulated the price paid by aged care workers when they spoke of the abject nature of the environment in which they worked.”
No one listening: “They have, (been told) but no-one was listening”. Those academics who had done research spoke out about “paucity of aged care workers’ clinical decision making skills” and other issues. They were targeted by the providers, and the research done “has been ignored by the aged care sector”. Instead “kudos is given to those who implement the most cost effective strategies irrespective of their outcome”.
- No surety of standards in Cert III Aged Care Insite in Workforce 1 October 2011
Who is pressing for minimum staffing levels
In both the USA and Australia, nursing unions and those who have direct experience of the system have been pressing for mandatory minimum staffing levels for many years. These are the people who actually see and experience what is happening. The problems of poor care due to insufficient as well as a lack of trained nursing staff are widely acknowledged. The focus has been both on numbers of staff and on their skills, as revealed in the recent NSW Inquiry into the need to have registered nurses on site at all times.
The Australian Nursing and Midwifery Federation (ANMF) said yesterday it was "heartened by a commitment" by Senator Lazarus that he supported the union's campaign for mandated staffing levels in aged care.
In their meeting with Senator Lazarus the union had outlined "the staffing crisis in aged care and the urgent need to address this at a time when there is a current shortfall of 20,000 nurses in the sector," Ms Thomas said.
"The senator appreciated these concerns and the lack of quality care in some nursing homes because of poor staffing, as these issues had also been raised by community members in his home state of Queensland," she said.
Source: PUP Senate leader makes the case for ratios in aged care Australian Ageing Agenda, 11 Feb 2015 (The Comments on this article are interesting)
NSW inquiry recommends minimum staffing levels. The move for minimum staffing ratios was supported by the 2015 NSW senate review into the proposal to abolish the current requirement that all nursing homes have a registered nurse on duty at all times. Not only did the review advise against repealing the legislation requiring registered nurses, but it recommended that the NSW government press the commonwealth to introduce minimum staffing requirements for all nursing homes in Australia.
Support from a for-profit: The owner of one for-profit provider that claims to have a model that provides exemplary care agrees that there are major problems in staffing across the sector. His comments referring positively to the recent meeting between the nursing unions and Senator Lazarus are below.
"... We agree wholeheartedly that the typical traditional nursing home or aged care facility, not only in Brisbane and on the Gold Coast, but across Australia, has inadequate staffing levels and carer to resident ratios to provide quality aged care.
"... Our staff to resident ratio is much higher than that of any traditional aged care facility or nursing home in the Brisbane or Gold Coast area.
Source: Media release - Tall Trees aged care provider - Why the Typical Aged Care Staffing Level isn't Good Enough for Tall Trees Care Communities, PRWire, 25 Mar 2015
Writing in similar vein elsewhere he concluded, "By today's aged care standards, we are overstaffed. And we will stay that way." Hopefully this is not just a marketing ploy and their claim to a mission is real. It would have helped if they had indicated what their ratios were. We would then have had a yardstick against which others could rate themselves. Prospective residents would have had a real measure for rating nursing homes and the market might then have started working.
In 2000 in the USA, an expert panel recommended 4.5 hours of direct nursing care per resident per day. They considered that there were risks of harm to residents when levels fell below 4.1 hours. At the time the poor levels of care across the USA were considered to be related to an average of only about 3.5 hours per day. We don't know how aged care in Australia measures up because industry has refused to disclose. Government and their various reviews have supported them in this. Leaked documents suggest that at a maximum our residents are getting on average 3 hours per day but it could be much less. This is close to the 2.9 hours below which the US has found a majority of residents are likely to be harmed.
The claim to a lack of evidence is nonsense and is simply because true believers never look to see if there is evidence. They don't want to know about it. The response is to label the policy as ideology when this is in fact their problem and then in desperation to call on the flawed accreditation system as proof. We have vast amounts of evidence about what happens in a corporate marketplace when these matters are "left to each individual agency".
Where is the evidence for workforce planning?
Australia is unique among developed nations in that it does not collect and make available objective assessments of standards of care, nor of staffing levels and staffing expertise. As I have indicated elsewhere, this situation was probably created in order to protect government and industry in 1997 when both were vulnerable to a backlash by the community.
The most reliable evidence that there are too few staff in Australian nursing homes comes from families who have had bad experiences and from nurses who are disturbed by what they see and what they are required to do. It is the number who are complaining that is so worrying. If we want evidence and guidance we need to look overseas. The USA has been collecting evidence and analysing it for over 20 years. Government agencies have set out clear guidelines for safe staffing.
The problem in the USA is that the information it possesses has not been used effectively. In Australia, we have pretended that it doesn't exist but that is beginning to wear very thin. We need to look at what is happening in Australia before we go to the USA data and what they recommend.
Australian stories from the bedside
There is exceedingly limited accurate evidence about the impact of staffing in Australia. Until such evidence is collected and made available, only "true believers" can make claims about "no evidence" and believe they are credible. Many complain about the complaints system but its not only unhappiness about the way complaints are dealt with. Its also the failure to use it as a means of collecting and analysing information.
The Department of Social Services was unable to help the NSW Inquiry into Registered Nurses by giving them information about complaints.
The data indicates a greater number of complaints about staffing numbers than about qualifications of staff, such as the presence of registered nurses. However, as indicated above, this does not provide a basis to make conclusions about the number of providers failing to have adequate numbers of staff or adequately skilled staff."
There is no shortage of complaints about care and the levels of staffing in Australian nursing homes. These come from families who have seen what is happening in individual nursing homes and from staff whistleblowers. Several examples are quoted on these web pages. I have listed many comments from the coal face on the web page Those who know. For more evidence simply look at the comments below the articles on Australian Ageing Agenda, The Age and other newspapers linked to from this site.
In September 2006, I wrote a long article about the problems and inadequacy of staffing in nursing homes in Australia. I quoted from a large number of articles over the previous few years. Read that and ask yourself if anything has changed or if its got worse
- Nurses in the aged care system The Corporate Medicine website, September 2006
In her submission to the 2010 Productivity Commission Joanne Bryant, an enrolled nurse, describes her experiences and the massive changes that have occurred to nursing in nursing homes when she returned to nursing after 17 years away from it. She was horrified and described it as being transported to another planet.
What greeted me on my return was chaos, staff shortages, stress leave, bullying, neglected patients, and the word budget was now used more than the term patient care.
The lack of staff horrified me. The outward appearance of the facility was attractive to woo potential customers, but staff were at a minimum. There was a Registered Nurse (RN) somewhere on another floor, but her patient load was even bigger than mine. I just had to cope. Which I did in a muddled stressed out kind of way.
Health Care, or non-care as I call it, is a profit driven industry, and as long as it remains profit driven, staff and patients will suffer.
Source: The truth behind aged care - one nurses perspective Productivity Commission website
Many others are making similar allegations:
But it’s the cuts to the hours of care provided at Terrace Gardens in Farrar that has seen it described as a "disaster waiting in the wings" by the union representing nurses.
“One carer was rostered for two hours on their own when a resident fell and injured their back. The resident and carer had to wait until someone was available to help,” she said.
“The staff are distressed about the care and treatment of residents ... with constant cuts they feel they are unable to provide the level of care needed.”
Source: Palmerston nursing home cuts jam rations and staffing hours to save money NT News Aug 4, 2015
Carers struggle to take care of dementia cases to the best of their ability, but the workload is often beyond their capacity, as many patients have reached a state where most functions are gone.
"The ratio needs to be at least one-to-two in order to effectively manage a very old and sick person."
Gray is concerned that the pressure resulting from a lack of resources and personnel is affecting the elderly. Meanwhile, it is essential for people in this demanding job to be properly trained
"Australian citizens will be lucky to receive proper treatment in the near future, at the rate the government is making cuts on aged care.
Source: Aged care staff overwhelmed neoskosmos.com Aug 20, 2015
After one of their members in a nursing home told her CWA friends what staffing was like at night, the Tasmanian Country Women's Association took action:
CWA members from around Tasmania approached nursing homes in their areas and asked about their staffing levels, about the services they had for respite care as well as for people suffering from dementia and Alzheimer's.
Ms Young said the situation in some aged care facilities was alarming.
"Some of the ratios for staff and residents was quite alarming," she said.
Source: Tasmanian CWA alarmed by shortages in staff, specialised services in nursing homes ABC News, 7 Sep 2015
Research at the bedside: RMIT University, Flinders University, three leading aged care providers and an employee union have combined in a research project in order to tell us what matters in the provision of aged care.
Providing care requires direct person-to-person interaction. The foundation of high-quality care is the relationship between the care worker and client or resident. Hence, the benefits of healthy, satisfying and safe jobs for care workers will flow on to create care relationships and services that are healthy, satisfying and safe—in other words, high-quality.
For example, providing high-quality care requires skills and confidence. While formal training provides a strong foundation and is highly valued by employees, care workers also benefit through mentoring from experienced colleagues. Real-time access to an experienced ‘buddy’ or mentor means that targeted advice and guidance is available for new, challenging or complex care situations.
Furthermore, like many service workers, care workers are low paid (as regulated by industry awards). Adding insult to injury are common problems with inadequate and/or irregular hours, not being paid for travel between clients for work activities (such as community care) and expectations to attend work training and meetings on unpaid personal time. Financial strain is common for these workers, leading to high levels of stress and dissatisfaction.
When organisations invest in workers, as our partners did, and improve working conditions (for example, by increasing regular hours or by providing paid training opportunities), they reap significant benefits—a committed, stable and engaged workforce willing and able to create high-quality care relationships and services.
Source: CARING FOR OUR CARERS: HOW QUALITY JOBS UNDERPIN QUALITY CARE Cover story UNISA Business school Magazine Issue 9 November 2016
What is so revealing about this research is not only what it says but that we need all this effort and investment and so many credible researchers in order to try to persuade our leaders and those who provide care of the obvious - what hopefully most of us have known for at least 50 years! There is another similar study at the link below. These both tell us what should be obvious but it is good to have it confirmed by the experts.
- What’s it like living in aged care? Researchers shed new light on quality of life Australian Ageing Agenda 28 Oct 2016
A theoretical analysis
It is perhaps worth stopping to think about what is happening more theoretically as Dr Axxxxx Dx Bxxxx did in her doctoral thesis.
She focuses on the discourses (ways of thinking and discussing) surrounding aged care particularly what is said and what is not said - what I have called the elephants in the room. She takes this down to the bedside, This is essentially an approach to the construction of knowledge, how we understand the situations in which we find ourselves. She looks at the consequences of ignoring what we don’t want to know and what others who see things differently are trying to tell us. Power and not knowledge determines the way in which we understand what we are doing. This can be very different to what is actually happening. She looked at how we got the system we did and then followed that down to the care not given to individual residents at the bedside.
She quotes social scientists to show how by setting the parameters for these discourses "The incorporation of power is able to render the individual and collective bodies under control through a process of making them docile, asleep, silenced, and disciplined to the dominant discourse - thereby governing their acts, attitudes, and modes of everyday behaviour and practice".
When we get to the bedside we see the way that the provision of care is understood as a result of this and can contrast that with what is actually happening there but which no one seems to see. The nursing profession no longer has any control of what nursing is seen to be. She explores all this in depth and the practical consequences.
Looking at the way nursing knowledge no longer influences policy
The nursing profession finds itself in a perilous situation and largely being silenced, despite nursing being the core business of residential aged care. The government has been surreptitiously eroding the very nature of nursing through the aged care reforms, and is determining what nursing care is and what nursing care is not, as well as who can provide nursing care and undertake nursing work.
In looking at the care of residents
More often than not the discourses were in direct conflict or contradictory to each other - none more so than the documentation compared to the reality of the nursing practices.
Because of the divergent discourses that constituted, constructed, and influenced the nursing care for the residents, the nursing was not of an acceptable standard or quality and was being driven and constructed by non-nurses at the bedside, as well as through the governmentality of the disciplinary system. This construct for nursing care provision was dangerous to the residents, the nurses and non-nurses, the industry, the government, and the public. - - - The domain of nursing practice was being eroded, devalued, and denigrated.
The residents received nursing that was custodial in nature and of an unacceptable standard, and through their subjectivation were nursed as objects in a mechanistic way.
Source: BEHIND OPEN DOORS A Construct of Nursing Practice in an Australian Residential Aged Care Facility Page 298-300 Dx Bxxxxx Flinders University October 2006
The proposed Community Aged Care Hub is intended to bring another more independent group to the bedside, one with the capacity to redefine the discourse in real terms and the power to drive that into the consciousness of the nurses, the managers and politicians.
Developments in workforce planning
Despite the paucity of data there has been some useful recent work in Australia. But workforce planning started long before this and most current planning has been based on the flawed 2010/11 Productivity Commission Inquiry. This debate largely ignores the US material that is readily available.
The prediction that many more staff would be needed in 2010 led the Labor government to create a financial carrot for providers encouraging them to pay more and employ more. Marilyn Harrington and Rhonda Jolly recognise the problem and indicate:
A Workforce Compact, introduced as part of the 2012–13 Budget, was to provide an employer who met certain conditions, including raising wages to the rate specified, to qualify for access to government-provided workforce supplement payments.
The (subsequent) Government has subsequently dismantled this policy - - - (because) - - - - the Government believed that providers would not sign the Compact, as the funding provided fell short of paying for the wage increase.
Strategies to address the growing shortage of workers in the child care, aged care and disability support sectors are likely to involve either reducing quality standards or increasing costs, if not both.
Source: The crisis in the caring workforce Harrington and Jolly, Parliament of Australia (undated - accessed 26 Aug 2016)
It seems the unions welcomed the incentives strategy but the industry were opposed.
Outsourcing the problem: The Abbott government instead contracted out an audit of the aged care system to Health Outcomes International in 2014 and promised a workplace policy. It was looking for efficiencies. When the stocktake was finally released it was not particularly helpful and we did not get a workforce policy from Turnbull, the new Prime Minister. It was all about processes, guidelines and impact but it is difficult to see how it reached any conclusions when it did not look at staffing or outcomes for residents where information is not available.
- Questions raised over aged care workforce programmes: Stocktake Media Release Minister for Health 11 Dec 2015
- STOCKTAKE AND ANALYSIS OF COMMONWEALTH FUNDED AGED CARE WORKFORCE ACTIVITIES Final Report Dept of Social Services 11 August 2015
The industry has its say: Frustration about the lack of planning and perhaps the growing negative publicity has led the industry to prepare some documents of their own. Its reports have a very different approach to the critics. A White paper prepared for Aged Care and Community Services (ACSA) by Richard Baldwin and Professor John Kelly in July documented the current workforce and painted a stable and far rosier picture than that described by Montague et al in 2015 (see next slider), They found for example that in 2012 the “Turnover (% of workers in their current job less than a year) is lower (15.8%) than the mean of all Australian women workers (18.9%)”. Yet Montague et al claimed a turnover rate of 25% in 2015.
- The Aged Care Workforce in Australia White Paper (Baldwin & Kelly) ACSA 30 July 2013 (circulated for comment)
In February 2015 Aged Care and Community Services developed a Position Paper based in part on the earlier White Paper.
- THE AGED CARE WORKFORCE IN AUSTRALIA Position Paper ACSA February 2015
Delayed workforce strategies: The article linked below addresses the long delay in the overdue release of the governments audit of the workforce programs and of a promised workforce strategy. The widely different views are revealed. This is a major problem for government as their policies have been largely responsible for the problems in aged care and more of the same will only please the industry and make things worse. The providers are particularly anxious about this and are pressing their interests publicly.
One provider conceded that "the provider peaks are becoming increasingly suspicious that the Federal Government is backing away from developing the workforce strategy announced by Fifield (minister responsible) back in January". There is a new Prime Minister and a new minister. Clearly the providers are worried about the strong pressure being exerted to specify levels of nursing staff and to collect real aged care data. They are advocating flexibility in staffing and opposing ratios to counter these pressures. In this market the key to success is cost cutting and that means reducing staff and skills
A union spokesperson “believes a perfect storm is brewing in residential aged care in particular, given the increasing frailty and acuity of seniors entering facilities, as a result of bolstering home care provision, coupled with predicted shortfalls in appropriately skilled workers, particularly registered nurses".
A staff member from the TAFE teaching personal care workers is worried that “the current workforce is too highly geared towards unregulated workers” urging the regulation of personal care workers. She stresses “another long-standing issue in the sector- the provision of quality clinical placements for students in aged care - - “.
- Frustrations rise over workforce Australian Ageing Agenda 2 December 2015
A Senate Inquiry: Inertia in addressing this problem led the senate to initiate an inquiry into the Future of Australia’s aged care sector workforce in March 2016. There were soon over 300 submissions testifying to the widespread unhappiness in the sector. A large number complained about the working conditions in the sector and blamed the financial pressures created by marketplace policies. The stories told by contributors from the coalface of care paint a picture of a sector in crisis.
When an early general election was called all outstanding inquiries simply ceased to exist. The new senate decided in late September 2016 to re-convene the workforce inquiry. With a slim majority, the new government will not be enthusiastic about addressing this fractious and divisive issue. It will be interesting to see what happens.
- Future of Australia’s aged care sector workforce. Inquiry by Senate Community Affairs References Committee 2016
The Senate Inquiry did meet on the 28th April 2016 and interviewed unions representatives, academics, doctors representing organisations and representatives of allied health professionals as well as representatives from a number of aged care and other bodies. I include here a few fragments from union and university academics who set the stage. The need for minimum staffing levels are mentioned but not explored.
Mr Eden (Union Rep): - - - So you have a de- skilled workforce in aged care, and they are under a lot of work pressures as well.
- - - but unfortunately, especially in the private for-profit area, it is all profit driven. They are perfectly happy to employ someone with a certificate III and get less out of them than someone with a certificate IV or above.
Mr Bekhazi (Union Rep): — -(the number of registered nurses that have moved out of the sector?) Over the last, let's say, five to 10 years, I think it is about 20 per cent that has been reduced to about 15 per cent, or 13 per cent.
- - -countries that are doing well with their aged-care sector—for instance, in the Netherlands- - by capping the patient to worker ratios and making sure there are psychologists in there working with people who are feeling depressed, not only have they improved the quality of care and increased the retention of staff, but they have actually reduced the percentage of inpatients with mental health issues.
Mr Eden: There seem to be some employers more than others that are attracting 457 visa holders. For example, FPCompany Newname C made a lot of positions redundant, especially throughout the Gippsland region, only to then advertise those positions and advertise that people with 457 visas may apply. There are other organisations which, because of the very poor treatment of the staff, cannot attract local employees any more because they have such a bad reputation. They are also advertising for 457 visa people to work for them.
- - - I also think part of the problem is the bullying within the aged care sector. There is a lot of focus on the funding, and many employers are now employing people purely to do ACFI funding. They do not do any direct care themselves. They are just there to generate income for the employers. ACFI documentation is a creative writing exercise at best, and fraudulent at worst.
Ms Svendsen (Union Rep): The government has actually got rid of all of the programs. The skills councils have now been gutted. We no longer have EScan available from them, and there was a lot of workforce data that came out of that in terms of projections, in terms of what we currently have and in terms of skill development and needs. We do not have Health Workforce Australia looking at projections in relation to health workforce issues anymore.
- - - I can say that our primary need right now is to get some workforce research done—data research.
- - - The reality around that stuff is, again, that that is guesswork off the top of our heads. We do not actually have the data. .... there is a need for the sector to have minimum mandatory standards.
- - - no funding providing people with encouragement to allow their staff to undertake further career development.
- - - know certainly that a number of our members would actively discourage their own children or grandchildren from entering the profession, simply because of the nature of the work.
- - - All of the mechanisms that might have actually addressed that, or considered it in a prospective area, are not there anymore; they have all been dumped.
Mr Jacobson (Union Rep): - - - the point is that we do not see - - that aged care should be a dumping ground for people who cannot find work.
Prof. Wells (Latrobe University): - - The main points that we want to make are that the centre is under-resourced and that the staff are too few, insufficiently trained and skilled, and not matched to demand, especially in rural areas. You will already have heard that from the people that have come before us, and also from other submissions.
- - - the skills of the staff who are currently in the aged care sector are not up to scratch. They are not up-to-date and they are not sufficient for the coming challenges,- -
- - - We just want to reiterate the point that the standards of the training courses are very inconsistent and often not very good. People in the aged care sector complain constantly about the lack of skills and the lack of knowledge of people coming into the sector.
- - - the issue of attracting people into this sector is to change our culture as to how we see ageing in the community
- - -But as the people before us said, there is no leadership in that from the Commonwealth government
- - - ageing has disappeared from the priority areas for funding
Prof. Charlesworth (RMIT): - - - does not recognise the increasing level of skill required - - no recognition of the complexity of the work.
- Future of Australia's aged-care sector workforce Community affairs References Committee - Hansard, 28 April 2016
Essential information is lacking
If we look at what staff are saying in submissions and in forums, the picture we get is bleak. If we look at the studies done by industry the picture that is painted is reassuring and shows that progress is being made. It is as if staff give very different answers to studies done by industry. Perhaps the contributors are drawn from different cohorts. In Australia the essential data we need for any sort of policy on staffing in aged care is lacking and the data we have is confusing and conflicting.
Limited Australian Data
The studies that are done don’t provide the essential information that is needed. We don’t know the numbers of each grade of staff and the time they spend giving care. We don’t know the level of care needed by the residents. We don’t know the number and type of failures in care, the standards of care and the quality of life provided.
The studies done by academics address a number of other issues but they can't get to grips with the issue of the number and skills of staffing or with the overall standards of care. I have mentioned a number of studies of nutrition and of other problems on other pages.
Research on recruitment of staff
For example, some interesting recent research looked at what attracted student nurses to enter aged care. They found that their clinical placements were critical. What mattered was support by their mentors and support by the personal care workers. It is clear that facilities where personal care workers are unhappy and where the culture is not welcoming will drive them away and be counterproductive. Student nurses will not be deaf to the strong criticism and unhappiness coming from many nurses in the industry and this will be compounding the staffing problems. Changing the culture within nursing homes from one that is focused on profits to one focused on care is going to be critical in solving the problems in the workforce but this is only one of the issues.
The study by researchers at the University of Tasmania found that the opportunity to exchange feedback with clinical mentors, a positive teaching and learning environment, and supportive personal care workers were three factors that directly related to the likelihood of graduates working in residential aged care.
The workforce challenge facing residential aged care was worsening, as vacancy rates for registered nurses (RNs) in aged care rose to 33 per cent in 2012, up from 26 per cent in 2003, while RNs made up just 15 per cent of the residential aged care workforce in 2012, down from 21 per cent in 2003, the researchers noted.
Source: Study shows ‘crucial steps’ to attract graduate nurses to aged care systems Australian Ageing Agenda, 18 Nov 2015
Research on staffing
When research is done it often turns up deficiencies. Research done by academics from three of our universities found that there was a 25% turnover in staff indicative of a major problem with staffing. The researchers considered that even if government was blind, the industry itself could do something about the growing problem of staffing.
Australia needs “far-reaching policy development” to improve employment conditions, salaries and training in aged care, a new paper concludes, with one of authors telling Australian Ageing Agenda the government is “blindfolded” regarding workforce issues.
“It costs a lot of money to keep on recruiting people when you’ve got that turnover,
“The working conditions need to be made more attractive so seniors can get the care that they rightly deserve in Australian society,” said Dr Montague. “There seems to be a blindfold over government policy in this area. They seem to think, ‘let’s worry about this later’. Well, the problem is now and it’s going to become a burgeoning problem, a worsening problem as times go on.”
Dr Montague said: “Clothed ears. Blinded eyes. Blunted policy; put it off until we absolutely need to attend to it. While in the interim, the people who are working in the industry and people being cared for in that industry sector are suffering.”
Dr Montague said that the lack of attention to the sector’s ongoing workforce woes was age-discrimination on a “bureaucratic level.”
Source: Government blind to urgent workforce issues: expert Australian Ageing Agenda, 23 Oct 2015
The original identifies the major problems in the aged care workforce and the failure of government to develop a strategy for addressing them. They indicate that “Inadequate conceptualisation and policy support from government have led to a lack of well-planned strategic policies to address staff turnover given that is a major concern that has been poorly handled by the sector and government.”
- Attracting and retaining Australia’s aged care workers: developing policy and organisational responses Montague A et al Labour & Industry: a journal of the social and economic relations of work Volume 25, 2015 - Issue 4
An example of a for-profit company operating a luxury facility that had made employment conditions better for staff was described. But with the market pressures driving cost cutting few can afford to do that. Even the not-for-profits are cutting back on benefits like maternity leave for staff.
- Union targets aged care home over removal of paid parental leave for workers ABC News 11 Nov 2015
Research compared the incidence of failures in care with type of provider
Baldwin, Chenoweth, and dela Rama(Australian Journal of Public Administration January 2015 page 1-14) reviewed the international and limited Australian literature examining the performance of differently organisational types of provider of care in the USA, the UK and Australia, including when available the staffing. But most of the basic information needed to do that was not available in Australia. All they could study was the incidence of sanctions. They found that for-profit owned nursing homes were sanctioned more than twice as often as not-for-profit homes. As information about staffing is not disclosed they could not assess the role that staffing played in this.
The study is based on a statistical analysis of data about sanctions since the system of accreditation and sanctions was introduced in 1999.
Mr Baldwin's analysis supports the findings of previous local and international research. The higher rate of sanctions in for-profit services was first identified by Australian gerontologist Anna Howe and Dr Julie Ellis in 2010.
Source: For-profit providers more likely to be sanctioned: study Australian Ageing Agenda, 8 Oct 2014
In an article in The Policy Space, Baldwin summarised his review of the international literature:
The most researched structural factor is ownership as it is a predictor of other factors that may influence quality such as staffing levels, organisational culture and financial performance.
- - - most research studies using large samples have reported that residents in not-for-profit facilities enjoy better quality of care and have better outcomes than those in for-profit facilities. - - - The evidence on indicators of financial performance tends to favour the for-profit sector.
Source: The Future of Aged Care in Australia: A Call for Evidence Based Policy by Richard Baldwin, The Policy Space, 22 Sep 2015
There is international data and guidance
The USA has been collecting data for a long time. Its problem is that it does not do anything effective with that information. I have followed reports going back to 1994 in the USA. During this period, the full extent of the problems of the corporatised market in that country unfolded. Issues about staffing have been central to the developments there and they have been studied. I have only kept a record of some of this material.
USA Data and guidance
The evidence is no longer contestable: There are three major readily measurable determinants of care in the international literature:
- staffing numbers,
- staffing skills as measured by qualifications (particularly registered nurses), and
- the intensity of the profit motive.
In Australia, we need to add distance from a major centre to that, so we have four.
2002-2006 Staffing recommendations not met
In the USA, expert panels have looked at the evidence, and government organisations have made studies. Clear recommendations have been made. But in that country, the marketplace dominates and dictates. Politicians are in the pocket and controlled by the market - even more so than in Australia. Applying recommendations has proved impossible - even after they had promised the electorate they would do so.
A panel of academic researchers supported by the government recommended in 2000 that nursing home residents get 4.5 hours of direct nursing care daily. Last year, the Centers for Medicare & Medicaid Services, the division of the Department of Health and Human Services that provides two-thirds of the money to nursing homes, reported that facilities with staffing below 4.1 hours per resident per day may provide a level of care that results in harm and jeopardy to the residents.
This year, the U.S. Department of Health and Human Services reported to Congress that more than nine out of 10 nursing homes lack enough employees to provide adequate care and that most would have to increase staff by at least 50 percent to do the job properly.
"It's pitiful. It's criminal. It's a tragic commentary on our society that people are dying in our nursing homes because they need help and aren't getting it," said Catherine Hawes, professor and director of Texas A&M University's Southwest Rural Health Research Center and a national authority in evaluating nursing home quality. "These preventable causes of death have been known for years, and in moments of despair those of us in the field ask why nothing has been done."
Source: Woefully inadequate staffing is at the root of patient neglect St. Louis Post-Dispatch October 14, 2002
Five years ago, the Legislature made a promise to nursing-home residents. In exchange for limits on their ability to sue homes for abuse or neglect, Florida promised it would meet federally recommended minimum staffing levels
Yet lawmakers still have not kept their promise that, in exchange for lawsuit limits, residents would receive 2.9 hours per day of nursing aide care.
Why is 2.9 hours per day so important? An eight-year federal study found that below 2.9 hours, most residents "needlessly suffer harm." This means residents aren't fed when they are supposed to be; they aren't turned in their beds often enough to prevent bedsores; or they aren't assisted to the bathroom.
Source: Still waiting for nursing-home staff increase Orlando Sentinel, 10 Feb 2006
Adequate staff numbers of both trained nurses and less highly trained assistants are critically important. Without sufficient feet on the ground to do the work, even the best trained staff will fail. Nothing that Professor Nay has said contradicts that. This is usually assessed by calculating nursing hours per resident.
It is when the performance of the different types of provider are examined that the importance of staffing levels and skills is laid bare.
Controlled studies eliminating variables are impossible to conduct in the sector but the associations are so consistent and so logical that the burden of proof must be to disprove it.
In Australia the Aged Care Act in 1997 removed all accountability in regard to staff levels and to standards of care. We do not have the information we need in Australia and unless we use the US data we are making policy in the dark and that means it is going to be based on ideology - again!
The pattern: There is a clear pattern in the international literature based on ownership and profit pressures starting with not-for-profit providers (mostly faith based) extending through private for profit, then market listed corporate for profit and ending with private equity. Staffing levels and staffing skills are best and failures in care lowest in the not-for-profit owned facilities. Staffing levels and skills are lowest in the private equity groups and the failures in care are highest.
For many for-profit homes, the issue comes down to the bottom line. For-profit homes, on average, have almost 32 percent fewer nurses and 12 percent fewer aides than nonprofit homes, according to a study published last year in the American Journal of Public Health.
Source: Woefully inadequate staffing is at the root of patient neglect St. Louis Post-Dispatch, 14 Oct 2002
Minimum staffing levels and staff distribution
A study in 2009 analysed available data in California which has a higher minimum staffing requirement than other states. This study found that low levels of both total staffing and registered nurses(RNs) were associated with failures in care. Nursing homes that met state minimum staffing levels (3.2 hrs per resident per day) “received fewer total deficiencies and quality of care deficiencies than nursing homes that failed to meet the standard”. Interesting was that this improvement did not extend to serious deficiencies. Those who met the state standard did no better than those who did not. But meeting the higher federal CMS recommended standard of 4.1 hours per person per day reduced the number of serious deficiencies.
Nursing homes with higher RN staffing levels received significantly fewer total and Quality of Care deficiencies. Interestingly the number of less highly trained licensed practical nurses (LPN) had little impact on failures in care or quality of life. Nursing assistant (NA) levels had a positive impact on all the parameters measured.
The study found that “higher LPN staffing may contribute to decreasing quality rather than increasing quality” because they were employed instead of RNs. It favoured a combination of RNs and NA’s and suggested that cost cutting when meeting minimum standards may have resulted in the employment of LPNs rather than RN’s which may have contributed to the failure to reduce more serious failures.
- A Panel Data Analysis of the Relationships of Nursing Home Staffing Levels and Standards to Regulatory Deficiencies H Kim et al J Gerontol B Psychol Sci Soc Sci. 2009 Mar; 64B(2): 269–278.
Charlene Harrington (emeritus professor of sociology and nursing at the UCSF School of Nursing) has been central to work on this in the USA. Her 2011/12 study is typical and unequivocal.
The top 10 chains have a strategy of keeping labor costs low to increase profits," Harrington said. "They are not making quality a priority."
Low nurse staffing levels are considered the strongest predictor of poor nursing home quality.
From 2003 to 2008, these chains had fewer nurse "staffing hours" than non-profit and government nursing homes when controlling for other factors. Together, these companies had the sickest residents, but their total nursing hours were 30 percent lower than non-profit and government nursing homes. Moreover, the top chains were well below the national average for RN and total nurse staffing, and below the minimum nurse staffing recommended by experts.
The 10 largest for-profit chains were cited for 36 percent more deficiencies and 41 percent more serious deficiencies than the best facilities. Deficiencies include failure to prevent pressure sores, resident weight loss, falls, infections, resident mistreatment, poor sanitary conditions, and other problems that could seriously harm residents.
The study also found that the four largest for-profit nursing home chains purchased by private equity companies between 2003 and 2008 had more deficiencies after being acquired. The study is the first to make the connection between worse care following acquisition by private equity companies.
Sources: Low Staffing and Poor Quality of Care at Nation's For-Profit Nursing Homes Health Services Research Article UCSF 29 Nov 2011
The published article: Nurse Staffing and Deficiencies in the Largest For-Profit Nursing Home Chains and Chains Owned by Private Equity Companies Harrington C, OlneyB, Carrilp H & Kang T Health Services Research Volume 47 Issue q pt1 pages 106-128 Feb 2012
2014: Private Equity the worst
A recent study in the Journal of Health Care Finance finds that Florida nursing facilities owned by private equity firms have fewer registered nurses and more deficiencies than chain-owned for-profit facilities and that the longer the facilities are owned by private equity firms, the fewer registered nurses they employ and the more deficiencies they have. The researchers found that changing ownership patterns underscore the need for better, more explicit nurse staffing standards and stronger, more effective enforcement.
Facilities owned by private equity firms had 21% higher deficiencies than for-profit chain-owned facilities and "there was a positive association of deficiencies with progressive years of equity ownership.
However, other research over the years has clearly documented that for-profit facilities in general, especially those that are chain-operated, employ fewer nurses and have more deficiencies than not-for-profit and publicly-owned facilities.
This confirms Harrington's 2011 finding that private equity was the worst offender in reducing staffing and the biggest threat to care.
2016: The latest update on US staffing recommendations
The USA unlike Australia, collects data. A government body, U.S. Centers for Medicaid and Medicare Services (USCMS or usually CMS) analyses that information and makes recommendations based on it. The problem in the USA is not data but a provider and political block. Charlene Harrington and her group have been active leaders in analysing and studying this data. Collaborators from the University of California, Vanderbilt University and The University of Vancouver in Canada led by Harrington have written a 2016 review making the argument for adequate minimum staffing levels in the USA.
- The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes Health Serv Insights. 2016; 9: 13–19 Published online 2016 Apr 12. Harrington C et al
Some states in the USA do have minimum staffing levels but they have been so reduced by pressure from providers that they are almost valueless. As this report and Australia’s Professor Nay both indicate more skilled staff are often required but there are minimum staffing levels below which it is difficult for anyone to provide care safely. The CMS therefore provides “recommended minimum standards” as well as “average expected staffing based on resident acuity”. This is what the CMS expects the average to be when allowing for the adjustments needed to care for those with greater acuity. The writers of the revue want adequate minimum standards properly enforced with penalties for failing to meet them.
US data and recommendations
The recommendations in the USA are given as HOURS PER RESIDENT DAY (HPRD). Because data is collected and is available the authors are able to report the staffing levels in 15,391 US nursing homes. In Australia we can’t even do it for one!
The figures given are for what in the USA are called
- Registered Nurses (RNs) - - a minimum of 2-4 yrs training
- licensed vocational/practical nurses (LVNs/LPNs;) - - 1-2 years training
- Certified nursing assistants [CNAs) - - - about 2 weeks training
|Recommended minimum standard||0.75||0.55||2.8||4.1|
|Average expected staffing based on acuity||1.08||0.66||2.43||4.17|
Interestingly the strongest relationship with “quality” was with the time spent by RN’s, then total nursing time and time by CNA’s. There was less association with the trained but less experienced nurses. This is interesting when we look at some of the criticisms being made of newly qualified nurses in Australia (for example the comments on the article linked below).
In comparing these figures we should note that Australia’s Level III and Level IV trained staff seem to be better trained than the CNA’s in the USA. But at the level of the basic time intensive services needed in much of aged care it may be that numbers are as important as training provided there are enough well trained staff in close attendance. It is interesting that greater acuity was found to need a greater proportion of registered nurses rather than more staff.
Rough comparison with Australia: If we convert these figures to percentages then we can see this as a minimum of 18% registered nurses. When acuity is factored in then on average 26% of staff providing care should be registered nurses. This approaches the roughly one third that were required in Victoria in Australia before 1995.
In Australia 21% of staff were registered nurses in 2003 but that fell to 15% in 2012 so is probably even lower today. Because we don’t collect data and don’t have recommended levels our providers can believe whatever takes their fancy and can happily reduce registered nurses from 33% in 1995 to below 15% (less than half) today without any data to justify that.
- Study shows ‘crucial steps’ to attract graduate nurses to aged care Australian Ageing Agenda 18 Nov 2015
Unlike Australia there has been some improvement in staffing with the mean HPRD for RNs at 1.00 and the mean Total HPRD at 4.54. But this is because there are a number of very good facilities with the top 10 percent exceeding these figures by a long way. The situation becomes clearer when the median is used.
The review indicates that “Total facility-reported median staffing levels gradually increased from 3.7 hprd in 2009 to 3.97 HPRD in 2014 and RN hours increased from 0.5 to 0.7 HPRD in the same period, with wide variations across states”.
The average for the total HPRD for the lowest 10% was 3.18 which is only just above the 2.9 level where “most residents needlessly suffer harm”. When the median is considered over half of all nursing homes have fewer registered nurses and less total nursing hours than the government recommended minimum levels. It is clear that in the USA there is still a long way to go.
Comment on this
There is a lot more in this review and I include some quotes below.
Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. - - there is a need for higher minimum nurse staffing standards for U.S. nursing homes - -
Second, the barriers to staffing reform - - - include economic concerns about costs and a focus on financial incentives - - enforcement of existing staffing standards has been weak - - strong nursing home industry political opposition - - .
Recently, the U.S. Office of the Inspector General found that 33% of Medicare nursing home resident sample experienced adverse events, resulting in harm or death during the first 35 days of a postacute skilled nursing stay. - - - - Sixty percent of the adverse events in the study were related to substandard treatment, inadequate monitoring, and/or failures or delays in treatment by nursing staff and others— -
The regulation of nursing home staffing in the U.S. is expected to be of interest to researchers and policy makers in other countries that have low nursing home staffing standards and staffing levels such as in Canada and England. (note Australia is not included — they don’t measure or record standards or staffing so there is no information)
Over 150 staffing studies have been documented in systematic reviews, conducted primarily in the U.S. but also including studies in Canada, United Kingdom, Germany, Norway, and Sweden. The strongest positive relationships (with quality) are found between RNs - -. Total - levels - and - CNAs- are also related to quality.
High professional staff mix (ratios of RN to total staffing levels), low turnover rates, consistency of staffing, and low use of agency staff are all strongly associated with high quality.
- - - numerous studies have consistently shown that higher state minimum staffing levels (beyond the federal minimum requirements) have had significant positive effects on staffing levels and quality outcomes.
- - (in the USA) half of the nursing homes have low staffing and at least a quarter have dangerously low staffing.
The actual total staffing level for almost 60% of facilities is below their expected level based on facility case mix. Almost 80% have RN staffing levels below, 30% have LVN staffing below, and 54% have CNA staffing below the expected levels
Compare with Australia: Australia does not collect or publish any of the information quoted here and is unable to do comparable assessments. It is essential that until we collect data of our own we accept the best that is available. This is it.
Why there has been so little reform in the USA
The other issue that this review addresses is the reason why there has been so little improvement and the barriers to staffing reform in the USA. This should interest us in Australia because we seem to have similar problems. In the USA, unlike Australia, the problems are recognised and acknowledged by government. Efforts have been focused “on market-based strategies rather than on regulatory requirements such as staffing standards”. Trials of incentives to improve staffing suggest “that regulatory requirements may have more impact on staffing than market-based policies”.
Perhaps Binstock’s argument that the U.S.’s ideological shift to neoliberalism beginning in the late 1970s - - - can explain the unwillingness to enact stronger regulatory and staffing requirements
- - the primary policy focus has been on controlling health expenditures including nursing home costs, and increased staffing standards appear to conflict with cost controls.
Medicare does not conduct financial audits and has no limits on administrative costs and profits,- - -(there are) incentives to upcode resident acuity - - payment rates are not directly tied to nurse staffing levels - - incentives for cost-shifting - - focus on overall cost controls rather than quality outcomes - - nursing homes are able to make choices on how to allocate their resources with few regulatory restrictions.
The profit incentive has been shown to be directly related to low staffing. For-profit nursing homes and for-profit chains operate with lower staffing and more quality deficiencies (violations) compared with nonprofit facilities. Facilities with the highest profit margins have been found to have the poorest quality.
Numerous investigations by governmental and Congressional agencies have found that U.S. nursing home violations are underidentified, and serious violations are underrated by state surveyors, while enforcement varies widely across and within states. Often facilities are not given penalties for serious violations, or the penalties are so minimal that enforcement does not result in compliance. State political leadership has been found to be a factor influencing the stringency of nursing home oversight, - -
- - - Within the U.S. regulatory environment, the enforcement of current staffing requirements has been weak. - - - - New approaches are needed to make the enforcement of existing staffing standards more effective in improving staffing and quality.
The role of politics
The review also indicates that the political situation in the USA has “been a major factor preventing the adoption of higher staffing standards” and that “nursing home industry has consistently opposed regulatory requirements and supported higher reimbursement rate policies and payment incentive programs to improve nursing home quality”. In addition political “conservatives tend to strongly oppose regulatory approaches in contrast to liberal views that tend to support government interventions in the marketplace”.
Other factors that the revue mentions include that
- the industry influences “public policies through campaign contributions, association lobbying, and educational activities”
- “revolving doors between nursing home companies/associations and government may occur at the federal and state levels” which is why “public officials and providers have been found to hold similar views supporting market-incentive programs rather than regulatory approaches”.
- “there has been a large growth in old-age interest groups in the U.S., the effectiveness of their advocacy has been questionable and very few of these advocacy groups focus on nursing home issues”.
- financially struggling advocacy groups “have not been able to overcome the strong industry opposition to higher staffing standards”
The review concludes by indicating that “The problems of low nursing home staffing have also been found in other countries such as the Canada and England”. The conclusion is:
Compelling evidence supports the need for higher U.S. minimum nurse staffing standards, adjusted for resident acuity, to ensure adequate quality of nursing home care as a necessary precondition for making other quality improvements such as in leadership, management, and training.”
Much of what this review says is applicable in Australia,
- The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes Health Serv Insights. 2016; 9: 13–19 Published online 2016 Apr 12. Harrington C et al
Bringing this together
What are the implications of all this and how can we use this information?
Variability: The variability of residents needs may well impact on the number of staff required, but that is not an argument against a minimum requirement. In the USA there are recommended hours of staffing per resident per week, although they have not been enforced (see reports below). As in Australia, mandatory minimum staffing levels have been strenuously resisted by the industry, and it is their lobbying power that has prevented this.
Protocols: In health care we have developed protocols for grading risk, prognosis, appropriate therapy, likely diagnoses etc. This grading and grouping is to guide clinicians and administrators in making decisions.
It is remarkable that there is no simple system for grading the nursing needs of aged care residents. Surely every nursing home administrator needs an easy to use instrument that can be regularly and easily evaluated. If staffing needs vary so dramatically that minimum levels cannot be implemented, then this would be essential. This is the only way that management could respond flexibly to patients' care needs and adjust staffing.
When money is involved as in home care, the care needs of the residents is assessed in order to qualify them for the sized financial package they need and will receive. But when it comes to staffing, the walls go up and the rhetoric drowns out the logic of allocating them the number of hours of nursing care they need and requiring nursing homes to staff accordingly.
As in the USA, nursing experts should specify the daily hours of trained nursing and nurse aids that each grade of care would typically require. As accurate data on performance is collected the needs could be adjusted. These ratings of need and the extent to which the regular staffing profile of each nursing home met the guidelines, would be critically important for prospective residents and for the proposed aged care hub when advising them.
If there was transparency and if providers were as meticulous in documenting care and its requirements as they are in tracking their costs and profitability, we would already have the data we need to evaluate aged care in the same way as other countries do.
As an outsider looking in I cannot see any grounds for not doing this. I invite providers to explain why it does not happen.
Mandatory staffing levels
The Harrington article in the slider above and the references in the final slider going back into the 1990's, reveal that commercial success as revealed by profitability in an unregulated vulnerable market is closely linked to cost cutting, principally of staff and as a consequence to deteriorating levels of care. This is in order to fuel profits and remain competitive.
The private equity and market listed corporations are far more successful in the market than the not-for-profit facilities that provide much better care. Those who provide good care struggle in this marketplace and those who save money by reducing staffing and care prosper. The market works for shareholders at the expense of residents who suffer. This is the very opposite of the way markets are supposed to work. It is a typical culturopathy.
Mandatory staffing was pressed for in the USA, but like almost every other measure that might have impacted on profitability in the marketplace it was defeated by the massive corporate lobby. It is even more powerful than that in Australia.
What minimum staffing levels tied to resident acuity for both nurses and nurse aids would do, would be to force the for-profit corporations to spend more on care which would be improved. To get maximum benefit we would also need an effective customer in possession of both recommended and actual facility figures to redress the forces driving culturopathy. Those who provide good care would have a much better chance of succeeding in this marketplace.
Is Australia really different?
When we don't study our own aged care system, it is simply not rational to simply reject international findings and claim they do not apply to Australia and that we are strangely different - in some way superhuman.
There may be factors that are different but I don't know any that would impact on the way the market operates. I see Australians as human too. I would welcome an explanation as to why we are different?
It was fascinating to see this Twitter post in reference to accreditation ratings. The Quality Agency could not have been unaware of Baldwin's finding that for profits were sanctioned for poor care twice as often as not-for-profits:
No discernible difference based on ownership type in meeting accreditation outcomes says QLD state manager, aged care quality agency #lasaq
An article in the Australian Ageing Agenda followed:
Not-for-profit aged care providers are no better at meeting accreditation standards than for-profit organisations and ownership type has “no discernible” impact on passing accreditation, the Australian Aged Care Quality Agency has said.
The agency’s Queensland state manager, Tracey Rees, told the LASA Queensland conference last week that ownership was not a performance factor.
“There’s been some suggestion in the industry and in the community that the not-for-profit providers are better at meeting expected outcomes than the for-profit providers – that is not what our data is showing us at the moment,” she told the event.
“It shows that there is no discernible difference at an industry level in their performance at audit at all.”
Source: Quality Agency rejects ownership factor on accreditation - Australian Ageing Agenda, 25 Mar 2015
I phoned Ms Rees and eventually obtained the figures on which the claim was based from her. I indicated my view that these were crude figures and the important variable of locality had not been taken into account. I invited her to check the way her figures were obtained and to correct her claim. When that did not happen, I challenged her with the evidence by email and on the comments section of the web page to substantiate her claim or else withdraw it. Neither Rees nor the Australian Aged Care Quality Agency responded. The matters are addressed more fully in discussion in the comments below the article above. Baldwin contributed as well.
Unless the Agency has changed the way it reports its figures, the Quality Agency were well aware, when they provided Rees with the figures, that their data was deceptive and that this statement was false.
The Agency deliberately chooses to present its data inaccurately. The flaw in their assessment of data was pointed out to them in 2008, but they had ignored this. Truth cannot be allowed to intrude into belief.
When the important variable of distance from a major centre is considered, it is obvious, from the figures the agency regularly present, that the claim is flawed.
The agency's own figures show that metropolitan areas perform much better than rural centres and hardly any for-profits operate in rural areas. To attain the agency's performance values showing that for-profit and not-for-profit perform equally well in meeting accreditation standards, not-for-profits must be performing 3 to 4 times as well as for-profits in metropolitan areas.
When the data from accreditation reports were properly analysed in 2008 by Aged Care Crisis, this is exactly what was found.
In their larger study in 2014 where they considered all of these variables Baldwin, Chenoweth, and dela Rama also documented that distance from a major centre was associated with more sanctions but when variables were addressed for profits were sanctioned more than twice as frequently as not-for-profits.
For-profit aged care services have a higher rate of regulatory failure, according to new research that found private providers were more than twice as likely as not-for-profits to have government sanctions imposed on them over a 13-year period.
Source: For-profit providers more likely to be sanctioned: study - Australian Ageing Agenda, 8 Oct 2014
There is growing disquiet about the operation of the aged care sector. In the absence of better information, the safety of residents requires that we accept that our developing corporate marketplace is replicating the behaviour of that in the USA. We need accurate information we can trust urgently. In the meantime, the public need protection and properly enforced minimum standards would help.
A role for the community
When I wrote about staffing issues in 2006, I indicated that the solution for the problem in staffing created by politics and the unregulated market lay with the community.
The Community Aged Care hub and staffing
My own view is that whatever system we have, communities should play a pivotal role in running and overseeing the operation of nursing homes in their community. Neither politicians nor market moguls can be trusted to deliver the care the community expects.
The community needs to place itself in a position where it has the muscle to ensure that funding is fair in the light of what the country can afford and what the community is prepared to contribute. It also needs to be in a position where it not only knows but sees what is happening in the local nursing homes so that it can balance funding and care. Organisational structures in the community are needed to accomplish this.
Source: Nurses in the aged care system Corporate Medicine website, Sep 2006
The proposed Community Aged Care Hub is intended to fill that role. The collection of accurate data about staffing and care so that aged care policy can be based on evidence and informed community debate is a key function of the proposed hub. The hub would be on hand to check that resident staffing needs were being assessed, that appropriate levels of staffing were in place and that the multiple other factors impacting on care were attended to.
Recommended staffing levels preferably based on acuity are clearly required and the hub would work to see that they were applied flexibly and effectively. With a properly functioning hub in place, recommended staffing levels would be a necessary guide to fall back on but making them mandatory might not be so important. The hub would know exactly what was happening in the nursing homes and in the community. It would be in a position to address it locally with management or politically through the community and through its central structure. The market would work for residents because the community would be there to protect them.
More from the USA
Many studies were done in the early years in the USA. Here are some more.
Additional international reports 1998 to 2016
To illustrate the nature of the problem here are some additional US references addressing these matters. They also describe failures in the regulatory system and the impotence of politicians in the face of the powerful corporate lobby. Are we seeing the same situation developing in Australia?
1998: In Florida
A six-month Tampa Tribune investigation has found that residents of for-profit homes had higher than average rates of reported neglect and abuse. Homes owned by four large chains - Beverly Enterprises Inc., Integrated Health Services Inc., Vencor Inc. and Mariner Health Group Inc. - were more likely to fall below state standards than other homes.
... Meanwhile, the system for protecting nursing home residents is so heavily weighted in favor of the nursing home industry that bad homes are given repeated chances to stay in business. Shortcomings at the state agency that regulates nursing homes have further exacerbated the situation, records show.
Even when a long pattern of neglect exists, the system to protect nursing home residents protects the industry instead, a review of scores of agency records has found. Often, nothing happens until there's a crisis.
State Rep. Carl Littlefield dubs it the "unholy alliance" - the relationship between Florida's largest nursing home trade association and the agency that regulates the industry.
More than 10 years ago, Congress heralded its passage of new laws to ensure humane treatment of people in nursing homes. Another institution, however, has quietly imposed its own standards:
State and federal records show business profits can come at a high human cost.
About one-quarter of Florida's nursing homes fell below state standards during annual inspections between January 1997 and March 1998. Among four of the state's six major chains - Beverly Enterprises Inc., Integrated Health Services Inc., Vencor Inc. and Mariner Health Group Inc. - the substandard rate was 32 percent to 40 percent.
"All you have to do is look at the nonprofits to see what's happening," said Jean Venturino, a visiting nurse who sees patients in several area nursing homes.
"Maria Manor, Menorah Manor, in St. Pete, they're nonprofit. They have an ethic of caring," Venturino said.
"Investors look at the short term. Investors look at returns and dividends. They're not looking at quality of care," Bell said.
Working in the evenings, Poinelli said, she found supply cabinets locked, and she searched from floor to floor for bandages and catheter bags. Often she couldn't find them, which meant patients did without.
Frequently alone with as many as 40 people, Poinelli would find some wet or hungry, pleading for help, she said. But she couldn't detour to help them or her patients wouldn't get their medications on time.
The nursing director's job had become a revolving door, she added. "It seems like I had a new boss every day. ... I started having nightmares."
Source: Money or mercy? - The Tampa Tribune, 15 Nov 1998
The Tampa Tribune series "Money of mercy" from which the quotes above were taken comprises multiple articles with different titles published on the same day analyzing the crisis in aged care in Florida, a state where the large corporate chains dominated and had close links with politicians.
2001: writing about the USA but published in the British Medical Journal
Non-profit nursing homes are associated with better staffing and higher quality services as well as with residents having a lower probability of death and infection. Facilities owned by investors have fewer nurses and higher rates of violations, or deficiencies, on annual surveys of nursing homes. Profit making facilities were found to have 30% more violations of standards assessing quality of care and more deficiencies in measures assessing quality of life than non-profit facilities.
Profit making facilities have 20% fewer staff than non-profit and government run facilities. Poor quality care in nursing homes is associated with low wages and few benefits, high rates of employee turnover, and heavy workloads.
Source: Regulating nursing homes: Residential nursing facilities in the United States Charlene Harrington BMJ VOLUME 323 1 SEPTEMBER 2001
By 2001 the problems were better recognised and seen as national:
The weakness of the standards on staffing is made worse by an ineffective system of survey and enforcement in which responsibility is devolved to the states. - - - The General Accounting Office has found that those conducting surveys are unable to detect serious problems in the quality of care -
The lack of government control over public funds is a cause for concern. Currently, less than 36 cents in every dollar spent on nursing facilities is spent directly on care. No limits are set on the amount of returns that can be allocated to shareholders, on salaries for chief executive officers, or on spending on capital and administrative costs.
These corporations have wide discretion over the spending of large amounts of public funds, but at the same time there is little financial accountability. Fraud and financial mismanagement are widespread throughout the industry as is poor quality care.
- - - and government regulatory bodies are subject to lobbying by the industry. There is also a reluctance to use the enforcement penalties and sanctions available.
Source: Regulating nursing homes: Residential nursing facilities in the United States Charlene Harrington BMJ VOLUME 323 1 SEPTEMBER 2001
These quotes, published in the British Medical Journal could be describing the situation and lack of accountability that we now have in Australia
In a peer-review study published in September of last year by the American Journal of Public Health, Harrington and four other experts concluded: "Investor owned (for-profit) nursing homes provide worse care and less nursing care than do not-for-profit or public homes."
The study found that for-profit homes employ about one-third fewer licensed nurses than nonprofit homes. The authors also reported that government inspectors found 46.5 percent more care deficiencies at for-profit homes than nonprofit facilities.
"Reduce the staff. Increase the profits. If you're a corporation, it's good business sense. If you're a nursing home patient, it's obscene greed that could kill you," says Catherine Hawes, a professor at Texas A&M University's Department of Health Policy and Management and the senior investigator on several government research projects.
Her view is typical of many people who study the industry.
"The really unimpressive-looking facilities can be spending their money on staff and be offering great care," Hawes said.
Source: Inadequate Medicaid payments squeeze homes' level of care St. Louis Post-Dispatch October 14, 2002
Identifying the cause of thousands of preventable deaths each year in America's nursing homes is not difficult, but fixing the problem is far more complex.
A panel of academic researchers supported by the government recommended in 2000 that nursing home residents get 4.5 hours of direct nursing care daily. Last year, the Centers for Medicare & Medicaid Services, the division of the Department of Health and Human Services that provides two-thirds of the money to nursing homes, reported that facilities with staffing below 4.1 hours per resident per day may provide a level of care that results in harm and jeopardy to the residents.
But nationally, the average home provides about 3.5 hours, according to a study last year by Charlene Harrington, a professor of sociology and nursing at the University of California at San Francisco and a nationally recognized expert in evaluating nursing home care.
For-profit homes, on average, have almost 32 percent fewer nurses and 12 percent fewer aides than nonprofit homes, according to a study published last year in the American Journal of Public Health.
Source: Woefully inadequate staffing is at the root of patient neglect St. Louis Post-Dispatch October 14, 2002
Corporate Chain 2001
|Mariner Health Care||$688,029||8.3|
|Integrated Health Services||(-$30,657)||11.5|
|Other Georgia for-profit-homes||$92,877||6.5|
Source: THE BOTTOM LINE OF CARING: National chains earn poor inspection reports The Atlanta Journal and Constitution July 28, 2002
With the exception of Integrated Health Services, the number of deficiencies is roughly proportional to the average profit generated by the facilities.
Integrated Health Services was in disarray with a large deficit, struggling in bankruptcy. It was trying to generate profits in order to find a buyer for its nursing home business. It failed to do so and never emerged from bankruptcy.
The information comparing the private-for-profit in the last row with the corporate market listed chains is as clear cut. Other studies show that the not-for-profits out-perform them all in providing care.
"The root of evil is lack of staffing," added Carlton Bennett, a Virginia Beach lawyer who handles many similar cases. A study conducted by the U.S. Department of Health and Human Services in 2001 supports this view. It found "strong and compelling evidence of the relationship between staffing ratios and quality of nursing home care."
Virginia is one of the least generous states when it comes to Medicaid funding. It ranked 47th in per capita Medicaid nursing-home spending in 2001.
Some homes, like Sentara Nursing Center in Chesapeake, provide as little as 2.2 hours of care per patient per day, the data show.
Source: Safety, care violations widespread in region; staffing and money are critical, but too often fall short The Virginian-Pilot(Norfolk, Va.) April 27, 2003
A study of turnover rates for staff showed a dramatic association with lower staffing levels, lower quality, for-profit ownership and higher bed size.
- Study: Low staffing levels, for-profit ownership equal higher turnover McKnights 6 February 2006
Private equity became interested and started investing extensively in nursing homes in the mid 2000s. Until that time the for profit chains had been the prime offenders. The New York Times was the first to document that a new and much more greedy shark had entered the sector.
Those investors include prominent private equity firms like Warburg Pincus and the Carlyle Group, better known for buying companies like Dunkin’ Donuts.
As such investors have acquired nursing homes, they have often reduced costs, increased profits and quickly resold facilities for significant gains.
But by many regulatory benchmarks, residents at those nursing homes are worse off, on average, than they were under previous owners, according to an analysis by The New York Times of data collected by government agencies from 2000 to 2006.
The typical nursing home acquired by a large investment company (ie private equity) before 2006 scored worse than national rates in 12 of 14 indicators that regulators use to track ailments of long-term residents.
The typical large chain owned by an investment company in 2005 earned $1,700 a resident, according to reports filed by the facilities. Those homes, on average, were 41 percent more profitable than the average facility.
But, as in the case of Habana, cutting costs has become an issue at homes owned by large investment groups.
Source: More Profit and Less Nursing at Many Homes The New York Times 23 September 2007
McKnight's Long-Term Care News
McKnight's Long-Term Care News is a magazine serving the US aged care industry. It comments briefly on research and other issues. The USA has a rich data source that can be studied.
US states that had introduced higher minimum staffing standards were found to have higher overall nursing levels as well as higher RN staffing levels in their nursing homes
- Higher standards improve staffing levels in nursing homes, study finds McKnights 31 May 2007
Research has shown a high 21% risk of falls in newly admitted, short-stay nursing home residents. Facilities that had higher CNA-to-resident ratios had fewer falls.
- Fall risk in new nursing home residents tied to CNA staffing levels, study says McKnights 7 Jun 2012
Hand hygiene deficiencies found by inspectors increased from 7.4% in 2002 to 12% in 2009. Facilities with fewer RNs, LPNs and aides had significantly more deficiencies than facilities with more staff.
- Hand hygiene deficiencies are tied to staffing levels, study finds McKnights 28 Aug 2012
Research across multiple states confirms that minimum staffing levels improve care but interestingly one of the impacts was that they employed fewer registered nurses. This perhaps suggests that the skills mix should also be a requirement.
- Nursing home staffing standards reduced severe deficiency citations, researchers find McKnights 30 May 2014
This study of staffing showed differences between different US states. The obvious takeaway was that additional staffing translates into better care. An average of 22 extra minutes of direct care per resident daily made a big difference. The report did not look at the way profits and different providers operated and instead targeted a lack of money as the key concern. It concluded that until the “world feels that nursing homes are staffed adequately, demands for additional workers will continue”.
- Yet another report takes aim at nursing home staffing levels McKnights 22 Sep 2014
New Mexico is trying out an interesting strategy to improve staffing and so care. It is attempting to sue nursing homes by “alleging insufficient staffing made proper care impossible”. It is using studies of the time taken to carry out tasks to support its case as well as confidential witnesses from facility staff. They have indicated that managers were aware that there were too few staff to provide care.
- NM uses unique tactics to sue nursing home chain over care, staffing issues McKnights 8 Dec 2014
This New Mexico case is ongoing. The defence are arguing that the minimum state level in New Mexico is 2.5 hours per person per day and this is all they have to supply. The argument that more is required is not legal.
- Report: Data used in NM nursing home lawsuit clashes with industry staffing standards McKnights 3 Apr 2016