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Community Affairs References Committee
23/02/2017
Future of Australia's aged-care sector workforce

BIRKS, Professor Melanie, Head, Nursing, Midwifery and Nutrition, James Cook University

DAVIS, Ms Jennifer, Senior Lecturer, Nursing, Midwifery and Nutrition, James Cook University

LYNWOOD, Mr Shaedon, Student, James Cook University

[14:15]

CHAIR: Welcome. Could I just double-check that you have been given information on parliamentary privilege and the protection of witnesses and evidence. Okay, thank you. Do you have anything to say about the capacity in which you appear?

Mr Lynwood : I am a second year Bachelor of Nursing Science student at JCU.

CHAIR: Thank you for coming. I invite whoever wants to make an opening statement to make an opening statement, and then we will ask you some questions.

Prof. Birks : Thanks, initially, to the committee for inviting us to speak at this hearing. Personally, if I can speak for myself, I have limited experience in working in aged care as a registered nurse, but I do have extensive experience in the education of nursing students. I would like to address two terms of reference of this committee, the first being the challenges in attracting and retaining aged-care workers, and the other being the role and regulation of registered training organisations, including work placements and the quality and consistency of the qualification awarded.

In respect of the challenges that are faced in attracting and retaining aged-care workers, there is a perception that aged-care nursing is less glamorous than nursing in the acute sector. This perception is fed by a belief that nurses working in an aged-care setting require a lower skill set than those working elsewhere, and often there is this perception, which I am sure the committee is aware is erroneous, that nurses who work in aged care work there because they could not get another job in another setting.

I have undertaken and published research that looks at the career trajectory of nursing students. The findings of this research have reinforced other studies that have shown that nursing students want to work in areas with machines that make beeping noises and work with babies in areas such as midwifery or paediatrics. I, anecdotally, as a routine measure each course intake, ask students where they would like to work. I will have a lecture theatre full of hundreds of students and I will say, 'Who wants to work in emergency?' and the hands will go up. 'Who wants to work in critical care?' and the hands will go up. 'Who wants to work as a midwife?' and the hands go up. 'Who wants to work in aged care?' and if I am lucky there is one or two students who will put their hands up.

Mr Lynwood : There is.

Prof. Birks : There is. One or two students will put their hands up. I do wonder whether or not the perception of aged care as being less glamorous than other areas in nursing puts people off owning up to their career intention. But I have noticed recently that there has been a change in the number of students who are interested in working in aged care, and I think that this is the result of the pathways that universities now make available for students who come from non-traditional, non-school-leaver backgrounds—so people who are working as assistants in nursing or personal care attendants who want to further their career and are passionate about providing quality aged care and seeking further qualifications as a means of doing this.

In reference to the other term of reference, the role and regulation of education providers including workplace organisations, in education and universities we strive to dispel this myth that aged care is not a specialist area, because it certainly is. We do instil in students the understanding that there is a broad and deep and complex skill set that is required for people who work in these areas as much as it is in emergency departments or paediatric settings.

Unfortunately, there is considerable pressure on schools of nursing in respect of placements, because we struggle to find quality placements that are affordable. The funding that is available for placements is pretty much gone and this creates huge problems for us. In our current curriculum, initially, we attempted to put the aged-care placement in the final year of study in recognition of the specialist nature of it and to reinforce the specialist nature of it. Unfortunately, acute care settings prefer students with a more advanced skill set and so as a result of that our first-year students were forced back into the aged-care setting.

In our curriculum that we intend to implement next year, there is an increased focus on working with our industry partners to develop new models of education and placement that will see the focus shift back to where it should be, which is on the achievement of learning outcomes regardless of the setting.

Thank you. I will hand over to my colleague.

Ms Davis : I will just reiterate Melanie's comments about thanking you for the opportunity to appear. My understanding of the terms of reference is that you are not taking any more new submissions and I think I would, if—

CHAIR: If you have some additional information that you want to give us, please do. We are about trying to learn as much as we can.

Ms Davis : I am a nurse, a midwife and a health information manager, so I declare that bias. I have worked in aged care as a young nurse, and over recent times I have undertaken a project for the Department of Social Services, examining ways to improve older people's access to health care. I am about to submit my PhD, which has examined the policy and operational interface between health and aged care, and a big part of that was looking at the body of work around workforce and what needed to change within our current system to accommodate the policy reform.

The key point that I would like the committee to consider is that we have conflicted expectations of aged care currently. In the past, historically, aged care has been hostels and nursing homes with a really high nursing staffing profile and, in that context, aged care was also able to provide health care. But following the Productivity Commission report and the aged-care reforms, the Living Longer Living Better reforms, there has been a shift. Aged care is more about social support, so it is about accommodation and providing personal support. We now have a community who still expect aged care to be able to provide some form of health care and access to health care and we also have nurses who work in that setting who are constrained by that environment.

If I could, I will just talk about some key points that have come out of my PhD studies that relate to what you are looking at. In terms of the composition of the workforce, previously it had a high nursing profile. It was a lot easier, if you like, to access primary health care in that setting. There was health care on site and there was no need to have to transfer care to other settings. I am talking about residential and community. I think the aged-care workforce is still poorly defined in terms of a broader understanding amongst health professionals and the community. They still think that the aged-care workforce is also health care. It is a one-stop shop, if you like. But we listened to the concerns from Blue Care and others today that aged care now operates in a business model. It is not a care model. And you have talked about the shift in care now to a consumer-directed care model that is also within a competitive market that functions according to business models.

The participants in my study identified their work environment as risk averse. There is a compliance culture, and whilst nurses and GPs in those settings wanted to support a consumer directed care model, they also needed to function in an environment that constrained their capacity to support decision-making by people. Someone might have had a fall, and so to cover themselves legally they might transfer them to a hospital so that if something happens and they end up in a coroner's court, they would be seen to be covering all their bases. That happened in some settings even if the consumer said, 'No, I didn't want to be transferred to hospital.' I want to allude to those sorts of conflicts that the workforce is trying to face.

We know that there is an ageing workforce in nurses and general practitioners. In the longer term there are declining numbers of GPs who have an interest in providing care in that setting, and we also have a nursing workforce, both community and residential, who are underutilised. They are unable to use their full scope of practice. They might be the sole nurse or the sole practitioner. There is limited practical support for them there. We know that care delivery models are changing. I have talked about how they are more business models rather than person centred models. Often the business imperative will necessarily in those environments override what might ideally be the consumer choice, and the staff working in those settings are having to weigh up those sorts of things. There is limited continuity of care and of carers because of those pressures, so care tends to be episodic and reactive rather than proactive. We know that older people have better outcomes from care that has a reablement and restorative focus, where we can be proactive rather than reacting to an incident or to their deteriorating health.

We have a policy direction that advocates healthy ageing, independence and so on, yet we have funding systems that measure dependence frailty. Again, people working within aged care have that conflict. We are supposed to be restoring people to whatever they were, yet there is a financial incentive built into how we measure dependency, for example.

I do have some suggestions on how we might address some of these; I do not want to just talk about the problems. There will necessarily be competition across other sectors, not just for aged care. The policy direction is for greater expansion into the community. Some of the work I have done shows quite clearly that we need locally developed flexible models that involve multiple disciplines and are not just controlled by one discipline. For example, GPs currently function as gatekeepers to other health services. Community care, aged care and primary health care access is particularly important for older people, so they need timely access to care, rather than an incident where they might have to wait eight hours for a locum to come and visit them. That is comparable to poor access to services in rural and remote settings. Those locally developed flexible models are collaborative, and the witnesses before us spoke about the need to develop them.

If we think about the underutilised nursing workforce, there is an opportunity there. Senator Macdonald talked about physician assistants, but I think there is already an underutilised workforce that could be more agile and flexible and would also offer opportunities. There is a career development pathway that might be more attractive for people like Shaedon who want to pursue a career in nursing. We could introduce a model where there would be a graduate entry program into aged care, but also a pathway into a higher qualification, if you like, as a nurse practitioner. Those nurses or health professionals—it does not necessarily have to be nurses—could function as what we call boundary spanners. They effectively negotiate care and have eyes on the person. There is continuity there; they know them. They can share information about quality-of-care outcomes. But I think the key to that is the locally developed models—multipurpose services in areas where there are those business restrictions, particularly in rural and remote, so, rather than having a specialist workforce, we have a generalist one that functions similar to the remote area nurse models, where those advanced practitioners work across the community and they are able to work across different settings.

CHAIR: I am going to have to ask you to wind up so that people can ask you questions. By the looks of it, you have got a lot more detail about that in the paper you want to give us.

Ms Davis : That is a question. If there is the opportunity to present something, if the committee is happy to take it, I can provide something.

CHAIR: That would be really appreciated.

Ms Davis : Okay.

CHAIR: I am just conscious of making sure people get to ask questions.

Ms Davis : I will leave it there then.

Mr Lynwood : I am a second-year Bachelor of Nursing Science student studying at James Cook here in Townsville, and I am here to explain the reasons behind why I have an interest in a future career in aged care. My interest comes from observing and learning about what characteristics make someone more suitable to work with the elderly. From what I have learned, I believe a career in aged care requires compassion and a desire to better the health of individuals who are just in unfortunate circumstances. The fact that I am passionate about wanting to become a nurse motivates me to pursue any career in nursing really, but I feel as though I possess a few personal characteristics that just occur naturally to me while working with elderly patients, such as being able to empathise with them and develop relationships naturally. They are just a few attributes I believe I possess that make me more suitable for a career in aged care. But what really motivates me is the thought that I can make a real contribution if I work in aged care. I have hopes of eventually directing a nursing home one day so that I can make a real impact. These are just all thoughts at the moment, but that is why a career in aged care really interests me.

Senator POLLEY: It is so good to have someone come along today with your perspective. I think that is really important. I do get encouraged in my home state when I go to a residential home and see younger members of staff there. It is encouraging. Ms Davis, you did not actually get to the point in your opening comments about the solutions. This is a free hit. Can you tell me what the federal government needs to do and what the sector needs to do to rearrange so that we have a very competent and committed workforce going forward?

Ms Davis : I think there needs to be a review of the expectations of aged care—what is aged care actually going to provide?—and that co-dependent relationship with health care. The government currently subsidises personal support for people to either stay at home or, when they cannot stay at home, cannot be supported at home, to move into permanent accommodation. That is clearly the policy issue. However, if you think about the clients that we are looking after, they are increasingly older and frail. They are all the things that you have heard. So we need to not lose sight of that relationship in terms of workforce.

What is that workforce going to look like? Is aged care just going to be the providers of the personal and social support and the accommodation, and someone else provides health care? We have a federal system that funds aged care and primary care—GPs—and we have a healthcare policy that is funded across three levels of government. It is that relationship, I think, that perpetuates the siloed systems of care that we have. In a way, health policy works as a barrier to a person-centred model, because health care is still focused on the profession and the institutions. We need to break the professional boundaries that Blue Care spoke of earlier, around those industrial relations issues. How do we develop a workforce that is truly specialist generalist, if you like—that can be flexible and agile and work across those boundaries and those policy boundaries? How do we work that out?

That is where something like the nurse practitioner model is needed—someone who could work across. It will challenge professional roles, for sure. I think there needs to be some leadership in that way.

Senator POLLEY: Not just from evidence that has come before the committee but from my experience travelling in the country and visiting a lot of residential homes, I think it is from those that have a very close working relationship with their universities that we see an increase in nurses coming into the aged-care sector, because they have a much closer relationship and more placements. We have also seen across this sector, over the last four or five years, some pilot projects whereby residential homes run a program with the universities. They have nurses, ambos and different professionals—GPs—spending time in that residential facility so that they have a greater understanding, because there is a big difference. There must have been something rather than your own personal skills, Shaedon, that attracted you into this sector. Was it your time in your placement?

Mr Lynwood : My last placement was in a subacute unit at Townsville Hospital, and the majority of those patients are elderly. It really did attract me when I worked with those patients. I feel as though it is pushing me towards that sort of sector. If I was to graduate it would be very satisfying for me if I was to work in aged-care. It is more about the patients, for me. You can easily learn all of your skills and if you are passionate about being a nurse you could take your skills anywhere, but being able to work with elderly patients is what interests me.

Senator POLLEY: We have had evidence from those who support the use of a ratio methodology for having nurses in residential homes. Do any of you want to put on record your view as to whether ratios for nurses equate to a better outcome for those residents?

Ms Davis : My personal view would be yes. At least establish a minimum, I think. It does not necessarily have to dictate numbers, as such, but I think there needs to be an established minimum where you actually can demonstrate that there has been someone with a critical clinical eye who knows the clients and what their health needs are.

Senator POLLEY: In terms of your training at university for your nursing degree, how much time is spent in studying the effects of dementia. It is one of those health needs that is dramatically increasing and most likely will continue to do so over the next two decades unless we find a cure. How much time is put into skilling up your students to be prepared to go into that workforce within the aged-care sector?

Prof. Birks : We try as much as possible to take a lifespan approach, so that is a topic area that will find its way into a variety of subjects across the curriculum. Usually, in our earlier nursing subjects in preparation for students who are going to be working in the aged-care sector, there would be content in the form of lectures and labs, but it is probably less than it should be and needs to be because it competes with the many varied areas that we are required by our accreditation body to include in the curriculum.

Senator POLLEY: How do we change the perspective that the public—and potential nursing staff—seem to have that aged care is not as rewarding as any other field? How do we change that? Is it just something within the public that we need to continually monitor? We have had people giving evidence say that it is not considered to be as sexy as working in ICU, but I think it is quite the reverse.

Prof. Birks : I think the best way to make it appear more rewarding is to actually make it more rewarding. When we have a situation where in some states in Australia you get paid less for working in aged care than you do for working in the acute sector, we are putting a price on it. We are immediately quantifying its value, which is really quite shameful.

How do we change the image? In respect of the image of nursing in general, the profession is largely responsible for its own image. I think that is something that we need to tackle from within. My colleague may disagree with me.

Ms Davis : I would agree that we need to demonstrate that there is some parity being valued. But it extends to society as well. Unfortunately, the media portray the negative. I am a positive language advocate, so I would be recommending that we try to get some positive news stories out there—what it good about it. We know that they are there, but the negative always seems to be how it is portrayed.

Senator IAN MACDONALD: Mr Lynwood, you are in your second year. Do you go out into aged-care homes as part of your course?

Mr Lynwood : It depends what is allocated to you. You can put in a preference. I was originally allocated, on my second placement, to work in a nursing home, but at the last minute they could not do placements, so I was reallocated to subacute. But, yes, work in aged care is available.

Senator IAN MACDONALD: You told us why you were interested in taking aged care. What do your friends and colleagues in the nursing faculty say about not being interested? Is there a bit of chatter around the coffee table about why they prefer other things?

Mr Lynwood : Yes. There is that aspect about most elderly patients being incontinent and that some are very dependent. There can be a nasty, unattractive side to it, so some students might not have the tolerance to be able to care for dependent patients, and some other things might seem more attractive to them.

Senator IAN MACDONALD: Good on you for doing it. But you have had no experience in an aged-care home yourself yet?

Mr Lynwood : In an aged-care home, no.

Senator IAN MACDONALD: Do you ever think that once you try it you might not like it? I guess it is all a bit hypothetical, isn't it?

Mr Lynwood : Yes, that is probably hypothetical. I have a lot of insight into it. As I said, my mum was an AIN. Her sister was a nurse and midwife, but when she was young my aunty worked in a nursing home. It gave me a bit of insight. My mum was telling me examples. At the Shalom nursing home she has walked in on patients who have passed away. Sometimes it cannot be a pretty sight. I have worked with dependent patients and subacute who were elderly, but I probably have not had an unpleasant patient, which you could probably find in an aged-care facility. My mum has told me, 'I think you suit the role of being a DON in a nursing home.' I have hopes of becoming such a thing. They are just all doors for me to open.

Senator IAN MACDONALD: Good on you. Let's hope you do run your own aged-care home one day. Professor, is the course of study for would-be nurses who want to do aged care different to the general course of study?

Prof. Birks : No. Most Bachelor of Nursing qualifications are generic. The aim is to enable the graduates to register as a nurse. At James Cook University we do not offer a specialist stream in aged care, but other universities do. Usually these are at postgraduate level. Not a lot of institutions offer them because, again, they are not seen to be attractive.

Senator IAN MACDONALD: As part of your university work, do you assess students? Do you form a view and is this taken further in references on whether particular students would be suitable for any particular nursing category, in this case? Do you see students and say, 'You're a dead-set certainty for aged-care,' or, alternatively, 'You would be no good at all in aged-care'? Do you make those sorts of assessments?

Prof. Birks : It is not something that we do routinely. We have about 1,600 students so it is difficult for me to get around to all of them.

Senator IAN MACDONALD: Yes, of course.

Prof. Birks : But we employ a body of clinical facilitators, and I often get feedback from students when they are told by their facilitator, 'Yes, you'd be great in this environment or that environment'. In my personal experience, students who are interested in aged-care have come from that area. So, they are currently working as an assistant in nursing.

For example, I did a tutorial yesterday and there were only 30 students there. I asked who was interested in a career in aged care and three people put their hands up.

Senator IAN MACDONALD: Three.

Prof. Birks : Yes. I nearly fell over, I have to say! It was the first tutorial for the year and they were first-year students getting to know each other. The question was, 'Why do you want a career in nursing?' The responses were things like, 'I want to work in aged care because I have been an assistant in nursing in an aged-care facility and I love it. I want to be in a position where I can give people their dignity back.' That is a common thread.

Before I became a researcher myself, as a new graduate I was a research assistant who shared the opinion that aged care was somewhere where you go to work because you have nothing else to offer—where nurses go to die, really. I participated as a research assistant on a study; I interviewed nurses in various different aged-care facilities, fully expecting them to tell me that their reason for wanting to work there was because they could not get a job anywhere else. One person said that it suited her because she had young children and it was close to her home. Every other single person I interviewed said, 'I work in aged care because I make a difference and I feel like I am needed.' That really changed my perspective on aged care.

Senator IAN MACDONALD: Yes. This is probably a politically incorrect question, Mr Lynwood. You are a bloke, and a big bloke—and I can ask both of you this—is there some sort of focus on size because you might need physical strength in an aged-care home that perhaps you would not in a normal nursing—

Prof. Birks : That has not been my experience, but Shaedon might have a different opinion. Usually, if we want strength we send them to orthopaedics!

Senator IAN MACDONALD: Okay.

Mr Lynwood : My size has not really benefited me. It has probably been a disadvantage, especially in bending over beds! It has not been beneficial.

Senator IAN MACDONALD: Perhaps I should not have asked!

Senator WATT: Thank you again to everyone for coming. Ms Davis and Professor Birks: one of the things I am interested in is what experience you have in retraining older workers who are changing careers and thinking about coming into aged care. Is there much interest by older workers in pursuing a career in aged care? Are there things that we could be doing differently to attract people?

Prof. Birks : I will go first. We have quite a large percentage of mature-age students coming into our undergraduate degree. I would have to say that those who do express an interest in aged-care are usually mature-age students, because they are the ones who have had the experience and who know how rewarding it can be and the contribution that they can make.

Senator WATT: Are there any specific strategies that you are aware of that target mature-age students to pursue careers in aged care?

Prof. Birks : The Australian College of Nursing for many years used to offer—I am not sure if they still do—scholarships for people wanting to undertake studies in aged care.

Ms Davis : They still do.

Senator WATT: Okay. One of the reasons I asked that is that we read a lot these days about changes to the workforce that are going to happen with automation. There is a lot of discussion about the impact, particularly on older men from traditional industries—jobs being disrupted and that kind of thing. And from time to time you read stuff about having to find ways to make some of the growth industries more attractive to older men, even though that may break down or be against gender stereotypes and that kind of stuff. Is that something that you think would be worthwhile? Is there anything that we could be doing to make these sorts of careers more attractive to older men?

Prof. Birks : What I am thinking about is something that I know Jenny would probably like to comment on. As Jenny has already mentioned, and as our colleagues from Blue Care spoke about before, it is really about the quality. It is not just a matter of recruiting people who are upright and breathing. The people in these facilities deserve quality care, so it is about recruiting quality people. But that is often difficult to do, for the reasons that we have discussed.

So the issue is clearly defining what aged care is, distinguishing it from health care and then determining, on the basis of aged care being distinguished from health care, what sort of workforce we are looking at. What is an aged-care workforce? Then using the underutilised qualified people we currently have, such as nurse practitioners, is probably the route that we would be encouraging the industry to take. Jenny might want to add to that.

Ms Davis : I guess it is just challenging people to think differently. When we talk about the aged-care workforce, there is a group of people who would like to volunteer. It does not necessarily have to be a paid role, particularly for older men, for example. We know that men's sheds and those sorts of things are really beneficial for people who might be living at home alone or in a residential facility because they have some social interaction. So we need to think about the paid model and the unpaid model as well. The aged-care workforce is not just the paid workforce. It is about how those relationships could be targeted as well.

CHAIR: Thank you very much for your time today. Ms Davis, we will be in contact about getting your submission, because that would be really appreciated.