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Standing Committee on Health, Aged Care and Sport
15/03/2018
Quality of care in residential aged-care facilities in Australia

BONNER, Mr Rob, Director, Operations and Strategy, South Australian Branch, Australian Nursing and Midwifery Federation

CURRIE, Ms Patricia (Trish), Professional Officer, Aged Care, South Australian Branch, Australian Nursing and Midwifery Federation

[13:48]

CHAIR: Thank you for joining us this afternoon. Do you have any objections to being recorded by media if they happen to be present today?

Mr Bonner : No.

CHAIR: I'm required to remind you that these are formal proceedings of the parliament. The giving of false or misleading evidence is a serious matter and in some circumstances could be regarded as contempt of the parliament. Today's proceedings are being recorded by Hansard and your evidence this afternoon attracts parliamentary privilege.

Would you like to make an opening statement?

Mr Bonner : Yes, if it's convenient, I could just give a brief—

CHAIR: We like people to keep it to under five minutes!

Mr Bonner : Yes. I note the submission that was lodged by the federal office of the ANMF on 8 February, and on which we rely.

The aged-care accreditation system's failures present a significant problem in providing public confidence that quality of care can be assured in residential aged-care facilities. The position of the ANMF SA branch is that accreditation alone as a process is unlikely to provide the answers that we are all seeking. For example, public and private hospitals also undertake accreditation processes, albeit under different standards. However, in addition, public hospitals are subjected to things like annual performance agreements with state departments and a range of other policy and operational rules which go to the adequacy of care that they provide to their patients. For example, nurse-sensitive indicators are measured, including things like urinary tract infection rates, respiratory infections, the rate of falls within the environment, hospital admission rates and transfers, waiting times in emergency departments, elective surgery rates and day surgery proportions. That approach is consistent with the development of the national quality indicators as recommended through the recent Carnell report for the aged-care sector.

The federal office's submission makes clear that, without regulation of safe staffing levels and skills mix, assurance of quality of care is impossible across the aged-care sector. The current staffing levels and skills mix across the sector are deteriorating rather than improving, despite the ongoing increase in the need for care and services, in particular within the residential sector. The National Aged Care Staffing and Skills Mix Project's Meeting residents' care needs, a report released by the ANMF in late 2016, sets out the evidence of the clear demand for improved staffing levels and skills mix and identifies the significant level of missed care—that is, care that is not provided to residents. With residents receiving an average of only 2.84 hours of nursing and personal care per day, there is no real prospect of the system being able to deliver the quality and level of care that is needed. That report identifies the need to increase the level of care to an average of 4.3 hours of resident care per day.

We must also deal with a mix of staff that is providing nursing and personal care services to residents. The need for complex health care, end-of-life and palliative care, rehabilitation and medication management continues to grow. We have seen increasingly over the last 18 months to two years cases of providers seeking to move medication administration to personal care assistants and reduce their registered nurse enrolled nurse workforce to save on costs in South Australia. The level of training provided to personal care assistants does not provide them with the capacity to properly oversee medication administration, including assessing the need for medication changes, interactions and monitoring unintended reactions.

In relation to the well-known circumstances at Oakden, we note the recent release of findings of the ICAC in South Australia. The experience of residents in that facility was clearly unacceptable and fell short of the standards appropriate for their care. It is the view of our organisation that the accreditation and quality management systems fail to work to protect those residents. The fact that Oakden went through many checks and accreditation processes following the failure of the accreditation in 2008 reflects the reliance on auditing paperwork and policies and processes rather than any deeper analysis of care standards being received by residents. The staffing turnover relies on short-term contract and agency staff and a seemingly high proportion of overseas nurses on fixed-term contracts. This all compounded the relatively low staffing arrangements in that facility.

We also note that the minimum staffing level specified within the enterprise agreement had seemingly been applied to that facility without regard to the actual needs of residents at any particular time. That is, the minimum numbers had become the de facto actual staffing arrangements for the service. We support the views of the ICAC commissioner in suggesting that managers of services had and continue to have a continuing obligation to determine for themselves whatever minimum staffing level in the circumstances is adequate.

I should note that, since the initial report of the team led by the chief psychiatrist, ANMF SA branch has actively assisted in leading change to clinical practice through implementation of our evidence based practice guideline relating to the alternative to the use of restraints. This training was provided to all nursing and personal care staff in the facility and is consistent with national and international standards of practice. Thank you.

CHAIR: Thank you. I might kick off. Just on using Oakden as an example, one of the things that was striking about that was the very few people who did raise the alarm about what was happening in Oakden amongst the workforce generally or amongst management within a department. I am wondering whether you have considered why that was so? I would've thought that, at the very least, you have a moral obligation, if you see practices happening that you don't believe should be, to report them. But, obviously, you need the right culture where people feel confident to do that. Have you reflected on why, for such a large workforce, there seem to be so few people reporting their concerns?

Mr Bonner : I think that the independent commission noted the fact that there were reports that had gone from staff to middle level management of the place, and that there had been a number of instances of reports by the unions of behaviours that suggested a bad culture in the place. Certainly, I know that there were a number of allegations of bullying and harassment made by our members and our organisation in relation to the way that site operated over the years, and that never got the proper scrutiny that it required. It was the blockage of that middle management to executive that seems to have created the problem. I guess, for us, it's demonstrative of the need for that to be recorded in some sort of more transparent way that means that everyone knows that it's gone to the levels within the organisation that it needs to go to.

Clearly, with things like the use of restraint in the place, if the safety learning system had been used appropriately it should have identified the misuse of the level of restraint in that facility years ago. We were implementing change in the restraint policy of a neighbouring hospital four years ago and have had remarkable change in that environment, whilst Oakden almost next door was going the reverse way. It's about ventilating and making that known.

CHAIR: Moving on to the national picture, you referenced the Carnell Paterson report a couple of times in your submission. I am wondering whether you think that it does provide, basically, the framework for moving forward, or do you think that there are major deficiencies in its recommendations, and, if so, what would they be, or things they've recommended that you don't think the government should do?

Mr Bonner : What we would say is that change to the accreditation system is one answer to the puzzle, but accreditation is not, in our view, a fulsome way of ensuring the achievement of appropriate standards. Then the national quality framework that sits alongside of that needs to be developed and grow teeth of its own, so that we do make public the performance of organisations against the national quality indicators that emerge from the process. I think that aligns better with the mixed response that occurs within the public hospital system, for example.

Mr GEORGANAS: Thanks for appearing before the committee to hear your evidence. You mentioned the Oakden case where there'd been reports, and it's in the report that came out, that the staff had reported but it never got through. And, because of that reporting, there were even reports of bullying and harassment that took place. In your capacity as a workers' representative group, what sort of message does that give to others who may see a serious incident? I asked the same question of most of the witnesses that appeared today: do staff have the ability to report things freely without repercussion, knowing that their career progression could be in doubt across the board? You would represent many, many staff members who are in that position, I suspect, or have been in that position. How do we better that so they have the ability to speak out without the repercussions? In this case the outcome was bullying and harassment of that particular staff member, which then would mean that they won't speak up. It also gives a message to others that they won't speak up either.

Mr Bonner : I listened to the evidence that Mr Hearn gave and I think he's right. In his organisation, they have pretty robust policies and procedures. It's probably the largest provider in the state, too, so it's relatively easy to be anonymous in a survey of thousands of people. Most aged-care facilities are not managed within that kind of scale, so affording a level of anonymity to individuals within an aged-care facility is not easy. That does work against people volunteering to speak out, regardless of what the policies of the organisation are. You might be the only registered nurse on the shift, so it's pretty obvious, if there's an anonymous complaint, who made it. Those things do make it more difficult. One of the things that could be done more fully is the way that they deal with reaccreditation of things like registered training organisations, where the agency conducts a survey through a random sample of all of the students who have used the facility. You can do that with staff over the previous number of years to identify whether there were particular issues. That's collected externally by the accreditation body rather than by the employer.

Mr GEORGANAS: Is it common for your organisation to represent people who have been in that situation?

Mr Bonner : Yes, it's relatively common to deal with cases of bullying and harassment.

Mr GEORGANAS: Because of reporting?

Mr Bonner : I don't think it gets to that point. People are broadly unwilling to be publicly critical of circumstances unless it reaches the particular point at which it becomes impossible for them to not speak out.

Mr ZAPPIA: I have a couple of questions. Firstly, with respect to nurses, can you tell me how many currently work in aged-care facilities and would you also be able to tell me whether they are registered nurses or enrolled nurses? If you can't, can you take that on notice and provide us with that information?

Mr Bonner : We can certainly take it on notice and provide you with the information that's available. It has to be said that it's usually survey based, so it will be either through the registration process—the data is usually two or three years out of date by the time it's published—or through the NILS surveys that are conducted by Flinders University every three or four years. In broad terms, in South Australia there are about 3,000 registered and enrolled nurses. About two-thirds of those are registered nurses. The personal care group of the workforce is at around 7,000 or 8,000.

Mr ZAPPIA: I'd also be interested in the latest figures, if you were able to get them—say, over the last 12 months or thereabouts—compared to two or three years ago. I'm trying to determine whether there has been a trend with fewer nurses of both kinds, registered and enrolled, now working in aged-care centres as opposed to years ago.

Mr Bonner : Some of that data is in the report that I referred to the committee, which is the one we published in late 2016. It documents the trend of substitution of registered and enrolled nurses by personal care workers and assistants in nursing, depending on the state or territory you are in, over the last 10 or more years. I'm happy to provide that referencing. That's in line with the Productivity Commission data. We can provide an update to that as best we can.

Mr ZAPPIA: Can you comment on the kinds of nurses that are more appropriately suited to aged-care facilities—registered versus enrolled—and perhaps even compare those with aged-care workers? In other words, what are the benefits or advantages of each of those three categories?

Mr Bonner : It is about meeting the total personal care, complex health care and support needs of residents. The study that I alluded to suggests that, in order to meet the needs of the resident profile as it currently exists, about 30 per cent of the workforce should be registered nurses, about 20 per cent should be enrolled nurses and about 50 per cent should be personal care assistants—assistants in nursing. That is the kind of proportion that should be there. We are currently dealing with a total registered and enrolled nurse proportion of workforce of around 30 per cent and 70 per cent in broad terms in personal care assistants. So there is a significant gap between what is there now and what is assessed as being required, given the kinds of interventions that are going on.

Mr ZAPPIA: Separate to those ratios, do you have a view about staff-to-resident ratios in the broader sense?

Mr Bonner : Our view is that the ratio is currently 2.8 in round numbers of hours per patient per day or resident per day, and it needs to go to an average of 4.3 given the care needs of residents today.

Mr ZAPPIA: A 50 per cent increase in staff.

Mr Bonner : It would. We well recognise that that kind of thing is not going happen overnight, but that is the kind of gap that is there presently between what the bundle of care is that is required to be delivered to meet residents' assessed care needs now, the time it takes a nurse or a care worker to deliver those care interventions and what is required for the future. We think there needs to be a clear plan to move to those kinds of levels over time, given that complexity and demand continues to grow.

Mr ZAPPIA: Given the figures you've just quoted, to your knowledge do any of the providers come close to the 4.3? I say that understanding that in a bigger facility you can get better value for your staff than in a smaller facility, so the ratios might vary for that reason alone.

Mr Bonner : The best numbers that I am aware of are around 3.2 hours per patient per day now. That would be the sort of higher end of the aged care facilities in South Australia. There were some aged care facilities that were operating slightly higher staffing levels, and they have been cut to that 3.2 approximate level over the last eight months really by the way the funding system has constrained the capacity of those organisations to resource their rosters.

Mr ZAPPIA: Based on your members' feedback, do you have a view about which providers your members prefer to work with? Maybe this should be an in camera type question, because I am trying to find out directly from the people that work within an industry which facilities they regard as being the ones that they would willingly work for, as opposed to those which they wouldn't.

Mr Bonner : As you are aware, some organisations are higher performing than others. Yes, we are aware of circumstances where our members report, and objectively, that there are better industrial relations practices, better bargaining outcomes and the like than others. Yes, those things do exist. I don't know that I would like to be on the public record as endorsing particular organisations.

Mr ZAPPIA: That is why I said that perhaps the question should have been an in camera question; it was for that reason. I am not trying to get that specific information but I am trying to get a clear picture in my mind as to whether information that comes to this committee about some good and bad providers is shared by the nurses who work within the system already and who would therefore understand, I believe, who are the good and bad providers that are out there.

Lastly, in 2018 Oakden didn't meet its accreditation standards. I have not read the report in full. I've got parts of it in front of me now, but I haven't read the report in full. Can you advise us as to why it didn't meet the accreditation standards?

Mr Bonner : My recollection is that it failed about 13 of the 40 or so different elements for accreditation that applied at the time.

CHAIR: I think it actually varied over that period leading up to its accreditation. So initially I think it was 30 out of 44 that it failed.

Mr Bonner : And some of those were around clinical standards and clinical practice. Others were more organisational and the like. It's fair to say that there was, in my view, a very genuine attempt at the time by appointing a nurse adviser and by appointing external consultants to work with the organisation to address that. Indeed, they were reaccredited. I think that's where the rub comes in in terms of whether or not there was actual practice reform at the operational level versus did the organisation have sufficient paperwork policies and procedures in place to satisfy the agency that it had covered the gaps in terms of the policy that was missing? So it's not our view that there is any evidence there was significant actual performance change, although there was then a reaccreditation of the facility.

Mr ZAPPIA: If your members working within a facility are not happy about the way the facility is operating, do you encourage them to advise your federation about that?

Mr Bonner : Absolutely.

Mr ZAPPIA: When they do that, what do you then do with that information?

Mr Bonner : It depends on the circumstances. Typically we talk to the organisation involved. As I say, the most significant behaviours that we became aware of at Oakden were around the culture of bullying and harassment, the temporary nature of the workforce and what that meant in terms of people's willingness to speak up and speak out. Those were all raised with the organisation but to little end.

Mr ZAPPIA: Lastly, my understanding is that some of the nurses who work within aged-care facilities are employed through temporary work agencies. Is that the case? If so, is that widespread?

Mr Bonner : Indeed, there is a very significant reliance on casual and agency staff across the aged-care sector—an over-reliance in our view. That creates a level of vulnerability that's undesirable. It also creates very real problems in terms of professional practice in terms of ensuring continuity of care, proper handover and ongoing case management of residents' needs. So, as well as the pure number and mix of staff, we believe we need to deal with the employment arrangements of people to properly deal with the issues of quality and continuity.

Mr ZAPPIA: Thank you.

CHAIR: Thank you very much for your evidence this afternoon. You'll be given a Hansard transcript of today's proceedings. If there are any corrections that you'd like to make to that, contact the committee secretariat. We thank you very much for your time.

Mr Bonner : Thank you.

Committee adjourned at 14:13