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Standing Committee on Health, Aged Care and Sport
05/03/2018
Quality of care in residential aged-care facilities in Australia

BUCHANAN-GREY, Ms Marina, Executive Director, Professional, Australian College of Nursing

WARD, Adjunct Professor Kylie, Chief Executive Officer, Australian College of Nursing

Evidence was taken via teleconference—

CHAIR: Welcome. We obviously are in a public environment. There are no members of the public here yet, but I did see a group at lunch who were here this morning, so I assume they'll come back in, so just be aware that you're in an open environment. TV and media were here this morning, but I don't think teleconferences make for great TV visuals, unfortunately.

Ms Ward : That's probably a blessing. I'll keep that in mind.

CHAIR: I'll just go through the formalities I need to start off with. I just need to remind you that these are formal proceedings of the parliament. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. Thank you for your detailed submission. Adjunct Professor Ward, would you like to speak to your submission and make an opening statement?

Ms Ward : Thank you, Chair, for this opportunity. The Australian College of Nursing welcomes the opportunity to speak today on this very important topic of quality of care in residential aged-care facilities in Australia. As we know, Australia's population is ageing, and elderly Australians are expecting and deserving of high-quality care when in residential aged care. Unfortunately, cases of poor care and abuse have surfaced in the media, and these are serious concerns which can and must be addressed.

Nursing has considerable value in aged care. Nurses, with their training, wide-reaching presence and public trust, are one of the most appropriate health professionals to assess and care for the elderly. Nurses are best placed to respond to potential problems regarding mistreatment of residents in residential aged-care facilities. Without nurses fulfilling vital roles in residential aged-care facilities, risk of mistreatment is increased. Nurses spend more time with residents than any other health professional. This allows nurses to gain a greater understanding of the residents' needs. As a result, nurses get to know the residents more closely and they notice when changes occur—for example, any injuries, changes in appetite or behaviour, or deterioration. Nurses are also advocates for residents, families, carers and communities. Nurses' advocacy is about ensuring residents are cared for when they cannot care for themselves, and speaking for them when they cannot speak for themselves. Primarily we wish for all those in our care to feel empowered to advocate for themselves; only when this ability is diminished will a nurse assume the role.

Law reform in New South Wales removed the requirement for a registered nurse to be onsite 24/7 in aged-care facilities. This is of great concern, as enrolled nurses and assistants in nursing, however titled, must work under the direction and supervision of a registered nurse. They do not possess the education, knowledge and skills to substitute for a registered nurse. At a time of increasing aged-care service demand, retaining the number of nurses should be a key priority, and the Australian College of Nursing's position is that regulation of residential aged-care facilities should, at a minimum, mandate a requirement that a registered nurse be onsite and available at all times to promote safety and wellbeing for residents. I reiterate that the Australian College of Nursing strongly supports the requirement for a registered nurse to be on shift and available at all times in residential aged-care facilities.

As the pre-eminent and national leader of the nursing profession, the Australian College of Nursing strongly advocates for industry-wide mandatory training for aged-care workers about mistreatment, prevention, detection, response and mandatory reporting. This training should take into account the multicultural nature of Australian society by considering our ethnically and culturally diverse elderly population. The Australian College of Nursing is also strongly supportive of the regulation of assistance in nursing workforce, however titled, through participation in the National Registration and Accreditation Scheme and the establishment of a practice framework which articulates a minimum level of education, a defined scope of practice, and national codes, standards and guidelines. Further to this, the Australian College of Nursing believes investment in leadership training is essential to drive strong and positive cultures whereby open disclosure is encouraged and near misses are included in the collation of incident reporting to encourage quality improvement. Thank you.

CHAIR: Thank you very much. I might kick off the questioning. You mentioned that in New South Wales the requirement for a registered nurse had been removed. I'm just wondering if you could give us an overview of what happens nationally. For example, in other states are there requirements that registered nurses be in place in residential aged-care facilities?

Ms Ward : Correct, on all shifts.

CHAIR: In every state and territory apart from New South Wales?

Ms Ward : Yes. All other states and territories have the requirement. We are concerned that the changes in New South Wales may motivate other providers to push and lobby the government for the same, as a cost reduction.

CHAIR: In other jurisdictions, generally, what are the nursing numbers in a facility? Is it generally one per facility or is it more? Is it population based at each facility or needs based? How is it determined?

Ms Ward : There's actually not a national framework or guideline, but in other jurisdictions there's at least a registered nurse on every shift. The makeup of facilities varies considerably to the layout to the physical buildings to where people are staged in their healthy ageing process and what level of care they need. The old terms high care and low care come into place. A registered nurse may be the only registered nurse on a shift where there may be up to 150 to 200 residents. But it might be a smaller population, maybe 30 or 40, who require a higher level of clinical care and oversight from a registered nurse. However, the registered nurse still has responsibility for any resident when they're called to respond to an accident, an incident or a deterioration. So this isn't one size fits all. We are very concerned about New South Wales, so we have made it very clear that at a minimum there should be a registered nurse, but, of course, we would expect higher numbers of registered nurses and enrolled nurses. What we have at the moment is that the highest proportion of workers providing care are not licenced.

CHAIR: Do you have any statistics on what the change in New South Wales has actually meant, for example, the number of aged-care facilities that have discontinued having a registered nurse since that change?

Ms Ward : We don't. We could canvass our members and find out. The legislation has passed to remove the registered nurse, but, at this stage, our members have not said that facilities have actioned that, so we could look into that for you. Most providers understand the importance of nursing care and that, in fact, not every resident sleeps at night. There are some patients who have behavioural problems and cognitive impairments. People with dementia, in particular, are very nocturnal and spend a lot of the evening awake, and in the daytime they're more likely to be sleeping. So the requirement for good care—to be able to assess and manage patients from a holistic approach considering their clinical, emotional, psychosocial and physical requirements as well as any cognitive impairments or behavioural problems—becomes as important at night as during the day. The original talk in New South Wales was around removing a registered nurse at night, and we can look into that for you.

CHAIR: In other states, would there be residential aged-care facilities that have a significantly larger number than just one?

Ms Ward : Absolutely. We're seeing that as the minimum. We're surprised and disappointed we even have to mandate that there is one. What we found in canvassing our members was that there are some facilities that would have a registered nurse on but they're in management duties as the director of nursing, the quality manager or the coordinator or are taking on different responsibilities in management or paper driven processes. So, whilst they were on site physically, they're not in the environment where they can oversee direct care. That's a concern to us as well. It shouldn't be a token position. There should be a registered nurse that is available to oversee the clinical care and all of the requirements of holistic care for residents.

CHAIR: Are you aware of any academic studies or clinical studies that assess different health outcomes based on the presence or availability of registered nurses in aged care?

Ms Ward : Yes, there are many studies. We can get you a list of studies globally to show the direct correlation between registered nursing care—and enrolled nursing care but particularly registered nursing care—and patient outcomes particularly. We could look into residential aged care, but the proportion of quality indicators and improved outcomes to registered nursing care is internationally demonstrated.

CHAIR: If you could provide that, that would be great.

Dr FREELANDER: We have a number of aged-care facilities in my electorate of Macarthur, in south-western Sydney. Are you aware of any quality assurance programs that have looked at the role of registered nurses in aged care?

Ms Ward : From undergraduate through to postgraduate, there are many different types of organisations that look at the role of the registered nurse in aged care. I'm not sure what would be specific to quality assurance apart from the direct correlation to patient outcomes. One of the things that you would really understand is the complexity of the residents in care and what is required of a registered nurse around that. We want people to be well. We want people to have a healthy approach to their ageing. There are many different reasons people enter a residential aged-care facility, but, with the complexity of the polypharmacy and the vulnerability of the deterioration, there are many factors that we would take into consideration. We can get you some information, but specific to—

Dr FREELANDER: I'm just wondering if the College of Nursing itself is undertaking any studies in aged-care facilities about the role of registered nurses and their position in quality assurance programs.

Ms Ward : We haven't commissioned specific research. We work in collaboration within the industry, within the tertiary sector with the deans of the universities and with the council of the Commonwealth and state and territory chief nursing and midwifery officers. The Australian College of Nursing actually has the National Nursing Executive Community of Interest, and every nursing executive in the country has opportunity for membership in that, and that includes all aged-care facilities, public hospitals, private hospitals as well as primary and community care. From that, we really are able to get a litmus test of the real issues that are happening and understand the impact that it has. If we don't staff aged care with registered nurses and appropriate staffing, it has an impact on our colleagues as GPs and other health professionals and on the public health system if transfers are made to the acute setting.

Dr FREELANDER: Can you give us any reason why the New South Wales legislation was enacted—why there was a wont to remove registered nurses from aged care.

Ms Ward : I can't speak as an expert. I can speak through the lens of the concerns that we raised at the time and the motivation for it as we understand it. It is really around workforce provision. If it's difficult for some organisations to get a nurse to work a night shift or to work different shifts, that shouldn't be the motivator to change the legislation and dilute the quality of care. It is our understanding that that was the motivator—it was around having the workforce. What happens if that happens to hospitals or to any other setting is it's not okay to compromise the quality of care provided to the public and to communities. What we would say, have said and will continue to say is that it is up to providers, industry and those employing people to have a culture and flexible workplace practices and to be able to support their workers moving into the future rather than dilute the workforce and dilute the quality of care.

Dr FREELANDER: Have you had many complaints from your members about difficulties in providing quality of care in aged-care facilities?

Ms Ward : The membership of the Australian College of Nursing is made up of people in very senior and influential positions in all industries and particularly aged care—they're CEOs, executives, directors of nursing, professors in aged care. We all share overarching concerns as well as those specifically an industry will have—industry-specific concerns may be dementia specific or area specific. Just this year, we have launched four policy chapters. At our policy summit in April we will be bringing the healthy-ageing policy chapter together to determine the priorities for the nursing workforce in Australia around aged care, but our other three policy chapters include chronic disease, end-of-life care and workforce sustainability. We see that all four policy chapters are absolutely relevant to the ageing nation in residential aged care and in other areas of primary and community care, and the elderly being cared for in acute settings, as well.

Mr ZAPPIA: Thank you for your evidence thus far. Can I just ask about the New South Wales situation. When was the requirement changed that registered nurses are no longer required?

Ms Ward : I believe it was last year. Let me get one of my team to find that exact date and I will get back to you.

Mr ZAPPIA: It was in in the last 12 months or thereabouts?

Ms Ward : Yes.

Mr ZAPPIA: I would imagine, therefore, that it might be still too early to try and form a view as to whether that has been detrimental to the welfare of residents. Has there been any evidence, even in the short space of time, that the change has been for the worse and not for the better?

Ms Ward : Not based on the legislative changes, but we don't really need to see care deteriorated to be able to advocate for the importance of it, and that is something that's very important to the Australian College of Nursing. We don't want incidents and concerns to happen to say we needed a registered nurse. We're hoping that we won't get to that, and I know where you're coming from. There is so much data globally to show the direct correlation of registered nursing care, even against a third tier, an assistant in nursing. What we're seeing throughout Australia is increased numbers of assistants in nursing and the effect that that has had on care when assistants in nursing are replacing enrolled nurses and registered nurses. We know that we need to do that in the skill mix, and there are areas of need and priority. But there has been enough research now internationally, through Dr Linda Aiken, to show that there are poorer outcomes in terms of patient experience and morbidity and mortality.

Mr ZAPPIA: Have all of the providers of service—the aged-care industry generally—done away with registered nurses, or, to your knowledge, have most of them still retained registered nurses?

Ms Ward : Most still retain registered nurses. It is a three-tier or two-tier workforce—by that, I mean there may be a registered nurse and then you will have many assistants in nursing who are unlicenced workers or certificate IV workers or enrolled nurses. It is really dependent on the facilities themselves, and the organisations, as to how they provide their staffing in the staffing model. There are also many other types of workers that are required, for those living in residential aged-care facilities, to have all of their needs met—like lifestyle workers and others.

So we don't work in isolation. But, in terms of the care that is provided and the clinical oversight, at this stage, for the most part, there's at least a minimum of a registered nurse. Better organisations have more registered and enrolled nurses, and have that proportionate. We have seen a bit of a trend where, because the cost of a registered nurse is more expensive than an enrolled nurse and an assistant in nursing, some facilities will compromise the number of registered nurses and have a lot of assistants in nursing. The challenge for us is each level has a place, but the number of registered and enrolled nurses is diluting and the number of assistants, however named, is increasing. There is no prerequisite to being accepted into doing a course as an assistant in nursing. There are concerns around the calibre and the quality within those 120 hours of workplace experience that that assistant level obtains.

Mr ZAPPIA: You made reference a moment ago to better organisations. What is your definition of 'better organisations'? Is it based on your perception of the level of service they provide, or is it based on the number of complaints they get about their facility?

Ms Ward : I guess anybody in any industry has an understanding of what is required. It's really around the culture and the leadership capabilities at the top. As much as we would like to see a national dataset of nurse-sensitive indicator outcomes or quality indicators, we all know that that can be interpreted in many different ways. My organisation might have a really positive, healthy culture of reporting near misses. The level of severity of, let's say, a pressure area or a fall—it could be an assisted falling to the floor, or it could be a fractured neck of femur—is different. In the reporting, you don't want underreporting just so the statistics look good, and you don't want a culture where the staff don't feel like they can speak out. It's really important in the Australian College of Nursing that the executive, the nursing leaders and all the other leaders are looking at a positive, healthy culture where people are safe to speak out, where ideas and innovation are encouraged and welcomed, and where the staffing isn't fixed on every shift. There may well need to be some changes or some additions in staffing as you contract and expand to the needs of the residents at any given time.

Mr ZAPPIA: Lastly, are you aware of any other comparable country to Australia that has, in your view, a better aged-care system in place?

Ms Ward : This is a really good question. The Australian College of Nursing is a member of the International Council of Nurses. There are different countries doing things differently and better. The Scandinavian countries are always worth looking at. Spain has an interesting approach. I'm heading over to Singapore this week to speak at a conference around care and the elderly. But there are so many factors that come into it, and that is the challenge for us.

We've looked at what's best at the Australian College of Nursing. We are a member of the National Aged Care Alliance, so we get to participate in many different areas of discussing aged care outside of nursing-specific areas and across industries. Again, as soon as you bring up an area that is doing quite well—if you think of Denmark the systems are so strong in education and in other areas—you need to look at the social fabric of that society.

In Asian countries they have a whole different approach to how they care for the elderly. There's a lot more care at home and a different approach to the care. The Spanish have more of a medical model. If we're having trouble staffing aged-care facilities with nurses and registered nurses, would doctors want to come and sit there? There are all of these challenges. There are great things happening but there are many factors to consider. On behalf of all of the nurses and the workers in aged care for the most part there's so much that is being done well. It's these incidents—how can we regulate and monitor those organisations that aren't lifting their game and investing where they should?

One of the areas to look at, if I may, is around education. We get feedback from some members to say that they would like to have some training in mental health nursing, for example, because of the complexity of some of the residents. The mandatory training is around some basic core physical elements of nursing, and the organisations won't support the training. The workers don't always earn enough money to be going out and investing. There needs to be a little bit of broader look at regulation, accreditation, expectation and strong investment in that education and professional development.

Mr GEORGANAS: I know you touched a little bit on the reporting mechanisms that nurses have. In many cases nurses are at the forefront, or are sometimes the first people, or the first person, to see a sign of something not being quite right. You mentioned in your report that there may be a need for greater independence in terms of reporting. Do you find that your members may be reluctant to report something, or to take it further, due to repercussions from their employers down the track? That would be a big decision-making thing if your job's at risk. Perhaps you're going to feel isolated or ostracised, perhaps you're not quite going get that promotion that you're after or perhaps you're not going to get a job in another facility if you're bringing things to the forefront that shouldn't be happening. As the nurses representatives, do you see many cases like that where some of your members have been given a bad deal after reporting a particular incident, or incidents, or whistleblowing?

Ms Ward : It's a really important point to make. For me, personally, I've spent 20 years of my 27 years of nursing in and out of aged care and aged-care facilities working as a nurse. We have the perspective of members and then we all have our own stories. That happens at a couple of levels. It's certainly a career-limiting move to challenge management, and what does that mean or how do you have a voice? That's why it's important to invest in leadership, and the requirements of not just the management and ticking the boxes of what a manager needs to do, as those in positions of promotion, power and influence need to understand what it means to encourage healthy and active disclosure of any concerns.

The other component to that is that what we find is the nurse executive or the most senior nurse in an organisation is quite often the only clinician. Unlike in our public health system, where you might have your director of medical services, your director of nursing and allied health, quite often the nursing leader is the only one on that executive, sitting in amongst finance and others around capital development. At several levels, the conversation to advocate for quality and investment in a workforce that can provide that care becomes very challenging. It's a systematic problem. It's not only limited to the carer by the bedside, so to speak.

CHAIR: In your submission you draw a marked distinction between what you describe as mistreatment and neglect. We haven't for the purposes of this inquiry sought to define mistreatment, but I'm wondering why you seek to make that differentiation. To me mistreatment the way you've defined it almost requires some type of malice, whereas I would have thought neglect can be just as harmful as mistreatment.

Ms Ward : Yes. Sometimes one's a stand-out incident, but neglect can happen almost subtly, over a period of time or directly attributable to the culture and the standards set by nursing and nursing leadership. I'll talk directly to that. Let's just take, for example, nutrition. Everybody can be supplied a meal, but, if residents aren't supported and encouraged to eat, that's a perfect example of how deterioration and neglect can occur if there aren't good systems in place to support residents being assisted to feed and then monitoring of who's not eating and what that means for wounds, healing, exercise, range of motion, sleeping or many other factors that come into play. We see that they're both very significant. There is that important difference, and it is around the level of care, observation and oversight that a resident and their families should expect.

CHAIR: Okay. Mr Georganas has one last question.

Mr GEORGANAS: I meant to ask this earlier. In your opening statement you spoke about the need to take into account different communities like multicultural communities and the diversity that exists in our nation. In your view, how is that currently implemented around the country? I know that we have CALD-specific nursing homes and areas where there are needs, but there is other diversity such as same-sex couples, for example. We heard some media this week that the aged-care facilities aren't really catering to them or do not have the ability to deal with it.

Ms Ward : It has been very traditional. Even for those who are married, the make-up and layout of many facilities are all single rooms. There is the challenge of adjoining so that people can still live in a marriage scenario and require higher-level care. It's really important, particularly now and with the focus last year on marriage equality, which raised many issues around mental health, wellbeing and antidiscrimination. The layout of the facilities has been traditional, and there are now providers who are really starting to address this. There are many areas of diversity. Even from a culturally and linguistically diverse perspective there are still areas of opportunity and growth. And it's not only in our resident population but our workforce as well. How do we support that? How do employers support that for their workers? There is much more to be done, and I would hope to see that anybody's who's planning on building a facility or expanding has that as part of the inclusion process.

Mr GEORGANAS: Thank you.

CHAIR: Thank you very much. That's been very useful. You'll be sent a copy of the Hansard transcript. If there are any errors or omissions on that transcript, could you let the committee secretariat know by 20 March. Similarly, if you're able to provide that reference list of studies by that date as well, that would be very handy.

Ms Ward : We can certainly do that. For your information and mine: the registered nurses were originally challenged and taken from residential aged-care facilities in 2014, but it was challenged in 2017 when they went to have it overturned but failed.

CHAIR: Great. Thank you very much to both of you for your time this afternoon.

Ms Ward : Thank you.

Proceedings suspended from 13:36 to 14:05