FEATURE

22 AUSTRALIAN NURSING JOURNAL DEC 08/JAN 09 VOLUME 16 NUMBER 6

AGECOMING OF the challenges of nursing an ageing population

According to the Grant Thornton Aged Care Surveyreleased last month, profit margins are narrow-ing and demand for more personalised and resi-dent-focused care is increasing, leaving the

industry stretched, stressed, and appealing for increasedfunding from the Commonwealth. The federal governmentis currently reviewing parts of its aged care funding mix,with industry representatives pushing for a change to meetwhat they see as the real costs of the sector, costs whichthey argue are increasingly outstripping funding.

At the same time, the Rudd Government has stepped upinspections of the nations 2,800 aged care facilities toensure they are meeting set standards of resident care. Thecrackdown, by the Aged Care Standards and AccreditationAgency (ACSAA), has involved 7,000 visits to aged carehomes around Australia this financial year and resulted insanctions or other action against 11 facilities across thecountry.

Although over 90% were found to meet standards andthe ACSAA says the standard is generally high, its an envi-ronment in which the Australian Nursing Federation (ANF)wants to ensure more nurses enter and stay in the sector.

But it argues the wages gap between those working inaged care and those in the hospital system, who can earnbetween $150-250 more a week, is a big disincentive.

ANF assistant national secretary, Lee Thomas says thismeans an Australia-wide shortage of nurses and midwivesis even more acute in the aged care sector. By and largenurses are voting with their feet. The cost of their groceriesand petrol are going up, so they go to a job where they canearn more money and enjoy better conditions, she says.That puts pressure on the nurses that choose to remain inaged care, there are fewer and fewer of them available andthis leads to problems in staffing levels and skills mix.

While the industry blames inadequate Commonwealthfunding for the wages discrepancy, the ANF isnt convinced.The union argues for more accountability, saying millions ofdollars provided by the Howard Government to bridge thegap didnt end up in nurses pockets.

ANF national secretary Ged Kearney wants the federalgovernment to create a more transparent system. Wewould like to know how much of the income they get fromgovernment goes to paying salaries, wages and residentcare costs. The CEO of the Aged Care Association ofAustralia (ACAA) Rod Young denies the industry failed topass on funds targeted for nurses wages. The problem istheres a total disconnect between what the Common-wealth pays residential care services for their nursing staffand what state and territory governments pay their staff.

Richard Grey, the director of Catholic Health Australias(CHA) Aged Care Services agrees. That (HowardGovernment) money, the Conditional Adjustment Payment(CAP), was aimed at a number of things, including helpingto close the gap. It certainly went some way to meetingincreases in wage costs but all it did was make-up for sevenyears of inadequate indexation of the care subsidy.

Both agree nurses in aged care should be paid more butthey argue the sector will need an additional $450 million ayear from the federal government to make this happen.

FEATUREAustralia 2048: 25% of the population is aged 65 or over,the number of young peopleentering the workforce hasplummeted to a tenth of thelevel from 40 years ago and thedemands for aged care servicescontinues to grow. This is thereality facing Australias agedcare industry, an industryalready struggling to meetdemand and recruit enoughskilled staff to meet the needsof the increasingly high careresidents in its facilities. Cate Carrigan reports on thechallenges facing nurses working in aged care.

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TRENDS AND PRESSURES IN AGED CARE

There are 2.5 million Australians aged over 65 ofwhom half need some level of assistance in theirday-to-day activities.

Over the next 40 years, the number of Australiansover 85 will quadruple to 1.6 million.

Community care programs, assisting people in theirhomes, are provided to 760,000 Australians (thedemand for home-based services has grown rapidlyin recent years).

As of June, 2007, there were 145,000 Australians inresidential aged care services and 70% of theseresidents were defined as having high care needscompared to 58% in 1998.

There is a growing demand for high levels of care,single bedrooms and extensive services and amenities.

Service providers average earnings per bed were$2,934 in 2008 compared to $3,211 in 2007 (modern, high-care, single bedroom facilitiesreported the worst returns for providers).

The increasing costs of construction and lowreturns are leading to a downturn in the building of new facilities.

Providers cite the regulatory and pricing frameworkas disincentives to further investment.

WA has 10% of aged care residential facilities; theNorthern Territory 1%; Tasmania 2%; New South Wales31%, Queensland 22%; SA 12%; and Victoria 24%.

Source: Grant Thornton Aged Care Survey October, 2008.

* A detailed picture of the trends in the aged care workforce by

the National Institute of Labour Studies at SAs Flinders

University is due to be released later this year by the

Department of Health and Ageing.

Rod Young, CEO of the AgedCare Association of Australia(ACAA)

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Rod Young says the federal government could have pro-vided the money as part of its recent $10 billion fiscal stimu-lus package, saying the 200,000 aged care workers wouldhave been happy to spend a wage increase. But a spokes-woman for the Federal Minister for Ageing Justine Elliot saysthe government is already putting more money into the sec-tor, with $41.6 billion being provided over the next fouryears, and funding per resident per day to rise 8% over2008-2009. She says the increased funds will help providersdeliver quality care and that providers are required under the1997 Aged Care Act to ensure there are adequate numbers ofappropriately skilled staff to meet the individual care needsof residents.

While acknowledging the discrepancy between wagespaid in the hospital and aged care sector, she says wage lev-els vary from state to state and from employer to employerand are not due to Commonwealth aged care funding.

In addition to increased wages, the ANFs Lee Thomassays the skills mix in aged care needs to be addressed toensure each facility has the right number of staff with theappropriate level of skills to look after the residents. Whileits essential to have the range of skills brought in by regis-tered and enrolled nurses, assistants in nursing care andpersonal care assistants, we cant start substituting oneclass for another just because theres a nursing shortage.

To try and stop residential nursing facilities employing toofew nurses, the ANF wants the federal government to intro-duce mandatory staffing levels and skills mix for residentialaged care facilities. At present, the ANF argues there shouldbe 4.5 nursing hours per patient day, but Ms Thomas saysthis is currently being reviewed to take into account theincreasingly high care needs of those in residential facilitiesas 70% now fall into that category. Twenty to 30 years agowe had many reasonably independent residents but now,with the move to community care at home, only the mostseverely affected are coming into residential care facilities.

For the industry, the notion of a mandated skills mix isviewed as unreasonable and too restrictive. CHAs RichardGrey defies anybody to come up with a mandated skills mixto cover facilities ranging from a five-bed hostel with lowdependency residents to a 160-bed high care facility.

Rod Young from the ACAA has similar concerns. A man-dated skills mix doesnt work well in an industry where youare regularly changing your staff mix depending on the resi-dents.

The ACAA also worries about the consequences if theindustry cant find the staff to fit the mandated formula.There are some real difficulties with obliging providers tohave specific skill mixes and specific numbers of staff whenwe are already struggling to recruit those people, Mr Youngsays. If we could have sufficient trained nurses comingthrough the nursing schools and we could pay adequatewages then we might have a chance of being able to meetany prerequisite.

Ageing Minister Justine Elliot also has reservations; with aspokesperson arguing aged care providers are alreadyresponsible for maintaining an appropriate skills mix andthat its not clear there is a single optimum staffing level andmix. However the spokeswoman says the introduction ofminimum staffing levels will be considered after the impactof the new Aged Care Funding Instrument (ACFI), which wasintroduced in March, is fully assessed.

One thing both the industry and ANF support is anexpanded role for nurse practitioners in the aged care sector.ANF national secretary Ged Kearney believes aged care is aperfect avenue for nurse practitioners (NPs). A lot of thequality of care standards could be improved if we could get

St Marys Villa at Concord inSydneys West is a stand-alone 77-bed nursinghome and hostel run bythe local Catholic Parish.

There are 34 high care nursing homebeds and 33 hostel beds, some ofwhich are also high care.

The DON, Lucille McKenna, believesits a facility that has the skills mixjust right, with enough nursing andnon-nursing staff to ensure a happyworkplace and well cared forresidents. Part of that mix is a generalmanager who is on site five days aweek; a deputy DON whos a RN, a RNhostel manager, another RN working

on the floor of the nursing home and highly skilled assistants innursing (AINs).

Nearly all the AINs have either a Certificate III or CertificateIV in aged care, and the facility also employs a physiotherapistand a physiotherapist aid for two days a week. All of theseextra staff, including a Catholic nun who helps with theemotional needs of the residents, make our work so mucheasier, Lucille says. We feel were very lucky and privilegedbecause we seem to do so much better than so many otherfacilities.

St Marys Villa has resisted taking the path of AINs supplyingmedication to nursing home residents, although Lucille saysvery competent AINs administer some medicines in the hostel.

But while she is very happy with the skills of her AINs shebelieves its time for those working as assistants in nursing tobecome licensed, something also supported by the ANF but notby the ACCA, which views it as unnecessary.

I think anyone whos dealing with residents at this veryintimate level should be licensed. We have had publicisedincidents lately where staff have been employed at facilitiesafter being dismissed by another, says Lucille. Licensingwould ensure these workers were called before a board toaccount for their conduct.

Although its a well-run place with a happy team, Lucille hasconcerns about the future of facilities such as St Marys Villawhere 30% of the nurses are already past retirement age.People like me came into aged care because I love theautonomy of it but its hard to attract young nurses. Why wouldyou come to aged care where the work is just as demanding asthe hospital sector but the pay is much less?

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The right mix:St Marys Villa

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better assessment access for nursing home residents andthats where nurse practitioners could step in.

We know that GPs dont visit nursing homes; the remu-neration is poor, they dont have time and we dont haveenough GPs; so introducing highly-skilled and specialisednurse practitioners could deliver very good care. MsKearney says central to expanding the NPs role would befreeing up their access to the MBS and PBS schemes,something currently under consideration by the federalgovernment as part of a move to increase the use of NPs inthe health system.

The ACAAs Rod Young agrees. If they are going to fulfiltheir function to the best level possible they need prescrib-ing and diagnostic requesting capability. If they dont havethat then their roles are quite limited. Mr Young would likethe industry to be able to employ nurse practitioners toservice two or three facilities, to ensure they had enoughwork. Employing nurse practitioners would also open up anew clinical career path for nurses in the sector, enablingthem to get a promotion but stay doing the work they love.

While these issues are being debated within the agedcare sector, the biggest concern for industry is the fundingformula, with the ACAAs Rod Young arguing that unless thefederal government changes the financial levers soon,some providers will be facing financial difficulties. Theindustry argues the current funding mix, comprising thenew Aged Care Funding Instrument (ACFI), which providesaround 70% of funding and is based on residents careneeds, and the Conditional Adjustment Payment (CAP), isinadequate to meet the needs of the sector.

Mr Young says in its submission to the federal govern-ments review of aged care funding, the ACAA argued forthe implementation of an aged care specific index, takinginto account wage movements and other industry costs.

While the industry would like to see an easing in restric-tions on how much they can charge clients, the ACAA isaware many people cant afford to pay any more. In themain residents are asset rich and income poor. With 90%either whole or part pensioners, you cant ask them to payany more then the current 85% of their pension for theiraccommodation, says Mr Young.

While Ageing Minister Justine Elliot wouldnt be drawnon an aged care specific index, her office says the CAPreview will take into account the need for further financialassistance to encourage efficiencies and will be consideredas part of the 2009-2010 Budget.

But while the sector awaits the results of the review, itstill faces the reality of a shrinking workforce and the age-ing population over the next 20-30 years. Rod Youngargues more will have to be found to attract young workersin an increasingly competitive jobs market. For its part, thefederal government says its provided funding in the 2008-2009 Budget for a range of programs to improve ageingand aged care services, including funding for programs toaddress workforce shortages.

A new program, with funding of $6.9 million over fiveyears from 2007-2008, has been established to increase thenumber of qualified nurses in aged care services by provid-ing a cash bonus of $6,000 each for up to 1,000 nurses whoreturn to work in the aged care sector after at least a 12month absence. An additional $1,000 will be provided toaged care providers for each eligible nurse they employ toassist with the cost of re-training and re-skilling the nurse.

The ACAAs Rod Young argues the challenges of attract-ing the workforce are high but imperative if the industry isto meet the future demands for aged care. There will beenormous strains on our ability to deliver care and if wecant provide attractive conditions for our staff they willsimply go elsewhere.

Ged Kearney and Lee Thomas agree and want to see anew era of cooperation between providers, governmentand the ANF in working to attract and retain nurses in agedcare so that older Australians receive the high quality ofcare they deserve.

FEATURE

* The NSW Department of Health has estimated Debbies work has saved the hospital $1.5 million in hospital admissions for over 65s.

WE KNOW THAT GPS DONT VISIT NURSING HOMES; THE REMUNERATION IS POOR, THEY DONT HAVE TIME AND WE DONT HAVE ENOUGH GPS; SO INTRODUCING HIGHLY-SKILLED ANDSPECIALISED NURSE PRACTITIONERSCOULD DELIVER VERY GOOD CARE.

The far north coast of New South Wales has one of the highestconcentrations of older Australians, with a quarter of the population of PortMacquarie aged over 65 years. Its here that Debbie Deasey works as atransitional (trainee) nurse practitioner treating the elderly in their homesand residential aged care facilities and keeping them away from theemergency department at Port Macquarie Base Hospital.

Working from the hospital and with the help of her very supportive GPmentors, Debbie assesses and, where necessary, prescribes medication,which is then authorised through the GPs (this will change next year whenshe becomes an authorised NP). So if someones aged over 70 and cantaccess their GP, Ill go out and help treat them for a variety of things,including pneumonia, infections, delirium or checking catheters.

A local girl who started as a hospital cleaner around 16 years ago, Debbiecompleted her registered nursing studies before undertaking a Masters inGerontology. She began work as a transitional aged care nurse practitioner inOctober 2007, and loves the choice it gives the elderly. The patient is safe,the staff are happy and it prevents an ambulance trip and an emergencypresentation. The other patient benefit is a next day review of the treatmentand the extra time Debbie can take as a nurse practitioner. They like thatone-on-one service they can ask questions and Im not as rushed as a GP.

Im also looking at the patients from a nursing perspective, so I take intoaccount the family, the environment, medications and the education I canprovide, she says.

It also empowers the residential facilities by enabling them to get a nursepractitioner in straight away to take care of something simple like adehydration. Debbie would love to see more nurse practitioners working inaged care within residential facilities and in the community. But she sayseasing up the restrictions on PBS and MBS benefits access is crucial to thisexpansion.

Making a difference: the nurse practitioner