Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697646181010.pdf (Australia)
Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish RE: Senate Submission: Aged Care Workforce We are submitting this advice as two registered nurses with collective nursing experience in emergency nursing and cancer care, management experience as a Nursing Unit Manager in a large metropolitan teaching hospital, experience with workforce development in aged care, and research experience in the area of dementia, palliative care, and hospital systems and governance.
We are currently nurse academics, with one still practicing clinically, with membership of several national nursing organisations.

Part of the motivation for this submission is hearing our Registered Nursing students speak of their experiences working as Aged Care Workers in Residential Aged Care, which gives us cause for serious concern regarding the future aged care workforce.

Some of their comments are also included in our submission.
Kasia Bail and Laurie Grealish Kasia Bail, RN, BNurs(Hons),GCHE Dementia Collaborative Research Centres PhD Candidate Assistant Professor, Disciplines of Nursing and Midwifery, Faculty of Health Health Research Institute, Synergy: Nursing and Midwifery Research Centre Dr Laurie Grealish RN, Phd, MN, FRCNA, Associate Professor of Subacute and Aged Nursing School of Nursing & Midwifery, Griffith University and Gold Coast Hospital & Health Services Centre for Health Practice Innovation, Menzies Health Institute Queensland Adjunct Associate Professor, The Education for Practice Institute, Charles Sturt University NHMRC TRIP Fellow 2016-17 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish Executive summary The evidence of associations between skilled nursing care and patient outcomes cannot be ignored.
Residential Aged Care Facilities are home to older people with complex, unique and at times unpredictable care needs.

Families, unable to continue to care for their loved one, feel heavy responsibility when they agree to an aged care placement.

For many, the care required is not simply assistance with activities of daily living, but also the administration of multiple medications and medically-ordered treatments.
The negative effects of polypharmacy and acceleration of disease is exacerbated by limited clinical assessment by a registered nurse (RN), a General Practitioner, and no access to a comprehensive geriatric assessment by a qualified geriatrician.

Increased numbers of RNs in residential aged care facilities provides a strong link between primary and tertiary health services, and may also reduce uncomfortable admissions to hospital for minor illness such as urinary tract infections.
Having sufficient Registered Nurses (RNs) available to assess, interpret, liaise, document and promote health care will be key to any quality measures that are eventually determined.
Having a healthy work environment (engaged and responsive managers, sound interdisciplinary and specialty access and relationships, strong satisfaction with patient care quality) that supports RNs to work to their capacity will also be essential for the recruitment, retention and development of a workforce to meet the needs of this population.

This submission focuses on four key points that relate to the Senate inquiry into Aged Care Workforce: 1.
People in Residential Aged Care Facilities (RACF) are living with accumulated multiple complex chronic and acute conditions which determine their need for nursing care; 2.

Registered nursing (RN) needs to be recognised (and further researched) as an intervention cost, not a labour/overhead cost; 3.

RNs provide an important clinical link between primary health care services and tertiary (specialist) services that has been limited by limited numbers of RNs; 4.
Nurses and aged care workers are motivated by delivering quality care.

Poor quality and poor satisfaction with care delivery is detrimental to the aged health workforce.

To further bolster the above points, this submission also offers: 5.

Summary of nursing and caring roles; 6.

Evidence of poor quality care in the form of clinical/reported cases; 7.
Summary of nurse sensitive outcomes research demonstrating associations between nursing care and quality outcomes, though is under-developed in residential care.
Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish Summary of recommendations Summary of recommendations in this submission specific to Government responsibilities for the aged care workforce: recognise complexity of older residents in RACF and the need for clinical staff; a. b. be responsible for ensuring adequate coverage by RNs; c. recognise the need for a critical mass of RNs to assess and intervene with residents, supervise enrolled nurses and Aged Care Workers, and liaise with other health care providers; recognise that evidence continues to develop regarding the value of nursing staffing and resident outcomes, but that logic, argument, case studies and public opinion are part of the developing and supportive evidence; d. e. ensure providers disclose staffing skill mix before people enter RACF; f. find ways to minimise the imbalance between metropolitan and rural services would aid in effectiveness of the market approach; g. enable development of Nurse Practitioners as a sustainable specialised clinical intervention for RACF; recognise and act on the limitations of a ‘competitive self-regulated market’ approach to RACF and prevent a failed market.
ensure wage parity for RNs and ENs with the acute sector; enable ample educational, mentoring , job variation, promotion, development, organisational voice opportunities (equivalent to the acute sector); formal recognition of excellence in nursing care increase opportunities for aged care nurse practitioners h. i. j. k. l. a. b. reduction of red tape/confusion for NP Practice Guidelines; reduction of limitations to PBS access regarding the cross over between employment by the public health sector but delivery of health care outside of the public health institution recurrent funding for permanent positions (not just trials/pilots); m. increase incentives for General Practitioner and Pharmacists to work with RACF.
c. Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish 1.

People in RACF are living with accumulated multiple complex chronic and acute conditions which determine their need for nursing care People in RACF are living in their home.
While we recognise that their homes should have a focus on wellness and quality of life, it also needs to be acknowledged that residents of high care facilities, formerly known as nursing homes, are likely to be living in these facilities due to difficulty managing the symptoms of multiple diseases in their private home.
Multiple diseases, or co-morbidities, require significant clinical care including symptom monitoring through assessment, administration and evaluation of treatment, and changes in treatment as various chronic diseases progress or new acute diseases such as gastroenteritis are acquired.

In Australia, 49% of people aged 65–74 have five or more long term health conditions, as have 70% of those aged 85 and over (Australian Bureau of Statistics, 2010).
Older patients are more likely to have complex comorbidities, functional and cognitive decline, unpredictable illness trajectories and less easily recognisable displays of symptoms (Hickman et al., 2007, Mitty, 2010).
There is increasing understanding that small events in hospital can trigger larger complications; such as untreated pain resulting in decreased patient movement, leading to lower lung volumes, atelectasis and respiratory depression – this is termed ‘cascade iatrogenesis’ (Thornlow et al., 2014).

Nearly 10% of hospitalisations come from RACF, and one-in-three admissions to RACF are from hospital.
The main health conditions requiring admission to hospital from either respite or permanent residential care were respiratory and circulatory conditions, and injury due to a fall.

People admitted to hospital from residential care (either respite or permanent) were more likely to have Staphylococcus aureus (golden staph) and pressure ulcers (Australian Institute of Health and Welfare 2014); these are potentially avoidable conditions.
The population in RACF have increased in high care needs, from 48% in 1998, to 82% in 2014.

The proportion of residents over the age of 80 years have also increased, and there has been an increase in aged care places from 2003 to 2012 of 25.2% (AIHW 2015).

Consequently, the population in RACF are older, and more complicated, than in recent history.

However, the staff looking after them are less qualified than they have ever been before (King 2013).
As at 2012, there are 2,326 fewer full-time equivalent (FTE) RNs working in aged care than there were in 2003, (AIHW 2015).

The proportion of average beds per facility have increased, from 46 in 1998 to 70 in 2014.

So there are more older, complex patients, but less nurses and larger facilities.

The largest proportion of facilities (at 37%) are private, for profit, which by definition are incentivised by profit margins, and therefore may perceive staffing as a modifiable cost.
For-profit facilities are more likely to have Government sanctions for poor quality care (Baldwin et al., 2015), and higher nurse turnover (Wendsche et al 2014).

This increasing and ongoing trend of replacing RNs with AINs is a substantial skill loss placing pressure on the residential aged care sector, and has no sound evidence base.

4 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish 2.
Registered Nursing needs to be recognised as an intervention cost, not a labour/overhead cost RNs are known for providing simultaneous surveillance and intervention (Bail et al., 2013); and are thus a prophylactic intervention for wellness promotion, and an acute intervention for disease prevention or minimisation.
Nursing provides clinical care for people with complex chronic and acute conditions, who may need support with activities of daily living, but may also need symptom monitoring through assessment, administration and evaluation of treatment, and changes in treatment as various chronic diseases progress or new acute diseases are acquired.
Decisions about who does care should be based on the understanding of physiological and pathological disease processes common to older people, and understanding of pharmacological, psychological and environmental impacts on the experiences and health of older people.

However, only 11% of the aged care workforce are RNs (Beattie, 2015), educated to promote and maintain health and prevent illness for individuals.
Consequently, the average length time RNs spend with patient is 2 x 6 minutes (12 minutes delivered in 2 lots); it is debateable whether RNs are still considered ‘hands-on’.

Therefore there are major challenges for RNs to have capacity to influence the quality of practice, and for research to determine best practice.

That is likely to be insufficient time to develop assessment and diagnosis of residents or to educate Aged Care Workers or family members about any findings.
That is insufficient time to establish responsiveness to treatment, to evaluate models of care, to maximise aged care staff knowledge, skills and attitudes (Beattie, 2015).

However, often the solutions to aged workforce issues is to ‘upskill’ and ‘train’ aged care workers: “In response to the increasing acuity of aged care consumers, funding for training should focus on increasing the capacity of staff to respond to high care needs.
This training should focus on increasing competencies in the areas of palliative care, allied health, medication management and wound care.” (Aged & Community Services Australia, 2015).
Yet the range of competencies highlighted: cultural competence, communication, as necessary for Aged Care Workers, and the dilution of RNs who are nominally supervising the Enrolled Nurses and Aged Care Workers, makes one wonder whether it is less training, and more education, and why not maximise the education system that is already established to support people with complex health needs.
Aged Care Workers may be trained to “do tasks”, but they are not educated to assess change or to conceptualise or communicate problems.

Upskilling Aged Care Workers in individual tasks (such as palliative care, wound care, medications) is not an evidence-based solution for the replacement, or dilution, of RNs.

For example, care workers have been found to have the same knowledge of dementia as family members (Robinson et al., 2014).
The researchers were investigating important aspects about dementia that enable appropriate care and communication strategies in daily practice, and found that RNs had the highest level of knowledge.
Elsewhere, only 38% of care workers correctly identified the need for increased protein and energy in residents with 5 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish pressure ulcers, and just 15% exhibited correct knowledge of fluid requirements.
Identified barriers to promoting optimal nutrition included insufficient time to observe residents (56%); being unaware of residents' feeding issues (46%); and poor knowledge of nutritional assessments (44%) (Beattie).

These highlight the need for strong clinical leadership to support any kind of training or education that can be facilitated for care workers; clinical leadership which we argue would be suitable to be provided by increased numbers of RNs in RACF.
Mandated ratios are one manner in which to ensure increase in RNs.

There is fight back against the mandated ratios in Victoria: “ratios are an arbitrary measure….

In one situation there may be residents who are all quite well, so less nursing staff is needed” (Heather Whitham, Aged and Community Services Australia manager government relations and policy on behalf of Aged Care Services Victoria, cited in Egan, 2015).
The trouble is that when residents AREN’T all quite well, there is no method to increase nursing staff and responsiveness of management can be problematic when decision making about staffing is driven by motivation for profit margins.

However, the competitive self-regulated market approach to aged care is fundamentally flawed.

Failed markets occur where there are few effective customers; people selecting RACF are often not in a position to make informed choices.
There is a power imbalance, information imbalance, service deficit in regions, often issues of urgency, and payment for service before service can be received or evaluated.

Government processes to ensure providers disclose staffing skill mix before people enter RACF, and finding ways to minimise the imbalance between metropolitan and rural services would aid in effectiveness of the market approach.
The evidence for mandating nurse staffing ratios may be limited, but so is the evidence for using Aged Care Workers in increasing numbers.

Nursing staffing ratios have been described as “a blunt tool to use when conversations and cooperation aren’t occurring, to develop policy that still protects patients” (Buchanen, 2014).
Facilities cannot be left to choose which care workers to employ; this must be Government determined, though mandated ratios is not essential it may be the only method that can determine that RNs actually get to spend time with residents at bedsides, dining tables and garden paths to do the assessments and interventions that are required.

6 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish 3.
RNs provide an important clinical link between primary health care services and tertiary (specialist) services, that has been limited by limited numbers of RNs Because clinical care is silent in current models of residential aged care, and continues to be silent in the proposed model, the role of the registered and enrolled nurse has been limited to managing other unregulated workers and delivering medical treatments.
There is emerging evidence regarding the value of clinical care provided by nurses, in acute settings (Duffield et al 2007).

While this evidence is yet to be consistently transferred to the residential sector (Nakrem 2009), there is evidence that the presence of clinically-focused RNs improves health outcomes by reducing complications (Needleman et al 2002, Johnstone et al 2006).
Expert clinical assessment and treatment from aged care nurse practitioners can potentially reduce expensive complications that would otherwise require transfer to hospital (ACT Health, 2007).

Approximately 25% of RACF residents visit hospital each year (AIHW 2010).

These figures do not include presentations to the Emergency Department if they are returned to the RACF within 24 hours (which is not uncommon).

Many of these hospital visits are potentially preventable.
The nurse practitioner role is essential to support the increasingly complex clinical requirements of people living in high care facilities, particularly when there is limited access to a general practitioner.

NPs are best used in the provision of clinical evaluation of residents in the early stages of acute illness; thus reducing the impact of the illness on the resident.

Currently the needs are being met by creative responses and innovations responding to identified local needs.
A lot of this work is negotiated across services and clinical disciplines, filling gaps in the system.

Information and support is provided to aid RACFs to be more self sufficient; thus making it a sustainable and context-sensitive approach.

By emphasising clinical care, resources for RNs working in a clinical, rather than management, capacity can be legitimate.
Examples of conditions that clinical RNs, supported by Nurse Practitioners, could manage without admission to hospital include: infections such as cellulitis, upper respiratory tract, urinary tract, wound; dehydration; gastroenteritis; pain management; palliative care; delirium; and behavioural and psychological symptoms of dementia (BPSD), falls for injury assessment.

A range of programs that are (or have recently been) in place are listed below: Cellulitis project (Sutherland hospital).
Wound care nurse specialist (CNS), provides RACF with support and equipment to diagnose and treat cellulitis within RACF.

Intravenous antibiotics and equipment taken from hospital to RACF.

Dementia Cafes (Concord Hospital).

Offers a place for consumers and health clinicians to engage informally, discuss service availability, respite options, prognosis, management strategies, debrief.

Led by a Dementia CNC.

DEMOS – Dementia Outreach Service, in Queensland.


Outreach service provided by NP specialising in dementia.

Particular focus on BPSD.

Train and model suggestions for practice 7 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish in interventions.

Service ensures that recommendations made by the team at the initial assessment are implemented (Borbasi, 2009).

RADAR: Rapid Assessment of the Deteriorating patient Aged at Risk.
(ACT) A team of Nurse Practitioners, geriatricians, access to allied health, see patients in the community (their homes or RACF) to provide timely assessment and treatment of conditions that don’t (yet) warrant hospitalization.

ASET Aged care Services Emergency Team.

(NSW) A team, usually led by a CNS, identified aged patients with unmet needs presenting to emergency departments.
In many instances, this role has evolved to extend support and leadership into RACF – because prevention is better than presentation to Emergency.

and also to identify cause or contributing factors) Shared Nurse Practitioners: Some RACF have developments under way to collaborate and share the cost of a NP between 3 organisations within the one jurisdiction.

Job satisfaction and equivalent renumeration to the public sector is an important part of recruitment considerations.
‘Geriatric Rapid Acute Care Evaluation (GRACE) Model of Care’ (Hornsby) GRACE provides an outreach service and a system of prioritised hospital treatment to improve the 'patient journey' for residents of RACFs.

Works collaboratively with residential aged care facilities and GPs to achieve our outcomes.

Works closely with the ASET team, who take responsibility for providing a similar service for hostel patients.

http://www.archi.net.au/e- library/moc/older-moc/grace.
Many of the deliverables (eg CNC delivery of antibiotics) will be relying on ‘standing orders’ from a medical officer, or other ‘outside the box’ strategies).

The examples provided demonstrate services that do not just provide a single clinical intervention (eg suprapubic catheter replacement) but a offer a hub for conferral of decision making, seeking advice, referrals, discussion, service linkage, and community development.

A critical mass of RNs is essential for any of these programs to be effective.
8 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish 4.

Nurses and aged care workers are motivated by quality of care provided In order to improving attraction, recruitment and retention in aged care, we argue that nurses and Aged Care Workers need to perceive that the care that they deliver is of high quality, and is valued by their organisation and their government.
Examination of nursing from a health economists perspective has highlighted that nursing production needs to take into account the ‘payment’, or intrinsic reward, that nurses receive through their satisfaction with delivering care (Chenoweth et al, 2014).

Decreased satisfaction decreases the intrinsic reward, effectively decreasing their ‘payment’ or motivation to work (Eggert, 3013).
Taking into account the nature of nurses’ care product and decreasing barriers to nurses’ care giving will be important for the development of the aged care workforce.

In most cases employers can enjoy the double dividends of nurses’ sustained high output of care and good patient outcomes.
Intrinsic reward for nurses as satisfaction with care also goes beyond just the individual nurse-patient relationship, and includes the working context that creates an environment for those relationships (Papastavrou et al., 2015).
To improve motivation, recruitment and retention in aged care, recognise and value the intrinsic rewards that nurses and Aged Care Workers seek, and offer: 1. wage parity for RNs and ENs with the acute sector; 2. ample educational and mentoring opportunities (equivalent to the acute sector); 3.
4. quality patient outcomes, improved patient satisfaction; this improves nurse and Aged job variation, promotion and development opportunities; Care Worker satisfaction; 5. nurses and assistants to have an organisational voice 6. formal recognition of excellence in nursing care 7. support with sufficient staffing levels, education and resources for a functional team of RNs, ENs and Aged Care Workers in RACF increase opportunities for aged care nurse practitioners 8. o reduction of red tape/confusion for NP Practice Guidelines; o reduction of limitations to PBS access regarding the cross over between employment by the public health sector but delivery of health care outside of the public health institution o recurrent funding for permanent positions (not just trials/pilots); 9. increased opportunities/incentives for General Practitioner and Pharmacists to work with a functional team of RNs, ENs and AINs in RACF 9 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish 5.
Summary of nursing and caring roles This summary is provided to aid clarity about the many roles, responsibilities and qualifications regarding nurses and assistants.

‘Assistants in Nursing’ (AIN) or ‘Aged Care Workers’ or ‘Carers’ refer to employees who support registered and enrolled nurses to deliver patient care.
American terminology includes unlicensed nursing personnel, unlicensed assistive personnel (UAPs) or unlicensed nursing personnel (UNPs), healthcare assistant, auxiliary nurse, clinical support worker, team leader, care assistant.

May have certificate or other limited training, but any education is generally unregulated, and the staff themselves are unregulated.

Nominally works under the supervision of a RN (hence the name ‘Assistant’ is arguably a more useful representation than ‘Worker’).
Enrolled Nurses (EN) monitor the symptoms of the disease to determine health and report changes to the RN and deliver routine medical treatments under the supervision of the RN.

This is similar to USA's Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LPN).

Also known as 'Division 2 nurse' (in Victoria) and 'state enrolled nurses' (SENs) in UK and registered practical nurses (RPNs) in Canada.

Diploma level of education, about 1 year.

Nominally works under the supervision of a RN.


Registered Nurses (RN) evaluate treatments and can determine the need for medical consultation or other allied health service, deliver complex medical treatments, and determine the need for specialised care.

Across the world, RNs generally a graduate from a University or college nursing program of 3-4 years, which contributes to their recognition by a national Registration Board of health practitioners to be licensed to deliver care as a nurse.
Some may have additional postgraduate qualifications.

As both RNs and Enrolled Nurses are accredited by a national regulatory body, they are often collectively referred to as ‘nurses’.

Clinical nurse specialists or consultants (CNC, CNS) are advanced practice RNs, who offer specialist skills and knowledge in a particular health focus; eg aged care, dementia care, wound care, ostomy care, continence care, palliative care.
Traditionally, clinical nurse specialists are focused within an area health service and may be available as consultants to residential care teams.

Most will have postgraduate education in the form of Graduate Certificate or Masters qualifications.

Nurse Practitioners (NP) provide education and leadership regarding health program development and complex care management, perform diagnostic tests, differential diagnosis, and prescribe medications and treatments within their area of specialty.
Nurse practitioners are also skilled at working across discipline, institutional and specialist knowledge boundaries, and as such are able to play a role in preventing hospitalization.

Most will have a Master of Nurse Practitioner qualification and also additional qualification in their specialty.

10 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish 6.a.
CASE STUDY – RN student experiences as Aged Care Workers I (Kasia) have a number of my RN nursing students who are 3rd years and about to graduate, who have worked concurrently as Aged Care Workers in RACF while studying.

I’m teaching them a unit this semester called ‘Leadership and Clinical Governance’.

They are telling me, in chilling detail, about: - - - being asked by their managers to document behaviours that patients don’t have.

(ie.
(ie.

“Ok we need 3 behaviours, 2 urinary conditions and 5 full nursing care”).

They are also observing notes being written about patients that aren’t consistent with the patient’s presentation (eg – the nurse documents ‘resident throws toothbrush’.

The resident is virtually immobile, all cares are attended for him, he can’t pick up a toothbrush, much less throw it).
their educator encouraging them to do their Certificate IV, but then their manager saying (once they are most of the way through) “oh we won’t be employing you as a IV, you’ll stay as a III”.

in any accreditations, the managers choose only certain staff to work, and change the staffing patterns, quite dramatically, for those days.

Ie the accreditation is not replicable in any way of the rest of their working time, or the patients living time.
In all cases the RN students/Aged Care Workers are swayed by their managers that these are the ‘right things to do’, for the ‘moral good of the residents and organisation’, because if they don’t get the money they won’t be able to have the staff to look after the residents.

The managers plead to the good will of the Aged Care Workers.

The students are aware this is probably exploitation, but have no real power to change anything, and are concerned about the wellbeing of the residents in the long term.
I sought advice from my colleagues working in this arena; senior researchers and policy advisors.

However, the only guidance was for the students to report the facility, even though they all acknowledged that this was not an uncommon scenario of other RACF.

The situation was fragile and the students were wary, and I could not find a way to help them to help improve the system, rather than individually punishing the organisation.
As the students were well aware, this may have the effect of punishing the residents, if the facility were to lose benefits, and so consequently was not in their interest.

So as student RNs, they learnt to observe unsafe and unethical practices, and as their ‘Leadership and Clinical Governance’ academic convenor I could not offer them guidance in any suitable voice or action available to them to attempt to change the course of events.
I have encouraged these students to submit their own senate submission, however given their lack of trust and faith in the system it is unlikely.

11 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish 6.b.
CASE STUDY – Coroners Case from death in RACF The below excerpts are taken from a E-resource for clinicians: ‘Communiqué’ (Residential Aged Care Communiqué, 2016), which offers two different experts examination of a recent coroner’s case.

This particular example and the expert opinions offer evidentiary support to a number of the principles discussed in the submission.

(Italics added for emphasis in relation to the points made in the submission).

Young, C, Ibrahim, J.

2015.


Case Report: Respite Care: It is not a holiday: “The coroner described this [particular case] as a “break down in the GP’s record keeping” and also considered the RACS staff had “not responded with sufficient urgency” to this matter.

There were several other clinical situations that should have prompted the RACS staff to seek a medical review.
These included; the fluid balance charts indicating evidence of poor oral intake and dehydration with poor urine output; concerns about skin integrity and pressure injuries; difficulty swallowing food and drink; evidence of a urinary tract infection and; continued agitation with need for airway suctioning.
The GP explained that his reasons for not visiting Ms W at the RACS was he believed he did not have visiting rights, it was an hour’s drive away from the clinic and he was not aware the oral intake was low.
The coroner concluded Ms W was nearing the end of her life when she was admitted for respite care and that although the care received by Ms W “was inadequate …, the condition that led to her death was difficult to detect and she could have died from it at anytime, anywhere.” The coroner found the RACS had inadequate admission procedures.

They failed to fully acquaint themselves with Ms W’s special care needs and to ensure that all staff were aware of the care plan.
The RACS failed to adequately assess Ms W’s clinical needs and seek the necessary clinical specialists.

They failed to ensure she received adequate hydration and nourishment, which increased her susceptibility to infection.
The prescribed and essential medication clonazepam was not provided as a consequence of the GP’s record keeping and the RACS slow approach to addressing an obvious discordance in the medical summary and the care plan.”… “The discharge hand-over did not give Mr W sufficient information about his wife’s deterioration to enable an informed assessment of how to manage her health care.

This contributed to a delay in seeking a medical review.
What was of interest and somewhat confronting if you read the finding in its entirety, is the expert’s comments that “it is unrealistic to expect such severely compromised patients to prosper in short-term respite care” and the coroner “accept [ing] that temporary respite care is unlikely to be able to reach that same standard” as provided by Ms W’s husband.
I would argue that we should not, and cannot, afford to accept these statements [from the coroner].” 12 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish Neville, C. 2016.

Expert Commentary.

Danger ahead: Residential respite care underway.


“If RACS management is admitting people with high care needs to respite care they need to ensure the ability to be in full and regular communication with the current team that attends to their health i.e.

in this case the GP, dietician, physiotherapist and speech pathologist, or that suitable locums are in place and contactable.
If the RACS has a shift work structure this has to be managed effectively to ensure some permanency of staff who will learn the idiosyncrasies of each resident, especially important for respite.

Casualization of the workforce to cater for organisational monetary efficiency may place residents at risk of a fast rotation of health workers who have not had an adequate handover of information.
Even permanent staff who are under time pressures due to skeleton staff/resident ratios may not prioritise getting to know someone or following up on their care when they will only be with them for a short period of time.

If staff do not have the experience, knowledge or skill level to manage someone with greater care needs, they may inadvertently miss obvious signs that the person’s health is deteriorating.
If RACS management is admitting people with high care needs to respite care they need to ensure the ability to be in full and regular communication with the current team that attends to their health i.e.

in this case the GP, dietician, physiotherapist and speech pathologist, or that suitable locums are in place and contactable.

Comprehensive communication processes go from pre-admission through to post-admission.
Cost saving measures for the workforce and poor communication processes can in the end be very expensive to the aged and health system as exemplified by this case as Ms W required an acute hospital admission before her death.” 13 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish 6.
Nurse sensitive outcomes research demonstrates associations between nursing care and quality outcomes, though is under-developed in residential care Nurse sensitive outcomes research has demonstrated correlations between nurse staffing and patient outcomes since the late 1990s in a range of countries including Armenia, Australia, Belgium, Canada, Germany, Iceland, Japan, Korea, New Zealand, Russia, Switzerland, Taiwan, Thailand, United Kingdom and the United States of America (Aiken et al., 2002, Aiken et al., 1999, Clarke and Aiken, 2008, Duffield et al., 2007, McCloskey and Diers, 2005, Needleman et al., 2001, Rafferty et al., 2007, Schubert et al., 2009, Tourangeau et al., 2006, Twigg et al., 2010, Van den Heede et al., 2006, Yang et al., 1999).
Higher RN staffing has been consistently associated with less hospital-related mortality, cardiac arrest, hospital- acquired pneumonia, and failure to rescue (death resulting from preventable complications) (Kane et al., 2007).

Kane et al.

(2007a) established that higher RN hours spent on direct patient care is associated with decreased risk of hospital-related death and shorter lengths of stay.
Higher RN overtime hours are associated with increased complications including hospital-related mortality, nosocomial infections, shock and bloodstream infections (Kane et al., 2007).

Another key factor that is linked with lower mortality is higher nurse education (e.g., proportion of nurses with nursing degree or higher) (Kane et al., 2007).
Gradually there has been a shift from nursing care and staffing being background variables investigating patient outcomes, to nursing care and staffing being the focus of study (Clarke and Donaldson, 2008).

The science of nurse sensitive outcomes thus developed upon the accepted recognition that patients respond to characteristics of the environments in which care is provided, and that this includes nurse characteristics such as staffing levels and level of education.
The bulk of nurse sensitive research is in acute facilities, but there is an increasing focus on aged care in acute hospitals, 2012 the rate of publications in 2012 being ten times higher than in previous years (Hofmann, 2013).

This example highlights the increased interest in the aged population and recognition of the complexity in managing this population.

Research that is nurse sensitive seeks to find proxies which are representative of nursing work.
Nurse sensitive indicators are often described in health evaluation terms of: structure indicators (e.g., organisational environment); process indicators (e.g., personal care coordination); and outcome indicators (e.g., patient outcomes) (See Table 2.1 for examples and differentiation of process, structure and outcome indicators) (Donabedian, 1966).
The phrase ‘nurse sensitive’ represents that the items being measured are reflective of nursing components, but are not exclusively resultant from nursing care.

This section shall explore indicators currently being used in RACF, move on to understanding what indicators are developed in hospital care for older populations, and briefly introduce what limited indicator research there is for the dementia-specific population, both in RACF and in hospital care.
The outcome indicators used in these four areas are summarised in Table 1.

14 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish There is significant tension, and consequently caution by researchers, between outcome indicators used for industry regulation, and outcomes indicators for investigative research.

Nakrem et al.
Nakrem et al.

(2009) reviewed the use of quality indicators for care in nursing homes for persons aged over 65 in USA, Australia, Norway, New Zealand, England, Sweden and Denmark.

Outcome indicators used for service evaluation included new fractures, falls, Table 1.
Nurse sensitive outcomes in aged and dementia care Research Setting RACF RACF for people with dementia Hospital care for elderly Hospital care for people with dementia Outcomes used Reference Pressure areas, physical restraint, functional status, composite quality score, mortality, hospitalisation, nutrition and incontinence Deficiency citations, pressure areas, physical restraint use.

Functional ability, pressure areas, and weight loss are the most sensitive quality indicators linked to staffing.
Physical restraints, falls and injuries Quality of life, agitation, and emotional responses to care delivery Pressure areas, hospitalisation or weight loss.
Infection, delirium, fall-related injuries, pressure sores Lower central line bloodstream infections, ventilator associated pneumonia, 30 day mortality, and pressure area Adverse events In hospital mortality Transfers to geriatric psychiatry, lack of serious falls, mortality, ADL, mobility and behaviour scores Cost, LOS, readmission, rehab, cognition, function, and patient and staff satisfaction Institutionalisation, death in hospital, or increased LOS, UTI, nutritional problems, delirium, falls (Spilsbury et al., 2011).
(Castle, 2008) (Bostick et al., 2006) (Luo et al., 2011) (Chenoweth et al., 2011) (Gruneir et al., 2008, Luo et al., 2010, Zieschang et al., 2010) (Ackroyd-Stolarz et al., 2011) (Stone et al., 2007) (Schilling et al., 2011) (Zieschang et al., 2010) (Ahmed and Pearce, 2010) (Zekry et al., 2009) (Stenvall et al., 2005) ADL – activities of daily living, LOS – length of stay, UTI – urinary tract infection, RACF – residential aged care facility mental or behavioural effects, cognitive impairment, specific bowel function items, weight loss, dehydration, pain, decline in range of motion, skin care, pressure areas, sleep and urinary tract infections; all of which were recognised to be nursing sensitive.
Nakrem et al., (2009) caution that while the use of nurse sensitive quality indicators is widespread in national regulatory approaches, they have been adopted with limited testing.

Furthermore, there can be substantial differences between quality scores and actual care given to residents, and meaningful differences in care are not necessarily identified by the adopted indicators.
A systematic review revealed that 40% of quality indicators currently in use show an 15 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish association with staffing levels (Castle, 2008).

This may be positive – in that 40% of current investigations of proxies are useful indicators of care related to nurse staffing.
Conversely, this finding also indicates that 60% of quality indicators may not be related to nursing care, but are still being utilised despite a lack of evidence to support their use.

This tension highlights a pertinent challenge for researchers in this growing field: that research that relies on regulatory measurements is limited in its exploration; and regulatory indicators without evidence to support their use have limited value as quality of care indicators.
Despite the weaknesses of data collection methods and poor empirical development of quality indicators for aged care, similar to acute, non-aged specialty settings, demonstrated association between higher total staffing levels (especially licensed staff) and improved quality of care using a number of approaches is consistent.

Higher aged care worker levels compared to nurses were predictors of lower deficiency scores after controlling for facility characteristics (Hyer et al., 2011).
Similarly, more nursing care deficiency citations are independently associated with decreased quality in resident outcomes (Castle and Ferguson, 2010, Temkin-Greener et al., 2010).

In other studies, these deficiency scores have been confirmed as being associated with resident outcomes, separate to nursing specific citations (Wan et al., 2006).
Direct time of licensed nurses per resident is associated with better outcomes, including: fewer pressure areas, hospitalisations and urinary tract infections (UTI); less weight loss, catheterisation, and deterioration in the ability to perform activities of daily living (ADLs); and greater use of oral standard medical nutritional supplements (Horn et al., 2005).
Reducing staffing levels or replacing licensed personnel with aged care workers was found to increase pressure area incidence (Hickey et al., 2004).

Patient outcomes have also been found to be related to staffing characteristics other than simply numbers and qualifications of nursing and care staff.

For example, one study indicates a significant relationship between high turnover of staff and poor resident outcomes (Bostick et al., 2006).
Another study found that unit time pressure (workload as perceived by nurses) increased the prevalence of both antianxiety and hypnotic medication use and pressure areas, and perceived unfair nursing management by staff was related to increased medication use for residents in elderly long-term care settings in Finland (Pekkarinen et al., 2008).
Interestingly, from a management/leadership perspective, the job tenure of top RACF management is associated with a decrease in prevalence of pressure areas and pain of residents (Decker and Castle, 2011).

Spilsbury et al.

(2011) explain that in residential aged care, to focus on numbers of nurses alone “fails to address the influence of other staffing factors (e.g., turnover, agency staff use), training and experience of staff, and care organisation and management” (Spilsbury et al., 2011).
Consequently, quality of care is influenced by the combination of (not just any one of) staffing levels, agency staff, stability, leadership and turnover (Castle and Engberg, 2007).

From staffing, to staffing characteristics, the understanding of impacts on patient outcomes can be extended to work environment attributes.

The work environment is also sometimes described in terms of workplace culture or organisation, or structural indicators.
These have 16 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish also been examined in RACF, and include care models such as primary assignment of staff to residents, and self-managed teams which have been found to have an impact on quality of care (through measurement of deficiency scores in USA on audits of RACF) (Temkin- Greener et al., 2010).
More perceived support from management was associated with less emotional exhaustion and less depersonalisation of staff (Jeon et al., 2011).

Staff RNs’ participation in facility affairs, the perception of a supportive manager, and resource adequacy are all positively related to RN job satisfaction (Choi et al., 2008).

The inference is made that improving job satisfaction for nurses can improve recruitment and retention, which can impact on patient outcomes (Lu et al., 2012).
However, to date this claim has not been demonstrated with trials (Chenoweth et al., 2011, Jeon et al., 2015).

Special care units, such as high level dementia care, in residential aged care facilities have had some focus, with findings of reduced pressure areas, hospitalisation or weight loss (Gruneir et al., 2008, Luo et al., 2010, Zieschang et al., 2010).
These kinds of units tend to have higher staffing, better specialty training and planned physical environments, which may contribute to the positive changes in outcomes seen.

There are other kinds of specialised units or services for this population, for example hospices, which use different kinds of outcome measures such as opioids for pain relief, dyspnoea relief and reported unmet needs.
These particular studies did not control for staffing levels/skill mix, which were likely to be higher in a hospice or special unit than a RACF (Kiely et al., 2010).

A common discussion point in the above research is regarding the quality of data available to make nurse sensitive claims.

The best national data sources in the USA for staffing and quality include the Minimum Data Set (MDS) and On-line Survey and Certification Automated Records (OSCAR).
However, the accuracy of this self-reported information requires further reliability and validity testing (Bostick et al., 2006).

Indeed, Bostick et al., (2006b) call for a nationwide instrument that to be developed to accurately measure staff turnover.

Large-scale studies using payroll data to measure staff retention and its impact on resident outcomes are recommended, as is using the most nurse sensitive quality indicators such as pressure areas, functional status and weight loss (Bostick et al., 2006).
Discussion is raised that RACF providers “tend to focus on the ‘big five’ QIs [quality indicators] – falls, pressure sores, weight loss, restraints and psychotropic medications – because: they are deleterious outcomes or processes that can lead to deleterious outcomes; they are readily documented; they are often linked to each other; they receive special attention in the survey process; and they are candidates for quality improvement” (Arling et al., 2007).
The presence of these in the research literature echoes the analysis of available data, rather than necessarily the most important outcome indicators.

Similar calls for improvements in data collection methods have been made in Australia (Heslop, 2015, Nay et al., 2004).
In summary of nurse sensitive outcome research in residential care, determining which outcomes for the aged are sensitive to nursing is complicated by the availability of regulatory focused outcomes, which have only partially been validated as sensitive to nursing.
There is also a decreasing emphasis on RNs actually providing bedside patient care in residential aged 17 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish care facilities; the trimming of the nursing workforce occurred before evidence was gathered and analysed to determine the effect on care quality with and without a greater proportion of RNs.
Despite these data limitations, falls, pressure injury, weight loss, physical restraints, psychotropic medications, functional status, and hospitalisation are consistently investigated with some evidence that they are modifiable by nurse staffing, skill mix and workplace environment in the residential setting.

18 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish Table 2.
Nurse staffing and aged care resident outcomes: reviews Systematic review (Castle, 2008) (Spilsbury et al., 2011) (Bostick et al., 2006) (Hodgkinson et al., 2011) (Backhaus et al., 2014) Setting/criteria for the review No.
Most common resident Nurse staffing measures 1991–2006 Research studies in Medline and CINAHL plus snowballing which offered empirical evidence of relationship between staffing and quality in nursing homes 1980–2008 Research studies with ‘quality’ adjacent to terms ‘care’ or ‘nur$’ in the title, which evaluated the relationship between nurse staffing and quality of care or resident outcomes 1975 to 2003 Research articles and government documents published reporting studies in which staffing measures have been validated and are reliable < 2007 Randomised controlled trials (RCTs), controlled clinical trials, interrupted time series and controlled before-and-after designs that evaluated nursing models in residential aged care Studies were eligible if they (1) examined the relationship between nurse staffing and quality of care outcomes, (2) included only nursing home data, (3) were original research articles describing quantitative, longitudinal studies, and (4) were written in English, Dutch, or German.
The methodological quality was assessed using the Newcastle-Ottawa scale, excluding 2 low-quality articles for the analysis.

outcomes/measures of quality 59 Deficiency citations, pressure areas, physical restraint use Full time equivalent (FTE) staff per bed or resident (e.g.
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RNs); combinations of different levels of nurses Functional ability, physical restraint use, pressure areas, catheter use/incontinence, deficiency citations, mortality rates, hospital admissions Incidence of pressure areas; falls; medication errors and adverse events; and validated quality of life measurements Staffing hours per resident/bed per day; staffing ratios per resident/bed; staff mix, staff utilisation, turnover rates and retention Primary care vs Team nursing (control) And Resident-oriented care model Vs usual care (control) Clinical outcomes, Pressure areas, Infections, Activities of Daily Living decline Mobility decline, Worsening behaviour, Abuse, Neglect, Restraint, Catheters, Pain, Deficiency citations for safety, Hospitalisation, Weight loss, Incontinence, Better mental state, Improvement in physical functioning, Side rail use Unit-level direct care hours/day (average RN, LPN, unlicensed); Resident level direct care hours/day (RN, LPN, Aid,); FTE per 100 residents (RN,LPN,NA); Nurse hours per resident per week; RN HPPD; Total staff HPPD; Time spent on direct care (RN/LPN/NA); Ave non/licenced staff time (Minutes); Staff expenses (RN/LPN) 19 Future of Australia’s aged care sector workforceSubmission 185 Senate Submission: Aged Care Workforce Kasia Bail and Laurie Grealish References: Ackroyd-Stolarz, S., Guernsey, J.R., MacKinnon, N.J., Kovacs, G., 2011.
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23 Future of Australia’s aged care sector workforceSubmission 185