Do We Need Mandated Staffing Ratios Or Staff Transparency In Aged Care?

22 July 2019

The title of this year’s Victorian Healthcare Week Great Debate was: Do We Need Mandated Staffing Ratios in Aged Care? Are we better off focusing on the quality outcomes for older Australians rather than mandated staffing ratios?

Lisa Giacomelli (Chief Operating Officer YMCA NSW) and I (Director, Aged Care Matters) received an invitation to speak on the opposing team. We were told we had been specially selected based not only on our expertise but also our ability to marry humour with intellect.

Lisa presented a strong case to show that mandating ratios does not guarantee quality.  Lisa used examples from the childcare industry, an industry that has mandated ratios.

“I have worked in the child care industry for nearly a decade. Ratios are mandated there and services are audited and checked by the regulator to ensure they are ‘in ratio’.

“When something occurs in a service when things don’t go to plan, the first question asked is always: ‘Are we in ratio?’ And I can tell you the answer is almost always ‘yes’.

“Being in ratio does not prevent poor practice, it does not prevent care standards being upheld, or staff taking their eye off what they are meant to be doing, or clients acting in a way that wasn’t anticipated, or allergic reactions to medication or accidents, nor does it prevent policies and procedures being breached.

“In fact, ratios can have the opposite effect. The need to be ‘in ratio’ (a golden term in the children’s services industry) causes all kinds of stress for coordinators and directors who spend their time finding staff and managing rosters rather than focussing on quality of care, listening to the voices of children and dynamic educational leadership. It’s hard to be inspiring when you are struggling to ‘stay in ratio’.

“Mandated ratios result in a higher reliance on agency staff which, due to the inconsistent nature of agency staff who do not understand the service or know the children, can create inconsistency of care, lack of commitment to the service and the role and undermine the safety that children feel in a familiar and consistent environment. Agency staff, whilst doing their best, just cannot have the same engagement with service and organisational culture, or with clients than long serving staff can.

“They also create a false sense of security. It is not difficult to envisage services believing that as long as we are ‘in ratio’ we are offering good quality, engaged and inspired care. Management and leadership can take their focus off what staff are doing to focus on how many staff are doing it. Leadership becomes more about rosters and less about staff development, more about regulation and less about client experience, more about ‘not getting caught out’ and less about the very people that aged care services are there to serve. This is the danger of ratios and they can be dangerous.

“If you want to mandate quality care – mandate engagement with clients, families and communities. Ensure that staff culture is positive, resilient and empowering. Train the best and brightest and pay them that way.”

Sarah began by asking the audience to raise their hands if they wanted all older people living in all aged care homes to have the best quality of life possible. As you would expect, there was a sea of raised hands.

“I am a public health researcher and aged care advocate. My research shows there are good aged care homes. However, anybody who has paid even the slightest attention to the Royal Commission on Aged Care Quality and Safety knows that not all aged care homes are good.

“In any profit-based system that relies on government subsidies, like pink batts, private colleges and aged care, there are always some shonky providers. These shonky providers thrive because of systemic and regulatory failures.

“Will the systemic problems in aged care be miraculously fixed by mandating staff ratios? The answer is indisputably ‘No’. A shonky provider will make up the numbers with the cheapest, most unqualified staff possible.

“My colleague has presented a strong case to show you that mandating staff ratios in childcare centres does not guarantee quality. To the opposition, I say: ‘Be careful what you wish for’.

“The opposition has used the same arguments that have been shouted for years. These arguments regularly appear as memes on social media. In response, the peak bodies for providers tweet their own memes. The memes and tweetsgo back and forth but nothing changes.

“It is unusual for an aged care advocate not to support mandating staff ratios. Other aged care advocates get very exasperated with me. They tell me it is simply ‘common sense’ that more staff on duty = better service. This was certainly not the case at my local café last Friday when 2 regular, experienced, competent and cute waiters were sick. They were replaced with 2 agency staff who knew nothing about how the café operated – not even how to use the coffee machine or where to find the tomato sauce. They did not improve the quality of the service. In fact, they reduced it.

“To address the systemic issues in the aged care sector, we desperately need ethical leadership. We need someone with a kind heart and open mind who can see past the vested interests. We need a Nelson Mandela, Jacinda Adhern or Greta Thunberg.

“During the past few years, the usual suspects have shouted for staff ratios. The other usual suspects have shouted for more government money. There has been a lot of noise but no leadership.

“Good leaders bring people with diverse views with them. They build consensus not division.

“So what should an aged care leader do?

“Firstly, they should listen to all key stakeholders – not just those with the loudest voice. They would also listen to staff, families, community members and, most importantly older people themselves. They would then bring all key stakeholders to the negotiating table.

“A good leader would put something achievable on the negotiating table – something that all key stakeholders may agree on. I propose we start with staff transparency.

“Yesterday, Rebekha Sharkie re-introduced her Private Members Bill that requires every aged care home to disclose and publish quarterly staff/resident ratios.

“Shonky providers will lobby against this legislation. However, good aged care homes with high numbers of well-trained staff have nothing to fear from staff transparency.

“When we have accurate staffing data we can perform the research needed to develop evidence based staffing guidelines.

“Rather than Staff Ratios that cause division, Staff Transparency is a much better place to start.”


Rethinking The Staff-Quality Relationship In Aged Care Homes

1 October 2018

The Aged Care Minister and provider peak bodies were recently asked to explain their opposition to mandating minimum ratios  of registered nurses in aged care homes.

This led to an opinion piece in which their claims were contested.

The Aged Care Guild has recently used a financial argument to oppose ratios, and priced mandated ratios as an extra $5 billion per year.

This is a bit rich from a peak body that represents the 8 biggest aged care providers – some with executives on extremely high salaries.

An article in the Daily Telegraph states: “The bosses of the biggest six aged care companies pocket seven-figure salaries and churn through $2.17 billion in taxpayer funds a year”.

Rather than use a financial argument, the government is using research from The Netherlands to support their opposition to ratios.

A letter from Office of the Hon Ken Wyatt MP contains the following paragraph:

“One of the latest staffing studies, compiled in April this year in The Netherlands, states: “There is no consistent evidence of a positive relationship between the quantity of staff and quality of care”.

It says: “We should think beyond numbers. Instead of focusing on the quantity of staff, we welcome initiatives that consider the quality of a team”.

I have read the research that is referred to in the Minister’s letter, and my assessment is the Office of the Hon Ken Wyatt MP has misinterpreted the findings of the Dutch research.

In 2016, Backhaus, Beerens, Van Rossum, Verbeek, and Hamers undertook a literature review for the Dutch Ministry of Health, Welfare and Sports.

The aim of the literature review was to summarise all the available evidence on the relationship between staffing and quality in aged care homes.

The editorial “Rethinking The Staff-Quality Relationship In Nursing Homes” (2018) provides evidence of a positive relationship between the quantity of staff and quality of care.

This is a matter of fact, not opinion.

It is important to critically read research papers, not to cherry pick sentences that support your position.

Although the authors state: “There is no convincing scientific evidence of a positive relationship between staffing levels or the educational background of staff and quality in nursing homes”, this statement needs to be critically examined.

The first question to ask is: Why did only a small number of studies meet the inclusion criteria?

The answer is crucial to the interpretation of the study. In many countries, there is a lack of data to analyse the relationship between staffing levels or the educational background of staff and quality in nursing homes.

It is simply not possible to undertake rigorous studies on staffing because data is either non-existent or not available to researchers.

In Australia, the data is collected by the Department of Health and financial organisations (e.g. StewartBrown) but this data is not available to the public, including researchers.

In contrast, the US not only collects data but also makes this data available to the public.

So it is important to note that Backhaus and her colleagues stated: “Studies that found a positive relationship [between the quantity of staff and quality of care] were mostly conducted in the US.”

The only country that analyses data on staffing and quality indicators showed a positive relationship.

The US data shows the more staff on duty, the higher the quality of care.

It is therefore not correct to conclude: “There is no consistent evidence of a positive relationship between the quantity of staff and quality of care”.

There is evidence. This evidence is found in the only country that not only collects data on quality indicators but also makes this data available to the public.

Clearly, quantity of staff is not the only determinant of quality of care. But it is a determinant.

Other important determinants are the quality of the team, the manager of the aged care home (responsible for staff morale, supervision etc.) and the owner of the aged care home licence.

It is noteworthy that over the past 20 years only 183 studies undertaken met the inclusion criteria for this literature review.

The most obvious conclusion to draw from this low number is the urgent need to undertake rigorous research.

In Australia, such a study could easily be undertaken. All Victorian-owned aged care homes have mandated ratios.

This provides the perfect ‘laboratory’ – both a control group (Victorian-owned) and an experimental group (private and not-for-profit).

Quality outcomes in Victorian-owned aged care homes could be compared with those in private and not-for-profit aged care homes.

The recent Aged Care Workforce Strategy Taskforce could have undertaken this research.

However, this taskforce morphed into an “industry led” Workforce Strategy Taskforce. Once again, “consultation” and “expert opinion” trumped evidence.

We urgently need empirical evidence to determine the relationship between the numbers and training of staff and standards of care in an aged care home.

This research is needed so we can have an evidence-based policy rather than one that is based on opinions.


What is it like to work in an aged care home?

26 July 2018

Aged care homes are places where our most frail and vulnerable older people live. How do we ensure the highest possible standards of care in aged care homes? Some claim a consumer driven and market based residential aged care system will provide ‘world class’ care; others claim we need effective regulation, government intervention and increased transparency to prevent neglect in aged care homes.

In recent years, there have been numerous heart-breaking stories about aged care homes. When stories about inadequate personal care, neglect, abuse and negligence are reported in the media, the aged care industry dismisses these stories as ‘one-offs’. But are they?

To answer this question, we need to hear from people who have first-hand experiences in aged care homes – residents, relatives and staff. They know what day-to-day life is like in aged care homes.

I recently asked relatives about the aged care home they visited. By sharing positive and negative views about aged care homes, and suggestions about how residents can have the best possible quality of life, relatives provide a rich source of experiences to inform policy. I have also interviewed residents.

I am now seeking the views of staff who work in an aged care home. Staff are often hard working, dedicated people doing a very difficult job for not much pay or professional kudos.

Managers, nurses, personal care attendants, kitchen, activities, reception, cleaning and maintenance staff are encouraged to share their first-hand experiences of working in an aged care home. We need to listen to staff’s experiences of their day-to-day work in an aged care home. We also need to know more about the working conditions in aged care homes.

There are around 2,700 aged care homes in Australia. Although many are excellent, some operate without enough staff. Unlike childcare centres, hospitals and schools, there is no federal legislative requirement for aged care homes in Australia to have staff-to-resident ratios or skill prerequisites.

Should ratios be introduced? Or are most aged care homes adequately staffed?

Would you recommend the aged care home where you work to your parents?

These are the type of questions that need to be answered to ensure an evidence-based approach to aged care policy.

Staff who participate in this study will be asked to reflect on what you like about your work, and what you don’t like. I am also seeking ideas for improving residents’ quality of life. If you could change three things in the aged care home in which you work, what would you change?

The survey begins with open-ended questions. This gives staff an opportunity to say as much or as little as you like about whatever you want.

All information will be kept confidential. No identifying information about you or the aged care home where you work will be published.

If your first language is not English, you may answer questions using your first language.

I am also collecting information about staffing levels in aged care homes. What is the ratio of registered nurses-to-residents in the aged care home in which you work? Is a registered nurse on site 24 hours a day?

The more survey responses I receive from staff, the stronger the findings. The findings will be used to lobby for improvements in working conditions for staff in aged care homes. Improved working conditions are not only important for staff but will also ensure a better quality of life for residents.

If you would like to share your views, please click here.


So Many Inquiries, So Little Action

9 February 2018

How many inquiries, reviews, taskforces, think tanks, consultations and consultant reports does it take for the government to change a light bulb in an aged care home? Over the past year or so, the government has investigated, among other things, the aged care workforce, reforms, accreditation, complaints scheme, innovation, standards of care and elder abuse – and still the light globe remains unchanged.

The numerous reports commissioned by the government generate recommendations that never see the light of day. Unless, of course, the recommendation is to: “Commission further research”. A consultant’s report invariably recommends more consultancies. These reports have become an industry within the aged care industry.

The Future of Australia’s aged care sector workforce Inquiry made several recommendations that would have made a significant difference to the lives of older people who live in an aged care home.

Recommendation 8, for example, suggested the government examine the introduction of a minimum nursing requirement for aged care homes. Recommendation 10 suggested the government require aged care service providers to publish and update their staff to resident ratios “in order to facilitate informed decision making by aged care consumers”.

Rather than accept these recommendations, the government established an ‘industry led’ Aged Care Workforce Strategy Taskforce. The Taskforce was given a budget of $2 million. How many registered nurses could have been enrolled in a Master of Gerontology course for that price?

The taskforce kicked off last December with a daylong Summit at the Melbourne Exhibition Centre.  The Summit was an opportunity for participants, particularly many who were new to the aged care ‘industry’, to learn from people with expertise in the aged care workforce. Instead, I hardly even heard the word “workforce” used all day.

The Summit began with a session by Simon Hammond from Hammond Thinking. Simon is a cultural anthropologist and global brand strategist. He began by telling us that aged care is all about the “vision” and “journey”. Perhaps Simon came up with the slogan for the Summit: “Think. Collaborate. Innovate”.

Simon began his session by showing us a video about Free Hugs. This video did not shift my thinking (if that was indeed its purpose). Instead, it left me feeling particularly discombobulated.

Simon then asked us to discuss our “fears, frustrations and desires”. This session could easily have been named “The day in the life of an aged care advocate”. I have spent many hours listening to residents and relatives talk about their fears, frustrations and desires – particularly whilst undertaking my research “Living well in an aged care home”.

Simon will also be running some daylong workshops “searching for a common belief into why the aged care sector matters”. These workshops “will create an opportunity for people from all parts of the sector to unite around insights, truths and beliefs pertaining to ageing and the aged care industry”.

I was initially informed that HammondThinking received $69,300 for “Strategic Planning Consultation Services”. Gobsmacking. More recently, I noticed his costs increased to $79,695.17, though no explanation is given for this increase on AusTender website.

In the afternoon, I attended 2 “Breakout” sessions. The first ‘Enhancing safety and quality’ demonstrated a dissonance between the participants who wanted to discuss ‘standards of care’ and ‘quality of life’ and the facilitator who was focused on ‘safety and quality’ in industries such as manufacturing and aviation.

The facilitator’s interest on more traditional ‘industries was not surprising given he is a forensic economist (employee of APIS). APIS received $210,633.00 for their contribution to the Workforce Taskforce (a significant amount of money that would employ many PCAs for a year in an aged care home).

My attempts to find out what APIS will contribute to the Workforce Taskforce were unsuccessful. After my 2nd email, I received the following reply: “I acknowledge receipt of your email.  Please note the queries you have raised need to be addressed to the Department of Health.” So I still have no idea (1) what a forensic economist actually does and (2) what insights APIS will bring to the aged care workforce strategy taskforce.

I was however interested in a participant’s comment during the Breakout session. He said: “We don’t expect the engine to fall out of an aeroplane. Instead, we focus on leg room and inflight entertainment and service.” The translation of this comment into the aged care ‘industry’ is: “We don’t expect pressure injuries, malnutrition, dehydration, falls, medication errors or financial gouging.

It would be wonderful if relatives had only to focus on activities, environment and services in an aged care home. Unfortunately the ongoing heart-breaking stories about neglect and negligence in aged care homes suggest the aged care ‘industry’ has a long way to go before it can be compared to the aviation industry.

The second “Breakout” session I attended was: ‘Translating research and technology into models of care and practice”. This session was even more frustrating than the first session. There is an abundance of research about optimal workforce (both numbers and skill set), models of care etc. We don’t need to re-invent the wheel.

Several researchers, including those at the Australian Association of Gerontology, encouraged the Chair of the taskforce to undertake a robust analysis of the national and international evidence on the aged care workforce. This evidence would have enabled the Workforce Taskforce to better evaluate the merits of key stakeholders’ opinions. Instead, the department opted for further consultation and engagement.

The lunch at the summit was delicious, and the ‘Think. Collaborate. Innovate’ corflute signs were attractive. However, paying $217,125 for Event Planet to provide event management services for the Aged Care Workforce Strategy Taskforce seems excessive. The costs for Event Planet increased by $67,474.90 to a total of $284,599.90. The reasons stated for this increase are: “extreme urgency or events unforeseen.”

It is unusual for me to be facetious, but I left the summit wondering whether I should give Working Dog a call for Series 4 of ABC TV series Utopia.

The next summit will be held on 17 April. I am sure the lunch will be delicious.


Market must stay out of aged care

Published in Courier Mail on 27 March 2017

Last month the Courier Mail reported yet another heart breaking story about aged care homes (Aged care nightmare: man’s scrotum ‘left bleeding’, 20th February). Many of us were shocked because we assume elderly Australians receive high quality care in aged care homes.

The Federal Government is promoting its reforms in the aged care sector as supporting a consumer driven and market-based system. However, the “consumers” in aged care homes are often frail, elderly people, many with dementia. How can they demand a high quality service on the free market?

There are around 2,600 aged care homes in Australia. Although some are excellent, many aged care homes operate without enough staff. Managers who are under pressure to meet their profit targets do so by reducing staff, placing vulnerable residents at risk.

Staff in aged care homes are often hard-working, dedicated people doing a very difficult job for not much pay. When an aged-care home has insufficient staff, there may not be time for staff to walk residents to the toilet or even help them out of bed. All too often relatives feed, shower and dress residents because staff are too busy.

A key to quality healthcare is a good staff-patient ratio. However, unlike hospitals, there is no federal legislative requirement for aged-care homes to have mandated staff-to-resident ratios or skill prerequisites. The decision whether to have a registered nurse on duty is at the discretion of the provider.

When registered nurses are on duty in aged care homes, residents have better health outcomes, a higher quality of life and fewer hospital admissions. However, registered nurses now account for less than 27% of this workforce, while personal care attendants make up 68%.

Some personal-care attendants gained their qualification to work in an aged care home after completing a five-week course. It is inconceivable that someone with only five weeks of training is qualified to provide competent care, particularly when there is no registered nurse on duty to supervise them. Is it any wonder relatives’ submissions to recent inquiries into aged care have highlighted inadequate personal care, neglect, and negligence?

Relatives complain because residents’ needs are unmet – when incontinence pads are not changed regularly, when bruises appear or skin tears, and when pressure sores are not treated appropriately, in some cases turning gangrenous. Complaints are also made when residents suffer from malnutrition and/or dehydration and are chemically restrained. The list goes on.

The accreditation process should play an important part in monitoring the standards of care in all aged-care homes, including whether adequate numbers of skilled staff are employed. The current accreditation standards are woefully inadequate.

Coronial inquests into separate deaths at two aged care homes in Melbourne, BUPA Kempsey and Arcare Hampstead, exposed inadequate care. Yet both BUPA Kempsey and Arcare Hampstead were fully accredited by the regulator, the Aged Care Quality Agency, with perfect scores of 100 per cent in all criteria. This suggests something is wrong with the accreditation processes.

Following the coronial inquiries, the Aged Care Quality Agency did not change the accreditation processes. Vague phrases such as “sufficient staff” continue to be used. In some cases, sufficient staff means no registered nurse on duty. It may also mean an inadequate number of personal-care attendants.

When taxpayers are subsidising the care of elderly people, the public’s investment needs to be protected in the form of regulation, mandated staff ratios and a rigorous accreditation system. The care of vulnerable older people is too important to be left to the whims of the free market.

Published in Courier Mail on 27 March 2017