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.”


Google Translator Did Not Help Me Understand The Aged Care Workforce Strategy Taskforce Report

6 December 2018

According to the script of the TV series ‘Yes Minister’, there are two basic rules of government: Never look into anything you don’t have to. And never set up an enquiry unless you know in advance what its findings will be.

During the past decade, there have been many inquiries, reviews, consultations, think tanks and a task force into aged care. These inquiries have resulted in a large number of recommendations, most of which have been ignored by successive governments.

The Aged Care Workforce Strategy Taskforce kicked off in December 2017 with a so-called “Summit”. As an attendee, I was given a lanyard with the slogan: “Think. Collaborate. Innovate”. The slogan, the free hug video and the break out sessions left me feeling discombobulated. However, the lunch was delicious.

With a $2 million dollar budget (courtesy of the Australian tax-payer), I expected the taskforce to answer the million-dollar question: Will standards of care be improved by the government mandating staffing ratios in aged care homes?

Everyone has an “opinion” about staffing ratios. Jane Seaholme’s petition “Mandate aged care staff/resident ratios” has around 300,000 supporters. Staff, relatives, residents, aged care advocates and unions all support staffing ratios in aged care homes. In contrast, those with power – politicians, peak bodies and providers – oppose staffing ratios. They defend their position by citing the 2011 Productivity Commission Report.

To settle the disagreement about the value of ratios in aged care homes, the taskforce needed data about actual staffing levels and quality outcomes in Australian aged care homes. They also needed to compare this data with international data. This would have provided evidence to support or refute the following claim: ‘Aged care homes with a higher staff-to-resident ratio have higher standards of care’.

Several researchers, including those at the Australian Association of Gerontology, encouraged the Chair of the taskforce to undertake a systematic literature review on staffing. A rigorous review of the evidence would have been money well spent. Instead, an annotated bibliography that lacked any critical analysis was commissioned.

Rather than rely on evidence, the taskforce regurgitated industry “opinions” about staffing ratios cited in the Productivity Commission and Tune Reports. Not surprisingly, staffing ratios were once again dismissed.

What was surprising, however, is the Report of the Aged Care Workforce Strategy Taskforce dismissed staffing ratios with only one sentence. “Static models or set staffing ratios will not assist in meeting these expectations or necessarily result in better quality of care outcomes.”

Rather than focus on the evidence, the report provides a transformational ‘Belief Statement’: “We exist to inspire people to want to care, enable people to properly care and enhance life through care. Because how we care for our ageing is a reflection of who we are as a nation.

This belief statement and the Unifying Vision of Care set the tone for this 40,000-word report. It is overflowing with jargon, modern management language and Don Watson’s so-called weasel words. This made the report difficult to read. The unifying vision of care (see Vision below) appears to follow the amusing instructions of “How to write a manifesto”.

A Unifying Vision of Care (Report of the Aged Care Workforce Strategy Taskforce, P 13)

Have you ever heard the laughter of a life fully lived?
Or been lost in the stories of someone who has traveled a million roads — and back?

We have.

Have you ever seen a person confined to a single room, whose only crime is to grow old?

We have.

Have you ever pondered why it is that being old is somehow being less?

We have.

In a world of youthful beauty, constant change and shortened use by dates, we have seen how
the simple act of stopping to learn, listen to and help our community’s older members,
has for many, become too hard.

We seek to change that.

We are the people who have the privilege to care for our ageing and we believe, deeply,
that access to good care must be easier and that the very notion of caring must change
from reactive and daunting — to proactive and inspiring.

We champion the simple ethos of a life well lived.

We want to inspire people to want to care; not feel the burden of having to.

And we strive to enable people to properly care — for their neighbours, friends or family.

Above all, we exist to enhance life through care —
from the moment the smallest help is needed to the moment the final breath is taken.

As aged care professionals we choose to care;
everyday, for every type of human in every type of condition.

Because ultimately, we believe how we care for our ageing
is a powerful reflection on who we are as a nation

It is not my intention to be disrespectful, but I needed to use google translator to understand the taskforce’s approach to building the workforce strategy: “The taskforce recognised that the strategy must be disruptive in its thinking, transformational in its approach, pragmatic to implement, and supportive of immediate improvements”. Huh?

I also needed google translator to ‘look forward’: “Looking to the future, the aged care industry requires a coherent strategy and key enabling infrastructure to support the strategic investment, translation and uptake of innovations designed to improve workforce capability, care quality and effectiveness”. Goodness me.

I am also unfamiliar with this lingo: “touchpoints for consumers in their ageing journey”, “a well-supported research translation pipeline” and “the creation of a research translation ecosystem”. Touchpoints, pipelines and ecosystems. What planet are you on?

One thing, however, was clear: the strategy was “developed with the industry, for the industry”. The bias towards an ‘industry-led’ (i.e. not a ‘consumer-led’) strategy was explicit. The aim was “to develop an industry-led strategy focused on the consumer”. Having no union or genuine consumer representation on the taskforce committee was also an ominous sign.

Not surprisingly, given the report’s abstruse language, the taskforce developed complex processes to address staffing issues. The success of these recommendations depends, in part, on a voluntary code of conduct by industry. These codes only apply to those providers who sign up to them. Good luck with that.

Unfortunately google translator did not help me to understand the findings of The Annual Aged Care Survey. I did, however, understand Korn Ferry, a US corporate giant, was commissioned by the taskforce to undertake this staff survey. I certainly wish someone would offer me $90,750 for doing a tick-a-box survey and then running the responses through a statistical computer program.

According to the report: “Korn Ferry knows more about human performance in the workplace than any other organisation.” Apparently “in order to open up career pathways, there are well-established and research-backed corporate methodologies that can be utilised to enable interaction between job families and opportunities to move across job families”.

Without explaining who or what are “job families”, or indeed the “Job Family Framework” methodology, Korn Ferry produced a colourful report – one for all the family. However, the analysis is poorly explained. Even with my expertise as a researcher, I could not make head or tail of it. Who could?

Reading the taskforce report, I was again reminded of the TV series ‘Yes Minister’, specifically one of Sir Humphrey Appleby’s most memorable quotes: “ I do see that there is a real dilemma here. In that, while it has been government policy to regard policy as a responsibility of Ministers and administration as a responsibility of Officials, the questions of administrative policy can cause confusion between the policy of administration and the administration of policy, especially when responsibility for the administration of the policy of administration conflicts, or overlaps with, responsibility for the policy of the administration of policy.”

Like Sir Humphrey Appleby, the taskforce report has a lot of words. But who understands them? And more importantly: who cares?

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.


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.


Here’s why we need nurse-resident ratios in aged care homes

Registered and enrolled nurses now account for less than 27% of this workforce, while personal care attendants (PCAs) make up 68%. Much of the hands-on care that registered and enrolled nurses once provided is now being provided by PCAs.

To read more