Time to Stop Marginalising Registered Nurses in Aged Care

Why are nurses, and registered nurses in particular, increasingly marginalised persons’ in aged care?
 

Australians are living longer and the overall percentage of the Australian population is aging. Australia’s population is projected to increase to 38 million by 2060 (an increase of 15 million from 2012). In terms of health Australians have a longer life expectancy and are generally healthier than previous generations. However, older people access health services proportionally more often than other age groups. In living longer, older Australians also have a high incidence of living with chronic disease, 49% of people 65-75 years had five or more chronic health conditions. This increases to 70% for people over 85 years. (AIHW 2013)

As at July 2013 there were 2718 residential aged care services across Australia with 186 278 resident places and aged care workers made up approximately 68% of the care workforce. (ANMF 2014)

With higher level acuity and health complexity of older people requiring residential aged care services and the expanding costs of care, staffing models of care in residential aged care facilities (RACFs) requires significant review and restructure.

Aged care services need to be provided by knowledgeable competent practitioners but are challenged by staff shortages, sufficiently skilled workforce to meet complex health care needs and ongoing reduction in staff/resident ratio (indeed there is no legislated mandatory minimum staff/resident ration in aged care faculties in Australia).

ACWs should be acknowledged and for the important role they play in providing direct care. ACWs assist with Activities of Daily Living (ADLs) and personal care needs such as toileting, washing, dressing, eating and drinking, mobility etc. The ACW role may further include carrying out some (indirectly) supervised health tasks (eg routine wound dressings, administration of routine medications). 

What is increasingly overlooked (and poorly acknowledged) is that the capacity of ACWs to provide safe and appropriate care is fundamentally dependent on the level of individualised nursing assessment of the older person undertaken by a registered nurse. 

To ensure safe, quality care, ACWs must have the knowledge and understanding of different health conditions, ability and awareness to recognise, identity and promptly report often, subtle changes in physical and/or mental health that may indicate deteriorating health status such as increased discomfort, loss of mobility, hearing or sight loss, signs of depression or anxiety. 

The important role of registered nurses in RACFs is to provide comprehensive health assessments, determine and develop plans of care, to identify individual clients at risk, to assess and intervene early for clients with deteriorating health and to ensure than clients with high level acuity and complex care and clients with high acuity are cared for by qualified registered nurses. 

I am not advocating, nor do I believe that only nurses should (or are able) to provide care. This is not necessarily addressed by increasing the number of registered nurses to provide direct hands on care, although the important role of registered nurses in reducing morbidity and mortality across a broad spectrum of health conditions is well documented. It best lies in ensuring nursing roles are positioned to encompass greater emphasis and resources on case management, clinical assessment, risk management and early intervention.

Registered nursing roles in aged should emphasise

·       Client-centred assessment, care planning and case management

·       Preventative management strategies

·       Safety/risk management strategies

·       Maintenance of self-care ability independence

·       Maintenance of adequate nutrition, physical activity

·       Facilitating client and family health literacy

·       Referral and access to interdisciplinary health care team

·       Liaison with other health services (eg acute care)

·       Staff (enrolled nurse and ACW) training and education (including competency based   assessment and review

The marginalising of registered nurses in aged care will mean that the roles and responsibilities of enrolled nurses and aged care workers will continue to expand well beyond their intended scope of practice and beyond their level of training and education and therefore, their capacity to provide safe, quality care – not because of any lack of intent but because they do not have the knowledge, skills or expertise that underpins the provision of such care.