An Analysis of the Impact of the
Provision of Registered Nurses 24/7 in Aged Care Facilities in NSW
March 2014
Registered Nurses 24/7 in Aged Care Facilities in NSW
The policy issue
Currently the NSW Public Health Act 2010 requires a Registered Nurse on duty at all times in a facility allocated places requiring a high level of residential care. This used to be ‘nursing homes’ and has been considered to be ‘high care facilities’. After 1 July 2014 there will be no separation of high and low care facilities. NSW is the only state where the State Government plays a role in setting the staffing mix, all other states leave this to the Commonwealth government who address this through the Accreditation System.
Background
Registered Nurses (RNs) are an invaluable part of the workforce in aged care. Nationally they make up 15.3% of the workforce, with Enrolled Nurses (ENs) comprising 21.9%. Nurses are a trusted and respected part of the workforce and the community values them and expects them to be a large part of the care for older people. Unfortunately RNs are also a limited resource and it can be hard to recruit RNs into aged care. They are also a more expensive member of the team, so they need to be deployed in areas of care in which they are most needed.
Workforce facts pertaining to RNs and aged care
1.72% of the workforce is permanent part time; 25-30% want to work more hours (not RNs); median age is 48 yrs. (2012 National Aged Care Workforce Census, DoHA)
2.Aged care providers report that many RNs seek to work the minimum number of hours they need in order to retain their practicing certificate, this restricts the shifts available; impairs continuity of care; and increases administrative and educational costs for the organisation.
3.The community care workforce will need to expand to deliver the increased number of packages funded under the reforms. In 2012, RNs were around 12% of the community direct care workers. This workforce grew from 46056 in 2007 to 54537 in 2012 and will keep growing.(2012 National Aged Care Workforce Census, p75, DoHA).
4.Approximately 66% of the aged care workforce is located in metropolitan areas. (2012 National Aged Care Workforce Census,p55, DoHA)
5.The ratio of direct care workers per residential operational place in NSW is around 0.7 although the ratio is higher in non-metropolitan locations. (2012 National Aged Care Workforce Census,p59, DoHA)
6.62.5% of aged care facilities reported a shortage of RNs, with 70.3% of facilities in remote locations reporting this, (2012 National Aged Care Workforce Census,p61, DoHA)
7.The most difficult staff to recruit are RNs with around 33% of facilities reporting RN vacancies, a figure that has increased from 25.7% in 2003 (2012 National Aged Care Workforce Census, p64, DoHA)
8.Around 30% of RN vacancies took more than 4 weeks to fill, with the average RN vacancy duration being 6.9 weeks in NSW. However in outer regional areas this was 8 weeks, remote 15.2 weeks and very remote 12.6 (2012 National Aged Care Workforce Census,p65-66, DoHA)
9.In the face of shortages, 63% of facilities asked existing staff to work longer hours and 53% used agency (non-PAYG) staff.(2012 National Aged Care Workforce Census, p62, DoHA)
10.Nationally, over half of all facilities (55%) used non-PAYG workers and 31.2% of facilities had used at least one agency RN in the fortnight of the survey. The use of agency RNs was only 26% in 2003. (2012 National Aged Care Workforce Census, p68-69, DoHA).
11.In NSW in 2003 only 19.1% of facilities had used agency staff; in 2012 this was 26.7% (2012 National Aged Care Workforce Census, p70, DoHA).
12.The current base hourly rate of pay for an RN in aged care $35.51
13.The base hourly charge for an RN employed through an agency is$39.41
Aged Care Facilities in NSW
There were 1239 facilities in NSW, and around 53% were low care.
Aged Care Facilities in NSW* – DSS Service List 2012
Location / High Care / Low CareInner Regional / 146 / 194
Major Cities / 354 / 365
Outer Regional / 67 / 90
Remote / 10 / 11
Very Remote / 2 / 0
579 / 660
* A facility is counted here if the DSS listed service has high care places or low care places counted respectively. AIHW (AIHW RAC A Statistical Overview 2010-11, Tables A1.2, A1.6) counts the total number of facilities for NSW as lower, ie 885 for 2011. This is because some services listed as having both high care places and low care places are counted as only one by AIHW. In the 2012 data there were 297 such double-up entries.
As at 30 June 2013, 57.6% of low care beds in Australia were being used for people requiring high care, as part of ageing in place.In NSW 51.7% of low care beds were used for ageing in place.(The Report on the Operation of the Aged Care Act 2012-13, p56.) Reviewing the reports for the last 4 years there is a clear trend of increasing numbers of operational low care beds being used for people with high care needs, or ageing in place. It has climbed by 20% in 4 years across Australia and 15% in NSW.
Analysis undertaken by Mirus in February 2014, using live data held by Medicare, revealed that 83% of all residents in a facility in Australia would be ‘high level of care’ using the Classification Principles made under the Aged Care Act 1997. They also found that there are 7.6% of facilities with less than half the residents having a high ACFI. It is probable that many residents with a ‘High’ score in ACFI may still not need an RN, as the care they require is not acute or curative, it is about comfort and quality of life. More analysis of the data is being done.
Over the last 4 years, despite the high care needs (as defined by the ACFI rating) of many residents in ‘low care’ facilities, the low care facilities have been able to determine the best staff mix based on resident need. This allows them to be flexible and meet changing levels of care, eg to support someone during an acute illness or during palliation. It has not resulted in any loss of quality as measured by increasing levels of sanctions or complaints. NSW has no significant difference in these measures compared to other states, and it is the only State requiring 24/7 RNs be on duty. (The Reports on the Operation of the Aged Care Act 2009-10; 2010-11; 2011-12; 2012-13).
Each quarter around 700 aged care providers participate in a benchmark study run by Stewart Brown. In their Aged Care Financial Performance Study, December 2013 (p17) they report that the use or RNs varies considerable across the benchmark bands. Facilities captured in Band 1 are high end high care facilities. Those in Band 5 are low care, and therefore lower revenue per resident. The top quartile results are for the 25% facilities performing best on financial indicators.
The table below states the number of hours worked by RNs per resident day for the 6 months ending 31 December 2013.
Band 1 / Band 2 / Band 3 / Band 4 / Band 5All facilities / 0.45 / 0.36 / 0.34 / 0.24 / 0.14
Top quartile / 0.40 / 0.40 / 0.29 / 0.11 / 0.06
There is a major difference in the number of hours of care currently provided by RNs in low and high care facilities. The challenge of finding enough RNs to equalise this level of hours is insurmountable and the cost is not sustainable.
Ensuring Quality of Care
The aged care sector is in NSW must comply with 144 pieces of legislation designed to protect the quality of care for clients. The most relevant to the protection of residents and the provision of quality is the Aged Care Act 1997 and the Accreditation system.The Australian Aged Care Quality Agency (Accreditation Agency) accredits all Australian Government subsidised aged care homes.
The quality assurance system is reinforced by a program of audits and unannounced
visits for residential aged care services and follow-up action as appropriate. Where providers are found not to be meeting theirresponsibilities under the Act and fail to remedy the situation, there is the possibility of regulatory action by the Department of Social Services, such as the imposition of sanctions.
There are 4 standards comprised of 44 outcomes that the facility must achieve, and one of these outcomesspecifies that: ‘There are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards’.Along with a vast collection of other regulations, these standards are providing adequate control of staffing levels linked to quality care and safety.
Future Goals and workforce needs
The future health and safety for older Australians depends on us deploying our limited resources in the best possible way to achieve their goals in a cost effective way. As the health and aged care systems come under increasing pressure to meet the needs of more people, with increasing levels of acuity, we need to ensure the limited supply of RNs is aligned to the best use of their expertise.
In aged care terms this means we need RNs involved in clinical assessment, palliative care; supporting people in their own homes, or a facility, during periods of acute ill-health; working as Clinical Nurse Consultants or Nurse Practitioners to relieve pressure on other health professionals and improve speed of response to the client; and ensuring that less qualified or experienced staff are receiving good on the job education and support. The use of Registered Nursing staff to cover night shifts is in most instances a dreadful waste of this precious and limited resource. Having a Director of Nursing cover an overnight shift and then work all day is dangerous.
We need new models of care and more flexible deployment of the staff available to us. Rigid rules on staff ratios or requirements for certain categories of staff can lead to poorer outcomes for clients, unnecessary costs and expose diligent facilities to the risk of being non-compliant with subsequent penalties.
Consequences
A requirement to have an RN on duty 24/7 in every facility would be impossible to manage, there are not enough RNs to sustain this. Failure to meet this requirement has harsh penalties for the facility, which is reportedly being avoided by:
- people being on duty for over 24 hours
- asking staff to work more hours than they wish to work, with burnout and resignations reported
- the very expensive use of agency staff
- less well skilled staff beinggiven a job and retaining it as they can’t be replaced easily
- increasing the employment of people with language difficulties
The estimated cost of employing an RN 24/7, regardless of the needs of clients, for a current low care 70 bed facility is $500,000*. The organisation would need at least 5FTE RN positions. Most would currently have 1 RN, so the over 4 FTEs need to be filled and funded. This is just the direct wage costs, not the indirect costs of increased supervisionor increased education for all the RNs employed to meet the FTE. (*4RNs x 58 weeks to cover leave entitlements, plus shift loadings)
As an example of the financial burden of agency staff, in a current rural high care facility with160 places in total, with 81 high care and 79 low care, they have an RN rostered in low care 7 days per week where possible on day shift only. The cost of agency nurses was $334,000 in the 2013 financial year and they have already spent $273,000 this financial year on agency staff to ensure they always had an RN on duty 24/7.
In order to avoid non-compliance with a fixed staffing ratio a facility manager must either somehow find any RN to have on duty, or move all residents who are considered ‘high’ need to a more appropriate location such as a hospital. This is clearly an unacceptable outcome for everyone.
Summary
There is a current shortage of RNs in aged care in NSW and this is getting worse. The shortage is worse outside metropolitan areas, but is also evident within cities. In most instances the aged care sector is also competing with the acute health care sector for nurses.
There is an increasing need to have skilled RNs available in some situations, which can be predicted and an appropriate care model provided eg palliative care or short term acute illness managed outside a hospital.
Fixed ratios or requirements for RNs to be on duty regardless of the need of clients will lead to unsustainable costs, adverse health outcomes and potentially to perverse responses to the policy.
We need new models of care that allow the deployment of RNs in the situations in which they can make the most improvement to client outcomes.
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