FEATURE

22 AUSTRALIAN NURSING JOURNAL DEC 08/JAN 09 VOLUME 16 NUMBER 6

AGE
COMINGOF
the challenges of nursing an ageing population
A
ccording to the Grant Thornton Aged Care Survey
released last month, profit margins are narrow-
ing and demand for more personalised and resi-
dent-focused care is increasing, leaving the
industry stretched, stressed, and appealing for increased
funding from the Commonwealth. The federal government
is currently reviewing parts of its aged care funding mix,
with industry representatives pushing for a change to meet
what they see as the real costs of the sector, costs which
they argue are increasingly outstripping funding.
At the same time, the Rudd Government has stepped up
inspections of the nations 2,800 aged care facilities to
ensure they are meeting set standards of resident care. The
crackdown, by the Aged Care Standards and Accreditation
Agency (ACSAA), has involved 7,000 visits to aged care
homes around Australia this financial year and resulted in
sanctions or other action against 11 facilities across the
country.
Although over 90% were found to meet standards and
the ACSAA says the standard is generally high, its an envi-
ronment in which the Australian Nursing Federation (ANF)
wants to ensure more nurses enter and stay in the sector.
But it argues the wages gap between those working in
aged care and those in the hospital system, who can earn
between $150-250 more a week, is a big disincentive.
ANF assistant national secretary, Lee Thomas says this
means an Australia-wide shortage of nurses and midwives
is even more acute in the aged care sector. By and large
nurses are voting with their feet. The cost of their groceries
and petrol are going up, so they go to a job where they can
earn more money and enjoy better conditions, she says.
That puts pressure on the nurses that choose to remain in
aged care, there are fewer and fewer of them available and
this leads to problems in staffing levels and skills mix.
While the industry blames inadequate Commonwealth
funding for the wages discrepancy, the ANF isnt convinced.
The union argues for more accountability, saying millions of
dollars provided by the Howard Government to bridge the
gap didnt end up in nurses pockets.
ANF national secretary Ged Kearney wants the federal
government to create a more transparent system. We
would like to know how much of the income they get from
government goes to paying salaries, wages and resident
care costs. The CEO of the Aged Care Association of
Australia (ACAA) Rod Young denies the industry failed to
pass on funds targeted for nurses wages. The problem is
theres a total disconnect between what the Common-
wealth pays residential care services for their nursing staff
and what state and territory governments pay their staff.
Richard Grey, the director of Catholic Health Australias
(CHA) Aged Care Services agrees. That (Howard
Government) money, the Conditional Adjustment Payment
(CAP), was aimed at a number of things, including helping
to close the gap. It certainly went some way to meeting
increases in wage costs but all it did was make-up for seven
years of inadequate indexation of the care subsidy.
Both agree nurses in aged care should be paid more but
they argue the sector will need an additional $450 million a
year from the federal government to make this happen.
FEATURE
Australia 2048: 25% of the
population is aged 65 or over,
the number of young people
entering the workforce has
plummeted to a tenth of the
level from 40 years ago and the
demands for aged care services
continues to grow. This is the
reality facing Australias aged
care industry, an industry
already struggling to meet
demand and recruit enough
skilled staff to meet the needs
of the increasingly high care
residents in its facilities.
Cate Carrigan reports on the
challenges facing nurses
working in aged care.
23
TRENDS AND PRESSURES
IN AGED CARE

There are 2.5 million Australians aged over 65 of

whom half need some level of assistance in their
day-to-day activities.

Over the next 40 years, the number of Australians

over 85 will quadruple to 1.6 million.

Community care programs, assisting people in their

homes, are provided to 760,000 Australians (the
demand for home-based services has grown rapidly
in recent years).

As of June, 2007, there were 145,000 Australians in

residential aged care services and 70% of these
residents were defined as having high care needs
compared to 58% in 1998.

There is a growing demand for high levels of care,

single bedrooms and extensive services and
amenities.

Service providers average earnings per bed were

$2,934 in 2008 compared to $3,211 in 2007
(modern, high-care, single bedroom facilities
reported the worst returns for providers).

The increasing costs of construction and low

returns are leading to a downturn in the building
of new facilities.

Providers cite the regulatory and pricing framework

as disincentives to further investment.

WA has 10% of aged care residential facilities; the

Northern Territory 1%; Tasmania 2%; New South Wales
31%, Queensland 22%; SA 12%; and Victoria 24%.
Source: Grant Thornton Aged Care Survey October, 2008.
* A detailed picture of the trends in the aged care workforce by
the National Institute of Labour Studies at SAs Flinders
University is due to be released later this year by the
Department of Health and Ageing.
Rod Young, CEO of the Aged
Care Association of Australia
(ACAA)
DEC 08/JAN 09 VOLUME 16 NUMBER 6 AUSTRALIAN NURSING JOURNAL 23
Rod Young says the federal government could have pro-
vided the money as part of its recent $10 billion fiscal stimu-
lus package, saying the 200,000 aged care workers would
have been happy to spend a wage increase. But a spokes-
woman for the Federal Minister for Ageing Justine Elliot says
the government is already putting more money into the sec-
tor, with $41.6 billion being provided over the next four
years, and funding per resident per day to rise 8% over
2008-2009. She says the increased funds will help providers
deliver quality care and that providers are required under the
1997 Aged Care Act to ensure there are adequate numbers of
appropriately skilled staff to meet the individual care needs
of residents.
While acknowledging the discrepancy between wages
paid in the hospital and aged care sector, she says wage lev-
els vary from state to state and from employer to employer
and are not due to Commonwealth aged care funding.
In addition to increased wages, the ANFs Lee Thomas
says the skills mix in aged care needs to be addressed to
ensure each facility has the right number of staff with the
appropriate level of skills to look after the residents. While
its essential to have the range of skills brought in by regis-
tered and enrolled nurses, assistants in nursing care and
personal care assistants, we cant start substituting one
class for another just because theres a nursing shortage.
To try and stop residential nursing facilities employing too
few nurses, the ANF wants the federal government to intro-
duce mandatory staffing levels and skills mix for residential
aged care facilities. At present, the ANF argues there should
be 4.5 nursing hours per patient day, but Ms Thomas says
this is currently being reviewed to take into account the
increasingly high care needs of those in residential facilities
as 70% now fall into that category. Twenty to 30 years ago
we had many reasonably independent residents but now,
with the move to community care at home, only the most
severely affected are coming into residential care facilities.
For the industry, the notion of a mandated skills mix is
viewed as unreasonable and too restrictive. CHAs Richard
Grey defies anybody to come up with a mandated skills mix
to cover facilities ranging from a five-bed hostel with low
dependency residents to a 160-bed high care facility.
Rod Young from the ACAA has similar concerns. A man-
dated skills mix doesnt work well in an industry where you
are regularly changing your staff mix depending on the resi-
dents.
The ACAA also worries about the consequences if the
industry cant find the staff to fit the mandated formula.
There are some real difficulties with obliging providers to
have specific skill mixes and specific numbers of staff when
we are already struggling to recruit those people, Mr Young
says. If we could have sufficient trained nurses coming
through the nursing schools and we could pay adequate
wages then we might have a chance of being able to meet
any prerequisite.
Ageing Minister Justine Elliot also has reservations; with a
spokesperson arguing aged care providers are already
responsible for maintaining an appropriate skills mix and
that its not clear there is a single optimum staffing level and
mix. However the spokeswoman says the introduction of
minimum staffing levels will be considered after the impact
of the new Aged Care Funding Instrument (ACFI), which was
introduced in March, is fully assessed.
One thing both the industry and ANF support is an
expanded role for nurse practitioners in the aged care sector.
ANF national secretary Ged Kearney believes aged care is a
perfect avenue for nurse practitioners (NPs). A lot of the
quality of care standards could be improved if we could get
S
t Marys Villa at Concord in
Sydneys West is a stand-
alone 77-bed nursing
home and hostel run by
the local Catholic Parish.
There are 34 high care nursing home
beds and 33 hostel beds, some of
which are also high care.
The DON, Lucille McKenna, believes
its a facility that has the skills mix
just right, with enough nursing and
non-nursing staff to ensure a happy
workplace and well cared for
residents. Part of that mix is a general
manager who is on site five days a
week; a deputy DON whos a RN, a RN
hostel manager, another RN working
on the floor of the nursing home and highly skilled assistants in
nursing (AINs).
Nearly all the AINs have either a Certificate III or Certificate
IV in aged care, and the facility also employs a physiotherapist
and a physiotherapist aid for two days a week. All of these
extra staff, including a Catholic nun who helps with the
emotional needs of the residents, make our work so much
easier, Lucille says. We feel were very lucky and privileged
because we seem to do so much better than so many other
facilities.
St Marys Villa has resisted taking the path of AINs supplying
medication to nursing home residents, although Lucille says
very competent AINs administer some medicines in the hostel.
But while she is very happy with the skills of her AINs she
believes its time for those working as assistants in nursing to
become licensed, something also supported by the ANF but not
by the ACCA, which views it as unnecessary.
I think anyone whos dealing with residents at this very
intimate level should be licensed. We have had publicised
incidents lately where staff have been employed at facilities
after being dismissed by another, says Lucille. Licensing
would ensure these workers were called before a board to
account for their conduct.
Although its a well-run place with a happy team, Lucille has
concerns about the future of facilities such as St Marys Villa
where 30% of the nurses are already past retirement age.
People like me came into aged care because I love the
autonomy of it but its hard to attract young nurses. Why would
you come to aged care where the work is just as demanding as
the hospital sector but the pay is much less?
24
24 AUSTRALIAN NURSING JOURNAL DEC 08/JAN 09 VOLUME 16 NUMBER 6
The right mix:
St Marys Villa
25
DEC 08/JAN 09 VOLUME 16 NUMBER 6 AUSTRALIAN NURSING JOURNAL 25
better assessment access for nursing home residents and
thats where nurse practitioners could step in.
We know that GPs dont visit nursing homes; the remu-
neration is poor, they dont have time and we dont have
enough GPs; so introducing highly-skilled and specialised
nurse practitioners could deliver very good care. Ms
Kearney says central to expanding the NPs role would be
freeing up their access to the MBS and PBS schemes,
something currently under consideration by the federal
government as part of a move to increase the use of NPs in
the health system.
The ACAAs Rod Young agrees. If they are going to fulfil
their function to the best level possible they need prescrib-
ing and diagnostic requesting capability. If they dont have
that then their roles are quite limited. Mr Young would like
the industry to be able to employ nurse practitioners to
service two or three facilities, to ensure they had enough
work. Employing nurse practitioners would also open up a
new clinical career path for nurses in the sector, enabling
them to get a promotion but stay doing the work they love.
While these issues are being debated within the aged
care sector, the biggest concern for industry is the funding
formula, with the ACAAs Rod Young arguing that unless the
federal government changes the financial levers soon,
some providers will be facing financial difficulties. The
industry argues the current funding mix, comprising the
new Aged Care Funding Instrument (ACFI), which provides
around 70% of funding and is based on residents care
needs, and the Conditional Adjustment Payment (CAP), is
inadequate to meet the needs of the sector.
Mr Young says in its submission to the federal govern-
ments review of aged care funding, the ACAA argued for
the implementation of an aged care specific index, taking
into account wage movements and other industry costs.
While the industry would like to see an easing in restric-
tions on how much they can charge clients, the ACAA is
aware many people cant afford to pay any more. In the
main residents are asset rich and income poor. With 90%
either whole or part pensioners, you cant ask them to pay
any more then the current 85% of their pension for their
accommodation, says Mr Young.
While Ageing Minister Justine Elliot wouldnt be drawn
on an aged care specific index, her office says the CAP
review will take into account the need for further financial
assistance to encourage efficiencies and will be considered
as part of the 2009-2010 Budget.
But while the sector awaits the results of the review, it
still faces the reality of a shrinking workforce and the age-
ing population over the next 20-30 years. Rod Young
argues more will have to be found to attract young workers
in an increasingly competitive jobs market. For its part, the
federal government says its provided funding in the 2008-
2009 Budget for a range of programs to improve ageing
and aged care services, including funding for programs to
address workforce shortages.
A new program, with funding of $6.9 million over five
years from 2007-2008, has been established to increase the
number of qualified nurses in aged care services by provid-
ing a cash bonus of $6,000 each for up to 1,000 nurses who
return to work in the aged care sector after at least a 12
month absence. An additional $1,000 will be provided to
aged care providers for each eligible nurse they employ to
assist with the cost of re-training and re-skilling the nurse.
The ACAAs Rod Young argues the challenges of attract-
ing the workforce are high but imperative if the industry is
to meet the future demands for aged care. There will be
enormous strains on our ability to deliver care and if we
cant provide attractive conditions for our staff they will
simply go elsewhere.
Ged Kearney and Lee Thomas agree and want to see a
new era of cooperation between providers, government
and the ANF in working to attract and retain nurses in aged
care so that older Australians receive the high quality of
care they deserve.
FEATURE
* The NSW Department of Health has estimated Debbies work has
saved the hospital $1.5 million in hospital admissions for over 65s.
WE KNOW THAT GPS DONT VISIT
NURSING HOMES; THE REMUNERATION
IS POOR, THEY DONT HAVE TIME AND
WE DONT HAVE ENOUGH GPS; SO
INTRODUCING HIGHLY-SKILLED AND
SPECIALISED NURSE PRACTITIONERS
COULD DELIVER VERY GOOD CARE.
The far north coast of New South Wales has one of the highest
concentrations of older Australians, with a quarter of the population of Port
Macquarie aged over 65 years. Its here that Debbie Deasey works as a
transitional (trainee) nurse practitioner treating the elderly in their homes
and residential aged care facilities and keeping them away from the
emergency department at Port Macquarie Base Hospital.
Working from the hospital and with the help of her very supportive GP
mentors, Debbie assesses and, where necessary, prescribes medication,
which is then authorised through the GPs (this will change next year when
she becomes an authorised NP). So if someones aged over 70 and cant
access their GP, Ill go out and help treat them for a variety of things,
including pneumonia, infections, delirium or checking catheters.
A local girl who started as a hospital cleaner around 16 years ago, Debbie
completed her registered nursing studies before undertaking a Masters in
Gerontology. She began work as a transitional aged care nurse practitioner in
October 2007, and loves the choice it gives the elderly. The patient is safe,
the staff are happy and it prevents an ambulance trip and an emergency
presentation. The other patient benefit is a next day review of the treatment
and the extra time Debbie can take as a nurse practitioner. They like that
one-on-one service they can ask questions and Im not as rushed as a GP.
Im also looking at the patients from a nursing perspective, so I take into
account the family, the environment, medications and the education I can
provide, she says.
It also empowers the residential facilities by enabling them to get a nurse
practitioner in straight away to take care of something simple like a
dehydration. Debbie would love to see more nurse practitioners working in
aged care within residential facilities and in the community. But she says
easing up the restrictions on PBS and MBS benefits access is crucial to this
expansion.
Making a difference:
the nurse practitioner