Minimum staffing levels

The 'myths' about staffing

National Seniors expressed the perception of many staff, of those who had fallen foul of the system and of those who had studied it.

The aged care peaks responded to Victoria's plans in impose mandatory staff levels by claiming that there is no evidence that ratios result in better quality care:  They have saying this so forcefully and with such authority that those who think otherwise seem to lack credibility.

Victorian Department of Health Report, Innovative workforce responses to a changing aged care environment 2011

In the article above, the industry based their objection to staff/patient ratios on the 2011 Victorian Department of Health Report, Innovative workforce responses to a changing aged care environment which it claimed, also emphasised the lack of evidence. The report did say “in reviewing the literature on ratios, little evidence could be found to sustain an argument in favour of them at this time. The report was advised by Professor Nay. But Baldwin reviewing multiple studies from the USA have shown a very convincing link between the number of staff and the number of failures in care as well a link between the focus on profits and the number of staff.

Perhaps it is the use of the word ratios that limited the literature search and is causing confusion. The number of staff is a crude figure in a complex environment but as the figures from the USA show it is very revealing of what is happening in the sector. At the very least we do need to know what it is and ensure that there are 'enough'. You can then build on that with other data.

The issue become clear when we look at that report.

The key word here is “enough” and the Victorian public system has always been well staffed so probably has enough. I also think there is much less disagreement here than the critics suggested. The report is promoting the Eden model of care and there is little arguments about what it says. It indicates in its conclusion that what is proposed would need “higher overall staffing levels”.  It collects the sort of data that will permit this.  It has recognised the problem but its attempts to address them have not worked.

The report focuses on skill mix and structure needed to meet the different requirements.  Although many US facilities are still a long way behind in sufficient numbers, the USA has succeeded in slightly improving them. It too is now looking closely at the skills mix needed, the minimum number of each type of staff below which facilities should not fall, and when more than the minimum of each is required.

What this reports says: It is worth looking more closely at the Victorian report which presses for a “skill mix and staffing levels based on a range of considerations including resident dependency, staff experience and context”. The focus is on person centred and not task centred care.  It is clear from the report and what it advises that including person centred requires more time and so more staff than we currently have in many facilities.

The report sets out principles:

It then goes on to look at responsibilities for clinical leadership, team leadership, management, personal care, lifestyle coordination/community liaison, hotel services and maintenance services. There is little to argue about here but it is worth noting some.

There is not much to really disagree with here.  The industry is being opportunistic in using this report to justify their position. They know that few will go and search for the original article.

• Innovative workforce responses to a changing aged care environment Victorian Dept Health 2011

If we look at the many reports in the 19 Years of Care section and particularly at the comments of staff and families on the web page Those who know it is very clear that what this report advocates is not happening in a large number of facilities and that is because there are simply not "enough" staff to start with. They don’t have the time to do any of this and only survive by being task focused.

If the industry were implementing these recommendations and if they were transparent about staffing and failures in care in doing so then minimum staff levels would not be required, but the evidence from the USA shows that when there are insufficient staff then requiring more staff improves care. We need to decide what enough is and require that, not as an end point but as a beginning - the minimum.

Compatible with the proposed hub: What this report suggests is not a top/down model. It advocates "participatory management styles, which are central to the model". It is clear that staff but particularly clinical staff will be contributing.  Clinical staff will have input into financial decisions. We should also note that the report included structures to “collect and analyse data” and the integration of the community. There is nothing here that is not entirely compatible with the proposed Community Aged Care Hub and which would not be facilitated by the involvement of this hub.

What has been happening to aged care training

Recent scandals: The exposure of the scandals involved the privatisation of TAFE courses in 2015/16 included aged care training. Large numbers of certificates were revoked because aged care and other workers had not received adequate training. I wrote about this on the web page Contracting government services to the market.

But those who saw what was happening had been complaining for years but no one was listening. Way back in 2011 Bxxxxx, a strong critic of what has happened to aged care wrote about the financial pressures that led to it.

No one listeing in 2011:  By 2011 Mxxxx Bxxxxx had over 20 years experience in aged care in a diversity of roles including RN, educator, researcher and academic.  She had been involved in the development of the Certificate III Aged Care Work in the mid-1990s. She indicated that “There were stringent guidelines for the RTO delivering the qualification and standards set for those who could teach the program”.

She indicated that “I have observed the deterioration of a once substantive qualification into a meaningless piece of paper”. This was “related to the demand for aged care workers and the focus on the fiscal rather than on the person – the person being both the person receiving the education and the person who is the potential recipient of care.”

Bxxxxx described the multiple factors that had led to a situation where poorly trained and clinically inexperienced staff were being funnelled into the system by the providers who were able to do this at minimum cost. “When RTOs are vying for contracts with aged care facilities, it is the lower cost and the shorter training time that is most important."

The culture: Bxxxxx confirms my own assessment of the dysfunctional culture that develops in market driven facilities. Her research “exposed the level of bullying between aged care workers when a different approach to skills development was introduced” and “articulated the price paid by aged care workers when they spoke of the abject nature of the environment in which they worked.”

No one listening: “They have, (been told) but no-one was listening”. Those academics who had done research spoke out about “paucity of aged care workers’ clinical decision making skills” and other issues.  They were targeted by the providers, and the research done “has been ignored by the aged care sector”. Instead “kudos is given to those who implement the most cost effective strategies irrespective of their outcome”.

• No surety of standards in Cert III Aged Care Insite in Workforce 1 October 2011

Who is pressing for minimum staffing levels

In both the USA and Australia, nursing unions and those who have direct experience of the system have been pressing for mandatory minimum staffing levels for many years. These are the people who actually see and experience what is happening. The problems of poor care due to insufficient as well as a lack of trained nursing staff are widely acknowledged.  The focus has been both on numbers of staff and on their skills, as revealed in the recent NSW Inquiry into the need to have registered nurses on site at all times.

NSW inquiry recommends minimum staffing levels.  The move for minimum staffing ratios was supported by the 2015 NSW senate review into the proposal to abolish the current requirement that all nursing homes have a registered nurse on duty at all times.  Not only did the review advise against repealing the legislation requiring registered nurses, but it recommended that the NSW government press the commonwealth to introduce minimum staffing requirements for all nursing homes in Australia.

Support from a for-profit: The owner of one for-profit provider that claims to have a model that provides exemplary care agrees that there are major problems in staffing across the sector.  His comments referring positively to the recent meeting between the nursing unions and Senator Lazarus are below.

Writing in similar vein elsewhere he concluded, "By today's aged care standards, we are overstaffed. And we will stay that way." Hopefully this is not just a marketing ploy and their claim to a mission is real.  It would have helped if they had indicated what their ratios were. We would then have had a yardstick against which others could rate themselves. Prospective residents would have had a real measure for rating nursing homes and the market might then have started working.

In 2000 in the USA, an expert panel recommended 4.5 hours of direct nursing care per resident per day.  They considered that there were risks of harm to residents when levels fell below 4.1 hours.  At the time the poor levels of care across the USA were considered to be related to an average of only about 3.5 hours per day. We don't know how aged care in Australia measures up because industry has refused to disclose. Government and their various reviews have supported them in this.  Leaked documents suggest that at a maximum our residents are getting on average 3 hours per day but it could be much less.   This is close to the 2.9 hours below which the US has found a majority of residents are likely to be harmed.

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Australian stories from the bedside

There is exceedingly limited accurate evidence about the impact of staffing in Australia. Until such evidence is collected and made available, only "true believers" can make claims about "no evidence" and believe they are credible.  Many complain about the complaints system but its not only unhappiness about the way complaints are dealt with.  Its also the failure to use it as a means of collecting and analysing information.

The Department of Social Services was unable to help the NSW Inquiry into Registered Nurses by giving them information about complaints.

There is no shortage of complaints about care and the levels of staffing in Australian nursing homes.  These come from families who have seen what is happening in individual nursing homes and from staff whistleblowers.  Several examples are quoted on these web pages.  I have listed many comments from the coal face on the web page Those who know.  For more evidence simply look at the comments below the articles on Australian Ageing Agenda, The Age and other newspapers linked to from this site.

In September 2006, I wrote a long article about the problems and inadequacy of staffing in nursing homes in Australia. I quoted from a large number of articles over the previous few years.  Read that and ask yourself if anything has changed or if its got worse

• Nurses in the aged care system The Corporate Medicine website, September 2006

In her submission to the 2010 Productivity Commission Joanne Bryant, an enrolled nurse, describes her experiences and the massive changes that have occurred to nursing in nursing homes when she returned to nursing after 17 years away from it.  She was horrified and described it as being transported to another planet.

Many others are making similar allegations:

After one of their members in a nursing home told her CWA friends what staffing was like at night, the Tasmanian Country Women's Association took action:

Research at the bedside: RMIT University, Flinders University, three leading aged care providers and an employee union have combined in a research project in order to tell us what matters in the provision of aged care.

What is so revealing about this research is not only what it says but that we need all this effort and investment and so many credible researchers in order to try to persuade our leaders and those who provide care of the obvious - what hopefully most of us have known for at least 50 years! There is another similar study at the link below.  These both tell us what should be obvious but it is good to have it confirmed by the experts.

• What’s it like living in aged care? Researchers shed new light on quality of life Australian Ageing Agenda 28 Oct 2016

A theoretical analysis

It is perhaps worth stopping to think about what is happening more theoretically as Dr Axxxxx Dx Bxxxx did in her doctoral thesis.

She focuses on the discourses (ways of thinking and discussing) surrounding aged care particularly what is said and what is not said - what I have called the elephants in the room. She takes this down to the bedside, This is essentially an approach to the construction of knowledge, how we understand the situations in which we find ourselves. She looks at the consequences of ignoring what we don’t want to know and what others who see things differently are trying to tell us. Power and not knowledge determines the way in which we understand what we are doing. This can be very different to what is actually happening. She looked at how we got the system we did and then followed that down to the care not given to individual residents at the bedside.

She quotes social scientists to show how by setting the parameters for these discourses "The incorporation of power is able to render the individual and collective bodies under control through a process of making them docile, asleep, silenced, and disciplined to the dominant discourse - thereby governing their acts, attitudes, and modes of everyday behaviour and practice".

When we get to the bedside we see the way that the provision of care is understood as a result of this and can contrast that with what is actually happening there but which no one seems to see. The nursing profession no longer has any control of what nursing is seen to be. She explores all this in depth and the practical consequences.

The proposed Community Aged Care Hub is intended to bring another more independent group to the bedside, one with the capacity to redefine the discourse in real terms and the power to drive that into the consciousness of the nurses, the managers and politicians.

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Developments in workforce planning

Despite the paucity of data there has been some useful recent work in Australia.  But workforce planning started long before this and most current planning has been based on the flawed 2010/11 Productivity Commission Inquiry.  This debate largely ignores the US material that is readily available.

The prediction that many more staff would be needed in 2010 led the Labor government to create a financial carrot for providers encouraging them to pay more and employ more. Marilyn Harrington and Rhonda Jolly recognise the problem and indicate:

It seems the unions welcomed the incentives strategy but the industry were opposed.

Outsourcing the problem: The Abbott government instead contracted out an audit of the aged care system to Health Outcomes International in 2014 and promised a workplace policy. It was looking for efficiencies. When the stocktake was finally released it was not particularly helpful and we did not get a workforce policy from Turnbull, the new Prime Minister. It was all about processes, guidelines and impact but it is difficult to see how it reached any conclusions when it did not look at staffing or outcomes for residents where information is not available.

• Questions raised over aged care workforce programmes: Stocktake Media Release Minister for Health 11 Dec 2015
• STOCKTAKE AND ANALYSIS OF COMMONWEALTH FUNDED AGED CARE WORKFORCE ACTIVITIES Final Report Dept of Social Services 11 August 2015

The industry has its say: Frustration about the lack of planning and perhaps the growing negative publicity has led the industry to prepare some documents of their own. Its reports have a very different approach to the critics. A White paper prepared for Aged Care and Community Services (ACSA) by Richard Baldwin and Professor John Kelly in July documented the current workforce and painted a stable and far rosier picture than that described by Montague et al in 2015 (see next slider), They found for example that in 2012 the “Turnover (% of workers in their current job less than a year) is lower (15.8%) than the mean of all Australian women workers (18.9%)”. Yet Montague et al claimed a turnover rate of 25% in 2015.

• The Aged Care Workforce in Australia White Paper (Baldwin & Kelly) ACSA 30 July 2013 (circulated for comment)

In February 2015 Aged Care and Community Services developed a Position Paper based in part on the earlier White Paper.

• THE AGED CARE WORKFORCE IN AUSTRALIA Position Paper ACSA February 2015

Delayed workforce strategies: The article linked below addresses the long delay in the overdue release of the governments audit of the workforce programs and of a promised workforce strategy. The widely different views are revealed.  This is a major problem for government as their policies have been largely responsible for the problems in aged care and more of the same will only please the industry and make things worse.  The providers are particularly anxious about this and are pressing their interests publicly.

One provider conceded that "the provider peaks are becoming increasingly suspicious that the Federal Government is backing away from developing the workforce strategy announced by Fifield (minister responsible) back in January".  There is a new Prime Minister and a new minister. Clearly the providers are worried about the strong pressure being exerted to specify levels of nursing staff and to collect real aged care data.  They are advocating flexibility in staffing and opposing ratios to counter these pressures. In this market the key to success is cost cutting and that means reducing staff and skills

A union spokesperson “believes a perfect storm is brewing in residential aged care in particular, given the increasing frailty and acuity of seniors entering facilities, as a result of bolstering home care provision, coupled with predicted shortfalls in appropriately skilled workers, particularly registered nurses".

A staff member from the TAFE teaching personal care workers is worried that “the current workforce is too highly geared towards unregulated workers” urging the regulation of personal care workers. She stresses “another long-standing issue in the sector- the provision of quality clinical placements for students in aged care - - “.

• Frustrations rise over workforce Australian Ageing Agenda 2 December 2015

A Senate Inquiry: Inertia in addressing this problem led the senate to initiate an inquiry into the Future of Australia’s aged care sector workforce in March 2016. There were soon over 300 submissions testifying to the widespread unhappiness in the sector. A large number complained about the working conditions in the sector and blamed the financial pressures created by marketplace policies. The stories told by contributors from the coalface of care paint a picture of a sector in crisis.

When an early general election was called all outstanding inquiries simply ceased to exist. The new senate decided in late September 2016 to re-convene the workforce inquiry. With a slim majority, the new government will not be enthusiastic about addressing this fractious and divisive issue. It will be interesting to see what happens.

• Future of Australia’s aged care sector workforce. Inquiry by Senate Community Affairs References Committee 2016
  • Terms of reference
  • Submissions

The Senate Inquiry did meet on the 28th April 2016 and interviewed unions representatives, academics, doctors representing organisations and representatives of allied health professionals as well as representatives from a number of aged care and other bodies. I include here a few fragments from union and university academics who set the stage.  The need for minimum staffing levels are mentioned but not explored.

Mr Eden (Union Rep): - - - So you have a de- skilled workforce in aged care, and they are under a lot of work pressures as well.
- - - but unfortunately, especially in the private for-profit area, it is all profit driven. They are perfectly happy to employ someone with a certificate III and get less out of them than someone with a certificate IV or above.

Mr Bekhazi (Union Rep): — -(the number of registered nurses that have moved out of the sector?) Over the last, let's say, five to 10 years, I think it is about 20 per cent that has been reduced to about 15 per cent, or 13 per cent.
- - -countries that are doing well with their aged-care sector—for instance, in the Netherlands- - by capping the patient to worker ratios and making sure there are psychologists in there working with people who are feeling depressed, not only have they improved the quality of care and increased the retention of staff, but they have actually reduced the percentage of inpatients with mental health issues.

Mr Eden: There seem to be some employers more than others that are attracting 457 visa holders. For example, FPCompany Newname C made a lot of positions redundant, especially throughout the Gippsland region, only to then advertise those positions and advertise that people with 457 visas may apply. There are other organisations which, because of the very poor treatment of the staff, cannot attract local employees any more because they have such a bad reputation. They are also advertising for 457 visa people to work for them.
- - - I also think part of the problem is the bullying within the aged care sector. There is a lot of focus on the funding, and many employers are now employing people purely to do ACFI funding. They do not do any direct care themselves. They are just there to generate income for the employers. ACFI documentation is a creative writing exercise at best, and fraudulent at worst.

Ms Svendsen (Union Rep): The government has actually got rid of all of the programs. The skills councils have now been gutted. We no longer have EScan available from them, and there was a lot of workforce data that came out of that in terms of projections, in terms of what we currently have and in terms of skill development and needs. We do not have Health Workforce Australia looking at projections in relation to health workforce issues anymore.
- - - I can say that our primary need right now is to get some workforce research done—data research.
- - - The reality around that stuff is, again, that that is guesswork off the top of our heads. We do not actually have the data. .... there is a need for the sector to have minimum mandatory standards.
- - - no funding providing people with encouragement to allow their staff to undertake further career development.
- - - know certainly that a number of our members would actively discourage their own children or grandchildren from entering the profession, simply because of the nature of the work.
- - - All of the mechanisms that might have actually addressed that, or considered it in a prospective area, are not there anymore; they have all been dumped.

Mr Jacobson (Union Rep): - - - the point is that we do not see - - that aged care should be a dumping ground for people who cannot find work.

Prof. Wells (Latrobe University): - - The main points that we want to make are that the centre is under-resourced and that the staff are too few, insufficiently trained and skilled, and not matched to demand, especially in rural areas. You will already have heard that from the people that have come before us, and also from other submissions.
- - - the skills of the staff who are currently in the aged care sector are not up to scratch. They are not up-to-date and they are not sufficient for the coming challenges,- -
- - - We just want to reiterate the point that the standards of the training courses are very inconsistent and often not very good. People in the aged care sector complain constantly about the lack of skills and the lack of knowledge of people coming into the sector.
- - - the issue of attracting people into this sector is to change our culture as to how we see ageing in the community
- - -But as the people before us said, there is no leadership in that from the Commonwealth government
- - - ageing has disappeared from the priority areas for funding

Prof. Charlesworth (RMIT): - - - does not recognise the increasing level of skill required - - no recognition of the complexity of the work.

• Future of Australia's aged-care sector workforce Community affairs References Committee - Hansard, 28 April 2016

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Limited Australian Data

The studies that are done don’t provide the essential information that is needed. We don’t know the numbers of each grade of staff and the time they spend giving care. We don’t know the level of care needed by the residents. We don’t know the number and type of failures in care, the standards of care and the quality of life provided.

The studies done by academics address a number of other issues but they can't get to grips with the issue of the number and skills of staffing or with the overall standards of care. I have mentioned a number of studies of nutrition and of other problems on other pages.

Research on recruitment of staff

For example, some interesting recent research looked at what attracted student nurses to enter aged care. They found that their clinical placements were critical. What mattered was support by their mentors and support by the personal care workers. It is clear that facilities where personal care workers are unhappy and where the culture is not welcoming will drive them away and be counterproductive.  Student nurses will not be deaf to the strong criticism and unhappiness coming from many nurses in the industry and this will be compounding the staffing problems.  Changing the culture within nursing homes from one that is focused on profits to one focused on care is going to be critical in solving the problems in the workforce but this is only one of the issues.

Research on staffing

When research is done it often turns up deficiencies.  Research done by academics from three of our universities found that there was a 25% turnover in staff indicative of a major problem with staffing. The researchers considered that even if government was blind, the industry itself could do something about the growing problem of staffing.

The original identifies the major problems in the aged care workforce and the failure of government to develop a strategy for addressing them. They indicate that “Inadequate conceptualisation and policy support from government have led to a lack of well-planned strategic policies to address staff turnover given that is a major concern that has been poorly handled by the sector and government.”

• Attracting and retaining Australia’s aged care workers: developing policy and organisational responses Montague A et al Labour & Industry: a journal of the social and economic relations of work Volume 25, 2015 - Issue 4

An example of a for-profit company operating a luxury facility that had made employment conditions better for staff was described.  But with the market pressures driving cost cutting few can afford to do that.  Even the not-for-profits are cutting back on benefits like maternity leave for staff.

• Union targets aged care home over removal of paid parental leave for workers ABC News 11 Nov 2015

Research compared the incidence of failures in care with type of provider

Baldwin, Chenoweth, and dela Rama(Australian Journal of Public Administration January 2015 page 1-14) reviewed the international and limited Australian literature examining the performance of differently organisational types of provider of care in the USA, the UK and Australia, including when available the staffing. But most of the basic information needed to do that was not available in Australia.  All they could study was the incidence of sanctions.  They found that for-profit owned nursing homes were sanctioned more than twice as often as not-for-profit homes.  As information about staffing is not disclosed they could not assess the role that staffing played in this.

In an article in The Policy Space, Baldwin summarised his review of the international literature:

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USA Data and guidance

The evidence is no longer contestable: There are three major readily measurable determinants of care in the international literature:

1. staffing numbers,
2. staffing skills as measured by qualifications (particularly registered nurses), and
3. the intensity of the profit motive.

In Australia, we need to add distance from a major centre to that, so we have four.

2002-2006 Staffing recommendations not met

In the USA, expert panels have looked at the evidence, and government organisations have made studies. Clear recommendations have been made. But in that country, the marketplace dominates and dictates. Politicians are in the pocket and controlled by the market - even more so than in Australia. Applying recommendations has proved impossible - even after they had promised the electorate they would do so.

Adequate staff numbers of both trained nurses and less highly trained assistants are critically important. Without sufficient feet on the ground to do the work, even the best trained staff will fail. Nothing that Professor Nay has said contradicts that. This is usually assessed by calculating nursing hours per resident.

It is when the performance of the different types of provider are examined that the importance of staffing levels and skills is laid bare. 

Controlled studies eliminating variables are impossible to conduct in the sector but the associations are so consistent and so logical that the burden of proof must be to disprove it.

The pattern: There is a clear pattern in the international literature based on ownership and profit pressures starting with not-for-profit providers (mostly faith based) extending through private for profit, then market listed corporate for profit and ending with private equity. Staffing levels and staffing skills are best and failures in care lowest in the not-for-profit owned facilities. Staffing levels and skills are lowest in the private equity groups and the failures in care are highest.

2009

Minimum staffing levels and staff distribution

A study in 2009 analysed available data in California which has a higher minimum staffing requirement than other states. This study found that low levels of both total staffing and registered nurses(RNs) were associated with failures in care. Nursing homes that met state minimum staffing levels (3.2 hrs per resident per day) “received fewer total deficiencies and quality of care deficiencies than nursing homes that failed to meet the standard”. Interesting was that this improvement did not extend to serious deficiencies. Those who met the state standard did no better than those who did not. But meeting the higher federal CMS recommended standard of 4.1 hours per person per day reduced the number of serious deficiencies.

Nursing homes with higher RN staffing levels received significantly fewer total and Quality of Care deficiencies. Interestingly the number of less highly trained licensed practical nurses (LPN) had little impact on failures in care or quality of life. Nursing assistant (NA) levels had a positive impact on all the parameters measured.

The study found that “higher LPN staffing may contribute to decreasing quality rather than increasing quality” because they were employed instead of RNs.  It favoured a combination of RNs and NA’s and suggested that cost cutting when meeting minimum standards may have resulted in the employment of LPNs rather than RN’s which may have contributed to the failure to reduce more serious failures.

• A Panel Data Analysis of the Relationships of Nursing Home Staffing Levels and Standards to Regulatory Deficiencies H Kim et al J Gerontol B Psychol Sci Soc Sci. 2009 Mar; 64B(2): 269–278.

2011-2012

Charlene Harrington (emeritus professor of sociology and nursing at the UCSF School of Nursing) has been central to work on this in the USA. Her 2011/12 study is typical and unequivocal.

2014: Private Equity the worst

This confirms Harrington's 2011 finding that private equity was the worst offender in reducing staffing and the biggest threat to care.

2016: The latest update on US staffing recommendations

The USA unlike Australia, collects data. A government body, U.S. Centers for Medicaid and Medicare Services (USCMS or usually CMS) analyses that information and makes recommendations based on it. The problem in the USA is not data but a provider and political block. Charlene Harrington and her group have been active leaders in analysing and studying this data. Collaborators from the University of California, Vanderbilt University and The University of Vancouver in Canada led by Harrington have written a 2016 review making the argument for adequate minimum staffing levels in the USA.

• The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes Health Serv Insights. 2016; 9: 13–19 Published online 2016 Apr 12. Harrington C et al

Some states in the USA do have minimum staffing levels but they have been so reduced by pressure from providers that they are almost valueless. As this report and Australia’s Professor Nay both indicate more skilled staff are often required but there are minimum staffing levels below which it is difficult for anyone to provide care safely. The CMS therefore provides “recommended minimum standards” as well as “average expected staffing based on resident acuity”. This is what the CMS expects the average to be when allowing for the adjustments needed to care for those with greater acuity. The writers of the revue want adequate minimum standards properly enforced with penalties for failing to meet them.

US data and recommendations

The recommendations in the USA are given as HOURS PER RESIDENT DAY (HPRD). Because data is collected and is available the authors are able to report the staffing levels in 15,391 US nursing homes. In Australia we can’t even do it for one!

The figures given are for what in the USA are called

• Registered Nurses (RNs) - - a minimum of 2-4 yrs training
• licensed vocational/practical nurses (LVNs/LPNs;) - - 1-2 years training
• Certified nursing assistants [CNAs) - - - about 2 weeks training

Interestingly the strongest relationship with “quality” was with the time spent by RN’s, then total nursing time and time by CNA’s.  There was less association with the trained but less experienced nurses. This is interesting when we look at some of the criticisms being made of newly qualified nurses in Australia (for example the comments on the article linked below).

In comparing these figures we should note that Australia’s Level III and Level IV trained staff seem to be better trained than the CNA’s in the USA. But at the level of the basic time intensive services needed in much of aged care it may be that numbers are as important as training provided there are enough well trained staff in close attendance. It is interesting that greater acuity was found to need a greater proportion of registered nurses rather than more staff.

Rough comparison with Australia: If we convert these figures to percentages then we can see this as a minimum of 18% registered nurses. When acuity is factored in then on average 26% of staff providing care should be registered nurses. This approaches the roughly one third that were required in Victoria in Australia before 1995.

• Study shows ‘crucial steps’ to attract graduate nurses to aged care Australian Ageing Agenda 18 Nov 2015

Unlike Australia there has been some improvement in staffing with the mean HPRD for RNs at 1.00 and the mean Total HPRD at 4.54. But this is because there are a number of very good facilities with the top 10 percent exceeding these figures by a long way. The situation becomes clearer when the median is used.

The review indicates that “Total facility-reported median staffing levels gradually increased from 3.7 hprd in 2009 to 3.97 HPRD in 2014 and RN hours increased from 0.5 to 0.7 HPRD in the same period, with wide variations across states”.

The average for the total HPRD for the lowest 10% was 3.18 which is only just above the 2.9 level where “most residents needlessly suffer harm”. When the median is considered over half of all nursing homes have fewer registered nurses and less total nursing hours than the government recommended minimum levels. It is clear that in the USA there is still a long way to go.

Comment on this

There is a lot more in this review and I include some quotes below.

Why there has been so little reform in the USA

The other issue that this review addresses is the reason why there has been so little improvement and the barriers to staffing reform in the USA. This should interest us in Australia because we seem to have similar problems. In the USA, unlike Australia, the problems are recognised and acknowledged by government. Efforts have been focused “on market-based strategies rather than on regulatory requirements such as staffing standards”. Trials of incentives to improve staffing suggest “that regulatory requirements may have more impact on staffing than market-based policies”.

The role of politics

The review also indicates that the political situation in the USA has “been a major factor preventing the adoption of higher staffing standards” and that “nursing home industry has consistently opposed regulatory requirements and supported higher reimbursement rate policies and payment incentive programs to improve nursing home quality”. In addition political “conservatives tend to strongly oppose regulatory approaches in contrast to liberal views that tend to support government interventions in the marketplace”.

Other factors that the revue mentions include that

• the industry influences “public policies through campaign contributions, association lobbying, and educational activities”
• “revolving doors between nursing home companies/associations and government may occur at the federal and state levels” which is why “public officials and providers have been found to hold similar views supporting market-incentive programs rather than regulatory approaches”.
• “there has been a large growth in old-age interest groups in the U.S., the effectiveness of their advocacy has been questionable and very few of these advocacy groups focus on nursing home issues”.
• financially struggling advocacy groups “have not been able to overcome the strong industry opposition to higher staffing standards”

The review concludes by indicating that “The problems of low nursing home staffing have also been found in other countries such as the Canada and England”. The conclusion is:

Much of what this review says is applicable in Australia,

• The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes Health Serv Insights. 2016; 9: 13–19 Published online 2016 Apr 12. Harrington C et al

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The implications

Variability: The variability of residents needs may well impact on the number of staff required, but that is not an argument against a minimum requirement.  In the USA there are recommended hours of staffing per resident per week, although they have not been enforced (see reports below). As in Australia, mandatory minimum staffing levels have been strenuously resisted by the industry, and it is their lobbying power that has prevented this.

Protocols: In health care we have developed protocols for grading risk, prognosis, appropriate therapy, likely diagnoses etc. This grading and grouping is to guide clinicians and administrators in making decisions.

As in the USA, nursing experts should specify the daily hours of trained nursing and nurse aids that each grade of care would typically require. As accurate data on performance is collected the needs could be adjusted.  These ratings of need and the extent to which the regular staffing profile of each nursing home met the guidelines, would be critically important for prospective residents and for the proposed aged care hub when advising them.

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Mandatory staffing levels

The Harrington article in the slider above and the references in the final slider going back into the 1990's, reveal that commercial success as revealed by profitability in an unregulated vulnerable market is closely linked to cost cutting, principally of staff and as a consequence to deteriorating levels of care.  This is in order to fuel profits and remain competitive.

The private equity and market listed corporations are far more successful in the market than the not-for-profit facilities that provide much better care. Those who provide good care struggle in this marketplace and those who save money by reducing staffing and care prosper. The market works for shareholders at the expense of residents who suffer. This is the very opposite of the way markets are supposed to work. It is a typical culturopathy.

Mandatory staffing was pressed for in the USA, but like almost every other measure that might have impacted on profitability in the marketplace it was defeated by the massive corporate lobby. It is even more powerful than that in Australia.

What minimum staffing levels tied to resident acuity for both nurses and nurse aids would do, would be to force the for-profit corporations to spend more on care which would be improved. To get maximum benefit we would also need an effective customer in possession of both recommended and actual facility figures to redress the forces driving culturopathy. Those who provide good care would have a much better chance of succeeding in this marketplace.

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Is Australia really different?

When we don't study our own aged care system, it is simply not rational to simply reject international findings and claim they do not apply to Australia and that we are strangely different - in some way superhuman.

There may be factors that are different but I don't know any that would impact on the way the market operates. I see Australians as human too. I would welcome an explanation as to why we are different?

It was fascinating to see this Twitter post in reference to accreditation ratings.  The Quality Agency could not have been unaware of Baldwin's finding that for profits were sanctioned for poor care twice as often as not-for-profits:

An article in the Australian Ageing Agenda followed:

I phoned Ms Rees and eventually obtained the figures on which the claim was based from her.  I indicated my view that these were crude figures and the important variable of locality had not been taken into account.  I invited her to check the way her figures were obtained and to correct her claim.  When that did not happen, I challenged her with the evidence by email and on the comments section of the web page to substantiate her claim or else withdraw it.  Neither Rees nor the Australian Aged Care Quality Agency responded.  The matters are addressed more fully in discussion in the comments below the article above. Baldwin contributed as well.

When the important variable of distance from a major centre is considered, it is obvious, from the figures the agency regularly present, that the claim is flawed. 

The agency's own figures show that metropolitan areas perform much better than rural centres and hardly any for-profits operate in rural areas. To attain the agency's performance values showing that for-profit and not-for-profit perform equally well in meeting accreditation standards, not-for-profits must be performing 3 to 4 times as well as for-profits in metropolitan areas.

When the data from accreditation reports were properly analysed in 2008 by Aged Care Crisis, this is exactly what was found. 

In their larger study in 2014 where they considered all of these variables Baldwin, Chenoweth, and dela Rama also documented that distance from a major centre was associated with more sanctions but when variables were addressed for profits were sanctioned more than twice as frequently as not-for-profits.

There is growing disquiet about the operation of the aged care sector. In the absence of better information, the safety of residents requires that we accept that our developing corporate marketplace is replicating the behaviour of that in the USA. We need accurate information we can trust urgently.  In the meantime, the public need protection and properly enforced minimum standards would help.

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The Community Aged Care hub and staffing

The proposed Community Aged Care Hub is intended to fill that role.  The collection of accurate data about staffing and care so that aged care policy can be based on evidence and informed community debate is a key function of the proposed hub. The hub would be on hand to check that resident staffing needs were being assessed, that appropriate levels of staffing were in place and that the multiple other factors impacting on care were attended to.

Recommended staffing levels preferably based on acuity are clearly required and the hub would work to see that they were applied flexibly and effectively. With a properly functioning hub in place, recommended staffing levels would be a necessary guide to fall back on but making them mandatory might not be so important. The hub would know exactly what was happening in the nursing homes and in the community.  It would be in a position to address it locally with management or politically through the community and through its central structure.  The market would work for residents because the community would be there to protect them.

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Additional international reports 1998 to 2016

To illustrate the nature of the problem here are some additional US references addressing these matters. They also describe failures in the regulatory system and the impotence of politicians in the face of the powerful corporate lobby. Are we seeing the same situation developing in Australia?

1998: In Florida

The Tampa Tribune series "Money of mercy" from which the quotes above were taken  comprises multiple articles with different titles published on the same day analyzing the crisis in aged care in Florida, a state where the large corporate chains dominated and had close links with politicians.

2001: writing about the USA but published in the British Medical Journal

By 2001 the problems were better recognised and seen as national:

These quotes, published in the British Medical Journal could be describing the situation and lack of accountability that we now have in Australia

2002

In a peer-review study published in September of last year by the American Journal of Public Health, Harrington and four other experts concluded: "Investor owned (for-profit) nursing homes provide worse care and less nursing care than do not-for-profit or public homes."

The study found that for-profit homes employ about one-third fewer licensed nurses than nonprofit homes. The authors also reported that government inspectors found 46.5 percent more care deficiencies at for-profit homes than nonprofit facilities.

Identifying the cause of thousands of preventable deaths each year in America's nursing homes is not difficult, but fixing the problem is far more complex.

Source: THE BOTTOM LINE OF CARING: National chains earn poor inspection reports The Atlanta Journal and Constitution July 28, 2002

With the exception of Integrated Health Services, the number of deficiencies is roughly proportional to the average profit generated by the facilities.

Integrated Health Services was in disarray with a large deficit, struggling in bankruptcy. It was trying to generate profits in order to find a buyer for its nursing home business. It failed to do so and never emerged from bankruptcy.

The information comparing the private-for-profit in the last row with the corporate market listed chains is as clear cut.  Other studies show that the not-for-profits out-perform them all in providing care.

2003

2006

A study of turnover rates for staff showed a dramatic association with lower staffing levels, lower quality, for-profit ownership and higher bed size.

• Study: Low staffing levels, for-profit ownership equal higher turnover McKnights 6 February 2006

2007

Private equity became interested and started investing extensively in nursing homes in the mid 2000s.  Until that time the for profit chains had been the prime offenders.  The New York Times was the first to document that a new and much more greedy shark had entered the sector.

McKnight's Long-Term Care News

McKnight's Long-Term Care News is a magazine serving the US aged care industry.  It comments briefly on research and other issues.  The USA has a rich data source that can be studied.

2007

US states that had introduced higher minimum staffing standards were found to have higher overall nursing levels as well as higher RN staffing levels in their nursing homes

• Higher standards improve staffing levels in nursing homes, study finds McKnights 31 May 2007

2012

Research has shown a high 21% risk of falls in newly admitted, short-stay nursing home residents. Facilities that had higher CNA-to-resident ratios had fewer falls.

• Fall risk in new nursing home residents tied to CNA staffing levels, study says McKnights 7 Jun 2012
  Hand hygiene deficiencies found by inspectors increased from 7.4% in 2002 to 12% in 2009. Facilities with fewer RNs, LPNs and aides had significantly more deficiencies than facilities with more staff.

• Hand hygiene deficiencies are tied to staffing levels, study finds McKnights 28 Aug 2012

2014

Research across multiple states confirms that minimum staffing levels improve care but interestingly one of the impacts was that they employed fewer registered nurses. This perhaps suggests that the skills mix should also be a requirement.

• Nursing home staffing standards reduced severe deficiency citations, researchers find McKnights 30 May 2014
  This study of staffing showed differences between different US states. The obvious takeaway was that additional staffing translates into better care. An average of 22 extra minutes of direct care per resident daily made a big difference. The report did not look at the way profits and different providers operated and instead targeted a lack of money as the key concern. It concluded that until the “world feels that nursing homes are staffed adequately, demands for additional workers will continue”.

• Yet another report takes aim at nursing home staffing levels McKnights 22 Sep 2014
  New Mexico is trying out an interesting strategy to improve staffing and so care. It is attempting to sue nursing homes by “alleging insufficient staffing made proper care impossible”. It is using studies of the time taken to carry out tasks to support its case as well as confidential witnesses from facility staff.  They have indicated that managers were aware that there were too few staff to provide care.

• NM uses unique tactics to sue nursing home chain over care, staffing issues McKnights 8 Dec 2014

2016

This New Mexico case is ongoing. The defence are arguing that the minimum state level in New Mexico is 2.5 hours per person per day and this is all they have to supply. The argument that more is required is not legal.

• Report: Data used in NM nursing home lawsuit clashes with industry staffing standards McKnights 3 Apr 2016

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