Editorial
 
In this edition of Te Puawai we have taken a particular focus on aged care from a number of perspectives. It is becoming increasingly clear that aged residential care service provision is in a fragile state with a combination of private ownership, funding and staffing issues weaving a complex but worrying picture.
The prime concern is that frail or sick elderly people can be sure that at their most vulnerable there will be places where high quality safe care will be received. Such care needs to be closely overseen by registered nurses and in the case of the hospital level beds, it should be more closely delivered by registered nurses or by caregivers whose appointment processes and training requirements and care provision are at least monitored by RNs.
Currently the residential care settings claim that budgets do not allow improved RN staffing but it would be interesting to know if parallels exist with acute hospital data around safe staffing. In hospitals we now know that cost cutting on registered nurse staff is a false economy causing increased costs through added length of stay, increased errors and nurse sensitive negative patient outcomes, not to mention increased nursing turnover, sick leave and job dissatisfaction. Such research has not been carried out on any significant scale in residential care settings but intuitively it could be suspected that for the residential sector as well, increased RN care would be cost effective.
There are many anecdotal stories of the lucrative nature of residential care ownership and I have no idea how such information can be checked and assessed. As always though there are choices to be made by owners and profit margins can be varied. The reports of RNs working for $15 an hour are deeply worrying, suggesting that neither the nurses themselves nor the owners have any appreciation of the value of that service.
Residential care settings are dependent on the declining general practice workforce for timely assessment and treatment of medical events, and transfer to acute hospitals often occurs unnecessarily. Such transfer is a huge physical and psychological disruption for an elderly person and the admission and subsequent care increase the burden on strained hospital services. During recent focus groups conducted as part of a research process I have observed at first hand how much more timely and appropriate care could be provided by nurse practitioners specialising in aged care. Consider the following imaginary scenario:
An elderly woman in a rest home becomes confused and delirious and obviously ill. Normally this is most likely to result in transfer to an acute hospital. An NP specialising in gerontology has been employed by the DHB to provide specialist care to the residents of four large local residential settings, along with teaching and support of nursing staff. She visits the elderly woman, diagnoses urinary tract infection as the underlying cause and prescribes antibiotics and inserts intravenous fluids. She visits twice daily and monitors and advises on care during which time the woman recovers her normal physical and mental status and remains in the residential setting.
Outcomes from her position as an NP in that role would be reduction in upsetting change or transfer for the frail elderly person, reduced hospital admission rates and reduced bed block. In addition the presence of a skilled NP would act as a source of increased teaching and thus capacity for staff in residential settings. It would also demonstrate a clinical career path to clinical leadership for nurses who are passionate about aged care. The automatic response to proposing such a position is to say that residential care settings cannot afford even a shared NP salary. I do wonder if anyone has ever actually costed out the price of GP visits, the price of the required 3 monthly GP assessments and the price of an unnecessary hospital transfer. I think they would find that such costs pale into insignificance alongside a NP salary, especially if that role were appropriately shared between a number of facilities.
For those RNs currently working in residential care all is far from well. Recent cases brought before the Health and Disability Commissioner reveal some of the issues. See www.hpdt.org.nz - Decision20/Nur05/09DI retrieved 28/4/06. Also see same reference Decision 28 (Can't find) . In one instance an RN on 24/7 call gave instructions by phone to a caregiver; these instructions were subsequently judged to have resulted in inappropriate care. Although the Tribunal admitted that her workload was inappropriate they found against her on the basis that she had never actually told her employers that her workload was unacceptable and unsafe. Her pay rate was $15 per hour and she was fined $10,000. The Tribunal makes the correct assumption that an RN should be accountable for advising when workloads are unsafe. However what is most concerning about this and what my research experiences have revealed is that RNs who have worked in such deeply oppressive circumstances are unlikely to have sufficient vision, courage or stamina left to protect themselves in such a manner. In addition many do not belong to a professional organisation and do not have indemnity insurance.
Perhaps a proper response would be for us to offer a draft letter to such nurses and support them to send it to the owners and managers of such institutions. What might such a letter say?
Dear (owner or manager)
Each duty we work sees us as the sole RN on duty responsible for the care and safety of (x) number of residents. We need to advise you that it is not possible as sole RN with this patient load, to ensure that residents and patients are appropriately assessed by us, that all medication is safely administered, and that patients receive the full level of care considered appropriate.
Our terms of employment here make no (or very inadequate) paid provision for ongoing education and professional development. Under the terms of the Health Professional Competence Assurance Act (2003) it is now a State requirement that we have a minimum of 60 hours of professional development each three years. Without this our practising certificates cannot be renewed when we are routinely audited by the Nursing Council of New Zealand. This would eventually result in us needing to cease practice.
In addition, it is a professional requirement of registered nurses that we take responsibility and accountability for the practice of caregivers who legally work under our supervision and delegation, yet we have no say in the employment or termination of employment of caregivers. We have no power to determine the level of training received by caregivers therefore we have no control over the safety or otherwise of their practice. In essence we have full accountability without control and this is untenable.
Continuity of staffing for this institution is also a concern. New registered nurses are obviously required yet novice RNs cannot be easily employed here as it is unsafe to leave a new RN in sole charge of so many patients as we are (or on sole call constantly as we are).
Our prime concern in writing this letter is the quality of care received by our patients or residents but it is also our legal responsibility for patient safety which we would be breaching by not advising you as we do.
I wonder what the outcome would be if all residential setting RNs whose conditions are unsafe or professional development levels inadequate sent such a letter. I also wonder why the outcome of the cases brought before the Tribunal, as mentioned above, have not created much more discussion and much more of an outcry.
The private ownership of residential care settings adds a layer of difficulty especially in terms of potential shared employment of NPs and DHB responsibilities towards the health and wellbeing of their communities. Other people know much more than I do about the certification and accreditation processes of the residential care industry but I suspect there is much of interest here. It would be wonderful if those with expertise could either write to Te Puawai or raise these discussions on the electronic discussion group. It would also be good to hear from those in situations where all is well and a vibrant, well educated RN staff is present in sufficient numbers and with sufficient professional development to provide the quality of care needed.
Professor Jenny Carryer
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