Providing Quality Care in Residential Aged Care settings - Viewpoint

Sylvia Roeters RN, PGDip Nursing (Older Person), MPhil, MCNA(NZ)

Co-ordinator Elder Person Nursing Network

Aged Care, in communities and in care facilities, is under considerable strain. Consumer groups, the general public, health professionals, health providers and the media are increasingly aware of the untenable situation of the Aged Care sector. The opportunity to discuss the complex issues facing this sector may be a catalyst to wider debate. In turn debate may assist in the creation and implementation of changes to workforce and practices that will reduce the strain on this sector. The following is a compilation of nurses' experiences received through local and national networks. It also includes personal observations collected through years of experience in this sector. This article focuses on some of the challenges and limitations that face Registered Nurses in the Aged Care sector. It also hopes to offer some thoughts on positive changes that would benefit this sector. Importantly, the challenges faced in the Aged Care sector should not be viewed in isolation particularly since some of the issues have relevance in the wider health sector.

Aged Care in New Zealand has traditionally been provided by a combination of charitable and ‘for-profit' organisations. These organisations have variations in their philosophies and goals, which underpin their service delivery. Consistency and quality of service delivery is measured and supported by the Ministry of Health certification and DAAs' accreditation processes. Quality and benchmarking systems are also available. However, in the busy day-to-day care environment these systems are often the first to be neglected. Quality and benchmarking systems are seen as an optional extra rather than a support system to ensure consistent care and practice. These systems have obvious benefit for those receiving care, especially as their needs increase. The acuity and frailty of people admitted to care facilities have steadily increased in the last eight years. Anecdotal evidence indicates that some years ago many people in rest homes walked independently. Now most admissions need a walking frame and require assistance with all daily activities. The majority of people admitted to care facilities have five to six pre-existing health concerns. Often these are of a chronic and debilitating nature, requiring skilled and experienced RNs to provide the appropriate assessments and care instructions.

RNs in care facilities frequently take on multiple roles, some with a management component and all have responsibility to supervise caregivers. Yet these RNs are only receiving minimal or no education on this part (or indeed any other part) of the RN role. Professional leadership is not always available and many nurses report directly to non-health professionals. RNs who are part of the management team often have divided loyalties. They feel the need to support management at the same time as supporting a large number of care staff, whilst continually focusing on the needs of their patients.

In many instances RNs in Aged Care are working as the only RN and with minimal if any professional support. RNs who often work in sole charge situations deal with increasing workload and additional responsibilities. To curtail the public concerns about the Aged Care sector, additional regulations and contractual requirements are frequently imposed. RNs increasingly find it difficult to keep up to date with the requirements without professional support. In these often sole charge positions professional isolation occurs not only because of the RNs' work environment but also because there are limited opportunities to network. Most networking opportunities are present in the evenings and are, of course, unpaid. As a result of the aforementioned professional isolation a number of RNs stated that although they have worked in a specific Aged Care facility for some time they had not been provided with the tools to accept and manage change management. Financial restraint for professional development puts professional practice at risk. Furthermore, the growth of the nursing workforce has fallen behind the level of population growth and the nursing workforce is ageing.

Pay rates in the Aged Care sector are varied. Although some providers attempt to pay well, the pay parity gap between the Aged Care sector and the Public sector is increasing. RNs in Aged Care with additional qualifications and experience seldom have these qualities acknowledged in their remuneration. Therefore the difference in pay for RNs with and without Aged Care specific qualifications is minimal. Funding for the Aged Care sector has not been significantly increased, despite the aforementioned increases in the needs of those admitted. This lack of funding should not be a barrier to improving employment conditions. It is far more costly in terms of distress, resource management and over all expenditure to have an inquiry into care practice. If monetary resource was spent on providing initial and ongoing assistance, as well as adequate remuneration, RNs could provide the required care without putting their professional practice at risk.

One of the largest barriers faced by RNs in the Aged Care sector is the prejudice in the greater health sector towards not only the older person but also the staff working in this sector. There is a perception that a career in Aged Care provides minimal opportunity for career advancement. As stated previously, within the health care sector, there is little recognition for the skill and expertise required to work with the complex health concerns of older people. Many RNs choose to work in Aged Care because they enjoy working with older people. Some go so far as to mention that they believe they are not suited to work in other areas. The lack of recognition, both financially and professionally limits confidence and a sense of identity. Conversely, although there is a shortage of RNs for Aged Care, lack of supported entry to practice, lack of fiscal or social recognition for the nature of the work, and no obvious career progression limit the numbers who will enter the area.

The issues and concerns surrounding Aged Care and RN employment and retention are multifaceted and an immediate instantaneous solution is not evident. Looking at the conditions in which a number of RNs work, it is not surprising that many nurses choose not to work in the Aged Care sector. Some owners and providers of care facilities have good systems for career pathways in place and are pro-active. Others have a 'band-aid' attitude and spend large amounts of time and resources on fixing issues and panic-management rather than assessing risk and ensuring support is available. Any steps towards recognising the value of nurses and nurse involvement on all levels of organisational decision-making can only have a positive outcome. The most effective way of ensuring appropriate care is provided is for RNs with qualifications and expertise in Aged Care to work in partnership with older people. Nurse Practitioner input in Aged Care would ensure a more efficient approach to care. There is ample evidence in literature that low numbers of RNs result in reduced quality of care and increased cost. The International Council of Nurses also expressed concern about this aspect of RN shortage and related this to an increase in unethical practices and subsequent formal inquiries. Discussions with colleagues indicate that inquiries are less frequent or non-existent in care facilities with adequate RN staffing and specialist qualified RN leadership.

Another positive step would be the provision of support and opportunities for RNs to connect and up-skill. Primary health care teams in some parts of the country are providing opportunities for networking across all primary health care settings. An example of this is the support provided by the Primary Health Care Practice Development Team in the MidCentral Health region. This team provides networking opportunities, education and professional support. Nurses in care facilities are being encouraged and aided to participate in these projects.

To summarise, the only way to ensure effective care and an appropriately skilled workforce is to invest in and develop opportunities for up-skilling, the provision of professional leadership, pay-parity, career pathways and support networks to share knowledge and manage changes effectively. It is only when providers, nurses and the wider health care sector work together to provide these opportunities and changes that effective care and a skilled workforce will become a reality. Only then will the comfort and safety of the very frail elderly who need residential care be guaranteed.