Weekly Wrap: 24 May 2020

Aged care news highlights from the week ending 24 May 2020.

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Fewer Nurses and More Worries: What the Data Tells Us About the Residential Aged Care Workforce

There has been a lot of research into the residential aged care workforce over the past few years and it has produced an abundance of data. To help you make sense of this data, we’ve identified five of the most relevant studies and summarised what they tell us about the residential aged care workforce.

The Studies

As you’ll see from these short summaries, each of the studies has a slightly different focus, so together they can help us to build a more complete picture.

National Aged Care Survey 2019 – issued by the Australian Nursing and Midwifery Federation (the ANMF Survey).

Issued in May 2019, this relatively recent survey sought feedback from aged care staff (nurses, carers, aged care workers, assistants in nursing, personal care attendants and personal care workers) and community members (residents and their friends and family) nationwide. About 2,700 staff and about 350 community members responded. The survey had the objective of “examining current concerns in aged care, adequacy of staffing levels and skills mix, adequacy of care delivery in residential aged care facilities, suggested improvements necessary of aged care, and voting intentions relating to aged care.”

National Aged Care Workforce Census and Survey 2016 – issued by the Commonwealth Department of Health (the Department of Health Survey).

This is the largest of the studies. It sought feedback from all Commonwealth funded aged care facilities and home care outlets. Over 15,000 aged care workers across Australia responded. This survey provides a lot of broad demographic information as well as some information on worker’s thoughts and opinions.

Centre for Health Service and Development Report 2019: “How Australian Residential Care Staffing Levels Compare with International and National Benchmarks” (the CHSD Study).

The CHSD Study was commissioned by the Royal Commission into Aged Care Quality and Safety and published in September 2019. This makes it the most recent of our five studies. However, much of the data it uses relates to the period 2003-2016. The study acknowledges that it is not always easy to compare Australian aged care homes with their counterparts overseas because there are “significant differences between the regulatory, funding and operational environments.” However, the authors of the study are confident that their focus is narrow enough to make the findings valid.

AMA Aged Care Survey Report 2017 – issued by the Australian Medical Association (the AMA Survey).

This survey targeted AMA members (doctors and people training to be doctors) and sought feedback on their “impressions and experiences of providing medical care to older people.”

University of Adelaide Working Paper for the Aged Care Workforce Strategy Taskforce 2018: “Attraction, Retention and Utilisation of the Aged Care Workforce” (the Adelaide University Report).

Completed in April 2018, this report does not gather new data, but rather analyses data from the Department of Health Survey mentioned above.


Who Are The Aged Care Workforce?

 Here’s what the studies tell us about the demographics of the direct care workforce in residential aged care:

The direct care workforce is shrinking

In 2016 there were approximately 235,764 residential aged care workers. About 153,854 of these were direct care workers. While the general residential care workforce has grown by about 50 per cent since 2003, the proportion of direct care workers is falling. In 2003, 74 per cent of the workforce were direct care workers. In 2016 that had dropped to 65 per cent (Department of Health Survey).

Most of the workforce are women in their forties, with about a third born overseas

The workforce is 87 per cent female with a median age of 46 years. Thirty-two per cent of workers were born overseas and 40 per cent of recent hires were migrant workers (Department of Health Survey).

The workforce is made up of a large and growing number of PCAs, a declining number of nurses, and many volunteers

The vast majority (70 per cent) of the residential direct care workforce are Personal Care Attendants (PCAs), and the numbers are growing. In 2016 Registered Nurses (RNs) made up about 15 per cent of the workforce, and that is roughly the same as it was in 2012. Enrolled Nurses, meanwhile, have dropped from 12 per cent of the workforce in 2012 to 10 per cent in 2016. Allied health professionals make up a small, and declining, percentage of the workforce (Department of Health Survey).

The Department of Health Survey estimates that in 2016 “an estimated 23,537 volunteers worked in residential aged care in the designated fortnight.”

Most of the workforce are employed on permanent part-time contracts

About 78 per cent of all direct care residential workers are employed on permanent part-time contracts. The proportion of casual employment has shrunk since 2003 and continues to shrink (Department of Health Survey).

Most of the workforce have higher education qualifications and receive ongoing training

Around 90 per cent of workers hold a post-secondary school qualification. Around 80 per cent had engaged in work-related training in the last 12 months and 58 per cent undertook Continuing and Professional Development (CPD). Levels of ongoing training in 2016 were much the same as those in 2012 (Department of Health Survey).

There is a lack of adequate training in regional and rural areas

The Department of Health Survey notes that “a lack of training for workers in regional and rural areas is evident.”

The workforce is under-utilised

Across aged care generally the workforce is under-utilised, with 30 per cent of residential and 40 per cent of home care and home support staff reporting that they would like to work more hours. This has led to some workers seeking additional employment elsewhere. In 2016, about nine per cent of residential aged care workers had more than one job (compared to five per cent of the general Australian workforce). Most of these second jobs were in the aged care or disability sectors (Department of Health Survey).


Major Concerns

ANMF Survey

The top four concerns reported by ANMF members were:

  1. Adequate staffing levels for meeting basic care needs
  2. Adequate staffing levels for providing high care
  3. Dementia management
  4. Levels of experience and qualifications held by nursing staff

The ANMF survey also gathered “in-depth responses” to concerns about inadequate staffing. These revealed that participants were particularly concerned about the availability of RNs and about inappropriate responsibilities being pushed onto less skilled/experienced workers.

The survey also found that, from the qualitative data, the most significant change between 2016 and 2019 was “an increased sense of despair.” Despite increased requirements and media scrutiny, aged care staff “feel that nothing has changed in relation to their workloads, their staffing levels, or their pay and conditions.”

Department of Health Survey

The top four “emerging issues” identified in the Department of Health Survey in relation to residential aged care were:

  1. Residential care homes are “opting for a workforce composition with lower use of direct care staff, which may have future implications regarding quality of provision.”
  2. Increasing demands for workers in the disability sector may have substantial impacts on the aged care workforce.
  3. Recent aged care reforms have made the workforce “fearful” about the sustainability their jobs.
  4. There is a disconnect between a workforce perception that staffing is increasingly inadequate and data which suggests that staffing ratios have “remained constant since 2012.”

CHSD Study

The CHSD study focused on staffing. It aimed to find the best system in the world for evaluating staffing levels and then apply that system to Australian residential aged care homes.

The CHSD decided that the best system was “the USA Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare system”, which uses a five-star rating. Refining that system for the Australian context, the CHSD’s judgement was that:

  • 1 or 2 stars represent unacceptable levels of staffing
  • 3 stars is acceptable
  • 4 stars is good, and
  • 5 stars is best practice.

Applying this system to Australian residential care services, the CHSD found that more than half of all Australian aged care residents (57.6 per cent) are in homes that have “unacceptable” 1 or 2-star staffing levels.

AMA Survey

The AMA survey asked respondents to rate the most urgent measures needed to improve medical care in residential aged care homes. The top two measures reported by respondents were:

  1. Improve availability of suitably trained and experienced nurses and other health professionals.
  2. Increase funding for medical practitioners.

Adelaide University Report

The key findings of the Adelaide University Report concern skills shortages in the aged care sector. The report found that:

  • nurses in the residential sector are in high shortage
  • skills shortages are worse in remote areas
  • skills shortages have been declining in the residential sector, but not in the community sector
  • there are many causes behind the skills shortages, but the most important ones are lack of specialist skills and training and a tight labour market that makes hiring more difficult, particularly for remote facilities.


What Can We Learn From the Studies?

If there is one message coming from all the studies, it is this: almost everyone working in aged care is concerned about inadequate staffing. This includes concerns that there aren’t enough staff overall, that there aren’t enough staff with relevant skills, and a particular concern that there aren’t enough RNs.

All the studies conclude that people are concerned, but are these concerns well-founded? One study suggests not.

On page 166, the Department of Health Survey begins by acknowledging that most respondents were worried that “insufficient staff numbers, higher workloads and the replacement of RNs with less qualified staff were impacting negatively on resident care.” But, the survey says, these perceptions were not supported by the data, which “indicated that overall staffing ratios and the proportion of RNs in the residential sector had remained constant since 2012.”

This finding – that there had not been a harmful drop in the proportion of RNs employed in aged care – is at odds with all the other studies. It is even at odds with the Adelaide University Report, which is based on the same data.

This illustrates an important point: data is meaningless until interpreted, and it can be interpreted in many ways. One unavoidable tool of interpretation is framing. Like a photographer looking through a lens, a data analyst cannot look at everything. They have to set limits and focus exclusively on what happens within those limits.

One of the limits set by the Department of Health Survey is time-period. Although the survey mentions data from 2003 to 2016, most of the discussion is restricted to what happened in the period 2012-2016. If you focus on that period alone, the claim that there has not been a harmful drop in the proportion of RNs makes sense: RNs made up 14.9 per cent of direct care workers in 2012, and roughly the same (14.6 per cent) in 2016 – no significant drop, nothing to worry about.

But as soon as you expand the frame, the interpretation changes. According to the Department’s own data, RNs made up 21 per cent of the direct care workforce in 2003. So, between then and 2016, there was a drop of about six per cent. In actual numbers, this means that between 2003 and 2016 about 1,500 direct care RNs left the job and were not replaced.

But why stop there? The frame can reasonably be expanded to include a few more relevant factors, such as:

  • the proportion of Enrolled Nurses (ENs) in direct care has been steadily dropping since at least 2003
  • regulatory requirements imposed on the aged care workforce have gotten more complex since the introduction of the Aged Care Quality Standards
  • advances in medical technology and an increased focus on consumer dignity and choice have increased options for consumers. This has increased the demands on the aged care workforce, particularly those with specialist medical skills.

When all these factors are considered, it looks like the worries of the workforce are in fact well-supported by the data.

To be fair to the Department, its survey report does say that “the discrepancies between the perceptions of residential workers and the findings from the census could benefit from further examination.” Hopefully, this “further examination” will challenge the way the Department interprets the data, and not just the way the members of the aged care workforce interpret what they see every day.


Speaking of Surveys…

The purpose of ACE feature articles like this is to answer some of your questions about the challenges arising from managing an aged care facility and meeting the new Aged Care Quality Standards. To help us ensure we keep writing what you want to read, please take a couple of minutes to complete this short survey. Contact details are optional!


Mark Bryan
Mark is a Legal Research Consultant at CompliSpace and the editor for ACE. Mark has worked as a Legal Policy Officer for the Commonwealth Attorney-General’s Department and the NSW Department of Justice. He also spent three years as lead editor for the private sessions narratives team at the Royal Commission into Institutional Responses to Child Sexual Abuse. Mark holds a bachelor’s degree in Arts/Law from the Australian National University with First Class Honours in Law, a Graduate Diploma in Writing from UTS and a Graduate Certificate in Film Directing from the Australian Film Television and Radio School.

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