Do we need RNs in nursing homes? The NSW government doesn’t think so

 

It seems that every day I keep being reminded of issues facing the ‘premature death’ debate in Residential Aged Care Facilities (RACFs). An article today again raised this issue on a matter that had gone under my radar, that the New South Wales (NSW) minimum legislative ruling regarding a registered nurse to be on duty in a RACF 24 hours a day seven days a week had been abolished. I must say as a registered nurse, healthcare worker, former aged care registered nurse and aged care manager I was appalled.

A little background

The NSW Public Health Act 2010 superseded the NSW Public Health Act 1991. Section 104 of the 2010 act stated that a nursing home (their definition) MUST be staffed by a registered nurse at ALL times. This act was intended to ensure that RACF residents who were needing what was formerly known as high care would be taken care of by registered nurses. When this act was passed the Commonwealth Aged Care Act of 1997 was in-place and defined what was considered as high and low residential aged care.

Changes to federal funding legislation

In 2013 the Living Longer, Living Better initiative was passed by the Federal Government. This initiative did several things, but the key factor in this initiative was to eliminate the distinction between high and low residential aged care. Essentially, the government, for all intents and purposes, said that every elderly RACF resident only needed basic care, eliminating the complex health care component. This jeopardized the Public Health Act’s nursing home definition, and therefore potentially removed the requirement for registered nurses to be rostered in RACF homes 24 hours a day. However, in July of 2014 the NSW government publishes an amendment upholding section 104 and continuing to require a registered nurse in RACF homes. This amendment was only an interim measure which expired in Demeber 2015.

NSW government inquiry into RACF care

On the 25th of June 2015 the NSW government begins an inquiry entitled “Registered nurses in New South Wales nursing homes“. The inquiry is finished and the report released on the 29th of October 2015. In it the committee makes several very important distinctions about the role of registered nurses within RACFs:

3.2 For many inquiry participants the administration and management of medication in aged care facilities by registered nurses was considered essential to ensure residents’ health and safety.

 

3.4 Leichhardt Council expressed similar concern about unqualified or inappropriately qualified staff administering medications, particularly Schedule 8 drugs, as it could lead to adverse health outcomes for residents.67

 

3.12 The ability of registered nurses to clinically assess the health status of residents was another important role highlighted by stakeholders

 

3.15 The Combined Pensioners and Superannuants Association asserted that the assessment skills and expertise of registered nurses were particularly critical in aged care facilities, as – unlike hospitals – there is generally no immediate access to a doctor and in situations where a resident’s health deteriorates rapidly, a registered nurse can be at hand to make a clinical judgement about the appropriate course of action.

 

3.18 A number of inquiry participants highlighted the fact that registered nurses have the necessary skills training and experience to provide end-of-life care as a reason to mandate their continuous presence in nursing homes.

 

3.26 There was general consensus that aged care staff and enrolled nurses can undertake the personal care needs of residents with dementia, however, some inquiry participants pointed out that registered nurses are still required to administer certain medications (as already discussed throughout this chapter) and manage more challenging behaviours.

 

3.33 Numerous stakeholders noted that the supervision of enrolled nurses and aged care staff is a key accountability for registered nurses in residential aged care facilities.

 

3.37 Registered nurses also supervise aged care workers. NSW Health’s Employment of Assistants in Nursing (AIN) in NSW Health Acute Care dictates that ‘an AIN will work within a plan of care under the supervision and direction of a registered nurse when providing aspects of nursing care’.

A number of groups, such as the Australian College of Nursing (ACN), submitted statements of support for the committee recommending keeping registered nurses within RACF. The highlighted concerns that although the federal government had eliminated the high and low care qualifiers in funding nursing home residents were requiring more skilled care due to their chronic conditions. Additionally, the ACN response highlighted the committee’s evidence that assistants in nursing (AINs) and enrolled nurses (ENs) needed in-person supervision as per the requirements withing their scope of practice.

NSW government refuses to take action

However, in April of 2016 the NSW government disagreed with the committee’s findings and overturned the amendment to the Public Health Act. In an article the then health minister Jillian Skinner stated that RACF facilities were regulated by the federal government, and therefore a NSW specific requirement would constitute double regulation.

The Shooters and Fishers party, led by R.L. Brown introduced an amendment to the Public Health Act 2010 which replaced the term nursing home with a definition more appropriate to the Living Longer, Living Better initiative. This would then bring the Public Health Act of 2010 current and uphold section 104 requiring 24 hour seven day a week registered nurse coverage. The bill was passed by the upper house in May of 2017 and voted down by the lower house on the 11th of May 2017.

What does mean for RACF residents?

Within nursing homes it is often, particularly in the evening/night and weekend hours, that the registered nurse serves as the in-charge for the facility. This means they are ultimately responsible for all care and function of the facility. It is during these times that rates of pay, due to penalties, is highest for registered nurses. So it stands to reason that this is the period where a registered nurse would not be rostered on.

But who will clinically assess a resident’s need for analgesia, and would a RACF allow a non-licensed AIN to administer schedule eight medications such as Endone or Ordine? If a resident falls in a facility during these hours who is going to make the clinical assessment of whether that resident is safe to be lifted, and whether that resident should be sent to hospital? If a resident shows signs of aspiration (coughing after swallowing, difficulty breathing during meals, etc.) on a Saturday morning and no registered nurse is rostered on until Monday morning, will that resident not eat for the weekend? I know these are extreme examples, but they are common within aged care facilities.

Registered nurses within facilities also handle administrative and safety tasks. They are often required to fill sick-calls during their shifts. Registered nurses are also seen as fire wardens and trained to respond to fire alarms if needed. Who is going to undertake these jobs if the registered nurse is absent? I know these are extreme cases, but currently there is NO legislative requirement for registered nurses to be rostered within aged care facilities at ANY time. It is the discretion of the facility to decide when to roster on a registered nurse. I wonder if families of loved ones in aged care facilities would be made aware of periods when a registered nurse was not employed, and how would they feel about this?

What does this mean for the hospital and greater acute health system?

From personal experience and common sense if a registered nurse is not available in an aged care facility if a resident is requiring as needed (PRN) medication an ambulance is called. An issue with aspiration, which could be assessed by the registered nurse, would need to be undertaken by the local hospital who would be the closest access to registered nurses. Any changes in a patient’s condition would require transfer to hospital as there would be no registered nurse on premesis to assess their condition and contact the resident’s medical representative.

This means increased workload on the ambulance service and emergency departments. In a period where the number of ambulance call-outs and emergency presentations is rising do we need a further burden on our health system? And it isn’t fair for the residents themselves. Transferring a elderly person, particularly one with dementia, to hospital can lead to disorientation and further complications in their treatment leading to longer stays in hospital.

Call to action!

Jillian Skinner stated in her 2015 statement that she would encourage federal adoption of the mandatory 24 hour registered nursing requirement through the Council of Australian Governments. NSW through their own inquiry found critical evidence that registered nurses provide an invaluable link to improving a resident’s health and well-being in aged care facilities. Every clinical representative body can attest to the need for trained clinical registered nurses to be on-duty at all times in aged care facilities.

There needs to be action on this subject, not just debate and fact-finding. The evidence is overwhelming for the need for minimum clinical supervision in aged care facilities. We need lawmakers to listen to their constituents and put into place minimum standards.

References

NSW Public Health Act 2010- http://www.legislation.nsw.gov.au/inforce/e20f1d11-6a0d-ec9a-fe79-d31ae57c52c3/2010-127.pdf

Workingcarers.org.au: Living Longer Living Better changes that might affect working carers-  http://www.workingcarers.org.au/index.php/work-n-care/reports/1467-living-longer-living-better-changes-that-might-affect-working-carers

NSWNMA: Timeline of events – registered nurses in NSW nursing homes-  http://www.nswnma.asn.au/wp-content/uploads/2013/09/Timeline-of-events-registered-nurses-in-NSW-nursing-homes.pdf

Legislative Council: Registered nurses in New South Wales nursing homes- https://www.parliament.nsw.gov.au/committees/DBAssets/InquiryReport/ReportAcrobat/5821/Report%2032%20-%20Registered%20nurses%20in%20New%20South%20Wales%20n.pdf

Australian College of Nursing: ACN submission inquiry into RNs in NSW nursing homes-  http://ACN_submission_inquiry_into_RNs_in_NSW_nursing_homes.pdf

Sydney Morning Herald: NSW Government abandons 24/7 nursing in aged care homes-  http://www.smh.com.au/nsw/nsw-government-abandons-247-nursing-in-aged-care-homes-20160430-goium1.html

Talking Aged Care: NSW registered aged care nurses on duty 24/7- https://www.agedcareguide.com.au/talking-aged-care/nsw-registered-aged-care-nurses-on-duty-24-7

NSW Legislature:  Public Health Amendment (Registered Nurses in Nursing Homes) Bill 2016-  http://www.legislation.nsw.gov.au/bills/84bb3a65-4581-4187-a2b8-90a8d6e7c659

Should Australia adopt a national Dementia plan?

 

Anyone who works in healthcare, particularly those in aged care, can attest to the fact that dementia is one of the largest problems facing our aged population. Here are a few Australian facts courtesy of Alzheimer’s Australia:

  • There are more than 413,106 individuals in Australia living with dementia
  • Currently 244 new individuals will be considered has having dementia every day
  • Dementia is the second leading cause of death of Australians
  • In 2017 the cost of caring for those with dementia in Australia is estimated to be 14.67billion
  • Dementia is the single biggest factor leading to disability of adults over the age of 65
  • Dementia accounts for 52% of those residing in aged care facilities (RACF)

It is a huge problem! In an article on the 2nd of June in Australian Ageing Agenda Maree McCabe of Alzheimer’s Australia has strongly encouraged Australia to join the international community in developing and funding a national Australian dementia policy. In the article it states that the World Health Organization (WHO) has adopted a Global Plan of Action on Dementia, and that Australia should join other countries in adopting it.

What is Australia doing about it?

The government’s response has not been favorable to Alzheimer’s Australia’s (AA) request. Dr Margot McCarthy told a Senate estimates committee that, although she was aware of AA’s request there was no national strategy but a series of increased funding for research and new dementia-specific programs. Dr. McCarthy also in her statement referred to the National Framework on Action on Dementia, but said the government had to decide on how to follow-through with the framework.

The National Framework on Action for Dementia 2015-2019 was developed by the  Australian Health Ministers Advisory Council (AHMAC) through a consultative process and merely serves to

The purpose of the Framework is to guide the development and implementation of actions, plans and policies to reduce the risk of dementia and improve outcomes for people with dementia and their carers. It does this by drawing on current evidence to promote dementia friendly societies and delivery of consumer-focused care.

The keywords here is ‘guide’ and ‘development and implementation’. This is NOT a national framework, but merely a fact-finding paper with the results of interviews and consultations on the problem. While the national framework policy does not give any direct action to the problems of dementia, there have been some attempts by the government to tackle dementia issues.

In June of 2016 the government began a commitment to tackle the issue of dementia in the community by the initiation of the Severe Behviour Response Teams (SBRT), a partnership between the government and Hammond Care. The SBRT is meant to be an assessment and management team designed to visit the individual and work to identify and create strategies to handle adults who suffer from dementia-related behaviours. The government also acknowledged at the time that specific dementia facilities for those with behaviours would be needed. Dr. Judd, then chief executive of Hammond Care, indicated that accreditation standards for aged care facilities had led to those facilities increasing in size and therefore “as nursing homes get bigger and bigger, it becomes harder not to have institutional buildings which are less homelike and more regimented… Today, the public areas of some aged care ‘facilities’ look more like airport lounges than lounge rooms” (quote by Dr. Judd taken from this article).

A year later and the Ageing Australian Agenda article confirmed that the special dementia units promised in 2016 were largely not developed. Therefore, the bulk of dementia-specific management of older adults rests squarely on the shoulders of current residential aged care staff and caregivers when dementia-sufferers are at home. But what about the WHO’s Global Action on Dementia? Wouldn’t that give some indication on where Australia should go?

The World Health Organization and Dementia

I have looked through the WHO’s website and cannot see any agreed final document on the global action on dementia. According to the WHO dementia has been labeled as a public health priority in 2012 and a Ministerial Conference on Global Action on Dementia did occur in 2015, resulting in a draft document of the same name. In the push for WHO development of information a site entitled The Global Dementia Observatory was meant to be a sharing house for information relating to statistics on global dementia and development of strategies to treat and handle those with dementia. However, in my research neither has the Global Action on Dementia been finalized nor has the Global Dementia Observatory been created and implemented despite statements made by Alzheimer’s Australia.

So from my perspective after looking at all of the information the WHO is no further in looking for a unified dementia strategy than Australia is. We continue to develop reactionary stop-gap measures to modify behaviours and reduce pressure on caregivers. But that does not help identify and treat the root cause. Non-government organizations like Alzheimer’s Australia and Hammond Care are doing great things to try and help this looming national (and international) epidemic.

We in healthcare are at the front-line of this issue. Of the patients I see a vast majority are over the age of 65, as they take up more acute healthcare beds. And while I do not have specifics of those with dementia I can say with my experience that many who enter our beds do. Dementia causes quite a few issues that can lead to life-shortening situations.

My thoughts

Those who follow this blog know that I have talked twice about the concept of ‘premature deaths’ a topic surrounding why individuals in aged care facilities are dying from un-natural causes. Falls was listed as the greatest cause of these premature deaths. I wonder if Mr. Ibrahim’s proposed study would look to identify of those falls how many patients have a diagnosis of dementia? Being reasonable and looking at common sense, if I do not have dementia and have all of my faculties would I not use the vast range of mobility aids and ask for help to prevent falling when I look to walk or even stand? Those with dementia do not have the for-sight to realize that they are no longer able to mobilize without help, and therefore are at higher-risk of falling.

Interestingly Dr. Judd in his address in 2016 also talked of aged care facilities becoming larger. This is another troubling point. Larger facilities mean more residents for staff to monitor in a larger space. Another interesting study could look at the amount of time each staff is given per resident. I think it would find that staff have difficulty in adequately supervising residents, particularly those with dementia who are prone to stand and walk- and therefore fall.

Unifying Australia’s stance on dementia and the associated research and programs would give clarity and focus within all aspects of the aged care community. Let’s face it, the aged care population is faced to grow over the next few years. And with it those with dementia is also most likely going to grow. It is a debilitating condition that we need to know more about to effectively care for and treat. I agree with Mrs. McCabe, Mr. Judd and the WHO that we need to put more focus on a unified and strategic plan to deal with this growing epidemic.

References

Australian Ageing Agenda: Australia behind as global dementia plan endorsed

Alzheimer’s Australia: KEY FACTS AND STATISTICS FOR MEDIA – NSW

Australian National Framework for Action on Dementia 2015-2019

Australian Ageing Agenda: Coalition to fund special dementia care units for severe behaviours

Dementia Behaviour Advisory Service

Hammond Care: Severe Behavoiour Response Team

World Health Organization: Dementia

 

Concerns raised about investigation of premature deaths in aged care facilities.

One day after this and other sites posted about Joseph Ibrahim’s calls to investigate the causes of what a coroner’s report called premature deaths in aged care two other articles have surfaced regarding the same issue.

Falls in residential aged care facilities

In an article in the Medical Journal of Australia Dr. Stephen Judd, chief executive of Hammond care- an aged care provider, discusses potential consequences if nursing home regulation were to be tighten in an attempt to lessen premature deaths from falls.

“If staff think they are going to get rapped over the knuckles if Mary falls over when she goes outside, they’ll lock the door so she can’t get out,” he said.

“All life is about risk; we have to encourage people to enjoy life, not just keep themselves hermetically sealed in a life of boredom,” he said. “Rather than trying to eliminate risks, we must manage risks intelligently.”

Interestingly I wonder if Dr. Judd is aware that most nursing homes do have locks on exterior doors to prevent residents with dementia from travelling outside? From my experience in aged care many, if not most falls, occur in the resident’s bedroom when the patient is found close to their bed. While I have not statistics evidencing this fact, I am sure Dr. Ibrahim’s report would reveal this.

Additionally, I also find it interesting that Dr. Judd stated that ‘staff’ would be responsible for denying freedom for fear of retaliation. Staff of nursing homes answer to the corporate bodies of said homes, so wouldn’t the fear they would be reacting to not come from the disciplinary action from corporate executives should preventable deaths not reduce? The article also reiterates the principles that I discussed in my previous post regarding the role of residential aged care. There exists a conflict between patient safety and freedom of choice. If a resident is unsteady on their feet and a falls risk but fiercely independent and wants to walk around a facility, does that facility have a right to restrain the resident to reduce falls?

Suicide prevention in residential aged care

Yesterday an article in the Australian Ageing Agenda by  Darragh O’Keeffe discusses the federal government’s stalemate on a decision of how to allow residents of Residential Aged Care Facilities (RACFs) to access the Better Access to Mental Health scheme (BAMH). The BAMH scheme, according to the federal Department of Health’s website

” Medicare rebates are available to patients for selected mental health services provided by general practitioners (GPs), psychiatrists, psychologists (clinical and registered) and eligible social workers and occupational therapists.”

However, according to Dr Margot McCarthy, deputy secretary of ageing and aged care, there is still discussion around how the scheme would be made available to residents in care facilities.

If an elderly member of the community was having depressive thoughts surely the GP would jump at the chance of engaging in this service to allow more treatment options for their patients. The same should be true for residents living in aged care facilities. The Medicare funding does change when a person goes into RACF care, however that should not change the available services to them. I hope that in the near future the Department of Health and Department of ageing and aged care can come to an agreement and make this valuable service available for residents in RACF homes, thereby moving towards reducing preventable deaths related to mental health conditions.

What does this mean for nursing staff and residents?

While the powers-at-be continue to struggle with how to research and tackle the issue of ‘premature deaths’ nursing staff in aged care facilities will continue to be in the firing line. Without clear-cut guidelines their actions and assessments will put the responsibility for minimizing the risks sits squarely on them. For residents and families the falls, suicides and choking will continue until the federal government and corporate aged care executives agree on a standard measure along with established preventative measures to minimize, and hopefully, eliminate the term premature deaths in aged care from existence.

References

The Medical Journal of Australia: Aged care falls deaths: a question of balance

The Australian Aged Agenda: No end in sight to aged care’s mental health blockage

The Department of Health: Better access to mental health care: fact sheet for patients

 

Premature deaths in aged care facilities, what is really the root cause?

 

A recent article in The Conversation by Joseph Ibrahim discussed recent findings that a large number of residents in residential aged care facilities (most commonly known as nursing homes) died as a result of ‘unnatural causes’. The three most prolific causes identified by a recent report from the coroner’s court was falls (81.5%), choking (4.4%) and suicide (1.9%). The study also stated that while in over 90% of the cases the cause of death was initiated in the nursing home over 67% of the actual deaths occurred in an acute facility, such as a hospital. This is reflected in the patients I see in my emergency department. The report goes on to say that these incidents result in a ‘premature’ death and are in many ways ‘preventable’. I would like to bring up some important factors which may confound such a simple statement.

While I do agree that there are most likely things that can be done within Residential Aged Care Facilities (RACFs) to minimize deaths related to the above items, I do think some moderation of the situation is in order. With the ageing-in-place legislation and current climate allowing elderly people to remain in their own homes longer RACFs are seeing residents coming to them older, and more importantly, more unwell with their disease process advanced. While not an excuse I wonder how much longer RACF residents would be able to functionally thrive in their own home rather than in a facility? From my experience of working in RACFs I can say that most likely a resident is placed in a facility due to either an acute turn in their condition (i.e. fracture or some major medical setback) or commonly due to a decline in mobility and functionality due to dementia which would preclude them from staying at home. Along with the decline in mobility and functionality is an increasing possibility for falls.

A second issue is exactly what is the role of a RACF in the health care continuum? According to the MyAgedCare website in a RACF ” Staff at aged care homes can help you with day-to-day tasks (such as cleaning, cooking, laundry); personal care (such as dressing, grooming, going to the toilet); or 24-hour nursing care (such as wound care, catheter care).” Additionally, the Aged Care Quality Agency standards for RACF homes is very general with standard 2.4 simply stating ” Care recipients receive appropriate clinical care” and standard 2.14 on mobility stating ” Optimum levels of mobility and dexterity are achieved for all care recipients.” These are very broad clinical statements with no specific measurable outcomes. They are also included with other standards such as 4.8 which state ” Hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment” and 3.7 ” Care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them.” Therefore, my question again is where does the RACF fit clinically within the healthcare continuum? Is it meant to be a sub-acute residential centre with clinical nursing care as a role on-par with items such as hospitality services and leisure activities?

This case can further be made if Mr. Ibrahim speaks to RACF clinical staff. In most RACF homes the registered nurse is the clinical decision maker for initial diagnosis and guides treatment of patients. However, they have limited assessment and diagnostic tools at their disposal. They have no access to blood tests, CT scanners or even x-rays within a reasonable time frame nor I have found a RACF with a 12 lead ECG machine which is seen as a critical piece of equipment in any hospital emergency department. Additionally, medical services are exclusively provided by general practitioners who can give limited medical support within their clinic hours and an after-hours GP service which does not know the patients and can only provide cursory and event-specific advice. This leaves the registered nurse having to care for a much larger number of patients than any hospital-based nurse would dream of doing with much less equipment and no medical support on-hand.

My worry is with Mr. Ibrahim’s study, as with many previous examinations of care given in RACF homes, will place the burden of responsibility for ‘premature deaths’ at the feet of the registered nurse. I think this is largely unfounded as the RACF system is flawed and needs a truly complete analysis and re-think moving forward. If the RACF is to prevent these events from happening then let us give the registered nurses on the floor appropriate staffing numbers, the right tools and education in assessment using them along with adequate medical support no matter the time of day or night and I think you will see the number of premature deaths decrease rapidly.

References

MyAgedCare: Aged care homes (nursing homes)

The Conversation: Many older people in care die prematurely, and not from natural causes

Aged Care Quality Agency: Accreditation Standards