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The NSW Public Health Act 2010 superseded the NSW Public Health Act 1991.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.
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