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Do We Need Mandated Staffing Ratios Or Staff Transparency In Aged Care?

22 July 2019

The title of this year’s Victorian Healthcare Week Great Debate was: Do We Need Mandated Staffing Ratios in Aged Care? Are we better off focusing on the quality outcomes for older Australians rather than mandated staffing ratios?

Lisa Giacomelli (Chief Operating Officer YMCA NSW) and I (Director, Aged Care Matters) received an invitation to speak on the opposing team. We were told we had been specially selected based not only on our expertise but also our ability to marry humour with intellect.

Lisa presented a strong case to show that mandating ratios does not guarantee quality.  Lisa used examples from the childcare industry, an industry that has mandated ratios.

“I have worked in the child care industry for nearly a decade. Ratios are mandated there and services are audited and checked by the regulator to ensure they are ‘in ratio’.

“When something occurs in a service when things don’t go to plan, the first question asked is always: ‘Are we in ratio?’ And I can tell you the answer is almost always ‘yes’.

“Being in ratio does not prevent poor practice, it does not prevent care standards being upheld, or staff taking their eye off what they are meant to be doing, or clients acting in a way that wasn’t anticipated, or allergic reactions to medication or accidents, nor does it prevent policies and procedures being breached.

“In fact, ratios can have the opposite effect. The need to be ‘in ratio’ (a golden term in the children’s services industry) causes all kinds of stress for coordinators and directors who spend their time finding staff and managing rosters rather than focussing on quality of care, listening to the voices of children and dynamic educational leadership. It’s hard to be inspiring when you are struggling to ‘stay in ratio’.

“Mandated ratios result in a higher reliance on agency staff which, due to the inconsistent nature of agency staff who do not understand the service or know the children, can create inconsistency of care, lack of commitment to the service and the role and undermine the safety that children feel in a familiar and consistent environment. Agency staff, whilst doing their best, just cannot have the same engagement with service and organisational culture, or with clients than long serving staff can.

“They also create a false sense of security. It is not difficult to envisage services believing that as long as we are ‘in ratio’ we are offering good quality, engaged and inspired care. Management and leadership can take their focus off what staff are doing to focus on how many staff are doing it. Leadership becomes more about rosters and less about staff development, more about regulation and less about client experience, more about ‘not getting caught out’ and less about the very people that aged care services are there to serve. This is the danger of ratios and they can be dangerous.

“If you want to mandate quality care – mandate engagement with clients, families and communities. Ensure that staff culture is positive, resilient and empowering. Train the best and brightest and pay them that way.”

Sarah began by asking the audience to raise their hands if they wanted all older people living in all aged care homes to have the best quality of life possible. As you would expect, there was a sea of raised hands.

“I am a public health researcher and aged care advocate. My research shows there are good aged care homes. However, anybody who has paid even the slightest attention to the Royal Commission on Aged Care Quality and Safety knows that not all aged care homes are good.

“In any profit-based system that relies on government subsidies, like pink batts, private colleges and aged care, there are always some shonky providers. These shonky providers thrive because of systemic and regulatory failures.

“Will the systemic problems in aged care be miraculously fixed by mandating staff ratios? The answer is indisputably ‘No’. A shonky provider will make up the numbers with the cheapest, most unqualified staff possible.

“My colleague has presented a strong case to show you that mandating staff ratios in childcare centres does not guarantee quality. To the opposition, I say: ‘Be careful what you wish for’.

“The opposition has used the same arguments that have been shouted for years. These arguments regularly appear as memes on social media. In response, the peak bodies for providers tweet their own memes. The memes and tweetsgo back and forth but nothing changes.

“It is unusual for an aged care advocate not to support mandating staff ratios. Other aged care advocates get very exasperated with me. They tell me it is simply ‘common sense’ that more staff on duty = better service. This was certainly not the case at my local café last Friday when 2 regular, experienced, competent and cute waiters were sick. They were replaced with 2 agency staff who knew nothing about how the café operated – not even how to use the coffee machine or where to find the tomato sauce. They did not improve the quality of the service. In fact, they reduced it.

“To address the systemic issues in the aged care sector, we desperately need ethical leadership. We need someone with a kind heart and open mind who can see past the vested interests. We need a Nelson Mandela, Jacinda Adhern or Greta Thunberg.

“During the past few years, the usual suspects have shouted for staff ratios. The other usual suspects have shouted for more government money. There has been a lot of noise but no leadership.

“Good leaders bring people with diverse views with them. They build consensus not division.

“So what should an aged care leader do?

“Firstly, they should listen to all key stakeholders – not just those with the loudest voice. They would also listen to staff, families, community members and, most importantly older people themselves. They would then bring all key stakeholders to the negotiating table.

“A good leader would put something achievable on the negotiating table – something that all key stakeholders may agree on. I propose we start with staff transparency.

“Yesterday, Rebekha Sharkie re-introduced her Private Members Bill that requires every aged care home to disclose and publish quarterly staff/resident ratios.

“Shonky providers will lobby against this legislation. However, good aged care homes with high numbers of well-trained staff have nothing to fear from staff transparency.

“When we have accurate staffing data we can perform the research needed to develop evidence based staffing guidelines.

“Rather than Staff Ratios that cause division, Staff Transparency is a much better place to start.”

 

Improving Transparency In The Aged Care Sector Will Benefit Everyone

10 July 2019

Last week, I was invited to comment on the requirement in the new Aged Care Quality Standards for open disclosure. I suggested all aged care homes and home care providers should be required to report adverse incidents not only to the older person and their family but also on their websites.

I am pleased both Ian Yates (CEO, COTA) and Darren Mathewson (Acting CEO of ACSA) have contested this idea for improving transparency. I always welcome debate. A public debate about transparency in the aged care sector is long overdue.

My research on residential aged care and in-home care indicates the public want more transparency in the aged care sector. Although many people, myself included, believe the care of frail older people istoo important to be left to the whims of the free market, both COTA and ACSA promote lighter regulation and a consumer driven and market based system, as outlined in the Aged Care Roadmap.

In a free market, so-called “aged care consumers” require access to information to inform their choice of product. For example, to make an informed decision when choosing an aged care home, “aged care consumers” require information about its standards of care. However, aged care homes are not even required to disclose their rosters/staffing levels. How can people make informed decisions about an aged care home’s standards of care when they do not have access to this vital piece of information?

In addition to staffing levels, I have tried unsuccessfully to get data on adverse incidents in aged care homes such as the incidence of pressure injuries, dehydration, malnutrition, medication errors and falls. This information is needed not only to help people make informed decisions when choosing an aged care home but also for an evidence-based discussion about standards of care.

The most common reason providers give for not sharing clinical indicators with the public are: (1) Privacy and (2) Commercial-in-confidence. It is not surprising, therefore, that Ian Yates opposes my suggestion for all adverse incidents to be reported on a providers’ website because it “would raise privacy and other issues”.

In my view, claims about breaching privacy are a red herring. I will use 2 examples to illustrate this.

Example 1

When my mother had a fall in an aged care home that contributed to her premature death, the manager informed me and apologised (i.e. open disclosure). I am not suggesting the provider should post on the company’s website “Joan Russell had a preventable fall that contributed to her premature death”. Of course that would be a breach of my mother’s privacy.

I am instead suggesting the company be required to publish information about the adverse event. This would include information such as: a fall occurred in the lounge room, the date of the fall and how/why it occurred. The web site should also contain information about what the aged care home has done to prevent a similar adverse event occurring to other residents.

Example 2

A 94-year-old woman was resuscitated in an aged care home despite having an advanced care plan stipulating ‘Do Not Resuscitate’. The aged care home did not practice open disclosure. The daughter had to fight to find out why/how/who resuscitated her mother.

In my view, the aged care home should be required to share information about this adverse event with the public without breaching the resident’s privacy. The public need to know the policies and procedures have been introduced to ensure other residents are not resuscitated against their wishes.

Several years ago, I asked Ken Wyatt to improve transparency in the aged care sector. I suggested public access to all reports produced by the Australian Aged Care Quality Agency by linking them to the ‘My Aged Care’ website.

Ken Wyatt took my suggestion to the Aged Care Sector Committee. The minutes of the meeting (obtained under Freedom of Information) show that Ian Yates opposed this suggestion for increased transparency. The committee decided the information in these reports was “too technical” for the public to understand. In my view, this was patronizing.

In the 1980s, I was part of a group of registered nurses in an intensive care unit who advocated for open disclosure policies. These open disclosure policies are now legislated in all public health services. I would like to see similar legislation in the aged care sector. I also welcome public discussion about this idea.

 

Older People At Risk Of Being Financially Abused – By Their Children

14 June 2019

The United Nations (UN) has designated today (15 June) as World Elder Abuse Awareness Day. The types of abuse to be aware of include financial, physical, sexual, social, psychological and emotional abuse. Financial abuse appears to be the most common.

While some older people are enjoying their wealth – travelling the world, their luggage broadcasting that they are spending their children’s inheritance  – others live in aged care homes, with their children keeping their eyes peeled on the ‘Bank of Mum and Dad’.

As economic conditions worsen, this second group is at greater risk than ever of being financially abused. Financial abuse involves taking or misusing an older person’s money, property or assets. It also includes persuading an older person to change their will through deception or undue influence.

Research has identified adult children, particularly sons, as the most common perpetrators of financial abuse. The victims are often women over the age of 80. Like other crimes perpetrated mostly on women – domestic violence and sexual assault – financial abuse is often a silent crime, unreported and unacknowledged. As a result, there is little reliable data on its extent.

The most vulnerable include older women with diminished capacity due to dementia and depression. According to the Office of the Public Advocate, older women are more likely to be declared legally incapable than older men. This may be due to the fact that women live longer than men. It may also suggest that older men are revered whilst older women are infantilised. This was certainly the case in Julie’s family.

Julie is a middle-aged woman with four older brothers who were all educated at elite private schools and have had successful careers. With unseemly haste, a few days after her father’s death, a GP was asked to declare Julie’s elderly mother legally incapable. That she was bewildered, grieving and in the first weeks of widowhood after 64 years of marriage was not taken into account.

After Julie’s mother was declared legally incapable, the youngest son, Tony*, became her financial power of attorney. Without any guidelines to help him manage his mother’s money in an ethical manner, Tony recommended his mother gift some of her money to her children. This gift would help his siblings with mortgages and other debts. “Mum doesn’t need this money and it’s going to be ours soon anyway”.

Julie was horrified. Should middle-aged men who all have professional jobs with decent salaries rely on inherited money to help them with loans they chose to take out to support their lifestyles? Julie told her brothers they had ‘early inheritance syndrome’.

Adele Horin coined the phrase ‘early inheritance syndrome’ to describe children with a sense of entitlement to their parents’ assets. These impatient children are not prepared to wait until their parents die. Children with ‘early inheritance syndrome’ often make ageist and sexist assumptions that devalue the rights of their elderly parents.

Tony assumed his mother, who had not been the family’s breadwinner, would find discussions about financial issues complex and stressful. He arranged family meetings to discuss ‘the family estate’ without his mother present. This was not only patronising it also disempowered his mother.

Julie’s eldest brother told his siblings he was planning his retirement. He unashamedly cast his eyes towards the Bank of Mum. Without blinking, he requested regular spreadsheets of his mother’s expenses so he could know his “financial position”. He assumed what was once ‘Mum and Dad’s money’ was now his money, not his mothers’ money.

There have been several legal disputes in which sons have sued their mothers over a ‘family estate’. In one case, a former pupil of a private boys school took legal action after the family estate was left to his mother rather than to him. The judge castigated him for having a “highly developed and unhealthy sense of entitlement“.

This gendered sense of entitlement is reminiscent of the Victorian era. In those days, a wife became her husband’s property, his chattel. A married woman could neither own property in her own name nor control her own money. The laws changed over a hundred years ago. Thankfully so too did attitudes towards married women. Older women may be the last bastion of Victorian traditions.

Soon after Julie’s mother’s 90th birthday party, three brothers complained that their mother’s monthly expenses were “excessive”. They wanted Julie to curtail these expenses. They also wanted to restrict their mother’s visits to her beloved beach house. Julie’s sister-in-law explained: “Your brothers are worried about their inheritance. What’s wrong with that?”

Julie defended her mother’s right to spend her own money. One brother supported her; the other three bunkered down, ensconced with others who shared their privileged views. These brothers refused to engage with Julie. They simply dismissed Julie’s views as offensive, describing her as mad and bad, as powerful men often do.

The financial abuse of older women is on a continuum of violence towards women. It should be a criminal offence. For financial abuse of older people to become a criminal offence, attitudes towards older people, particularly older women, need to change.