Staff to resident ratios
The concept of mandatory staff to resident ratios was one of the most contentious issues in this Inquiry. However, considerable consensus emerged on some basic concerns and issues including:
• levels of dependency and care needs have clearly risen among rest homes residents in recent years and care needs have become more complex
• different skills are required for people with different levels of need
• staffing levels must be responsive to the higher needs of care recipients, often referred to as increased acuity
• staff require the training and skills necessary to meet the needs of those they are caring for
• increasing the scope of caregivers’ practice may lead to stress
• increased managerialism in some residential settings is placing pressure on the time available for staff to interact socially with the older people they care for
• the need for adequate supervision and support for care workers, including both the regulated and unregulated workforce.
There are studies which show that the dependency levels of people living in rest homes and private hospitals in Auckland have increased considerably and that while twenty years ago 36 percent of this group were assessed as of high dependency, in 2008 56 percent of residents had high dependency . This increased level requires more time per person carrying out more complex tasks.
Not only has the volume of work increased but the tasks and skills required to complete those tasks have also become more complex and demanding. This issue plays out not just in staff to care recipient numbers but in the mix of staff and the level of skill required for caring for people at varying levels of acuity. Linked to this is the issue of scopes of practice and “scope creep” as carers are asked to do more in their daily work.
There was no unanimous support for mandated staffing ratios per se. But the positions of New Zealand Nurses Organisation (NZNO) and the Service and Food workers Union (SFWU) are unequivocal. While no-one who participated in the Inquiry disputed that the acuity threshold has increased, how that plays out in contractual obligations is highly disputed. The NZNO and SFWU are campaigning for mandatory staff–resident ratios and providers are asserting their right to determine how staff are deployed. The unions’ position is detailed in their aged care charter launched in 2011.
The charter asked for “Government to properly fund aged care services in New Zealand” and included as one of the four platforms of reform: “Compulsory safe staffing levels and skill mix so that every resident gets the care they need, when they need it. One of the biggest problems in aged care is not having the right staff with the right skills working at the right time. When the mix isn’t right it makes it much more difficult (sometimes even impossible) to care for the elderly safely and with dignity. We need clear regulations so that all aged care facilities are always safely staffed.”
There is considerable agreement on the need for appropriate staffing levels which reflect the higher needs of care recipients. The skill mix of the workforce is linked to the complexity of need. How appropriate staffing levels are determined and subsequently assured is the critical issue. Affordability impacts significantly on staffing levels too.
The Commission notes the work of the Ministry of Health Safe Staffing Unit which is currently refining the Care Capacity Demand Management tool which measures patient acuity and needs and matches staffing to those needs. The New Zealand Nurses Organisation (NZNO) advised the Commission that this model is being implemented in a number of DHBs and could be adapted for residential aged care.
Inadequate staffing levels will impact on the dignity and conditions of work for carers as well as the quality of care that is provided to older people. Given the labour intensive nature of the sector, staffing levels also have significant cost implications.
Age Concern is frequently told of situations where there are insufficient staff available to meet the needs of residents in a timely manner and that inadequate staffing levels are frequently cited in cases of institutional abuse that are referred to its Elder Abuse and Neglect Prevention Services.
The Ministry of Health advised the Commission that “staff numbers in aged residential care are based on the requirements to safely meet the needs of the consumer.” These are contained in Appendix 3.
How this works in practice was described by the manager of a large rest home, “we have a higher level of staffing than contracted. Staffing levels are reviewed on a daily basis. We have discretionary shifts, staffed by casuals. These are used to inflate or deflate staffing levels according to need. There is a minimum number of staff on the floor.”
However, participants in the Inquiry described different practices which suggested that “staffing up to meet need” may not be a robust measure and that they often worked “short.”
The manager of a rest home said, “managers have to manage staff-patient ratios. When patients come in and require a lot more time you can’t just put on another staff member because of funding levels. A number of not-for profit organisations have pulled out of the residential care sector. Our wage bill is huge.”
A common concern was the non-replacement of staff taking sick leave. A nurse said in her experience, “the replacement of staff in all the areas I have worked relate strongly to the patient numbers.” She explained that if the resident numbers "in house " are not at the recognised ceiling, then the first, call-in-sick staff member is not replaced. “The acuity of resident care and needs are not factored into this decision.” A group of migrant nurses working as carers observed that managers did not call in bureau carers or did not replace carers if someone called in sick. “Management divides up the clients among the carers”. Calling in staff was discouraged. “We are really scared of ringing in sick because of our manager. She tells us off.” Carers at a union meeting said that short staffing is rife, and is increasing. “Management are happy to run short. Two or three days a week we’re short staffed.”
The New Zealand Standard Indicators for Safe Aged Care and Dementia Care for Consumers SHNZ HB 8163:2005 are voluntary and sets a higher threshold than the Age Related Residential Care (ARRC) agreement. A member of the working group who developed the handbook for the Indicators with Standards NZ said that the workbook is a guideline rather than a prescribed standard which includes recommended hours per consumer per week. However, she told the Commission, funding constraints mean that if the guidelines became a prescription then the options for many facilities would be to cut staff or pay less. This residential facility manager said that many good recommendations were made in the Grant Thornton report but the industry and DHBs jointly needed to get on with the implementation. Mandated hours would constitute ratios of hours per staff per day and /or week.
Noeline Whitehead, a health researcher with considerable experience in the sector, said that the OPAL study showed that increased dependency levels had not been matched by an increase in minimum staffing levels. “In light of this it is difficult to understand the rationale for the reduction in the minimum registered nurse staffing requirements in residential aged care.” She says prior to 2002 and the introduction of certification, high level dependency (hospital) level facilities were staffed at a ratio of one nurse to five beds.
Therefore a 45 bed geriatric hospital would have nine full time nurses – a ratio of 1.14 hours per resident per day. Now, providers develop their own staffing levels as long as they meet the requirements of the ARRC Services Agreement. This requires one registered nurse on at all times, a minimum of 0.5 hours per resident per day in a 45 bed hospital level facility. The standards (SNZ HB 8163:2005) recommend “a registered nurse on duty at all times and a minimum of 1.14 hours per resident per day increasing to two hours per resident per day when levels of acuity amongst residents are high.”
A senior manager from a DHB said, “when the regulations changed and became guidelines a number of providers went to the minimum required.” A carer told the Commission, “facilities are staffed at the bare minimum prescribed by the DHB contract. It only takes change in the condition of one or two residents or someone to call in sick to end up “working short.” The Commission was told at a nurses union meeting about the difficulty that adherence to contractual agreements and staffing levels caused. The guidelines were said to be very complicated and “there are continual arguments about what they mean.”
A registered nurse working in the residential care sector wrote, “the staffing levels are always kept at an absolute minimum, often below the standard ratios, with increased work loads and rising dependency levels of residents. It would be nice to feel I had time in the day to complete all tasks and have some quality time with residents, but at the moment only getting the bare minimum done each day... feels like a ticking time bomb, an accident waiting to happen, a battery farm for elderly folk. Basic nursing cares are being missed, and although ultimately the RNs carry the responsibility for their practice, I think we are being set up to fail. Carers are treated even worse... they deserve more pay and much better conditions.” An enrolled nurse advocated for the “ratio of staff to residents to be allocated according to the amount of care needed not on the number of beds in the facility.”
Nurses and care workers who participated in the Inquiry reported increasing levels of acuity, involving higher dependency needs among older people, an observation borne out by research undertaken by Dr Michal Boyd from the University of Auckland and cited above. This is a complicating factor in workload issues.
A major residential care provider said, “the DHB controls and determines resident assessment acuity which in turn dictates the staffing and safety levels of facilities. The DHBs use this assessment to control cost which effectively means that people who should be categorised at hospital level get assessed at rest home level as it is a cheaper rate per day. This is a real issue for our facilities.”
Nurses and carers at an NZNO meeting told the Commission, “people who used to be looked after in hospitals are now being looked after in rest homes, and those who used to be in rest homes are now in retirement villages. Carers are doing far more than they used to. Care is far more complex and expectations are higher.” At a meeting of migrant nurses, increased workloads were related to “heavier clients” (both in terms of weight and demand) and an increase in paperwork.
Managers also referred to increased acuity levels and consequent staffing implications. One told the Commission, “it’s heavy work. Seven out of nine people needing PEG feeding are now assessed as rest home level care. Historically they would be assessed as hospital level care. Small boutique care facilities are struggling with the staffing component needed.”
Another manager agreed that staffing levels are a big issue. “Facilities need to be able to staff adequately for residents with high dependency needs. A floating pool of additional staff for that purpose would take the stress off existing staff. When we opened the facility, clients could walk down the corridor now there are people who require three or even four people to turn them. We need to fund for the right number of people and the right kind of support when people are bigger.”
A carer explained that people moved to hospital level care at a much more advanced state of need. “People stay at home or in rest homes longer so by the time they get into hospital care the level of acuity is much higher, for instance higher levels of dementia, not ambulant and people have mixed illness and conditions. When they fail (i.e. at home or in rest home care) they fail fast and hard. Also people are living longer and with increased medical interventions.”
Work intensification is not unique to the aged care sector, but the characteristics of the sector are exceptional because they involve the care of human beings. Hurrying care tasks are seen not only as compromising dignity for the client but also minimising opportunities for the additional less defined tasks of observation and interaction so critical to the role of carers as the eyes and ears of the workforce. A carer in a residential care facility said, “quality care needs quality time to be administered. Therefore patient ratios should be taken seriously”.
Grey Power Horowhenua said, “much work has been done by the nursing profession on client–staff ratios and needs to be taken cognisance of. The critical factors for optimum care of aged clients, is empathy, TIME and knowledge. (The ageing process slows our reaction times.)” The submission then pleaded, “if aged clients are to receive personalised care rather than being ‘warehoused’ it is imperative that staff client ratios are legislated for.” A care recipient living in a residential facility wrote, “the staff had too many people to look after and too short a time.”
Time to care
Both carers (nurses and support workers) and aged care recipients and their families expressed concern about insufficient time to provide adequate care. This applied both in the home care sector and in the residential care sector. The Commission heard that staff “working short” meant that critical care tasks were hurried and sometimes missed.
Staff at a residential facility made the following comments, “when there are only one or two RNs on the floor you can’t get to everybody. Observing is part of the job. Picking up subtle things and taking the extra time to sort things. Sometimes they want to tell you stories. Talking and reassuring is important and can work better than medicine. We report to the nurses ‘so and so is not herself today’ or report any changes we observe.”
A nurse observed that taking extra time to allow people to tell their story made them more settled and then they needed less medication. “The first choice is to talk. Ideally, RNs should shower people for their first three days so they could do observations etc, however, this is not possible due to their workloads.”
Other comments by carers about time constraints included:
• “You can’t sit and talk, it’s too rushed. It feels like you are processing people – like a production line.
• There are 12 residents per carer. That’s a lot. Once we have more than 46 residents we’ll get another carer. I can handle 10. You miss a lot of bits and pieces when you are rushing, you can’t fit in things like fingernails and having a chat. If someone is sick we get staff in and on the odd occasion we call an agency.
• The time restraints are a constant battle and to have more staff on duty to cope with the stress of rushing (would help) as I refuse to rush my residents through their personal cares so as I finish on time, as I do not get paid for working longer.
• Having more staff in each shift which would give the carers some time to spend with our patients and make them feel at home.”
Nurses and carers said that manual handling was particularly challenging when working short. “If two people are required to lift, and one carer phones in with a sick child and you don’t have a pool you can access then you end up below the minimum.” A carer from another rest home said, “with manual handling you cannot do it alone. Sometimes people get confused, shouting, yelling, spitting. You need a pair of workers. Every time you want to use a hoist you’d have to call someone.”
An activities assistant wrote that she was the only person in the facility in that role and that it was not possible to “provide quality care to 70 residents in the three wings by myself.”
A Grey Power member, with power of attorney for a number of people in rest homes, wrote of her concern about insufficient staff including physiotherapy time to provide rehabilitation on release from hospital. “When they get to the rest home there are not enough staff to even get the patients who may have had a stroke, for example, even take them for walks up and down the corridors a few times a day. One of the ladies I now look after could walk with the aid of a frame and a staff member in attendance when admitted to the home about three years ago. She can now not walk at all and never will. So much for rehabilitation.” She also talked about the unnecessary use of incontinence products because there was insufficient time to get to residents when they asked for assistance to go to the toilet.”
A carer, in her submission described the mix of dependency.
“I have 21 residents to oversee and attend to with one other staff member. I am team leader 4 pm shifts and 2 am shifts per week. Of the 21 residents in my area, four are independent. The rest are full assists! Their conditions range from Dementia, brain injury (accident and brain aneurisms), Huntington's, Cerebral Palsy, Spina bifida, alcohol dementia etc. The work load has tripled in the last year but the staffing levels have not changed which means stress levels are extremely high and residents are not getting the care they are paying for. I’m constantly spending time off the floor to attend to wandering residents and time spent attending to this means duties fall behind.
On my shifts alone I am responsible for:
• Medication dispensing
• Wound cares
• Meal preps and setting of tables and clearing tables/washing dishes
• Showers and shaves (personal cares)
• Laundry and rubbish collecting
• Mopping toilets and shower rooms
• 21 Resident reports/handover sheets/incident reports
• Dealing with falls and safety issues and behavioural issues plus many other issues.
As well as the above duties the demands of these residents are very high.”
However, the peak body for residential providers, (the New Zealand Aged Care Association) claims there is little research evidence to support the need for mandatory staff-resident ratios. “In relation to staff to resident ratios, these are set by a facility’s clinical manager (who is an RN) to ensure the care needs of the residents are being met. To date there have been no reports or research from HealthCert or DHBs to show a problem with current practices and procedures in how nurse managers set rosters in the aged residential care sector. We do note that the NZNO and SFWU have been advocating for the past ten years to establish mandated staffing ratios based on an argument about caregivers working too hard and poor care outcomes, but as yet have never produced any robust research to back up their claim. Many people would argue that they work too hard, and that they could do better if they were not pressed for time... In the aged care sector a claim of the work being too hard can only be justified if the required amount of care to be delivered under the contract is not delivered. To date there is no evidence from HealthCert or DHBs that there is a systemic failure to deliver the level of care they are required under contract to provide.”
Nurses said that their advice about necessary staffing levels was not always heeded. One RN said that if people talked about unsafe staffing levels they were asked, ‘what are you doing wrong?’ It was important that the advice of registered nurses and carers was accepted by managers and co-ordinators in each department. The Commission heard that staff felt unsafe in raising concerns about this issue. “You are not allowed to say you are understaffed,” a carer said.
Researcher Noeline Whitehead argues that there is a reasonable body of international research that indicates that there is a point when quality of care is likely to be compromised by care staff time. She pointed out that, “people tell me they can’t afford good staffing levels. I disagree, quality care saves on costs. When I was a facility manager, with decent staffing levels I saved on incontinence products and all sorts of things like the laundry bill because staff were doing what’s required of them. I didn’t have major issues with incontinence or pressure ulcers and there were less falls and skin tear problems. This is supported by research.”
An RN wrote to the Commission saying, “aged care must have regulated staff to resident ratios. But there needs to be flexibility in these ratios, so staff can deliver the right level of care for every resident.” She summed up the issue from a carer’s perspective. “Staff should be able to give the appropriate care to each resident each and every day. They should not feel that they need to work unpaid time to try and meet their residents’ immediate needs. They also should not be ending their shift feeling absolutely physically and mentally drained.”
Mandatory staffing ratios – the providers’ viewpoint
Chief executives of the large residential providers and senior managers including CEOs of DHBs were wary of the idea of mandatory staffing ratios. A number of participants said that mandatory staffing had been problematic in other jurisdictions and other parts of the health sector. The campaign for mandatory staffing in the early childhood sector, specifying staff to children ratios and staff skill levels, was referenced by both proponents and opponents of mandatory staffing ratios in the aged care sector.
Dwayne Crombie, chief executive of BUPA said, “I am not a fan of staffing ratios, I don’t want to lose the ability to manage.” However, he did support standard setting, “there are voluntary New Zealand standards which need to be redone to reflect rising acuity and provide reasonable workloads.” A senior manager from a DHB said, “there is a need to take the emphasis off ratios onto acuity. The learnings from Melbourne were that ratios just about broke the health services. In New Zealand we’ve had a bad experience with mandated ratios in mental health.”
The Ministry of Health said, “this method (proscribed staff ratios) has been tried in aged residential care and subsequently rejected for a variety of reasons. First and foremost, positive outcomes as experienced by residents, are arguably more important than any input measure and should be given greater priority. Further locking in a particular mode of service stifles innovation and creates barriers to possibly more effective ways of improving older people’s experiences.”
Geoff Hipkins, former chief executive of Oceania Group said, “internationally, Canada, United States, Australia, where they’ve tried to grapple with this issue of staff to resident ratio they’ve come unstuck. Health is not an industry where you can hold everything else equal. It is such a dynamic industry and you’re dealing with so many people issues. It’s very hard to be prescriptive about any sensible staff to resident rations. I just look at our funding now and, for example, dementia, we have people who are assessed as dementia sufferers and that can be anything from someone who may need some help putting milk in their coffee to a D5 who is literally borderline psycho-geriatric requiring permanent restraint, needing one on one. All that is encompassed within our dementia funding - we have this broad brush approach to funding that doesn’t really address acuity levels, dementia levels…it is a complete and utter farce to try and work in that system as the Grant Thornton report indicated.”
Simon Challies, chief executive of Rymans Healthcare said, “Australia is heavily regulated but they don’t have mandated staff ratios. The onus is on the provider to deliver not how to get there. Not having staffing indicators doesn’t make a jot of difference. Getting sanctioned or getting a bad reputation which leads to low occupancy makes a difference.”
A senior DHB manager said, “ratios are a blunt instrument. You need the right mix according to different needs. InterRAI works on a proper assessment and results in a case mix. The individual care plan should drive the care provided.”
Other rest home providers were concerned that current ratios relied on a mix of low dependency residents and high dependency residents. A manager explained that “easier, low dependency clients balance out the heavy, high dependency clients but if this balance is thrown out it’s difficult to manage. For example, it costs an additional $57 per week per client to peg feed someone. This expense cuts into the money available to pay carers.”
Senior managers from a DHB agreed with this analysis, “within rest home care there are clients with low dependency and high dependency. There is a risk that providers will skim off those with low dependency needs.”
The demands on lone registered nurses were of concern. The ARRC agreement requires a registered nurse to be onsite at all times. Nurses told the Commission that it was common practice for a retirement village to have one RN to cover a rest home and village. Technically, the nurse was not allowed to leave the rest home, but in practice if they were required to attend someone in the village they would assist.
A registered nurse working in aged residential care said, “in large facilities that include hospital rest home and villas there may be only one RN on the whole site. The RN must leave the hospital if there is a problem somewhere else on site. The whole facility is at risk in this circumstance.” Another registered nurse wrote, “I work from 15:15-23:15 myself having full responsibility for 50 hospital and rest home residents also apartments and 100 villas.” Another submitter said, “one registered nurse is meant to supervise a 30 bed hospital, a 30 bed rest home and a dementia unit as that is what the regulations allow. Not good enough.”
A registered nurse returning to the sector after some years away wrote in saying she would “cut all responsibility for village residents out of all job descriptions for Registered Nurses and carers working in care facilities... From what I’ve heard and observed this would boost morale no end.” She advocated for an RN in rest homes even if it was for a shift a day and a maximum of twenty hospital level patients per RN “with no responsibility for village and rest home residents.” (emphasis in submission). This submitter believed that “if you improve the RN’s situation a lot of the caregiver issues will resolve (provided their numbers do not get cut in between time) as they will get more input and supervision.” In response to this issue a funding manager from a DHB told the Commission, “an RN cannot leave the hospital. I don’t mind them taking a phone call; I don’t have a contract with the village.” Senior staff at a DHB noted that there are currently minimum standards for the number of RNs and that the drivers continue to trend toward the minimum standard. This was linked directly to the health outcomes of care recipients. “We can track this by noting the rate of hospitalisation.”
Researcher, Noeline Whitehead cites “a large volume of research that indicates the importance of registered nurses in providing quality care to high dependent residents”. In New Zealand and internationally she says, the “positive relationship between nurse staffing levels and the quality of nursing home care has been widely demonstrated to such a level that it is difficult to ignore the evidence.” “It’s frustrating when people say to me they can’t afford reasonable staffing I just raise my eyebrows and say, ‘you are talking to the wrong person.’”
Delegation of tasks to carers
We heard that in the case of very high resident to nurse ratios, nurses were restricted to a very limited range of tasks. For example, the Commission was told “one RN to 60 patients, all they are doing is administering medication.” Other participants, both workers and families, were concerned that in the absence of sufficient nurses, support workers were given the task of distributing medication. This was seen as a risk. “This is nurses’ domain and it is high risk to work outside scope of competence.” Concern was expressed about accountability in a situation like this. One participant stated “it seems outrageous to me that healthcare assistants are giving medication- that’s high risk. Giving someone the wrong meds could kill them.” Community support workers were noticing “scope creep” with more tasks demanded of them and on top of that, less time to do them.
A major home health provider identified the competencies required of community support workers at Level 3 include the following nurse supervised tasks.
Community support workers are in people’s homes, so any nurse supervision is invariably off site. The submission from the New Zealand Home Health Association (NZHHA), the umbrella body for home support service providers argued that staff–to client ratios should focus on levels of supervision available to care workers. They propose that the ratio of support workers (i.e. the unregulated workforce) to registered professionals be established and made mandatory.
The bottom line in aged care must be ensuring quality of care and the right of older people receiving care either in the home or in residential services to be treated with respect and dignity. For that to happen the Commission has come to the view that the voluntary standards developed by the sector (SNZ HB 8163:2005) relating to staffing should become compulsory.
The demands on carers and nurses in the aged care sector have increased as the dependency needs of care recipients have intensified. Their work has increased in complexity and in the level of skills required to safely meet the needs of the older people they care for. As a number of participants have submitted, quality care takes time. At the same time mandated staffing ratios have reduced.
Minimum levels are set by DHBs in the ARRC Agreement but the New Zealand Standards (SNZ HB 8163:2005) in relation to staff–resident ratios are voluntary. Many of the providers are reluctant to support mandatory staffing, other than levels contracted for on the basis that they want to retain the ability to determine the level and mix of staffing to meet the needs of the people they care for. The Commission believes that flexibility can be achieved on top of the minimum levels set in the standards but that a basic floor is required to protect older people, their families and the workforce. A minimum floor does not defeat the employers’ requirements for flexibility. Staffing issues in the home based sector relate to levels and access to supervision. Standards for adequate and appropriate supervision in the home based sector should also be mandatory.