Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report

3.7 - Adequate resources

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The availability of adequate resources has been identified in the literature as an important factor in achieving successful change (NHS Centre for Reviews and Dissemination 1999; Gustafson, Sainfort et al. 2003; Walter, Nutley et al. 2003; Greenhalgh, Robert et al. 2004; Meijers, Janssen et al. 2006), and lack of resources has been identified as a potential barrier to the use of evidence in residential aged care (Black and Haralambous 2005; McConigley, Toye et al. 2008).

The issue of resource availability arose in all projects in one way or another, generally framed as not enough resources hindering implementation and sufficient resources helping implementation. Resources can be considered in terms of time, money or staffing, or a combination of all three. Staffing involves not only numbers of staff but also factors such as staff mix and rostering of staff.

Instances where lack of money was a hindrance were quite specific e.g. the money required for environmental modifications, the money to purchase particular supplies (e.g. wound care products, oral health care products). The general tone of comments made in interviews or project progress reports was that residential aged care is not well-resourced, but there were exceptions:
We never have to beg for anything and we never want for anything. (F)
When we look at (name of facility), they are extremely well resourced, and I think if they want to do something they do it and they know that they will be funded. (P)
During two of the national EBPRAC workshops, one for Round 1 and one for Round 2, exercises conducted with groups of people working in facilities (95 people in total) identified the availability of adequate resources as either the highest or second highest ranked factor influencing the implementation of evidence-based practice (see Appendix 15).

Issues arose in several projects where the money was available to pay for staff to be released from their normal duties to attend education or work in the role of a facility ‘champion’ but staff could not be found to ‘backfill’ those staff. This is one of many examples where the availability of resources is perhaps better thought of as an issue of the capacity to change, within residential aged care. As can be seen from elsewhere in this report the scale of the changes made during the EBPRAC program and the fact that changes tend to be incremental are indicative of a relatively modest capacity to change. There does not usually appear to be much spare capacity (everyone is busy doing something) but unless some thought is given to how some capacity can be ‘released’ to make the change then change is less likely. People and services from ‘outside’ facilities can play an important role here by supporting what goes on ‘inside’ the facilities and bringing fresh insight into how change can be made. However, reliance on outside services raises the issue of whether such support is sustainable.

3.7.1 Staffing

Staffing within participating facilities varied significantly, with some facilities staffed entirely by registered and enrolled nurses with others staffed by a high proportion of personal carers. This diversity not only affects the available level of knowledge and skills within facilities but also the roles and responsibilities of staff. This situation manifested itself in various ways:

• Registered nurses, the category of staff best qualified to provide leadership, being seen to be too busy to get involved as local facilitators –
  (Registered nurses) are just consumed by management issues. There’s no clinical leadership and there isn’t anybody qualified to give that clinical leadership. (P)
• Some staff being appointed to the role of local facilitators (champions) but not having sufficient skills and/or confidence to perform the role e.g. provide education using a ‘train the trainer’ model –
  We chose champions who we saw identified with person-centred care … But in hindsight they probably weren’t necessarily leaders. It was looking at confidence levels and people who were willing to step up and lead their teams as well. (F)
• Some personal carers being unsure whether what they were being asked to do as part of a project really was part of their role:
  There was a little bit of hesitancy because the staff were saying well ‘I’m only a PC’ and ‘why should I be expected to do this as part of my role and I don’t get paid any more for this’. (F)

Although outside the scope of the evaluation these findings do raise two important issues with the potential to influence the ability of the sector to implement evidence-based practice.

The first relates to the role of registered nurses. As a percentage of total full-time equivalents working in residential aged care registered nurses decreased by 21.5% between 2003 and 2007 (Figure 2). The number of registered nurses in the sector decreased at the same time as the total workforce increased (Martin and King 2008). This has occurred at the same time as the dependency of residents has, for the most part, been increasing (Gargett 2010).
Top of pageFigure 2 Composition of residential aged care workforce, 2003 and 2007

Data in the table from Martin B and King D (2008) A picture of the residential and community based aged care workforce, 2007. Published by National Institute of Labour Studies, Flinders University, Adelaide.
The information below is a description of data provided in Figure 2 above.

Percentage adding up to 100%
2003

• Registered Nurses - 22%
• Enrolled Nurses - 10%
• Personal Carers - 59
• Allied Health - 9%

2007

• Registered Nurses - 18%
• Enrolled Nurses - 9%
• Personal Carers - 68%
• Allied Health - 5%

DoHA has argued in its recent submission to the Productivity Inquiry into aged care that the reduction in registered nurses (and enrolled nurses):
‘may in part represent efficiencies being made in the sector. Models of service which ensure the effective use of nursing expertise, and enable registered nurses to provide clinical leadership and overall care management for residents rather than a focus on tasks which can be undertaken by other staff with appropriate skills are essential for an efficient system. However the need for sufficient registered and enrolled nurses (and other allied health professionals) to ensure that aged care services can deliver the necessary level and quality of care into the future cannot be understated’ (Department of Health and Ageing 2010, p 59).
This tension between the need for efficiency and the need for quality care played out in the EBPRAC program in various ways – having sufficient registered nurses to provide clinical leadership (Section 3.5.1), engagement of staff (Section 3.9.1) and using facilitators to support and lead change (Section 3.3.3).

This suggests a need to re-think the role of registered nurses in residential aged care, which does not necessarily mean an increase in the numbers of registered nurses, as this comment indicates:
Nurses do well when people are sick, and not all old people in their care need clinical care. They need a different kind of care, and I don’t think nurses should be removed completely from aged care, but I think there’s a role for them to play that’s not within the way we staff places at the moment. We need people who are trained to provide older people with quality of life. (P)
The second issue arises from the fact that 64% of the total workforce are personal carers (in 2007, the most recent year for which data is available), of whom about 65% have a Certificate III in Aged Care, generally accepted as the base qualification for the role (Martin and King 2008). The competencies for Certificate III include ‘performance of a defined range of skilled operations’ and ‘adapting and transferring skills and knowledge to new environments and providing technical advice and some leadership in resolution of specific problems’. Some distinguishing features of working at the level of a Certificate III (although such features are not meant to be used prescriptively) include application of ‘known solutions to a variety of predictable problems’ and performing ‘processes that require a range of well developed skills where some discretion and judgement is required (Australian Qualifications Framework Advisory Board 2007).

The increasing clinical care requirements for residents and the changes in practice required for evidence-based practice raise the question of the extent to which this places unreasonable demands on personal carers, as indicated by this comment from someone with considerable experience training staff in residential aged care:
We’re expecting our Cert III workers to work well beyond that. So they are not equipped and won’t be equipped with the knowledge and skills to problem solve for example, it’s not part of that Certificate III level course. They don’t know enough about clinical issues to be able to problem solve when part of the problem is that. (P)
Certificate III competencies may be about ‘known solutions to a variety of predictable problems’ which is fine for a lot of the time but behaviour management, for example, can be about working out as yet unknown solutions to unpredictable problems.

No situations have arisen in the EBPRAC program where these issues have given rise to any concerns about resident safety – the issues simply arise from a combination of thinking about the staffing structure within residential aged care and the context of what happened in the program.
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