In hospitals and aged care facilities, especially nursing homes, there is a staffing crisis and this crisis is not resolved by simply increasing the nurse to patient ratios. Solutions that focus on supporting staff retention, including targeted training regimes specifically designed for geriatric care skills, are better for quality patient care. The comparison of nursing home staffing issues is addressed in the article below.

A comparison of nurse staffing at two different nursing homes:

A daughter had to find a nursing home for her father who was being discharged from the hospital after being treated for injuries caused by a fall. Her father had Alzheimer’s Disease and was getting very confused and injury prone. The hospital social worker told her that there were two nursing homes with openings in the area.

The daughter interviewed the DON (Director of Nursing) at both nursing homes to make a comparison of the staffing policies at each home. The questions were similar to both Nursing Home 1 and Nursing Home 2.

The questions and answers are as follows:

Q: Exactly who will be taking care of my father’s immediate day-to-day needs of getting in and out of bed, dressing, bathing, going to the toilet, grooming, hygiene, eating meals, hydration, medications, exercise, and therapy treatments?

Nursing home 1: We have an excellent staff of nurses who will see that he gets medications and therapies prescribed by his doctor and help him with all his activities of daily living.

Nursing home 2: He will be assigned to a certain section with a certain group of nursing staff organised into teams, and the team members will be responsible for your father’s care.

Q: Who are the nurses that will be responsible for his care?

Nursing home 1: I can’t give you the names of the actual nursing staff who will care for him. It's impossible for me to find out who is scheduled to take care of your father at any given time or day.

Nursing home 2: Here are the names and schedule of the team of nurses who are assigned to care for your father. As you can see from the care plan and schedule, there are exactly six nurses and nine PCA's (Personal Care Assistant's) who are responsible for your father's care 24 hours a day, seven days a week. You can keep a copy of the schedule and it will tell you the names of all the nurses who will be caring for your father at any given time or day.

Q: Can I see the staff schedule?

Nursing home 1: We don’t like families to see the staff schedule, and it doesn’t show who will take care of your father at any given time or day.

Nursing home 2: No problem. Other homes don't like to transparently show their staff schedule, because they just don't use good staffing and scheduling methods, like we do, that allows them to give you that kind of information.

Q: Do you have a schedule of staff who are supposed to care for my father at any given time or day?

Nursing home 1: We have a staff schedule that we prepare every two weeks, but we have to make a lot of changes for our fluctuating census and for the nursing staff who may or may not show up to work.

Nursing home 2: Unlike the other nursing homes, we only use a full-time nursing staff to care for our patients. We are then able to organise the nursing staff into high performance teams that have a carefully planned mix of personalities, education, skills/abilities, and experience.

We group the nursing staff into special team partnerships of three nurses and three nursing assistants for every eight-hour shift to care for certain patients. As you can see from the schedule I gave to you, every day there are two team members working and one team member off. Furthermore, the schedule is designed for all three team members to have the exact same schedule whereby each team member works the same amount of days (Mondays, Tuesdays, weekends, etc.) so that no team member has any better or worse schedule than their team partners.

The schedule may be adjusted now and then when there is a team member who can’t work on that scheduled day but the replacement is usually the other team member who is off. The only time we use a different replacement team member is during vacation times. Basically, however, the team partnership functions like a close nit group and team members will usually try to cover for their partners when necessary.

Another important thing that we are able to do, unlike the other nursing homes, is to design a schedule so that no team member is ever scheduled to work more than forty hours a week, or more than four consecutive days or less than two consecutive days. Every team member has at least two full weekends off and three consecutive days off every six weeks.

The schedule is designed to keep the team members from being overworked and tired which will enable them to avoid the medical errors and mistakes that are very common in most other nursing homes. We believe that our high performance teams will eliminate most medical mistakes and errors that are usually caused by the way the other nursing homes hire, organise and schedule a nursing staff.

We believe that taking care of nursing home patients is a very difficult job with a lot of responsibility, particularly for PCA's or PCW's, and that burden should not be put on one individual at any given time or day. It is the team that is responsible and accountable, and each partner will help the other one when necessary (such as in lifting, bathing, exercises, etc.).

We believe our staffing and scheduling methods are designed to provide the highest degree of quality and efficiency for the patient and will prevent the kind abuse and neglect that is caused by the chaotic nurse staffing and scheduling methods used by the other nursing homes.

Q: Why don't other nursing homes use your methods of staffing?

Nursing home 2: Mostly because the other nursing homes depend on the government regulators to tell them what to do to meet accreditation standards, and those standards make no mention of using good staffing and scheduling methods. Their standards are primarily concerned with checking paperwork and administration.

As a consequence of these bad practices, the consistency, continuity, and cohesiveness in nursing care is not important and the nursing homes are forced to ignore the problems caused by poor staffing and scheduling methods. Those problems are the nursing errors and mistakes that in turn causes abuse and neglect.

Q: How do I find out who is taking care of my father at any given time or day?

Nursing home 1: When you come to visit, you can ask the Director of Nursing.

Q: Will the Director of Nursing always know who will be taking care of my father at any given time or day?

Nursing home 1: No, because there are too many changes that must be made every day that are beyond the control of the Director of Nursing, who may not know where they or their staff may be working at any given time or day.

Q: With all these changes, how do you, or anyone else, know that my father is getting all the needed nursing care everyday?

Nursing home 1: No reply.

Q: What level or ratio of nursing care/hours will my father receive?

Nursing home 1: We adjust nursing ratios "appropriately".

Q: Is there a set amount of time or average nursing hours arrived at that my father will receive?

Nursing home 1: No. There are no minimum mandated staff resident ratios in aged care facilities. Nevertheless, we are sure he will get all his needed care.

Q: What makes you so sure?

Nursing home 1: As long as we do what the Australian Aged Care Quality Agency tell us to do about accreditation care standards, and our paperwork is up to scratch, we are in compliance with the law and that means we provide good nursing care.

Q: How will I know if my father actually received a certain amount of nursing care per day, if you don’t know exactly who will take care of him or when on any given day?

Nursing home 1: It’s not that we have no idea of who is caring for him and when on any given day, but it would take too many nursing hours to explain it in detail. We are already forced to spend many of those nursing hours figuring out how to meet accreditation standards. We just expect you to accept the fact that we are meeting accreditation standards.

Q: I like your standards better than (Nursing home 1). Can I admit my father to your nursing home?

Nursing home 2: Yes, and we hope that you spend a lot of time with the individual nursing team members assigned to care for your father.

Unlike many other nursing homes, we encourage family members to actively participate with the nursing team members who are responsible and accountable for taking care of the patients. In order to do that, we make sure that the families know exactly who is taking care of the patients.

Q: Does meeting the Australian Aged Care Quality accreditation standards mean that my father is guaranteed of being provided the best possible care according to his needs?

Nursing home 1: No, because the accreditation standards do not guarantee that your father will get a set amount of time/nursing care per day, we do not need to justify how many staff we employ at our facility. According to the Aged Care Act 1997, we have the power to "adjust" the staffing levels how we see fit. Suffice to say that we expend a lot of time and expense to meeting quality standards to assure you that we provide an "appropriate" level of nursing care.

Nursing home 2: Yes, but that is not our standard. Our standard is to organise and schedule our nursing staff to provide the best possible care and services to our patients and their families.

Nursing home providers are at a disadvantage if they do not pass the accreditation standards, and may lose funding. They may use overworked nurses and too many agency, temporary and part time care staff and nurses to fill in the hours necessary to meet these accreditation standards. Turnover and staff shortages are another result of the chaos caused by the lack of stability of the aged care sector.

The most profound result, however, is the patient abuse and neglect that is created by the chaos.

Q: Why can’t government regulators see the problems they are causing?

Nursing home 2: There is no short answer to that question. I would have to explain the history on how government regulations developed to keep pace with the growth of the nursing home industry, the funding mechanisms, and the contracts that were negotiated for the nursing staff and the nursing home providers.

Q: How does the government react and address the nursing home staffing problems that result in this abuse and neglect of the patients?

Nursing home 2: There have been many studies, research, inquiries, reports, and media attention that highlight the problems in residential aged care. The government still cannot, or will not see the real solutions to the problems. The conclusion of various studies, research, reports and inquiries confirm this.

Some reports stated that quality nursing care could not be provided in nursing homes due to their inadequate staffing. We agree with that conclusion, but we disagree as to their particular meaning of the term "inadequate staffing."

It is important to understand that inadequate staffing can also mean inadequacies in how staff are hired, organised, trained, as well as staff/resident ratios (which do not exist in Australia), to care for patients.

We also believe that it is better for patients to be taken care of by skilled and organised nursing teams. For example, you could have a facility with large numbers of staff, but still disorganised, mostly agency staff, and unskilled staff.

The basis of this article was sourced from QE Foundation, Inc. [George Ricci, President] and adapted for Australian nursing facilities