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Psychogeriatric Nursing Workforce in Australia: An Endangered Species?

Like in many other western countries, Australia has been experiencing negative consequences of health care workforce shortages for some time.  Much has been written about the impact of the health care system’s incapacity to meet present and future workforce demand particularly in the context of an ageing population and an ever-increasing prevalence of chronic diseases. Baby boomers now moving towards the older population challenge an aged care sector already struggling to provide quality care to an increasingly frail population (1). Nurses form the largest group of health care professionals.  As a nurse academic with both generalist and mental health nursing backgrounds, I would like to take this privileged opportunity to draw attention to ongoing problems associated with the psychogeriatric and aged care nursing workforce supply and demand, and the links between workforce and quality in health and aged care in Australia.

Who provides care of older people with mental illness in Australia? Recent national data on mental health services and their user characteristics (2) suggest the majority of the specialist mental health service users are those younger than 55 years old. Mental health services provide care for those who are younger than 65 years old, and older people requiring mental health care are often referred to either aged care services or psychogeriatric services (or specialist mental health services for older people in some states). Unfortunately, aged care service providers are in general reluctant to provide care/service to this special needs group largely due to the lack of skilled staff and resources/environment to provide adequate care as well as stigma attached to mental illness. The Psychogeriatric Care Expert Reference Group suggests that there is also a nation-wide shortage of psychogeriatric aged care homes and high dependency units and the demands for such services are expected to rise continually. This leads to care of older people with mental illness being provided increasingly in generic settings such as residential and community aged care (1). This represents an ongoing need for an adequately trained, skilled mental health nursing workforce in all care settings, whether it be specialist mental health for older people or a generic aged care setting.

According to the Australian Institute of Health and Welfare (AIHW) Nursing and Midwifery Labour Force Survey (3), of the total number of nurses employed in Australia in 2009 (n=276,751, approximately 4:1 ratio between Registered Nurses and Enrolled Nurses/Licensed Practical Nurses), one in twenty nurses and one in ten nurses indicated their principal workplace being in mental health and aged care, respectively. There is a growing older nursing workforce (the 50–54 years age group being the greatest number of nurses of all the age groups) and a continued female domination in nursing overall (over 90% of the nursing workforce), with an exception of almost a third of the mental health nursing workforce being male. Mental health nurses are on the skills in demand lists and predominantly employed in the public sector largely in psychiatric hospitals and mental health facilities (4). Notably, the term “mental health nurse”, according to the Australian College of Mental Health Nurses (ACMHN), means a nurse with additional undergraduate/postgraduate training in mental health/psychiatric nursing. In contrast, the definition of mental health nurse in the AIHW and many other national documents is somewhat loosely defined as it is inclusive of all nurses working in the mental health field. Similarly, the definition of “aged care nurse” used in the AIHW is not based on additional trainings/qualifications, although such additional trainings are recommended by their employer/aged care industry. A subspecialty of mental health nursing that focuses on older people’s mental health is psychogeriatric nursing. Over the last several decades this subspecialty of mental health nursing has made a significant contribution to the provision of expert care to older people with a serious mental illness and dementia often accompanied by behavioural disturbances. Along with psychogeriatricians, psychogeriatric nurses have often been the last resorts for situations where all resources and strategies have been exhausted and failed to remedy. There is no credible data about the number of psychogeriatric nurses in Australia. Anecdotal evidence suggests a steady decline both in psychogeriatric nursing positions and in mental health nurses taking up a subspecialty of psychogeriatrics, while there is a gradual increase in aged care or dementia care nurses entering into the subspecialty of mental health nursing of older persons, without being called psychogeriatric nurses. This perhaps is a reflection of the current aged care service characteristics with a large proportion of clients/residents with dementia and cognitive impairment requiring not only chronic and complex care but also management of behavioural and psychological symptoms of dementia. It is also a result of significant challenges that aged care providers have been experiencing in recruiting qualified psychogeriatric nurses.

This short review of the nursing workforce data in Australia indicates that the aged care and mental health sectors share many workforce issues common to the wider nursing sector and compete with the acute and primary health care sectors for a shrinking pool of qualified nurses (5,6). It is also clear that more often than not older people requiring specialist mental health services receive care in residential aged care settings where limited resources and staffing are available for such a condition. It is also assumed that a large number of older people requiring specialist mental health care may have been receiving care in the community as part of aged care services, but little is known about characteristics of the community aged care recipients. What is notable in these contexts is that as the aged care sector employs a majority of personal carers (e.g., personal care assistants or care workers) who may or may not be vocationally trained, there are also concerns unique to that sector. They include the registered nurse (RN) staffing ratios, or skill-mix as there is a continuing decrease in the RN workforce in residential aged care. Numerous reports have been published to substantiate the current workforce crisis in aged care (5,6,11).  The following is an excerpt from my submission to the Productivity Commission’s National Inquiry into the care of older people 2011 (1). Given the characteristics of aged care recipients and the workforce that provides care it feels quite pertinent to paint a picture of the current aged care sector.

Quality of care is dependent upon various factors (policy, environment, funding and regulations). However, it is unquestionable that the skills, attitudes and knowledge of those who provide care play a significant role in ensuring quality care. Furthermore, person centred care is central to ensuring care quality, and whether or not person centred care is provided depends largely on workforce capacity. The capacity of nurses in Australia, in particular those working in residential and community aged care, to deliver high quality care is falling. A range of related factors is causing this declining capacity to give quality care. In the context of a shortage of skilled practitioners, and a poor skill mix (too few skilled staff relative to less skilled staff), nurses are obliged to spend their work time on tasks for which only they are qualified. In this task oriented aged care work environment, nurses are no longer able to provide “care” that they want to and have been taught to give (holistic and humanistic care). Instead, they have become conditioned to work as part of a production line (e.g., doing ‘pills’, documenting, dressing wounds). As a result, the culture of nursing care in the aged care sector is no longer conducive to or supportive of person centred approaches to care, which require time with care recipients and flexibility in work organisation to enable care to be more tailored to individual needs. Care plans, for example, should provide the documentary basis for person-centred care. Such plans may exist as part of compliance procedures in residential aged care facilities today, but they frequently serve only a ‘ceremonial’ compliance function instead of functioning as a dynamic reference point for all workers caring for a particular resident.

Education and training are necessary for improving knowledge and skills for quality aged care, but insufficient to change the culture of aged care and the attitudes of those nurses who have been continually unable to practice what they believe in, while working with fewer resources and receiving lower wages compared to other nursing sectors.

Whilst perceptions may be recalcitrant, in practice residential aged care has gone from a parochial service for ‘nice little old ladies’ to demandingly complex clients including those people with a mental illness, requiring sophisticated knowledge and expertise (1, 5, 9, 13). Such complex care demands require that the direct care workers undertake perennial up-skilling as care methods and workplace safety practices evolve (14, 15). Combined with the need for developments in information technology support, this demand for care and technological expertise is set to increase (13, 15, 16). Such complexity places a greater emphasis on the quality of clinical and organisational leadership capabilities, still found in short supply across the profession (7, 12).

Diminishing student nurse enrolments, an ageing workforce and qualified nurse shortages are international concerns and have been reported often with numerous recommendations (5, 6, 8, 9, 13). However, these reports have yet to translate into significantly improved work conditions. Such endemic problems diminish the sector’s appeal in staff recruitment and render retention more difficult.

Aged care staff struggle constantly with negative status perceptions that are both internalised and external (10). Pearson et al., suggest internalised perceptions may be as much to do with ageism and status consciousness within the sector itself (11). Baby boomers who are likely to hold strong views on independence and autonomy tend to rate aged care facilities poorly (6). Furthermore, studies show negative attitudes toward various aspects of aged care affect nursing students who feel aged care nursing is not valued by peers, negatively influencing their choice of employment and the morale of those working in aged care (17,18).

There is an urgent need for a nationwide and focused effort to ensure the supply of the right workforce for the right job, with clear delineation of scope of practice, appropriate workload and skill mix, and maximum utilisation of the workforce (19). Perhaps there should be a concerted effort by the governments, professional bodies and health and aged care industries to promote psychogeriatric or specialist mental health nurses for older people, and to put measures in place to protect our endangered species.

References

1. Productivity Commission 2011, Caring for Older Australians, Report No. 53, Final Inquiry Report, Canberra.
2. Australian Institute of Health and Welfare 2011. Mental health services – in brief 2011. HSE 113. Canberra: AIHW
3. Australian Institute of Health and Welfare 2011. Nursing and midwifery labour force 2009. Bulletin no. 90. Cat. no. AUS 139. Canberra: AIHW.
4. Mental Health Workforce Advisory Committee September 2008. Mental Health Workforce: Supply of Mental Health Nurses
5. Hegney D, Eley R, Plank A, Buikstra E, Parker V. Workforce issues in nursing in Queensland: 2001 and 2004. Journal of Clinical Nursing. 2006 Dec;15(12):1521-30.
6. Productivity Commission. Trends in aged care services: some implications. Canberra: Commission Research Paper 2008.
7. Pearson A, Schultz T, Conroy-Hiller T. Developing clinical leaders in Australian aged care homes. International Journal of Evidence-Based Healthcare. 2006 Mar 2006;4(1):42-5.
8. Department of Health and Ageing. Aged Care Workforce Committee. Canberra: Department of Health and Ageing 2005 March.
9. Eley R, Hegney D, Buikstra E, Fallon T, Plank A, Parker V. Aged care nursing in Queensland – the nurses’ view. Journal of Clinical Nursing. 2007 May;16(5):860-72.
10. Moyle W, Skinner J, Rowe G, Gork C. Views of job satisfaction and dissatisfaction in Australian long-term care. Journal of Clinical Nursing. 2003 Mar;12(2):168-76.
11. Pearson A, Nay R, Koch S, Ward C, Andrews C, Tucker A. Australian Aged Care Nursing: A Critical Review of Education, Training, Recruitment and Retention in Residential and Community Settings: National Review of Nursing Education, Department of Education, Science and Training 2001.
12. Marquis R, Freegard H, Hoogland L. Cultures that support caregiver retention in residential aged care. Geriaction. 2004 March;22(1):3-12.
13. Hogan WP. The Organisation of Residential Aged Care for an Ageing Population. St Leonards: The Centre for Independent Studies 2007.
14. Aged and Community Services Australia. Caring for an ageing population: Submission to the National Health and Hospitals Reform Commission. In: ACSA, editor. 2008.
15. Aged Care Association Australia. Aged care Australia: Strategic policy solutions. Curtin: Aged Care Association Australia 2007.
16. Hogan WP. Outcomes from the Aged Care Review. Australasian Journal on Ageing. 2007 September;26(3):104-8.
17. Happell B. Nursing home employment for nursing students: valuable experience or a harsh deterrent? Journal of Advanced Nursing. 2002;39(6):529-36.
18. Cheek J, Ballantyne A, Jones J, Roder-Allen G, Kitto S. Ensuring excellence: an investigation of the issues that impact on the registered nurse providing residential care to older Australians. International Journal of Nursing Studies. 2003;9:103-11.
19. Jeon Y-H, Merlyn T, Sansoni E, Glasgow N. Optimising the Residential Aged Care Workforce: Leadership & Management Study. Canberra: Australian Primary Health Care Research Institute 2008.

Yun-Hee Jeon, RN, PhD is Associate Professor at Sydney Nursing School, the University of Sydney. Dr. Jeon is a member of the nursing care node for the Primary Dementia Collaborative Research Centre and she has been on the ACMHN Research Board/Committee for the past 10 years.

Acknowledgements

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