Taking care of our elders
“There’s just that feeling that this isn’t a proper life … that the quicker it’s all over, the better it is for everybody.”
The words of Merle Mitchell, an 84-year-old nursing home resident in Melbourne, seem to sum up the experiences of many older Australians living in aged care.
Merle was one of many residents who gave their personal accounts to the Royal Commission into Aged Care Quality and Safety. She observed that people went into aged care and were told, “This is your home now.”
“It’s not,” Ms Mitchell said. “It’s an institution, and it’s where you live, but it’s not a home – and no matter how many times they tell you, it’s still not your home.”
Experts and aged care workers told the royal commission that the sector’s failures were symptomatic of a society that has devalued the rights and needs of older people.
One of them was Patti Houston, a care worker in Perth, who said the prevailing attitude of Australians to aged care was: “Well, we’ll just stick them over there where we can’t see them and we won’t worry about that because it’s all a bit yucky when people get old and, you know, they’re just not themselves anymore.”
ACU’s Associate Professor Jenneke Foottit, a former aged care nurse, tends to agree. While our elders were once seen as learned, wise and worthy of respect, they’re now widely viewed as a burden: fragile, dependant, idle and senile.
“Australia used to be a nation that would take proper care of its older adults, and it used to take care of people who were disadvantaged and underprivileged,” says Associate Professor Foottit, Deputy Head of the School of Nursing, Midwifery and Paramedicine in Brisbane.
“I think there’s been a change of attitude about how we treat the vulnerable and disadvantaged, and in my view, that attitude extends its way to the aged care system and the failures we’ve seen over recent times.
“Older people, and particularly older women, are not seen as productive and are therefore not a useful part of the community anymore. It’s like they’ve passed their used-by date.”
‘Too stressful to care’
As well as her experience as a researcher and a teacher of nursing students, Associate Professor Foottit has had first-hand exposure to the sector, having worked as a registered nurse in an aged care facility in the early 2000s.
Overworked nurses and carers in aged care face multiple pressures on the job, she says, due in part to chronic understaffing.
“You have the unfortunate situation in aged care where the number of people who have to deliver the work is simply not enough to accommodate the needs of the residents,” Associate Professor Foottit says.
“You might have roughly 10 minutes to shower somebody, but that person actually needs 20 or 25 minutes. It’s the personal element that gets pushed out, because there’s not enough people and not enough time to do justice to what needs to happen, and to give these people proper care.
“You end up with nurses who are so emotionally blunted that they don’t care anymore, because it’s too stressful to care, or they burn out, give up and walk away.”
First-year nursing undergraduates returning from placements in aged care say they often struggle with the speed with which some of the work needs to happen.
“Their frustration is that they don’t get enough time to do what they need to do,” Associate Professor Foottit says, and so students feel “absolutely distressed about not being able to put into practice what we taught them.”
A litany of neglect
Dr Adam Burston has spent much of his academic career teaching and investigating ethics, including moral and ethical distress in aged care workers.
He says the neglect exposed by the royal commission was, for the most part, unsurprising.
“The types of things that came out in the report were known, and known for quite a long time, certainly by anyone working in the industry and those who conduct research, and more importantly, the recipients of the care,” says Dr Burston, a senior lecturer in nursing at ACU.
He was, however, surprised by the extent of the problem, with 40 per cent of Australians living in aged care facilities experiencing some form of elder abuse.
“It certainly is quite shocking how a culture has been allowed to develop where it’s just accepted that that’s the way it is,” he says.
“It’s an erosive thing that happens over time, where we have really poor standards of care delivered consistently across the sector, and that means there’s a culture through the industry where that’s become acceptable practice.”
One of the most positive outcomes of the royal commission, Dr Burston says, was that it gave a voice to Australians living in aged care, their families, and the nurses and carers working in those facilities.
“People have been given the opportunity to stand up and say, ‘This isn’t acceptable. This isn’t the way we should be providing care. It’s not within our moral remit,’” he says.
“And when you look at the moral distress that aged care nurses are experiencing, they feel restricted in their ability to provide the level of care they feel they should be providing.”
Underfunded and understaffed
The role of registered nurses in aged care homes has been gradually diminished since the late 1990s, when the previous requirement for an RN to be on duty at all times was scrapped.
In 2003, around a third of the aged care workforce was made up of nurses. By 2016, this had declined to 24 per cent.
At the same time, widespread cost-cutting in the sector has led under-resourcing and rationing, and many aged care homes are lacking basic equipment.
“At an industry-wide level, one of the core problems is that there’s insufficient funding to provide a service at the level it should be delivered at,” says Dr Burston, who is course coordinator of the Master of Health Administration at ACU.
“That flows onto issues around a lack of resources and understaffing, but also the over-reliance on the cheapest staff who have the least training, who are then under immense pressure to get through a huge amount of work in a limited time — and that’s where the care element is lacking.”
In this environment, many aged care nurses experience moral and ethical distress, described in the empirical literature as a situation where “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action”.
“This moral distress can have a lot of effects on the person that’s providing care, and that can manifest in a number of ways,” Dr Burston says.
“Sometimes it’ll be internalised so the person will start to withdraw, and they’ll start to feel stressed and feel that they’re not enjoying their work. They might even become burnt out in themselves, or they can externalise behaviours such as becoming rude and abusive to people they work with or the people they’re providing care for.”
That is why the focus on supporting those who provide care, as well as those who receive it, is crucial.
“It’s fundamentally important that a focus on ensuring safe and timely care relies on a workforce that feels safe and able to do that,” says aged care expert Dr Bridget Laging, a senior research fellow at ACU.
“Interventions to enhance recruitment, including addressing systemic ageism that has devalued older people and those who care for them, is an essential step.”
A cultural shift
Since 1997, there have 18 public inquiries and reviews into Australia’s aged care sector, and yet it’s still plagued by a culture of neglect and abuse.
So, is there any hope that this latest inquiry will inspire the changes required to meet the needs of older Australians? To care for them, to uphold their dignity, to ensure they’re safe, and to show them the respect they deserve?
“I’m hopeful, but at the same time, I’m sceptical as well,” Dr Burston says.
“I think the problems with aged care in this country are often seen as being too hard to solve, and I don’t think there’s the political imperative to effect the change required.
“Until our society decides that we’re going to demonstrate a heck of a lot more respect for older Australians, not too much will happen.”
Associate Professor Foottit agrees. She’s says Australia’s aged care system will only be fixed if systemic changes – including increased funding and tighter regulation – are supported by deep cultural change.
“We need real leadership on this,” she says. “We need statesman-like behaviour from somebody to say, ‘This is a problem that will need regulatory change and a substantial injection of funding, but long-term, we need a complete cultural shift on how we view older Australians’.
“The time has come for change. It’s time that Australia started treating its older adults with the respect they deserve.”
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