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Australian Aged Care Nursing:
A Critical Review of Education, Training, Recruitment and Retention in Residential and Community Settings

1. An Overview of Aged Care in Australia

1.1 - Residential and Community Aged Care
1.2 - Australia's Ageing Population
1.3 - The Aged Care Workforce
1.4 - Nursing Education and Training
1.5 - Recruitment and Retention of Qualified Nurses in Aged Care

1. An Overview of Aged Care in Australia

1.1 Residential and Community Aged Care

Approximately 20% of Australia's population over the age of seventy use aged care services. Home and Community Care services support more than half of this group, with the remainder being cared for in nursing homes (5%), hostels (3.7%) or through Community Aged Care Packages (0.2%).

Nursing care for older individuals is undertaken in a number of settings, including residential, community, acute and subacute areas. This review will report on the literature addressing both residential and community aged care. Residential aged care refers to the provision of accommodation and a range of services including appropriate staffing, meals, cleaning services, furnishings, furniture and equipment. Residential aged care can be further divided into high and low levels of care. High care relates to residents who have relatively complex care needs and are assigned on assessment to categories 1-4 on the Resident Classification Scale. The level of care required is broadly equivalent to the nursing home care provided under the previous system of residential care. A resident requiring low care is one who is assigned to classification levels 5-8 using the Resident Classification Scale. Low care required is broadly equivalent to the hostel level of care.

The Home and Community Care Program is a central element of the Federal Government's aged care policy, providing community care services to frail aged and younger people with disabilities, and their carers. The aim of the Home and Community Care program is to enhance the independence of people in these groups and avoid their premature or inappropriate admission to long term residential care. The bulk of home and community based services are provided under the auspices of the Home and Community Care program. This includes home nursing services, delivered meals, home help and home maintenance services, transport and shopping assistance, paramedical services, home and centre-based respite care, and advice and assistance of various kinds. Home and Community Care also provides brokered and co-ordinated care to some clients through community options and linkages projects.

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1.2 Australia's Ageing Population

Of the 19,157,000 people living in Australia, 9.4% are aged between 65-79, with a further 2.9% over 80 years of age. These numbers have increased substantially from 1976, where only 7.3% of the population were aged between 65 and 79 years, and 1.6% were over 80 years of age. In 2051, it is estimated that the number of persons aged between 65 and 79 years will increase from 9.4% to 16.7%, and the most dramatic increase will occur in the frail aged (the oldest old, 80 years and over) from 2.9% to 9.4%. As at 30 June 2000 (AIHW), there were 3,005 occupied aged care homes in Australia providing a total of 141,162 places. In addition, 18,149 community aged care packages were also provided. Of theses permanent residents, 62% high care residents (RCS1-4) and 38% low care residents (RCS5-8). A state and territory breakdown can be seen in Table 1.

Table 1. Residential bed and community packages in each State/Territory of Australia.

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1.3 The Aged Care Workforce

The statistics highlight the need to provide efficient and effective care for this group of the community. Economic constraints in aged care have led to the employment of a range of carers in aged care. These carers range in skill levels from registered nurses, through enrolled nurses to unlicensed personal care assistants. The 1999 labor force survey showed that the total number of registered and enrolled nurses in 1999 was 265,983, which is well below the levels of 1993 (281,455). The number of new registrations has declined by 23% between 1993 and 1999, from 68,625 to 53,103. In the same period, the total number of nurse registrations increased by only 0.1%, from 212,630 to 212,878. Of these, total nurse employment was estimated to be 221,988, which was similar to previous years. Conversely, the number of persons in nursing support occupations has increased significantly between 1991 and 1996, with 20,402 nursing assistants, and 16,706 personal care assistants.

The most recent available data (AIHW, 1996) shows that 38,272 nurses were employed in geriatrics and gerontological nursing, 8.2% less than in 1993. Of these, 34.0% were employed in public nursing homes, 39.8% in private nursing homes, 13.4% in hospitals and 3.2% in hostels. A State and Territory breakdown can be seen in Table 2.

Table 2. Number of geriatric or gerontological nurses in each State/Territory of Australia.

In a breakdown of private and public nursing homes, statistics have indicated that the number of gerontological/geriatric nurses employed in public nursing homes decreased from 18,260 in 1993 to 13,426 in 1996. Over this period, the number employed in private nursing homes fell from 17,019 to 15,251.

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1.4 Nursing Education and Training

There are various education and training options for individuals wishing to undertake a career in nursing. Registration as a nurse requires the completion of a bachelor degree in nursing. Numerous university courses are currently available in nursing, including bachelor degrees, graduate certificates, graduate diplomas, masters degrees, professional doctorates and the PhD. Specialist education in gerontology is available and varies across educational institutions around Australia.

Training to become an enrolled nurse is generally conducted within the Vocational and Educational Training (VET) Sector. Enrolled nurses typically undertake a Certificate 4 in nursing through VET and some private providers. Traineeships are available in some states, whereby trainees receive payment in return for service provision as part of the training process. VET also offers courses for Assistants in Nursing (also referred to as nursing assistants, care assistants, personal care workers, and certified nursing aides). Specialist education and training in aged care is available through both the higher education sector and VET, but it would appear that uptake for such courses is poor.

Nursing assistants generally receive on the job training but an increasing number are undertaking aged care training at the Certificate 3 level offered by the VET sector and a number of private providers.

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1.5 Recruitment and Retention of Qualified Nurses in Aged Care

Aged care has long been considered a low status area of nursing. There is ample evidence that nurses would prefer to work in acute care settings, and often find themselves working in aged care because it suits family commitments or because they are unable to gain suitable employment elsewhere (Nay, 1993; Stevens, 1995). Until relatively recently, long-term aged care was typically custodial in nature. There was a widely held view that, as 'nothing could be done' for older people and they were 'only going to die anyway', skills and knowledge were unnecessary. Kindness and a strong back were seen to be the main requirements for working in nursing homes (Peisah, 1991; Nay, 1993). This view was reflected in the staffing of non-Government nursing homes in Australia, where over 50 percent of 'nursing' staff had no nursing qualification (Rhys-Hearne, 1986).

It is now recognised that gerontological nursing is a specialised field and that custodial care is entirely inappropriate. Professional and Government standards demand high quality individualised care that maximises potential, supports self-care where possible and provides palliative care as needed. However, there is some evidence (e.g. from the Australian Nursing Federation survey, 1997), and increasing concern being expressed at aged care committee meetings (e.g. of the Royal College Nursing Australia, and of the Gerontic Society; Extended Care Society of Victoria) that the numbers of qualified nurses in aged care are decreasing at the same time as demands for care are increasing. A better understanding of the reasons for attrition from the aged care nursing workforce and what incentives would encourage qualified staff to return to the workforce is vital to meet future health care demands.

A number of studies have been undertaken to examine the reasons for aged care nursing shortages, factors associated with the decision by qualified nurses to either remain, return to, or enter aged care nursing, and strategies to decrease attrition rates and improve recruitment. These include studies undertaken by Pearson, Nay and Koch (2001) and Nay and Closs (1997), which both explored issues surrounding the recruitment and retention of aged care nurses. A number of Australian workforce studies have also been undertaken in recent years to examine nursing shortages in aged care. These studies will be reviewed in Chapter 3.

The objective of this report was to critically review the issues surrounding the education and training of nurses, and the attrition and recruitment of qualified nurses in residential and community aged care.

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