Put ‘nursing’ back into aged care: Nursing care is essential to aged care homes beyond the COVID-19 pandemic

Early in the COVID-19 pandemic it was evident that older people were most at risk of death from the virus (Wu et al., 2020; Zhou et al., 2020). Since that time, numerous reports have highlighting the high numbers of Covid-19 related deaths of older people, with the majority of these fatalities from aged care facilities (Yoursih et al., 2020).

The tragedy that arose in aged care homes globally as an outcome of the COVID-19 pandemic has been claimed to be the result of years of neglect (Werner et al., 2020). For example, aged care homes have been described as ill-equipped to stop the spread of the virus, lacking the resources to do so, and staffed by underpaid and untrained workers (Werner et al., 2020, p. 903). Other factors related to increased vulnerability of residents, including the spread of COVID-19 are timely access to medical care, nutrition, medication practices and hygiene in the facilities (Russell, 2020). These serious claims require investigation and action.

Recognition of the problems in aged care nursing homes is not new. In most countries, including Australia, some of our most vulnerable older members of society are accommodated in aged care homes which have poor funding structures which cannot support adequate care ratios of suitably qualified staff which is compounded by insufficiently regulated institutions (Werner et al., 2020). The pandemic has brought these issues to the forefront, exposing the years of neglect and failure by the institutions and governments to ensure a safe place to live and call home whilst ageing. These aged care homes should have registered nurse-led 24 hour care with timely access to high quality multidisciplinary review for those older people who need it.

While distressing, it is not surprising that aged care homes have been so seriously affected by the virus as residents tend to be frail, often with serious co-morbid medical conditions that make them especially vulnerable to the virus, and often unable to care for themselves (Russell, 2020). In addition, aged care homes are shared facilities where people are in close proximity to each other and sharing common areas making the risk of inter-personal infection transmission even greater (Davidson & Szanton, 2020).

Of course, it is important we remember that aged care homes are not health care facilities or hospitals but rather social care homes where the goal is to provide as close to a home atmosphere as possible. Darbyshire and Dwyer (2020) argue that this is an illusion more than anything. However, this illusion of ‘home’ has meant that some important elements central to effective communal living such as infection control, have fallen off the radar. This places older people living with multiple comorbidities and complex health needs at end of life in these long term residential care settings at high risk. While infection prevention and control is well established and maintained in acute health care settings, aged care facilities are responsible for establishing their own infection control committees and processes (Russo & Shaban, 2020), with limited governance and process surrounding how well it is achieved and maintained.

Recent research reported that of 131 aged care nursing homes in Australia, only 30 (22.9%) had an infection control committee (Mitchell et al., 2019). It is not surprising then that the recently released report of the Royal Commission into Aged Care Quality and Safety in response to COVID-19 found that aged care homes were unprepared for the current COVID-19 pandemic (Aged care and COVID-19: A special report). As a result, the commission recommended that all aged-care homes should have one or more appropriately trained infection control staff. We argue, as have others recently (Russo & Shaban, 2020) that this crucial area of safety in health should be provided by registered nurses. Registered nurses bring a unique and broad range of skills and expertise to the health care environment (Davidson & Szanton, 2020), including a sound knowledge of infection control practices.

Of concern is the fact that staff in aged care homes tend to have limited training, or be untrained and unskilled. Further, these workers tend to be female, poorly paid, with access to few benefits, often not fluent in English, and employed on a casual basis (Russell, 2020). In the cases where registered nurses are employed in these facilities, they claim they are often unable to complete all tasks due to inadequate time and resources, hence cases of missed care are common (White et al., 2019). White et al. (2019), in their study of missed care in nursing homes, found that 28 percent reported they lacked sufficient time to perform required surveillance of patients, 20 percent said they failed to complete procedures and 28 percent reported they had left care plans unfinished. Residential aged care communities’ and staff would benefit from ownership around their workforce, evaluation and promotion needs to ensure cultural sensitivity and community ownership, this can lead to better acceptance and sustainability (Peake et al., 2019).

Despite the rhetoric, older people residing in care homes often have no autonomy over who comes and goes from their place of residence and are dependent on facilities to have robust practices and governance to keep them safe. In this current pandemic, we have seen vulnerable residents fall ill and lose their lives as a result of staff transmission. It is essential to engage and develop nursing as leaders in knowledge translation and developing evidence-based practice capabilities to improve outcomes for people in nursing homes, organisational efficiencies and creating satisfying work environments (Hickman et al., 2014). The residential care sector has a reliance on casual staff and so many workers work in multiple settings to make up a fulltime job equivalent, and this practice of staff working in multiple homes is associated with the spread of infection in this current pandemic.

The Covid-19 pandemic demonstrates the value and urgent need for registered nurses to be a strong presence in aged care homes where ratios are constantly reviewed to determine ongoing acuity and care needs to appropriate staffing levels so people can have their needs met (Harrington et al., 2020). Registered nurses have extensive education and exposure to extensive clinical learning experiences prior to registration, and subsequently, in many jurisdictions, have a requirement of continuing professional education which is mandated and regulated through annual registration. The knowledge and skills of registered nurses cannot be replicated by unregulated personnel. While a persuasive body of literature exists demonstrating the positive effects of registered nurses to outcomes for patients (Aitken et al., 2010), Davidson and Szanton (2020) highlight the lack of this evidence in the long term and residential care environments. As a profession, we must act to generate the knowledge required to argue for a stronger presence of nursing within residential aged care homes.