Call to action: greater investment in the registered nurse role is required to improve care outcomes for dementia patients living in residential aged care and their families

The number of people living with dementia will triple by 2050 (World Health Organization, 2012). Dementia is a complex terminal illness and international global public health priority (World Health Organization, 2012). Whilst enormous efforts focus on dementia treatments, there is an equally urgent need to address workforce issues and invest in increasing the registered nurse role and ratios in residential aged care to meet the projections. In most high-income countries residential aged care facilities have evolved over the past two to three decades from homes for the aged into slow-stream hospices, caring for our most vulnerable community members (Allen, Chapman, O’Connor, & Francis, 2008). This population has complex care needs requiring the input of a range of health professionals, such as geriatricians, general practitioners, registered nurses and care assistants (Hickman, Rolley, & Davidson, 2010; Phillips, Heneka, Hickman, Lam, & Shaw, 2014). Over this same time period the number of registered or enrolled nurses working in residential aged care facilities has fallen and those that remain have been largely relegated to managerial responsibilities. As a result the bulk of nursing care in residential aged care is now provided by a largely unskilled and unregulated workforce. Without the prerequisite dementia knowledge, skills or training, these staff are supervised by a small number of registered nurses (Hullick et al., 2016). This is in contrast to emerging evidence from long-term care and acute care setting, that nurse qualifications impact outcome. It also differs significantly from standards in countries like Germany, where a minimum RN ratio of 50% is mandatory (Aiken et al., 2010).

Residential aged care is one of the most complex health care settings, because of the multitude of resident’s needs, the high demand for care coordination and the high vulnerability of residents. Providing high quality person-centred aged-palliative nursing care is essential to improving continuity of care (Allen et al., 2008). However, attaining this vision requires a significant financial commitment, importantly public and private partnerships that focus on a preparedness to reorientate care to safeguard residents’ human rights and optimize their quality of life. Not the least being a commitment to increasing the registered nurse to resident ratios and ensuring that aged care nurses have ready access to point-of-care resources, the skills to appraise the current research and governance to implement the best evidence-based care. Residential aged care facilities that invest in providing care underpinned by best available evidence achieve better physical, behavioural and psychological symptom management outcomes for their residents (Morley et al., 2014). Yet, society and successive governments have largely resisted investing in a nursing workforce that can deliver this outcome. In an ideal world the most skilled aged-palliative care nurses would be leading interdisciplinary teams within these facilities, facilitating care transitions, managing symptoms and ensuring that residents and their families received clear and consistent information. Skilled nurses are best placed to arrive at sound clinical judgement about the complex needs of the resident that is based on both the best-available evidence and resident preferences. Whereas care assistances are more likely to provide “custodial care” (Smale, Epp, & Dupuis, 2004) as a consequence of workload demands and behavioural symptoms of residents that are not well understood and that put excessive strain on staff competences.

People living in residential aged care with dementia are highly vulnerable and can be socially isolated with no significant carer/family to act as their advocate. Without an appropriately skilled workforce these residents are at greater risk of receiving sub-optimal care. While some facilities are better at managing residents’ changing clinical status, those without around-the-clock in-house registered nursing expertise often inappropriately transfer residents to acute care for assessment and/or management of their symptoms. Any change in circumstances can exacerbate their condition and cause a great deal of confusion for the resident and his/her relatives. However, when transfers are necessary, nurses need to ensure that all relevant information is transferred as well. Not only might it include details about the care needed, but also information about advance care directives, that all too often do not reach the hospital before or with the patient. When clinically indicated, nurses are best placed to facilitate resident’s smooth transitions into and out of acute care and to ensure the communication processes are well managed and that poor communication does not compromise the resident’s quality of life.

Nurses must have the skills needed to effectively manage the complex needs of older people living with advanced dementia in order to safeguard their quality of life. Using pain as an exemplar, to assess whether pain is present, the nurse would need to (i) undertake a comprehensive pain assessment; (ii) evaluate the medical history; (iii) use appropriate communication strategies and (iv) implement appropriate pain management using evidence-based tools. Once pain has been established as the problem, the nurse will need to monitor non-pharmacological and analgesic interventions, educate the resident (wherever possible) and the family and lead the care team to ensure continuity of care. Given that pain prevalence in residential care may well exceed 50% (Takai, Yamamoto-Mitani, Okamoto, Koyama, & Honda, 2010), who would not want adequate numbers of registered nurses present?

Safeguarding the well-being, dignity and the human rights of persons in aged care facilities cannot be “deregulated”. Implementing policies to safeguard resident’s human rights is therefore an essential task for all levels of government and international communities (AGE Platform Europe, 2010). Innovation with governments and many of the private sector providers, who own residential facilities, is critical to ensuring registered nurses are a key component to improving care of patients across the sector. Industry and local communities should be investing and have a clear understanding that these aged-palliative residents with dementia have very chronic and complex needs.

Highly skilled registered nurses are essential to improve care. The registered nurse is fundamental to improving transitions of care for the patient, members of the interdisciplinary team and different care settings. This role cannot be done by just anybody, the registered nurse can met the needs and provide the care that residents deserve.