food for thought - nsw nurses and midwives' association · 4 | food for thought one of the...

NSW Nurses and Midwives’ Association PROFESSIONAL ISSUES | 11

Food for ThoughtNutrition & Hydration in Residential Aged CareREPORT ON THE NSWNMA 2019 AGED CARE SURVEY: PART THREE

2 | Food for Thought

In 2019 the NSW Nurses and Midwives’ Association invited members working in aged care settings to complete a survey about their experiences. Participants were invited to voluntarily provide responses. They were informed their details would remain confidential (unless prior approval was granted) and their responses used in submissions and reports. 1608 surveys were completed, and we thank those who took the time to share their personal experiences.

This report is part of a series of papers that will provide dialogue on the state of the aged care sector in NSW. The true value of safe staffing ratios in aged care cannot be underestimated in terms of the personal benefits for older Australians, and financial benefits to the economy. We believe this paper highlights the association between understaffing, underskilling, and poor personal and clinical outcomes. We also believe it provides rationale as to the cost benefit of a well-skilled and well-resourced aged care workforce.

Brett HolmesGeneral SecretaryNSW Nurses and Midwives’ Association

3

The nutritional needs of older people require specific consideration in residential aged care. Age related changes in physiology and immunity may result in a greater need for vitamin and mineral supplementation1. In addition, over 50% of all residents in residential aged care facilities (RACF) have dementia2. This makes them more susceptible to malnutrition3 and some may experience increased physical activity requiring higher nutritional intake to prevent weight loss4.

Despite the increased nutritional requirements, evidence suggests the daily average spend on food per resident, per day is as little as $6, much less than other healthcare settings5. It is therefore unsurprising to discover half of all residents in RACF may be malnourished6. A point recently substantiated in a study by the University of Melbourne. This found 68% of residents in the RACF they examined were malnourished or at risk of malnutrition. There was not enough meat and dairy provided in meals to meet even basic daily nutritional standards7.

There are nutritional guidelines for NSW hospitals8 and inpatient mental health facilities9 based on national recommended daily nutritional intake10. However, there are few benchmarks for the residential aged care sector set by the Aged Care Quality and Safety Commission (ACQSC). The current legislation governing aged care facilities is similarly lacking, requiring only the provision of adequate meals11, 12 and since 1 July 2019, the mandatory reporting on unplanned weight loss in RACF. The latter being a reactive measure rather than progressive step in the prevention of malnutrition.

In NSW, there are some locally developed nutritional guidelines that could be of value in RACF13. However, despite being referenced in the new ACQSC standards guidance14, failure to secure them in legislation means they have made little impact outside the Central Coast Local Health District where they were developed.

± half of residents in RACF may be malnourished6

The daily average spend on food per resident/day5

$6


One of the fundamental barriers to widespread implementation of best practice is the lack of recognition that RACF are healthcare providers just like public hospitals. This failure means that they are not connected into the same clinical governance that underpins public hospitals. Residents of RACF would benefit greatly from having the same evidence-based clinical standards that agencies such as the Australian Commission on Safety and Quality in Healthcare (ACSQHC) and the NSW based Agency for Clinical Innovation (ACI) require in hospitals.

Similarly, there would be enormous benefit from the sharing of knowledge on best practice initiatives, such as the International Dysphagia Diet Standardisation Initiative15, The Lantern Project16 and the Meaningful Engagement in Nutritional Understanding (MENU) initiative17. These form isolated pockets of good practice and research in relation to nutrition in RACF that if not chanced-upon by workers, remain unknown and therefore of little benefit to the majority of aged care recipients.

There is clearly a role for clinical benchmarking in RACF. However, failure to align the ACQSC to public healthcare quality benchmarking and knowledge, and failure to produce equitable standards across the public and aged care sectors is a a serious oversight by the Commonwealth Government. One that can only be attributed to ageist policy and malaise in making meaningful improvements to aged care.

This double standards approach to healthcare for older people is also driven by the sector’s insistence that RACF are a persons’ ‘home’ and any attempts to prioritise healthcare over lifestyle would inappropriately medicalise environments.

However, this mindset ignores statistical evidence which points to higher acuity among residents18. This is a dangerous tactic which has seen failures in care to a level requiring external intervention by a Royal Commission into Aged Care Quality and Safety.

Quality is increasingly determined by resident experience. Mealtimes are considered a main indicator of overall satisfaction with care and services, and significant in helping people adapt from home to residential care19.

This is recognised by the ACQSC who include mealtime satisfaction in Consumer Experience Reports (CER) to judge compliance against required standards. However, of the ACQSC surveys conducted in 2017-18, results showed 16% of care recipients only liked the food ‘some of the time’ or ‘none of the time’20. Given the significance of mealtime experience in relation to quality outcomes for residents, these results should have been a red flag for the ACQSC, resulting in immediate action to drive national benchmarking of nutritional standards in RACF.

16%+ of care recipients

only liked the food ‘some of the time’ or

‘none of the time’.

5

Food was not up to standard

because of lack of stock. Meals

were late due to a lack of staff

(breakfast served at 9:20). What's

more concerning is this facility

was already sanctioned.Registered Nurse, metro for-profit RACF

Due to short staff issues, food is

provided late and often cold.Assistant in Nrsing, rural for-profit RACF

We have to budget and had cut-backs on staffing and food, and management

don't seem to care. I have had to feed residents mash and gravy only, due to

the fact the kitchen didn't make enough food. Our large fridge broke down

and we had no milk for tea and coffee and no salads. Aged care needs big

changes and stop putting fees up when the quality and quantity is not there.

Our facility was great when I first started, we had everything and the staff

morale was high and residents were happy - now we all want out.Assistant in Nursing, rural for-profit RACF

The mealtime experience should be supported by appropriate staffing. Many residents, even if provided with meals of adequate nutritional content, require assistance to eat and drink. However 35% of members reported within the past week they had not enough time to assist someone to eat and drink, citing workload as a major contributory factor. The combined factors of poor

nutritional meal content and skeleton workforce creates an increased risk of malnutrition which, so far, has evaded both provider and regulator. It is little surprise therefore that 29% of members said they transferred someone to hospital owing to dehydration and/or malnutrition in the past year. While 30% said the provision of more nutritious meals would have reduced this number.

35% of members had not enough time to assist someone to eat and drink, because of workload

29% of members had transferred someone to hospital owing to dehydration and/or malnutrition

Skills mix was also a factor in determining whether residents received adequate nutrition and hydration. Those RACF employing only one Registered Nurse (RN) to over 150 residents were 12% more likely to lack time to assist people to eat and/or drink, compared to those operating on ratios of one RN to 50 or below residents. In addition, RACF employing RNs on ratios of one RN to 50 or less residents were also less likely to transfer a resident to hospital for dehydration and/or malnutrition.

Evidence suggests that whilst RNs have the expertise to identify and initiate strategies for effective meal management in aged care, their knowledge and expertise is not recognised21. With around 60% of respondents reporting they were operating on ratios of one RN to between

50 and 150+ residents. Even if their expertise was recognised, they would have insufficient resources or time to make an impact on resident mealtimes.

The last report by the former Aged Care Complaints Commissioner22 (now part of the ACQSC) showed the highest number of complaints were about RACF (75%). Of those, staff numbers and ratios was one of the top three reasons for complaint.

New quality aged care standards introduced from 1 July 2019 acknowledge the need for workers to be available to support people to eat and drink23. However, they should also recognise the role of the RN in mealtime management and that RNs caring for over 50 residents will struggle to provide the level of oversight required.

Residents are rushed,

residents are fed quickly and

drinks for hydration are not

being given. New staff are not

being taught correctly.Registered Nurse, rural not-for-profit RACF

Malnutrition is a cause of

avoidable hospitalisation.

Residents are often left to

feed themselves.Registered Nurse, rural not-for-profit RACF

My concern is that there may not be staff (me) in attendance to supervise

these residents with dementia, so they may tip the soup over themselves –

there may not even be cutlery on the table for them to use.

These residents need to be 'set up' safely to eat and drink.

On the shifts I work I do this supervising to monitor their ability to feed

themselves, swallow and have enough nutritional intake.Registered Nurse, metro not-for-profit RACF


7

A further factor in maintaining adequate nutrition and hydration in the elderly is good oral hygiene and dental care.

A person with painful teeth, gums or ill-fitting dentures will also face challenges in maintaining an adequate and enjoyable diet. Dental and oral hygiene is often performed during bathing in a morning and evening. However, almost half (48%) survey respondents reported within the past week someone had missed the opportunity for a bath/shower due to poor staffing levels. In view of this it is highly likely opportunities to attend to people’s dental and oral hygiene needs are frequently missed.

In NSW Central Coast the evidence-based Senior Smiles project has proven both cost efficient and beneficial to the oral health of aged care residents24 and in educating and up-skilling staff to provide oral care. However, despite sustained promotion of the initiative, it is underutilised and is a further example of isolated best practice that could easily be communicated through national clinical benchmarking.

The provision of adequate nutritional care will require significantly more investment than currently exists. The ACQSC must ensure it recognises the vital link between safe staffing and skills mix in the achievement of good nutritional outcomes when assessing compliance against quality standards in RACF. In addition, much greater investment in clinical benchmarking and sharing of good practice initiatives nationally.

The health costs of poor nutrition and hydration are far-reaching, as are the financial costs. For example, a person who is dehydrated is at greater risk of developing a Urinary Tract Infection (UTI).

The cost of treating a person in hospital for a simple UTI is $3400 and average length of stay 3.2 days25. Given the high level of poly-pharmacy and multi-morbidity within the resident cohort of RACF, it is likely this figure is much higher. Our survey showed that 65% of members had transferred a resident to hospital for treatment of a UTI in the past year. The potential financial burden on the NSW public health system could be in excess of $3.4 million in the past year alone. Given the possible negative effects of prolonged hospitalisation, in terms of risk of hospital acquired infections and even death, the personal impact for residents could be much greater.

When working short, oral care

is neglected.Assistant in Nursing, rural for-profit RACF

Certificate 3 aged care should be

compulsory credential requirement

for care staff. The current certificate

3 curriculum does not adequately

equip or skill care staff. There is a

deficit in essential knowledge of oral

care management.Registered Nurse, rural not-for-profit RACF

Residents are not able to get

the proper care i.e. oral care,

nutrition and hydration they need

due to the staffing ratio.Enrolled Nurse, metro for-profit RACF


Whilst there are many factors that could lead to UTI, particularly in catheterised residents, the increased availability of RNs was identified as a key factor in hospital avoidance in relation to UTI management. 59% of those working in RACF operating on ratios of one RN to 50 or less residents reported having transferred a resident to hospital for a UTI in the past year. This figure rose to 77% where ratios rose above one RN to 50 residents.

In addition, 74% of members felt having better staffing ratios would reduce the incidence of UTI. It would logically follow that increased staffing ratios would mean staff had more time to provide preventative care, such as assisting someone to drink, practice good infection control and assist people to the toilet in a timely way. All of which would have a significant impact on reducing incidence of UTIs and other complications of dehydration.

The findings of our survey paint a stark picture of life for aged care residents. Mealtimes should provide opportunity for social engagement and pleasure, but understaffing and underskilling leave residents malnourished, dehydrated and deprived of the opportunity to recapture what could be a pleasurable part of day to day life. The ability to meet basic nutritional needs should be common practice for providers, many of whom have a hospitality background. It appears as though the principles of good customer service are lost on the elderly, whose meals provide nothing but an opportunity to rationalise the service offered further.

Nutrition is not a luxury item, it is an essential element of basic care and a human right. Without adequate staffing, guidance and regulation we are literally leaving our elderly to starve to death in residential aged care. Leaving all of us with some food for thought.

Better staffing ratios would

mean staff being able to toilet

residents within an appropriate

time, reducing UTIs.Registered Nurse, metro for-profit RACF

Some residents who need feeding

miss out on fluids and food, as staff

are too busy to give these to them.Assistant in Nursing, metro for-profit RACF

65% of members had transferred a resident to hospital for treatment of a UTI in the past year

= $3.4 millionPotential financial burden on the NSW public health system

9

1. Wells, J. L. and Dumbrell, A. C. (2006). Nutrition and aging: assessment and treatment of compromised nutritional status in frail elderly patients. Clinical interventions in aging, 1(1), pp 67-79

2. The National Centre for Social and Economic Modelling NATSEM (2016) Economic Cost of Dementia in Australia 2016-2056

3. Meijers, J.M. et al. (2014) Malnutrition in care home residents with dementia. The Journal of Nutrition, Health and Aging, 18, pp. 595-600

4. Dementia Australia (2018) see guidance at: www.dementia.org.au/support-and-services/families-and-friends/personal-care/nutrition

5. Hugo, C. et al (2018) What does it cost to feed aged care residents in Australia? Nutrition and Dietetics, 75, pp 6-10

6. Bell, C.L, Lee, A.S. and Tamura, B.K. (2015) Malnutrition in the nursing home. Curr Opin Clin Nutr Metab Care, 18, pp. 17–23

7. Iuliano, S. et al (2017) Dairy food supplementation may reduce malnutrition risk in institutionalised elderly, British Journal of Nutrition, 117, pp. 142-147

8. NSW Agency for Clinical Innovation (2011) Nutrition standards for adult inpatients in NSW hospitals Available at: www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/160555/ACI_Adult_Nutrition_web.pdf

9. NSW Agency for Clinical Innovation (2013) Nutrition standards for consumers of inpatient mental health services in NSW Available at: www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/160555/ACI_Adult_Nutrition_web.pdf

10. National Health and Medical Research Council (2006) Nutrient Reference Values for Australia and New Zealand including Recommended Dietary Intakes. Canberra: Commonwealth Department of Health and Ageing

11. Australian Government (2018) Quality of Care Amendment (Single Quality Framework) Principles 2018. Available at: www.legislation.gov.au/Details/F2018L01412

12. Aged Care Quality and Safety Commission (2019) Results and Processes Guide. Available at: www.agedcarequality.gov.au/resources/results-and-processes-guide

13. CCLHD (2015) Best Practice Food and Nutrition Manual for Aged Care Edition 2.1. Available at: www.cclhd.health.nsw.gov.au/wpcontent/uploads/BestPracticeFoodandNutritionManualforAgedCareEdition2.1.pdf

References


14. ACQSC (2019) Guidance and Resources for Providers to meet the Aged Care Quality and Safety Standards. Available at: www.agedcarequality.gov.au/sites/default/files/media/Gudiance%20and%20Resources%20for%20Providers%20to%20support%20the%20Aged%20Care%20Quality%20Standards.pdf

15. IDDSI information can be viewed at: https://iddsi.org/

16. The Lantern project can be viewed at: https://thelanternproject.com.au/

17. Lea, E.J., Goldberg, L.R., Price, A.D., McInerney, F., Doherty, K.V.. Beattie, E. and Isenring, L. (2018) Barriers to optimising nutritional status in residents living with Dementia: rationale for development of meaningful engagement in nutritional understanding (MENU) project, 33rd International Conference of Alzheimer's Disease International, 26-29 July 2018, Chicago, USA (2018) [Conference Extract] )

18. AIHW (2019) GEN aged care data: People’s care needs in aged care. Available at: www.gen-agedcaredata.gov.au/Topics/Care-needs-in-aged-care

19. Watkins, R., Goodwin, V. A., Abbott, R. A., Hall, A., & Tarrant, M. (2017). Exploring residents' experiences of mealtimes in care homes: A qualitative interview study. BMC Geriatrics, 17(1), 141. doi:10.1186/s12877-017-0540-2

20. ACQSC (2018) AACQA Consumer Experience Report Trends. Available at: www.agedcarequality.gov.au/sites/default/files/media/AACQAConsumerExperienceReportTrends.pdf

21. Crack, J. and Crack, G. (2007) Promoting quality care for older people in meal management: whose responsibility is it? Australian Journal of Advanced Nursing, 25(1), pp. 85-89

22. Aged Care Complaints Commissioner (2018) Annual Report 2017-18. Available at: https://www.agedcarequality.gov.au/sites/default/files/media/Aged%20Care%20Complaints%20Commissioner%20%E2%80%93%20Annual%20Report%202017%E2%80%9318.pdf

23. Aged Care Quality and Safety Commission (2019) Aged Care Quality Standards 2018. Available at: www.agedcarequality.gov.au

24. Wallace, J.P. et al (2016) Senior Smiles: preliminary results for a new model of oral health care utilizing the dental hygienist in residential aged care facilities, International Journal of Dental Hygiene, 14(4), pp. 284-288

25. AIHW (2015) Hospital Performance: Kidney and urinary tract infections. Summary data from 2011-12. Available at: www.myhospitals.gov.au/our-reports/cost-of-acute-admitted-patients/april-2015/report/key-findings-average-cost-per-admission/kidney-urinary-tract-infections-without-compl

NSW Nurses and Midwives’ AssociationAustralian Nursing and Midwifery Federation NSW Branch

50 O’Dea Avenue Waterloo NSW 2017

PHONE 8595 1234 (metro)

1300 367 962 (non-metro)

www.nswnma.asn.au

NSWNMA/ANMF NSW Branch Legal Disclaimer

This publication contains information, advice and guidance to help members of the NSWNMA/ANMF NSW Branch. It is intended to use within New South Wales but readers are advised that practices may vary in each country and outside New South Wales.

The information in this booklet has been compiled from professional sources, but it’s accuracy is not guaranteed. While every effort has been made to ensure that the NSWNMA/ANMF NSW Branch provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the NSWNMA/ANMF NSW Branch shall not be liable to any person or entity with repect to any loss or damage caused or alleged to be caused

directly or indirectly by what is contained in or left out of this information and guidance.

Publised by the NSWNMA/ANMF NSW Branch, 50 O’Dea Avenue, Waterloo NSW 2017, Australia.

© 2019 NSWNMA/ANMF NSW Branch. All rights reserved. Other than as permitted by law no part of this publication may be produced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical,

photocopying, recording or otherwise, without prior permission of the Publisher. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is publised,

without the prior consent of the Publisher.

ISBN: 978-1-921326-26-4 (Australia)

Issued July 2019. Authorised by Brett Holmes, General Secretary, NSWNMA and Branch Secretary, ANMF NSW Branch, July 2019

The NSW Nurses and Midwives’ Association acknowledges the Gadigal of the Eora Nation, the traditional custodians of this land and we pay our respects to the Elders both past and present.


Food for ThoughtNutrition & Hydration

in Residential Aged CareREPORT ON THE NSW NURSES & MIDWIVES’

2019 AGED CARE SURVEY: PART THREE

ISBN: 978-1-921326-26-4 (Australia) I Issued July 2019


Food for ThoughtNutrition & Hydration

in Residential Aged CareREPORT ON THE NSW NURSES & MIDWIVES’

2019 AGED CARE SURVEY: PART THREE

food for thought - nsw nurses and midwives' association · 4 | food for thought one of the...

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