A lack of registered nurses is the next aged care crisis, but will anyone listen?

Maree Bernoth is angry. It doesn’t appear straight away; she’s affable on the phone and the kind of interviewee you enjoy chatting to on a Friday. She’s open and likes a yarn.

I ask her if I can record our conversation and she tells me that’s fine as long as I delete any swear words she might say, and I knew then that we would get on.

Sometimes, talking to academics can be quite formal, formulaic and a bit stiff. But Maree talks from a place tarred with sadness, so you get the feeling that honesty is the only option.

She is an associate professor at Charles Sturt University School of Nursing, Midwifery and Indigenous Health, but first and foremost she is a nurse and has spent two decades trying to get people to see the mess aged cared is in, hence her anger.

She’s tried to quell the outrage and spend her time working on positive things. She sometimes feels people won’t listen if she only talks about the negative. She co-wrote a book on healthy ageing in aged care along with other positive research endeavours, but when you care about something, and you see something wrong, you have to speak out.

Like on the shortfall of nurses in aged care.

In July, the royal commission found that by 2050 Australia will need over 200,000 registered nurses working in aged care. Currently we have 22,000.

Bernoth says that since the aged care reforms of the 90s, culminating in the Aged Care Act 1997, there has been a concerted push to get rid of the registered nurse throughout the sector as well as a reframing of what aged care is.

Before 1997, when Bernoth was working as an educator in a large aged care facility, for every 60 residents there was 308 hours per week of registered nursing time.

Today, she says, it’s down to a paltry 168 hours per week, even though there are frailer, more vulnerable residents in residential aged care and more care workers with variable education and experience who need supervision.

“The registered nurses are seen to be expensive. I think there's a perception also that they're not needed. This mantra that a nursing home is the person's home is a fallacy,” says Bernoth.

“A nursing home is not the older person's home, and anyone can see that it's not a home. That mantra meant that the focus was taken off their physical needs, their health needs. It was ignorant of the fact that older people who are so frail that they need to leave their homes to go into a facility have complex needs.

“One manager said to my grandmother, ‘The only thing that will change is your address.' Well, that's ridiculous. I mean, they don't have the kitchen, they don't have the freedom, they don't have the ability to welcome anyone anytime. They don't have the familiar things around them. They can't get up whenever they want. They can't eat whenever they want, whatever they want, as much as they want. There are so many differences.”

Bernoth says the COVID-19 pandemic has shown that the lack of qualified staff in the sector is a critical issue and that government, and just as importantly the aged care industry itself, must act to remedy the problem they created.

“The government's worried about the employment rate. What a fantastic opportunity to open up some more courses for care workers, more refresher courses for registered nurses, and make working in aged care something that's attractive and something people want to do, and provide the courses to enable them to go in there,” she tells me.

“But it's not just the government. It's the industry. Industry's got to pick up, you know? Industry's depleted this system to a criminal extent. Industry's got to play a part. They've got to stop with the spin, start looking at what's gone wrong, and make genuine attempts to improve the system. That's attractive then to people coming to work there.”

Why would anyone want to work in aged care at the minute, I ask her. And she agrees. The lack of pay parity for nurses in aged care versus hospitals is a hurdle and the scrutiny the aged care industry is currently experiencing is enough to put anyone off. But it’s a good challenge, she says, and a good career path for school leavers. We just need to remind people of that fact again.

“[Nursing students] don't always see the best of aged care. Often, they're working as assistants in nursing and don't get to see the registered nurse's role. The registered nurses working in aged care need to be role models and encourage people into aged care, as well. But also, there's not a career pathway.

“There's not a transition to practise pathway for graduate students going into aged care. And then when they're in there, skilled, unless they want to go into management, there's not a clinical nurse specialist or nurse educator or that sort of role for them to move to,” she says.

Mandated staff ratios would be a good start in fixing the issue, she says, as would some government intervention, making it easier for nurses to pursue post-grad qualifications. Industry too should provide good career advancement options.

Everything Bernoth says makes total sense and she, along with a group of aged care academics and advocates, have been signing the same tune for a while now, but successive governments don’t seem to be music fans.

I don’t mean to be a cynic, I tell her, but we’ve known about these issues for a while now, so is she confident anything will change post-royal commission?

“No,” she says before I can finish my sentence.

“I've been talking about abuse and neglect in aged care since about 2006. I published my first paper about older people dying from malnutrition in about 2012. I took that to the bureaucrats in Canberra. I took it to the federal government, and nothing happened,” she says.

“I presented it at a conference to aged care providers, thinking that would make a difference. At the end of me talking about how older people are dying of malnutrition, one of the CEOs of an aged care organisation said to me, ‘What a shame you can't say something positive about aged care?’

“So, no one's listening. It's caused me a huge amount of stress…” Her voice starts to break and is now strained as she struggles to hold back tears. “To know people are dying. And no one will listen, and then this happens, COVID happens.”

There is a heavy silence on the other end of the line. I manage to break it with an awkward: ‘Are you okay Maree?’ and tell her I understand her frustration.

“It's not frustration. It's anger. And a terrible sadness,” she tells me.

I try and empathise. It can be hard to write about aged care sometimes, I say, listening to the same conversations and seeing the same outcomes, the same horror stories of neglect can, at times, feel like the very definition of insanity.

“Australia as a society has been aware of it, there's been publications about it in the press. But there's been no huge outcry. We have Black Lives Matter and certainly black lives do matter, yes, but we have a huge outcry. There's public out in the street, we have demonstrations, but when older people die, it doesn't seem to quite resonate with people as much.

"Maybe it goes along with what Mr Abbott was saying, maybe we should sacrifice some older people for the benefit of the younger people. Is that how society feels?”

And now I’m angry too, and I feel like giving up. So why would anyone keep pursing this, keep banging on the door?

“Because I worked in aged care when it was fabulous. I've worked in aged care since 1985 and I've seen the difference that skilled registered nurses in aged care can make. I've also worked in the community and it's amazing the difference you can make to people's lives, but the driving force for me is that I can't get the images out of my head of what I've seen, and then with my research, what I've heard,” she says, again, with no hesitation.

“So, to live with myself I have to ... I want to, as long as the research tells me that it's going on, I want to be an advocate for older people.”

Bernoth feels strongly. She feels strongly about aged care, and takes her job, teaching the next crop of nurses, seriously.

“It's about changing their attitudes. It's getting them to think differently about working with older people. It's about building that level of excitement and letting them know just how sophisticated it is to be a registered nurse in aged care.

"That's a privilege for me, to be able to influence them like that. It's not about talking about all the negative things that are happening. It's trying to encourage them to think about the positives and those skillsets, and if the young students want to, or if any student wants to make a difference, aged care's certainly a place to go.

“A registered nurse working in aged care has so much opportunity to use their assessment skills, really sophisticated assessment skills, and make a difference in people's lives.

"A small thing in aged care can make a huge difference to the older person's life, but you have to know what that thing is. That thing comes through assessment skills.”

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