Attracting, training, and retaining aged care workers
...to ensure quality
care, aged care services must have adequate numbers of skilled, qualified staff
committed to providing person-centred care. The workforce must have appropriate
education, training, skills and attributes to provide quality care for older
people, including people with dementia, who frequently have complex care needs.
To attract and maintain the right workforce, equitable pay conditions and
appropriate career paths will be needed.
As Australia's aged population continues to grow, demand for aged care
workers will also grow. This creates opportunities for people looking to pursue
a career in aged care, but also creates challenges for the sector in
attracting, training and retaining a sufficient workforce. Indeed these
challenges are already being faced across the sector with providers reporting
skills shortages and significant difficulties recruiting and retaining
appropriately qualified staff. In order to meet future needs it will be crucial
for the sector to adapt and adopt strategies that will ensure it is able to
attract and retain a highly skilled and well trained workforce.
This chapter examines:
the key challenges in attracting and retaining workers to the
aged care sector;
staffing ratios in residential aged care facilities; and
the adequacy of training provided by Registered Training
Key challenges in attracting and retaining workers
As discussed in Chapter 2, the aged care workforce needs to grow by
about two per cent annually in order to meet future demand. However,
evidence received by the committee indicates that the aged care sector is
already struggling to attract and retain skilled workers. This presents
significant challenges for the sector in developing its workforce now and into
Submitters argued that the key challenges in attracting and retaining
workers arise from:
poor sector reputation;
poor working conditions, including high client-staff ratios;
a lack of career paths and professional development opportunities;
low rates of remuneration.
These challenges are particularly acute for care providers in regional
and remote areas of Australia, which submitters suggested experience additional
'challenges in accessing the necessary workforce to provide services to older
Australians living in these areas'.
The particular challenges faced by regional and remote care providers are
discussed in Chapter 4.
The committee heard that the poor reputation and perceptions of the aged
care sector are major barriers to recruiting and retaining newly qualified
graduates and people looking for work in the health and community sectors.
Professor Melanie Birks from James Cook University described to the
committee the negative perceptions around aged care work:
...there is a perception that aged care nursing is less
glamorous than nursing in the acute care sector. This perception is fed by a
belief that nurses working in an aged-care setting require a lower skill set
than those working elsewhere, and often there is this perception...that nurses
who work in aged care work there because they could not get another job in
These perceptions appear to develop early, with many nursing students
indicating that they do not view aged care as an attractive career choice.
For example, the Healthy Ageing Research Group (HARG) from La Trobe
University submitted that undergraduate and graduate nurses generally prefer
not to work in aged care settings.
Some submitters attributed such preferences to a lack of exposure to aged care
practice in clinical placements and poor understanding of aged care as a
complex specialist environment.
Benetas, a not-for-profit aged care provider in Victoria, submitted that
'the reputation of the Aged Care sector needs to be repositioned'.
Aged Care Illawarra Action Group (ACIWAG) agreed, submitting that aged care
work needs to be promoted as highly skilled and rewarding, with multiple
opportunities for career advancement.
Services for Australian Rural and Remote Allied Health (SARRAH) suggested a
marketing campaign that highlights the benefits of working in aged care, would
assist to attract a workforce, particularly in regional and remote areas.
These and other submitters argued that Government has an important role
in assisting to reposition the reputation of aged care within the health and
community services industry.
ACIWAG suggested that government and industry should work together to increase
the profile of aged care by building on the work already being undertaken by
ACIWAG in a regional context:
ACIWAG has responded to the competition for workers through
the kinds of marketing collateral developed, a vibrant social media presence
and the conduct of an annual Careers Expo for the sector. This work at a
regional level could be greatly enhanced if supported by government initiatives
that reinforced its key messages.
However, submitters also noted the importance of ensuring that the
sector attracts the 'right' type of workers.
Submitters argued that people not only require the appropriate subject matter
knowledge and practical competencies to be suited to work in aged care, but
must also possess the necessary soft skills required by the work. Such
soft skills include communication, empathy, and ability to work as a member of
For example, Jewish Care Victoria submitted that some people only choose
to work in aged care because they are unable to find work elsewhere:
There is a cohort of those drawn to do a Certificate III in
aged care because they cannot find jobs in their preferred field or their
qualifications (obtained overseas) are not recognised in Australia...These
workers are often frustrated and demotivated doing roles that they deem
'beneath them' due to the poor perception of aged care work. This sometimes has
ramifications in terms of the quality of care they provide...
The committee notes the concerns raised by aged care workers and
providers about the poor reputation attached to working in the aged care
sector, and the impact this has on attracting and retaining workers in the
The committee also notes some of the innovative approaches being taken
to try to change the negative image of the aged care industry.
The committee further notes that, underlying this negative image, are
some key workforce factors outlined below, that, if addressed, would also help
to change how potential aged care workers view the industry.
The aged care sector is generally associated with poorer working
conditions than comparable areas of the health and community services sector.
The committee heard evidence from several nurses and personal care
workers who described aged care as an unhappy and stressful environment in
which to work due to:
high resident to staff ratios, resulting in high workload
low registered nurses to personal care attendant ratios;
working longer hours to cover staff shortages;
an increase in strenuous activity, and workplace injury (related
to an increase in complex care needs).
The committee received evidence that direct care workers are managing
workloads that are unsustainable, leading to compromised professional standards
and quality of care, as well as adverse impacts on workers.
Nurses working in aged care expressed particular concern about their
ability to manage workloads as well as supervise other staff. For example, the
Queensland Nurses' Union submitted that as the numbers of RNs on shift at any
one time has declined, increased workloads have been placed on remaining RNs to
supervise a greater number of carers, diminishing RNs ability to provide quality
care to patients.
The Australian Nursing and Midwifery Federation (ANMF) included in its
submission short statements from some of its members who described the workload
pressures for nurses in residential care:
I am still unable to leave my section in the morning between
6-7am as there is no staff member to supervise the section, if I ask for help
from another staff member then that staff member will be leaving their section
unattended and they also will not be able to complete their round compromising
I am unable to safely complete my clinical responsibilities
to residents. One section upstairs is not safe for only one staff member to
work there, the residents are highly confused/delirious and are at high risk
for falls. Wanderers, aggressive and physically abusive toward staff and other
residents, they are mostly needing two staff to assist with care, and there is
only one staff member to look after them all.
Mrs Sonya Peck, an RN and member of the ANMF also explained to the
committee at its Launceston hearing, the immense workload pressures and
competing priorities nurses in residential facilities face:
As registered nurses we look after up to 36 patients per
wing. From the time the nurses hit the floor they are running to have their
handover, count medications, get their pill rounds started, and do their wound
care and direct staffing care. They are just the general aspects. You also have
admissions. For example, in the last few weeks we have had seven new admissions
to one wing. It really did put a great deal of extra workload onto the
registered nurses to complete all the paperwork in a timely manner and to get
the ACFI funding assessments started. It also took time away from direct
patient care, because you only have so many hours to do that care and then you
have to move on to your paperwork...
Nurses do not take breaks. They are unpaid for their
half-hour meal breaks and very rarely do any of our nurses take it, because
they cannot get through their workloads. The cuts at the moment are also
impacting on our work. We are having to do extra pain management – to make sure
our residents are not in pain, we have added massages which the physios were
doing – and that is an extra 40 minutes plus a day that can be added into the
nurses' time...Most of the residents do not finish on time; most of the nurses
are rostered off dayshift to finish at 2.45 but you can still see the bulk of
them sitting there from 3.30 to 4 o'clock completing paperwork and patient
care. They are not paid for that time – it is not authorised overtime – but
they are not willing to walk away and leave care, even though they may be
directed to hand it over. The next shift is also extremely busy. We cannot do
all the work we are expected to do in our time frame. Sometimes you are
actually threatened with disciplinary action if you do not complete what is
expected of you on your shift. They are not giving you new strategies on how to
fit this workload in.
Workplace health and safety
The incidence of workplace injuries has increased as the needs of patients
have become more complex and workload pressures have risen. For example, the
Health Services Union (HSU) told the committee that physical injury rates, such
as back, neck and shoulder injuries, are high, but that mental health issues
are also increasing, largely due to high workload and stress related issues.
The HARG noted that residential work in particular is recognised as
being physically and emotionally demanding, which can lead to risks to employee
health and wellbeing. Such risks may include development of work-related
musculoskeletal disorders, low job satisfaction and poor health.
In its submission the Health Workers Union (HWU) noted that it has
represented members who have sustained injuries and musculoskeletal disorders from
aged care work. While manual handling aids are available to avoid such
injuries, the HWU suggested they are not being widely utilised because there
are insufficient staff to help operate the devices, causing workers to lift and
transport patients without proper supports.
The HWU also noted that it has received reports from its members that
some clients also direct verbal and physical abuse toward staff, which can also
lead to injury.
The New South Wales Nurses and Midwives' Association (NSWNMA) echoed
these concerns, submitting that:
Over 90% of 'aged care workers had been subject to some form
of aggression from residents so it is unsurprising that workers are not only
demotivated to work in aged care, but quickly seek alternative employment in
lower risk environments.
An example of the injuries and abuse workers in aged care facilities may
experience was provided by Ms Jude Clarke, a delegate of United Voice, at the
committee's hearing in Perth:
My injuries over the years – I have had broken wrists from
residents grabbing on, saying, 'No I don't want to be moved. I don't want to
shower. I'm not going to eat,' so they grab your wrists. Your wrists get pretty
tender after a while, so I have had both wrists broken quite a few times. I
have my arm pulled out of its socket and ribs taken off the front and back by
that injury. That took me two years to come back from...
...I have been stabbed with scissors. I have been stabbed with
forks. I have been pushed, punched, kicked, had hair pulled out...That is the
risk that we take every day when we are out on the floor.
Professor Yvonne Wells, Coordinator at the HARG, told the committee that
the working environment in aged care facilities, particularly the physical and
emotional demands of the work, impacts staff attrition, attraction and
retention, and provision of quality of care.
The committee is concerned at the evidence presented to it in relation
to poor working conditions and threats to workers' health and safety, which the
committee has heard are impacted by issues including insufficient staffing
levels and the need for existing staff to cover staff shortages. These issues in
turn impact on the quality of care, and contribute to the poor reputation of
The committee considers poor working conditions an urgent matter given
the impacts on the need to grow and sustain the aged care workforce and on the
ability of staff to deliver a standard of care expected by the community.
Lack of career paths
Lack of clear career paths and opportunities for professional
development were cited by various submitters as disincentives for people to
work and stay in the aged care sector.
This was felt across a broad range of skill levels, from personal care workers
through to nurses and allied health professionals.
For example, JewishCare Victoria submitted:
Career paths are not well defined or articulated for most
aged care workers and there is an inconsistent approach within the industry for
career and succession planning that feeds into a public perception of a 'dead
The Quality Aged Care Action Group Incorporated also argued that 'there
is no career pathway in aged care', and suggested that workers are not rewarded
for seeking to enhance their qualifications:
Those workers who do gain extra qualifications in palliative
care or gerontology do not get any extra pay, even if they achieve post
graduate qualifications. We want to encourage expert knowledge in aged care but
we don't reward or value it.
Doctor Linda Isherwood, Research Fellow at the National Institute of
Labour Studies commented that qualitative research and interviews of nurses and
personal care workers in aged care showed that workers 'did not feel there were
sufficient career pathways once you were in aged care' and were keen to upskill
and assume more responsibility, such as supervisory roles or more clinical
The NSWNMA agreed, submitting that many workers are passionate about
working in aged care, but 'feel stifled in their roles due to a lack of a
structured career pathway and very few nurse practitioner and/or leadership
Ms Brenda Oganyo from United Voice also told the committee that 'there is zero
progression for the personal-care workforce within the industry'.
One of the biggest challenges for aged care workers in respect of career
progression appears to be the lack of 'expert roles' which they can strive to
Mechanisms to address lack of
Queensland Health suggested that a career structure in aged care would help
to attract more workers to the sector. Queensland Health explained to the
committee the career structure that it currently has in place:
We have nurse unit managers, clinical nurse consultations and
registered nurses providing clinical support. They are also linked into
hospitals and can access the clinical services that are needed. The aged care
industry does not have that. I think those are the sorts of things that would
make the aged-care sector a bit more of an attractive service to come to.
Representatives of James Cook University agreed that a career structure
for aged care workers would make the sector more attractive for people who want
to pursue a career in nursing. Ms Jennifer Davis suggested a model which offers
a graduate entry program into aged care, and pathway opportunities into higher
qualification, such as upskilling to a nurse practitioner.
The Australian Council of Trade Unions (ACTU) were also supportive of
establishing a career structure for the sector, suggesting that pathway options
to undertake specialised training, such as in dementia or palliative care,
mentoring new entrants and graduates and developing career pathways linked to
wage progression should all be examined as options.
The Department of Health (department) has stated that consideration of
initiatives to establish career opportunities for people in the aged care
sector is a matter for service providers and the industry to manage, and
The department's view is that setting minimum standards and
having lots of rules about how people should be employed and what mix and all
those sorts of things actually creates some problems due to the diversity of
what may be required by a small community-based provider in a remote community
versus a large commercial provider in an urban centre. So there is not a
one-size-fits-all model here.
The committee notes that career paths in the aged care sector are not
clearly defined, and play a role in the inability of the sector to attract and
retain staff. While some providers rely on their own career structure
initiatives to attract workers, there is an inconsistent approach within the
industry to career planning and succession, with other providers offering
limited or no career and development opportunities.
The committee commends those providers who have established their own career
structures and continuing professional development models for their staff. The
committee agrees that such models should be explored to identify best practice
models that could be replicated nationally across the industry.
Aged care workers, both skilled and semi-skilled, are paid significantly
less than similarly qualified workers in comparative sectors. The wage
disparities between the aged and acute care sector, for example, cause many
nurses and PCAs to feel undervalued and underpaid in their roles.
Submitters highlighted the low rates of remuneration as one of the key
barriers to recruiting and retaining workers in the aged care sector.
Nurses and personal care workers
Individuals and organisations submitted that the remuneration rates for
nurses and personal care workers in aged care are:
less than wages paid in the health and disability sectors for
not reflective of the value and responsibility of the work.
Remuneration for nurses in the aged care sector is significantly lower
than for nurses working in the acute care sector. The committee received
evidence that RNs and ENs are paid about 100 dollars less per week in aged care
than acute care.
The wage disparity between the two sectors creates significant difficulties for
aged care providers to compete for nurses, and undervalues the important work
of nurses in aged care.
For example, the ANMF commented that the low remuneration levels undervalue
aged care work:
The pay for the majority of aged workers, both skilled and
semi-skilled, simply does not reflect the nature of the work and the level of
responsibility required nor does it value the importance of providing the best
care possible to Australia's frail elderly.
The NSWNMA agreed that aged care work is undervalued stating that aged
care workers are paid significantly less than people working in other sectors
that require comparatively lower skills and training:
...across all comparable types of jobs people at the checkout
get paid better than assistants in nursing; people who are supervising a small
division get paid better than an assistant in nursing with a certificate III
who is termed a team leader.
Unions and employee representatives have raised concerns that the
changing aged care sector will adversely impact on the pay and conditions of
aged care sector workers. For example, unions have noted that in the scheduled 4
yearly reviews of the Aged Care and Social, Community, Home Care and Disability
Services Industry awards by the Fair Work Commission, which are currently under
way, some employer groups have made submissions seeking to:
remove the requirement for a regular pattern of hours. In
other words, a part-time employee, if they are successful with their award
change, would only need to be given a minimum number of hours that is less than
38 but could be expected to work fluctuations on that, week-in week-out, day-in
day-out, without considering the needs of that worker and their own caring
needs or family responsibilities.
Further, Professor Sara Charlesworth of the School of Management at RMIT
University argued that the introduction of CDC is being used by employer groups
to argue for further eroding aged care workers' entitlements:
Aged Care Employers (ACE) argued in a submission to the Fair
Work Commission that ACTU claims for some improvement of conditions for casual
and part-time workers 'all run contrary to CDC in that they all reduce
flexibility, increase regulation, increase costs and put significant barriers
in the way of CDC'.
The committee has also heard about the growth in 'zero hour contracts',
which seem to be increasingly used by aged care service providers instead of
permanent, regular work contracts. United Voice, a union which represents a
range of employee groups in the aged care sector, including personal carers,
gardeners, cooks and cleaners, submitted that:
Such contractual arrangements provide workers with no
guaranteed weekly hours and thus no guaranteed weekly income. The employer is
not obliged to provide the worker with any minimum working hours, and the
worker is not obliged to accept any of the hours offered.
The committee heard that the impact of these kinds of contractual
arrangements on both employees and the quality of care available to aged care
service users can be significant. For employees, it can mean a high degree of
uncertainty about income and hours to be worked, which in turn affects the
ability to manage financial affairs and plan, placing 'particular strains on
people accessing aged care services, Professor Sara Charlesworth argued that:
Good quality care in both residential and community-case
based settings requires a stable workforce, adequate staffing and an
appropriate staff mix, as well as working conditions that allow workers the
time to develop and maintain care relationships with the elderly and
importantly to use their skills.
Allied health and medical
The committee also received evidence from allied health and medical
professionals that the aged care sector is not an attractive career choice due
to the low rates of pay.
For example, at the committee's Melbourne hearing, the Royal Australian
College of General Practitioners told the committee that general practitioners
(GPs) receive higher pay when working in a clinic compared to an aged care
facility, with estimates that 50 per cent of the work of GPs in residential
care is unfunded.
The wage disparity between clinical and residential care, means that aged care
work is often a last choice for AHPs and GPs.
Mechanisms to improve remuneration
To overcome issues regarding remuneration, submitters supported a
strategic approach whereby the Australian Government works together with
industry to develop a strategy to improve remuneration in the aged care sector. For example,
Leading Aged Services Australia (LASA), a peak body for service providers,
suggested that government should work with stakeholders to co-design a
workforce strategy that includes a focus on remuneration.
The ANMF suggested that any future remuneration measure would need to
ensure wage parity with the health and disability sector and be able to respond
A mechanism which ensures the aged care sector achieves and
maintains wage parity with the acute care sector must be developed. Such a
mechanism must respond to changes in wage rates and accommodate an effective
indexation system that provides employers with adequate funds when wage rises
are negotiated. It must also incorporate a transparent and accountable
IRT Group and the ACTU also suggested that portability of entitlements,
such as accrued leave, would encourage mobility in the industry and help to
attract people to the sector.
Submitters suggested that low remuneration is intrinsically linked to
insufficient funding, and that government needs to increase funding in order
for the sector to improve remuneration.
The committee notes the inconsistency between the pay and conditions
enjoyed by acute health care and disability workers compared to those available
in the aged care sector. The committee also notes that aged care remuneration
is often lower than less skilled jobs, or those with less responsibility, in
The committee is concerned that pay and conditions for workers in the
aged care sector are becoming more uncompetitive with other sectors. The
committee considers that the move to 'zero hour' contracts, which are intended
to provide flexibility for aged care service providers, but which have the
impact of further marginalising aged care sector workers, is making the
industry a less attractive alternative for workers.
Remuneration in the aged care sector will clearly affect the ability of
the sector to grow to meet the needs of the ageing population.
Lack of funding
Several aged care providers argued that their ability to attract and
retain workers would be enhanced if they received greater funding which would
make them more competitive.
Submitters expressed concerns that reductions in funding to the for-profit
sector, in particular, has increased competition for workers, and hindered
their ability to attract a workforce.
For example, at the committee's Bunbury hearing, Hall and Prior Health
and Aged Care Group told the committee that the loss of payroll tax funding for
for-profit providers has made it harder to compete for staff with
not-for-profit providers, such as churches and charities who can utilise tax
deductibility status for salary-sacrificing options which reduce wage costs.
Juniper also told the committee that the successive reductions in
funding across a range of programs have impacted their ability to support staff
to seek to 'improve their skills, knowledge and qualifications'.
At the committee's hearing in Broome, Mrs Raelene Siford, the Executive
Manager, Residential, at Juniper told the committee that:
The funding that is allocated to aged care is really designed
around services that operate in the metro or rural areas of Australia. It
certainly does not take into account costs associated with the remoteness of
services in the Kimberley. A number of examples of those costs are employing
staff. The cost of transferring them from a metro site to the country can be up
to $12,000 just to get them up there. That is the cost of flights, transferring
their furniture—all their goods and chattels—and you do not have that cost in
the metropolitan areas or the rural areas. But there is no recompense designed
to meet the needs of the Kimberley for anything like that in the funding
The committee acknowledges concerns that reductions in funding have
impacted the sector's ability to recruit and retain workers, and offer higher
rates of remuneration.
The committee notes that the Government committed in its 2017-18 Budget
to provide funding to assist providers in rural and regional areas, in
particular, to grow their workforce. The committee is of the view that this is
an important first step to addressing the impact previous reductions in funding
have had on the sector.
Several submitters expressed concerns that the ratio of registered nurses,
personal care attendants and clients leads to poor quality of care and
stressful working conditions. To overcome this issue, some submitters supported
the introduction of mandatory staffing ratios.
However, the committee also heard evidence from a number of submitters
who were not supportive of mandated staffing ratios, mostly because they
considered it would not resolve issues and would impose unnecessary regulatory
burden and expense on the sector.
The committee understands that mandated staff ratios in the aged care
sector are not currently government policy.
section examines the various arguments presented to the committee for and
against government regulation of mandatory minimum staffing ratios in aged care.
Mandated staffing ratios: the case for
Some submitters supported the introduction of mandatory staffing ratios
due to concerns that staff and clients are not adequately supported. In
particular, the committee heard that there are not enough nurses in some
facilities to provide appropriate medical care.
The ACTU was supportive of mandated ratios on the basis it would improve
the quality of care delivered, and reduce unsafe work practices:
We are concerned that high [patient to staff] ratios are
creating unreasonably high workloads, leading to unsafe work practices that
compromise both patient and carer safety. Consideration should be given to
requiring aged care providers to publish minimum staff/patient ratios which,
which will enable older Australians to make informed choices about their care
The ANMF suggested that mandated ratios would lead to better outcomes
for patients, and reduce health costs, as has been observed in the acute care
In the acute setting, the implementation of safe mandated
minimum staffing has been shown to prevent adverse incidents and outcome,
reduce mortality and prevent readmissions thereby cutting health care costs. It
is widely agreed that the same improvements could be achieved in the aged care
The HWU agreed, submitting that the aged care sector should have
mandated staff-to-patient ratios as is the case in comparable health and
community sectors, such as hospitals and child care centres.
The committee also received evidence from some submitters that mandated
staffing ratios would assist to retain workers who can become too stressed by
high workload pressures, and consequently choose to leave aged care for sectors
with better working conditions.
Mandated staffing ratios: the case against
The committee received evidence from several aged care providers who did
not support mandatory staffing ratios. Providers argued that ratios could
stifle innovation. Providers also suggested that mandatory ratios are
incompatible with consumer directed care which is expected to change the role
of rostering and service provision to be customer, rather than industry led.
For example, LASA, submitted that a mandatory staff ratio is a 'blunt
instrument' that does not take into account changing care needs or acknowledge
the broad-ranging skills of the workforce.
JewishCare Victoria agreed stating that it does not support mandated
staffing ratios as it considers quality 'care is achieved through adequate
training and competency...and not through additional staff'.
Alternative model: mandated minimum
An alternate approach to mandated staffing ratios is mandatory minimum
Prior to July 2014, all designated 'high care' facilities in NSW were required
to have an RN on duty at all times. Following changes to Commonwealth
legislation which resulted in the removal of that requirement, the NSW
Government agreed to maintain mandated minimum nursing requirements for
facilities formerly designated as 'high care'.
In October 2015, an inquiry into RNs in NSW nursing homes, conducted by the NSW
General Purpose Committee No. 3, recommended that the requirement for all aged
care facilities to have a RN on duty at all times be reintroduced in legislation,
and extended to all facilities with residents with high care needs.
Submitters to the NSW inquiry highlighted the success mandatory minimum
nursing requirements have had in NSW in ensuring the provision of quality care,
and improving health outcomes for patients.
Ms Jan Barham MLC, former Chair of the General Purpose Committee No. 3,
submitted to this inquiry that the mandatory nursing requirement should be
implemented across the Commonwealth.
Ms Jennifer Davis from James Cook University was supportive of
establishing a mandatory minimum nursing requirement, stating that if the
Commonwealth government does not introduce mandated ratios it should:
At least establish a minimum...It does not necessarily have to
dictate numbers, as such, but I think there needs to be an established minimum
where you can actually demonstrate that there has been someone with a critical
clinical eye who knows the clients and what their health needs are.
The NSWNMA was also supportive of the viewpoint that residential aged
care facilities should be required to have nursing staff rostered at all times.
A representative of the Health Services Union (HSU) indicated support
for an examination of ratios or some other means to ensure appropriate staffing
levels in residential aged care facilities:
There are a couple of different models, and ratios is
certainly one that I think has some merit, because we are seeing a severe lack
of staff in residential aged care, and we would certainly support a model that
would see better and safer staffing.
The committee heard that the Australian Health Ministers' Advisory
Council (AHMAC) agreed in February 2017 to ask the government to consider, in
its development of a single aged care quality framework, 'the inclusion of a
standard that requires that clinical care provided in residential aged care be
best practise and provided by a qualified clinician'.
The Australian Law Reform Commission (ALRC) in its recent report
commissioned by the Attorney General, Elder Abuse – A National Legal Response,
made the following recommendation:
Recommendation 4‑7 The Department of Health
(Cth) should commission an independent evaluation of research on optimal
staffing models and levels in aged care. The results of this evaluation should
be made public and used to assess the adequacy of staffing in residential aged
care against legislative standards.
The committee is concerned that the ratio of workers to patients in some
aged care facilities is too low and risks compromising the quality of care
The committee acknowledges concerns expressed by residential care
providers that mandatory staffing ratios may not resolve current issues and
could stifle innovation and impose greater regulatory burden and expense on the
sector. The committee also acknowledges, however, the AHMAC agreement to
consider a clinical care standard in its development of the aged care quality
framework and more particularly the ALRC recommendation to evaluate optimal
levels of care and make use of and publish the results of this analysis.
The committee considers that a compromise position may be to mandate a minimum
number of nurses working at any one time and that there should be a registered
nurse present at all times. The committee considers such an approach may be less
burdensome for employers than mandating a nurse-to-patient ratio.
The committee notes that the sector may require additional funding and
support from governments in order to meet such a mandatory minimum requirement.
The committee also considers that a mandated requirement for residential
aged care facilities to publish their staff to client ratios should be
Training personal care workers
Training for personal care workers is provided by Australia's vocational
and education training (VET) system and delivered by registered training
organisations (RTOs). Students can gain aged care specific qualifications
through VET including Certificate III in Aged Care and Certificate IV in Aged
This section examines the quality of training currently provided to personal
care workers (PCWs), areas for improvement, and the potential for greater
regulatory oversight including the establishment of a national register of
workers and setting of mandatory minimum training standards.
Quality and consistency of training
Many submitters expressed concerns that VET training programs do not
adequately equip PCWs with the necessary theoretical and practical skills and
knowledge for work in the aged care sector.
Key concerns expressed by submitters regarding the quality and
consistency of training programs included:
inconsistency of program quality across RTOs;
varying length of programs offered by RTOs with some being too
short to develop adequate skills and experience;
non-compliance with national training standards;
limited work placement opportunities in aged care offered during
lack of training on dementia and palliative care.
Consistency of training
The committee heard that the quality and consistency of training
provided by RTOs varies considerably, with courses varying in length, entry
requirements, and opportunities for on-the-job training:
In the various RTOs, courses range from four weeks to six
months full-time. There is no national consensus on what is an acceptable time
frame, and many RTOs unfortunately have little or no practical experience
embedded into that certificate in aged care.
Many submitters expressed concerns that the length of courses provided
by some RTOs are inadequate to ensure students receive the level of training in
skills and competencies required to work in the aged care sector. The NSW
Nurses and Midwives' Association also raised concerns about 'training delivered
online with no safety checks on how much they have learnt or whether they can
apply learning to practice'.
The concern in relation to aged care training delivered online was echoed by
the Western Australian Primary Health Alliance.
A 2013 report by the Australian Skills Quality Authority (ASQA), the
national regulator for Australia's VET sector, found that 70 per cent of RTOs
who offered a Certificate III in Aged Care ran the course for a period of less
than one year, despite the fact the Australian Qualifications Framework (AQF) guidelines
set a benchmark of one to two years as an appropriate course length for a
The Australian Centre for Evidence Based Aged Care (ACEBAC) at La Trobe
University submitted that there is 'a lack of standardised education' in the
aged care sector. ACEBAC further noted that despite the fact that there are
national standards for these courses, 'there can be a great deal of variance in
delivery standards between training organisations and States' resulting in
'large differences in skills and knowledge between workers'.
Many submitters highlighted concerns that some RTOs do not provide
students with the necessary skills to work in aged care, resulting in many
graduates not being job ready.
For example, Jewish Care Victoria noted:
Experience has shown that quality and job readiness of
personal care workers varies from RTO to RTO. Those RTOs with more stringent
selection criteria seem to provide workers better suited to an aged care
environment. Acceptance into a course should be made on genuine desire to work
in the industry...
The Salvation Army Australia (Aged Care Plus) also noted concerns that
'many Certificate III holders come with little or no knowledge of critical
topics like manual handling, infection control and basic understanding of what
personal care involves'.
A number of witnesses and submitters have indicated that service
providers do not hire people who have obtained their Certificate III through
We are targeting relationships with [training] providers that
we have confidence in because they provide the right levels of training, and we
are eliminating a number of providers out of our employment where we can. I
know that there has been a lot of work done around cert III training into
improving that standard, but we are still getting people applying or coming to
do work experience with us who have only just got the piece of paper, and we
are then expected to teach them.
Catholic Care in the Illawarra region in New South Wales argued that a
national standard that meets the needs of the industry is desirable, as in the
current system 'there are some RTOs that have only a nine-week program and they
may as well have just cut it off from a Weet-Bix box'.
The committee notes that a number of the concerns highlighted by
submitters were also raised in ASQA's 2012 inquiry into aged care VET courses.
Many submitters supported the implementation of ASQA's recommendations to
improve VET quality training in its 2013 report of that inquiry (see Box 1.1).
Box 3.1 – ASQA review of
aged and community care VET training courses
In 2012, ASQA initiated a
review of aged and community care VET training programs. The key findings of
the review set out in its 2013 report included:
training programs offered by RTOs are 'largely too short' and do
not include sufficient time for 'satisfactory skills development';
RTOs delivering high-quality programs face unfair competition
from RTOs offering cheaper, shorter programs;
most RTOs offering training were not compliant with the national
RTO leadership and staff had poor knowledge and understanding of
the national standards.
Representatives from ASQA told
the committee at its Melbourne hearing that there has been 'good progress' on
addressing the review's 10 recommendations, including revisions to the VET
training courses for aged care and introduction of workplace requirements.
However, ASQA remains concerned that around 25 per cent of courses offered are
'still too short for people to get properly skilled' and that no changes have
been made to minimum course length requirements.
national training standards
Under section 22 of the National Vocational Education and Training
Regulator Act 2011, it is a condition of registration for RTOs to comply
with the VET quality framework, including the national training standards. The purpose
of the standards is to ensure that training programs delivered by RTOs 'meet
the requirements of training packages or VET accredited courses'.
The ASQA's 2013 report, found that 87.7 per cent of RTOs offering aged
and community care training were not compliant with at least one of the
The committee is deeply concerned that the significant issues associated
with the provision of aged care workforce training are undermining, the
development of the aged care workforce, and will continue to do so until they
The committee is concerned by evidence that RTOs are providing
inconsistent standards of training and that many RTOs are offering programs
that are too short to ensure students gain the necessary skills and practical
training to ensure they are job ready.
The committee acknowledges that quality rather than duration of courses
is paramount, but considers that the length of some courses offered is far too
short to cover all the necessary skills and competencies required for aged care
work. The committee is particularly concerned by reports that some RTOs are
offering courses that range from as little as four weeks, which falls well
below the AQF guidelines.
The committee considers that greater regulatory oversight of RTOs in
regard to the duration, curricula, and on-the job-training for courses they
offer is urgently required. The committee is of the view that current national
training standards do not go far enough to achieve this, and more needs to be
done to ensure that RTOs are providing quality training to give students the
best possible training and work outcomes.
Changes to regulatory framework
The VET system is regulated by the Commonwealth, state and territory
governments through the Council of Australian Governments (COAG) Industry and
VET training packages are developed and approved by the Australian Industry and
As mentioned, the ASQA is responsible for registering RTOs, monitoring
compliance with national standards and investigating quality concerns.
In Victoria and Western Australia these roles are undertaken by the Victorian
Registration and Qualifications Authority and the Training Accreditation
Council Western Australia.
Submitters supported more 'nationally consistent' training standards for
RTOs, Some submitters offered suggestions on how to improve the existing
regulatory framework, including:
review of quality and accreditation processes for RTOs and
consideration of student outcome and feedback in ASQA audits of
public reporting by government on effectiveness of training
increased role for industry in ASQA auditing process (such as
development of 'companion manuals' for auditors).
Some of these same suggestions and concerns were raised during an
inquiry by the Senate Education and Employment References Committee (EEC) in
2015 (see Box 1.2).
Box 3.2 – Education and
Employment References Committee – VET inquiry
In October 2015, the EEC
reported on its inquiry into the operation, regulation and funding of private
VET providers. The EEC made 16 recommendations aimed at reforming the VET
ASQA conduct a review of RTOs to ensure they are complying with
national standards, enforce adherence to the AQF learning standards, and remove
non-compliant RTOs as VET FEE-HELP providers; and
ASQA be given the 'powers to take swift and strong action'
against RTOs 'found to be providing inadequate training to their students'.
In response to the EEC's
report, the government noted that they key concerns had already been addressed
through a range of reforms to the VET sector introduced throughout 2015,
introducing new standards for RTOs
providing a further 68 million dollars to fund ASQA
introducing the National Training Complaints Hotline and
supporting the Australian Competition and Consumer Commission's investigation
into complaints; and
measures to strengthen the VET FEE-HELP scheme.
National registration and minimum
As noted above, PCWs do not have regulated minimum training requirements
or ongoing professional development obligations, and are not subject to a
registration or licensing system. The lack of quality oversight of PCWs means
that consumers, families and employers cannot be sure that a prospective PCW is
suitable for employment or to provide care to a loved one.
To ensure greater oversight of the unregulated PCW many submitters
supported the introduction of national minimum training standards and
requirements for continuing professional development (CPD), and establishment
of a national register of PCWs.
Minimum training standards
As Australia's ageing population grows and clients' care needs become
more complex, it is expected that pressure and demand for quality training,
particularly in the areas of dementia and palliative care, will only increase.
However, quality of training is hindered by the fact there is no national minimum
standardised training requirements for aged care.
The committee heard overwhelming support for nationally consistent
For example, the ACEBAC submitted that there is a major need for
'standardisation of education requirements and clearly defined competencies'
for each level of worker in the aged care sector.
Submitters argued that standardised training, particularly of the
practical components of aged care courses, would ensure graduates have received
the same level of training and are work ready.
The ANMF recommended in its submission that minimum training standards
for PCWs 'should be linked to the Australian Qualifications Framework and
include a requirement for a recognised level of training to at least
Certificate III level'.
The Corporation of the City of Port Augusta suggested that training
standards and CPD requirements could be linked to a national register of
National register of
personal care workers
Some submitters suggested that a system of registration, similar to the
National Registration and Accreditation Scheme (NRAS) for health care workers,
would increase accountability of workers and provide an important safeguard for
consumers against abuse.
For example, the NSWNMA submitted that a registration system would
improve quality safeguards and raise standards of care.
The Aged Care Guild also argued that a national register would improve
administrative efficiencies for employers by providing easily accessible
background checks and employer reviews.
Ngaanyatjarra Health Service agreed suggesting that a review mechanism, such as
a website where employers can provide comments about an individual contractor's
performance, would assist employers to recruit adequately qualified and
Mrs Anne O'Reilly, Director of Community Services at the Corporation of
the City of Port Augusta, also suggested that a national register would capture
undesirable workers who may otherwise 'slip through' the gaps, and boost the
accountability and standing of the PCW workforce:
...there are some workers that do go from facility to facility.
You can try and do background checks. We all do our criminal history
assessments and check with referees but we all know that there are people who
can slip through the gap in that process as well. Secondly, I also think that
it may be an opportunity to give some more credence to personal care attendants
if there was some training and some continuing professional development
attached to that to try and improve the standing of personal caring carers in
the workforce community'.
St Ives Home Care agreed that a national register would improve quality
safeguards and help to ensure patients are cared for by well performing
These views were also reflected in the ALRC report, Elder Abuse – A
National Legal Response, which recommended that 'unregistered aged care
workers who provide direct care should be subject to the planned National Code
of Conduct for Health Care Workers'.
Other submitters did not support a national register of carers,
suggesting that the National Code of Conduct (NCC), and various state codes of conduct,
for unregistered health care workers is sufficient to regulate the PCW
For example, Aged and Community Services Australia argued that a
national register is not required as 'there are sufficient checks, balances and
measures in place to ensure that quality aged care is delivered'.
The NCC was approved by the Council of Australian Government (COAG)
Health Council in April 2015. The NCC does not impose minimum training standards
or CPD requirements. It is the responsibility of states and territories to
implement the NCC.
However, the Aged Care Guild (ACG), which represents private providers,
submitted that the NCC does not go far enough to ensure aged care workers are
adequately trained and 'would not meet the requirements and full intent of a
national registration process'.
The ALRC report, Elder Abuse – A National Legal Response, has
recommended the introduction of a new serious incident response scheme for aged
care, with oversight from an independent body with investigative powers, and a
national employment screening process which would be based on relevant
incidents under the new serious incident response scheme, criminal record
checks and relevant disciplinary proceedings or complaints.
The committee notes the same issues around training standards and
registration for personal care workers were examined in depth in relation to
the disability service sector during the committee's 2015 inquiry into violence,
abuse and neglect of people with a disability.
Three key recommendations were made in that report regarding national workforce
and workplace regulation of the disability service sector:
Establishment of a scheme to ensure national consistency in
disability worker training;
Establishment of a disability worker registration scheme,
including requirements for ongoing professional development; and
A national approach to State, Territory and Commonwealth service
delivery accreditation programs.
The committee is of the view that the same recommendations must apply to
the aged care sector, to ensure that consistent standards are met across both
sectors which are responsible for the direct care of vulnerable Australians.
Training nurses and health professionals
The committee heard concerns that training courses for nurses, medical
professionals and allied health practitioners do not include adequate
experience and exposure to the aged care system.
For example, Doctor Deirdre Fetherstonhaugh, Director of the ACEBAC,
told the committee at its Melbourne hearing that of the six Victorian
universities that offer an undergraduate degree in nursing, only one of those
offers a unit on aged care nursing as part of the degree.
Many submitters representing nurses, medical professionals and allied
health professionals supported the introduction of initiatives to give students
the opportunity to rotate through aged care placements during training, together
with placement opportunities for graduates.
For example, the Australian Medical Association submitted:
Offering appropriate and accredited medical training places
in aged care facilities would educate the next generation of doctors about
caring for the aged as part of routine medical practice. These places need to
be supported by appropriate incentives.
The Australian Nursing and Midwifery Accreditation Council (ANMAC), is
the independent accrediting authority responsible for developing accreditation
standards for nurses and midwives. Doctor Jo-Anne Rayner, Senior Research
Fellow at the ACEBAC, suggested to the committee that ANMAC should have a role
in ensuring that aged care becomes a core subject of the curricula for
undergraduate nursing degrees.
At the committee's Wollongong hearing, the committee received evidence
from representatives of TAFE Illawarra and IRT Group; both of which have
developed training and placement initiatives to ensure students can gain
experience in aged care.
For example, Ms Belinda Mackinnon from TAFE NSW described to the
committee TAFE Illawarra's workforce development initiatives, including the
Young@Heart Program, which is specifically targeted at encouraging young people
to undertake training in aged care, and various partnership initiatives with
universities that are aimed at building educational pathways into careers in
IRT Group also explained some of its training and development
initiatives that are provided by the IRT College (a RTO operated by IRT Group),
such as a school based apprenticeship and trainee program under which students
have to complete a minimum of 700 hours of paid employment, and a pathways
program that is in partnership with the University of Wollongong.
The committee acknowledges concerns that current training courses for
the medical profession do not offer adequate practical training in aged care.
The committee is of the view that a nationally consistent curriculum for
aged care specific courses should be considered for people who wish to
specialise in this area, and that a general overview course of aged care should
be included in all general nursing degrees to increase exposure to the sector.
The committee also considers that it is crucial that nursing students are given
greater opportunities to undertake placements in aged care.
The committee considers that ANMAC, as the national accreditation body, should
take a lead in developing and implementing such reforms.
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