Wed Aug 24

Complaints, missing persons, assaults – contracting outside workers in aged care increases problems

Written by: Nicole Sutton, Senior Lecturer in Accounting, University of Technology Sydney

Aged care homes struggling to meet staffing needs are increasingly relying on externally contracted care workers to make up shortfalls.

However, our new study ^[1], shows homes that rely more heavily on externally contracted care staff provide significantly worse quality of care.

With the government convening a national jobs and skills summit ^[2] next week, much attention is focused on addressing current staff shortages across the economy. Legislation ^[3] has just been passed to increase the numbers of workers in aged care homes, and our research indicates workers’ employment conditions are critical to ensuring higher quality of care is provided to senior Australians.

‘Agency’ staff across the sector

Within the residential aged care sector, approximately 9%^[4] of all the registered nurses, enrolled nurses and personal care workers are external contractors. Employed by third-party labour hire agencies, these “agency” staff work across different aged care homes on a temporary basis.

This sort of employment arrangement can help homes deal with short-term fluctuations in demand and staffing shortfalls. So it’s not surprising that as shortages have become more acute, this workforce strategy has become more commonplace.

In particular, as homes have struggled to maintain sufficient staff during the COVID pandemic, the use of agency staff has increased ^[5] across the sector.

As agency staff tend to work intermittently, there are concerns they lack familiarity ^[6] with individual residents and their unique needs. This can be disruptive and distressing for residents and their families and undermine the continuity of their care.

Also, as agency staff frequently work across different homes, they tend to be less efficient and require more supervision. This can can increase ^[7] workload pressures, stress and turnover of permanent workers.

The relationship between staffing and quality care

Our study ^[9] of 1,709 aged care homes over five years investigated the relationship between the quality of care provided by aged care homes and their reliance on agency contract care staff.

We found the use of agency staff was relatively common, with the majority of homes using agency care staff at some point.

More importantly, we found homes that rely more heavily on agency staff have worse quality of care. Specifically, they have higher rates of workforce-related complaints to the regulator, occurrences of missing residents, reportable assaults, preventable hospitalisations and instances of non-compliance with accreditation standards.

While this is the first such study in Australia, these results align with international evidence ^[10]. One striking similarity is how sensitive care quality is to even tiny increments of agency staffing. We found that even if just 5% of care time is delivered by agency staff, homes deliver significantly poorer quality outcomes.

Agency staff are less likely to be aware of residents’ individual needs and preferences. Shutterstock ^[11]

But we’re in the middle of a workforce crisis

Our findings suggest one way to improve quality of care is for homes to reduce their reliance on contract care staff. This could involve efforts to improve the recruitment, retention and rostering of permanent nurses and care workers.

However, in the current context, this might be easier said than done. With the industry in the midst of a massive workforce crisis ^[13], homes may have no choice but to continue to rely on agency workers.

In such cases, homes should adopt strategies to mitigate the potential for bad outcomes. For example, they might improve residents’ continuity of care by drawing from a pool of regular agency workers and investing in better orientation and shift handover processes.

In terms of policy, much of the recent reform agenda has focused improving staffing numbers and skills in aged care, through funding for training programs, mandatory care minutes, 24/7 registered nurses and addressing workers pay.

Another of Labor’s election promises was to implement a recommendation from the Royal Commission to require aged care providers to preference direct employment ^[14] over using contracted “agency” workers. This issue is now being investigated ^[15] by the Productivity Commission, which will hand its report down next month.

No quick fixes

Simply putting limits on agency staff is unlikely to work in the current context. Imposing caps may result in homes providing less total care to residents.

Rather, the widespread use of agency across the sector reflects a need to understand and address its root causes. As will be discussed next week at the jobs summit ^[17], staffing shortages are not isolated to aged care but widespread across the economy.

Policymakers also will have to be mindful of the impact of other reforms in play. For instance, the use of contractors may well increase as providers attempt to increase staffing levels to meet incoming mandatory minimum standards ^[18], while managing the demands and disruptions of COVID outbreaks.

Despite these challenges our research highlights the importance of finding ways to sustainably curb the use of contract staff so as to deliver the quality of care all senior Australians deserve.