What’s behind the nursing home disaster?

It’s hunting season on Australia’s aged care providers. After numerous complaints of abuse and undercover media investigations, the Federal Government formed a Royal Commission to investigate the quality and delivery of aged care.

Some of the stories emerging at public hearings have been sickening. Earlier this week, the distressed wife of a Tasmanian man named Neville King described living conditions in a nursing home in the north of the state. “If he were a dog I'd report it to the RSPCA and he'd be removed," she said.

She claimed that her husband had experienced mismanaged medications, missed showers that left him covered in dried urine, thousands of dollars in broken and lost property, and intimidation from staff. Once she found him crawling on the floor, delirious from dehydration.

But Dr King is a psychologist who was given an award as an Officer of the Order of Australia in 2018 for his pioneering work in cognitive and behaviour therapy. If a man of his distinction wasn’t cared for properly by nursing home staff, who will be?

An interim report from the Royal Commission, released a couple of weeks ago, was titled “Neglect”. That one word summarises the situation in some Australian nursing homes.

The major quality and safety issues cited by the Commissioners were:

  • inadequate prevention and management of wounds, sometimes leading to septicaemia and death
  • poor continence management. Many aged care residences don’t encourage toilet use or strictly ration continence pads, often leaving distressed residents sitting or lying in urine or faeces
  • dreadful food, nutrition and hydration, and insufficient attention to oral health, leading to widespread malnutrition, excruciating dental and other pain, and secondary conditions
  • a high incidence of assaults by staff on residents and by residents on other residents and on staff
  • common use of physical restraint on residents, not so much for their safety or wellbeing but to make them easier to manage
  • widespread overprescribing, often without clear consent, of drugs which sedate residents, rendering them drowsy and unresponsive to visiting family and removing their ability to interact with people
  • patchy and fragmented palliative care for residents who are dying, creating unnecessary distress for both the dying person and their family.

“It is shameful that such a list can be produced in 21st century Australia,” the report says. “At the heart of these problems lies the fundamental fact that our aged care system essentially depersonalises older people. A routine thoughtless act—the cup of coffee placed too far from the hand of a person with limited movement so that they cannot drink it, the call buzzer from someone left unanswered, the meal left uneaten with no effort to help— when repeated day after day, becomes unkindness and often cruelty. This is how ‘care’ becomes ‘neglect’”.

Sadly, this is not the first report into aged care in Australia. Nor will it be the last. Since 2005 there have been at least nine or ten major government reports into various aspects of aged care. According to a 2018 report to the Senate, “Perhaps the most compelling argument pointing to a regulatory system that is failing to provide adequate oversight of the aged care sector is the number of recent reviews and inquiries into various aspects of aged care service delivery.”

The Royal Commission has been given a nearly impossible task: to review aged care for all of Australia in about a year and a half and to suggest solutions. It is supposed to deliver its final report by April 30, six months from now.

With the best will in the world, this is impossible. In all likelihood, the Royal Commission is just going to produce another anthology of horror stories and another tranche of demands for huge increases in government funding for aged care. These will be competing with demands for huge increases for defence, climate mitigation, drought relief, disability care, universities, infrastructure etc, etc, etc.

Certainly the present situation can improve without revolutionary changes. Government bureaucracy can be streamlined, nursing homes can be regulated more closely, staff can be trained better, more elderly people can be cared for in their own homes.

But something is missing in the Royal Commission’s analysis: the role of families.

First of all, “neglect” is framed largely as a problem of not enough pennies in the pot rather than a fraying and shrinking family fabric.  

One striking paragraph illustrates its assumption that money will buy everything, even kindness:

As the need for care rises, the time spent by family and friends looking after their older loved ones will come at the cost of paid employment. This loss of working hours translates into a loss of taxable income and government revenue. Overall, less revenue for the Australian Government reduces its ability to subsidise aged care (page 84).

In other words, the authors of the report contend that voluntary unpaid care by family members – usually daughters – is undesirable. Women who are looking after their elderly parents or relatives are squandering precious resources. They should be conscripted into the workforce and pay their taxes -- which the government will then use to employ carers for their loved ones.

But isn’t this a recipe for depersonalising aged care? If we are really worried, shouldn’t we be trying to create a system which encourages loving family care instead of kindly institutional care? Even within families there can be unkindness, neglect and cruelty, but they will always be far more common in institutions like nursing homes.

Second, it overlooks the fact that much of the problem of “neglect” is due to three generations of fissuring, fractured, enfeebled families in the wake of the Sexual Revolution. With divorce so common and family size so small, many 21st century elderly will spend their twilight years alone. If social atomisation is a mental health problem for Gen Y, for ageing baby boomers, it can be a survival problem.

This is a well-studied problem.

Researchers say that aged care is more complex because family dynamics changed radically and unexpectedly after the 1960s.

The pressure on baby boomers can be intense. They had fewer children than their parents and had them later. According to a study in The Gerontologist, now many “are torn between helping young adult children and aging parents. Their aging parents incur chronic illnesses and disability, whereas their grown children face demands from economic downturns, prolonged education, and a slow transition to adulthood.” So, as they get older, “they are likely to experience: (a) caregiving for their parents; (b) losses of parents, siblings, and even children; and (c) eventual needs for care themselves.”

Furthermore, many of the Baby Boomers’ children are single parents, with around 40 percent of births nowadays to unmarried women. This will obviously make it difficult for them to provide care for elderly mother and fathers. They “may be struggling financially, working in unstable jobs, managing multiple stressors in their own lives, and unable to allocate time necessary to provide care consistently.”

Divorce has also made ageing difficult. Informal care is typically provided by a spouse or adult children, so childless, single or separated elderly may find themselves in difficulty.

“Married adults received significantly more informal care than unmarried adults … Those individuals who received care from both a spouse and adult children tended to have the most successful outcomes,” stated researchers from the University of Michigan, Ann Arbor, summarising a number of studies.

Divorce has weakened support networks. “With the increased rates of divorce and remarriage in the [baby boomer] cohort, individuals should not assume they will receive care from their stepchildren,” say the Ann Arbor researchers. Another study found that compared with widows and widowers, divorced elderly adults are less likely to live with their children and receive fewer hours of care from them.

Furthermore, intergenerational ties have weakened. An American study called the Longitudinal Study of Generations found that the strength of parent-care norms weakened between the 1970s and 1990s, while individualism grew.

Divorce makes this even worse: “current and former stepparents were less likely to be perceived by their stepchildren as parent-like figures because the affective quality of their earlier relationships was poorer compared with parent–child relationships in intact families.”

Aged care is a very complex issue. Unfortunately, with the lurid images of aged care abuse before them, Australians are treating government bureaucracy as the saviour and forgetting about the importance of family support.

This is wrong. The way to support the elderly tomorrow is to support strong, intact, biological families today. As some experts have pointed out, the bond between parents and children is a form of social capital which may remain latent for decades until action is required. The best superannuation is a big family.  

Shakespeare’s seven ages of man begin with “the Infant, Mewling and puking in the nurse’s arms and “the whining School-boy”. It’s then that government policy has to lay the foundations for aged care and implement policies which strengthen family ties.

Panicking when people sadly enter their “second childishness, and mere oblivion,— Sans teeth, sans eyes, sans taste, sans everything” is far too late.

Michael Cook is editor of MercatorNet


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