Reflections on a preventable horror show

By Marie Vaughan*, former Chief Nurse at Royal Freemasons Aged Care

Source: APNA Primary Times Spring 2020 (Volume 20, Issue 2)

The failings of government and management at aged care facilities during the COVID-19 crisis has brought historical negligence at the heart of aged care into the spotlight.

Many aged care facilities failed to provide safety for their residents and staff due to longstanding issues with management, funding, policy and society’s reluctance to address ageism, frailty and death with honesty and integrity.

Refocussing aged care to provide the necessary skills for clinical excellence and personal empowerment for resident families and staff could prevent more tragedy. This requires a focus on primary prevention to avoid the current preventable horror evidenced in the Royal Commission into Aged Care.


The rebranding of Nursing Homes to Residential Aged Care Facilities permits emphasis on the built environment over the need for adequate staffing and well-trained clinical and care staff. Clinical expertise and an evidence-based model of care has become secondary to marketability and a top-down management model that prioritised profitability and expansion.

The fallacy of lifestyle and choice stand in contradistinction to the reality of frail, aged, vulnerable people with multiple comorbidities - commonly dementia - who enter aged care only when their clinical and care needs exceed that which can be provided by family and community services and as such is rarely “a choice”.

Nurses continue to struggle to ensure residents receive the right care in the right time at the right place. There are access barriers to quality health care as medical care governance sits across general primary practice, medical specialist services, community services, acute care, state and federal government regulators. This leads to residential aged care falling between jurisdictions, being inefficiently regulated and underserviced.


COVID-19 has exposed some unpleasant analogies to abattoirs and prisons - protecting the community from the realities they wish to outsource to avoid confronting some of the ethical dilemmas. We warehouse the disempowered, marginalised and “non-productive” members of our society with a workforce that is underpaid, under-trained, under-valued and under-empowered.

Aged care staff and residents have shouldered the burden of coronavirus despite being completely unprepared and inadequately supported by providers and governing bodies.

The real value of essential safety, care, shelter and nutrition has been brought into sharp focus. People who provide these essential human services are the most casualised, predominantly female and migrant workforce. Because the nature of the work is so exploitative, people with options can choose alternative work that is less emotionally and physically challenging. 

This essential workforce is forced to risk their own health and that of their loved ones, often working with inadequate protection and conflicting messages from management and government. Staff often work across sites not only to secure a living wage but because any one of their employers is likely introduce a draconian cost-cutting restructure. A second employer then provides some insurance against lost income or impossible working conditions.


Residents in aged care are the sickest and frailest people, with the greatest proportion of those having some form of dementia. Despite complex, chronic comorbidities and health challenges, there continues to be inadequate clinical governance. There are jurisdictional problems between the state and federal governments and the governance requirements of providers.

"Clinical staff in residential care facilities need to have a sophisticated understanding of the referral pathways to advocate for residents to get the best possible health care."

Nurses are the key drivers in ensuring that residents have access to appropriate activities, nutrition, physical support, allied health and medical services. This is not just limited to clinical needs but includes lifestyle preferences and wishes that make our life not just bearable but rewarding. 


We hear from politicians lately that every COVID-19 death is a tragedy. Clinical staff know that the great majority of people in residential care die in their care. Staff plan for this within the constraints of staffing and clinical skills available and process the attendant loss and grief with minimal support.

Often these deaths are attended by peaceful and dignified end of life care for which staff are appreciated and respected by residents and their families. Staff can be justly proud.

They also witness preventable deaths and morbidity resultant from inadequate basic care, falls, fractures, dehydration, sepsis from preventable and unrecognised infections, undetected deterioration of chronic disease or delirium and overuse of behaviour modifying medications.

When staff are unable to provide the comfort and support for the residents and their families need it is indeed a tragedy for all.

"COVID-19 has exposed some unpleasant analogies to abattoirs and prisons."

While it is evident that increased funding is urgently needed, transparency is essential so that residents and families, as well as we the public, know our taxes are expended on direct and meaningful care that deliver better outcomes as opposed to marketing, managerialism and maximising income.

Aged care providers, and the bodies that fund them, direct staff with low pay and no recognition to provide complex and nuanced care that requires tact, understanding, compassion and human decency in a working environment that provides them with few of these things. Our society would prefer to outsource and commodify care as we would rather not confront death and dying, in the same way that we avert their eyes from the processing of animals and prisoners.

It is said that if abattoirs had glass walls many would become vegetarians. If nursing homes were truly transparent, what might we become? 


*Marie Vaughan is a Nurse Practitioner who has worked across the sector from community to acute care in clinical, research, education and advisory roles.  A contributing author of Pain in Residential Aged Care Facilities- Management Strategies, she is committed to a human rights and ethical perspective. 

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