I Could Do Much Better but the System Doesn’t Allow Me

We all want to do the best we can for our patients, but frequently encounter a wall of resistance that prevents us from doing the best we could. It is clear that the challenges faced in providing optimal care in nursing homes are deeply rooted in systemic issues. This study aimed to identify the key stakeholders and their respective perspectives impacting the nursing home system. We conducted a literature review, conducted key stakeholder interviews, and made personal observations on the workings of nursing homes. These revealed a complex cascading web of divergent priorities. Nursing home residents and their families prioritised personalised care that meets their diverse physical, emotional, social, and cognitive needs, while preserving dignity and functional abilities. However, staff face constraints due to low staffing levels, composition, and skills, as well as the demands of regulatory compliance. Nursing home management must manage the competing needs of residents and staff and the corporate owners’ need to achieve a satisfactory return on investment. This invariably results in levels of resource constraints with detrimental consequences for staff and residents. Government controls the overall financing and regulatory requirements which have two divergent consequences on the sector, constraining overall resources while simultaneously imposing resource intense operational requirements. All stakeholders share responsibility for the overall function and outcomes of nursing home care. Our findings in the Australian context identified the regulator’s requirements as a significant inhibitor to ‘good care’ delivery. While regulation is necessary, if it is too loose it fails to provide the necessary information of what is required, and if too tight, will prevent staff from adaptively delivering the needed care. Regulatory demands have led to both protocol-driven care and extensive documentation, diverting time and resources away from direct patient care, and contributing to high levels of staff dissatisfaction and turnover. The corollary of inappropriate regulation ultimately perpetuates poor care outcomes that regulation is aimed to prevent. High quality safe nursing home care requires a system design that across all its layers and stakeholders aligns with the needs of the frail elderly residents no longer able to cope on their own. Our systems-thinking informed research identified the interdependent reasons standing in the way of ‘doing much better’.