The royal commission’s final report highlighted the extent of abuse and devaluation of women in residential aged care. As Kathy Eager and Anita Westera explain, for the abuse to stop, systemic change is required.

We’ve heard a lot of horror stories in recent months about women being abused. It seems each new day brings yet another news item where a man (and they are invariably males) has used his position of power and influence to denigrate and abuse a female colleague, student, partner, acquaintance, client or worker. We thought we’d come a long way, in terms of equal rights, opportunities, respect . . . But the last few months have highlighted just how misguided we’ve been. There has been widespread condemnation of these situations and their perpetrators. And rightly so.

Around the same time these high-profile sexual assaults started making headlines another report was published, the substance of which also highlighted the extent of abuse and devaluation of (predominantly) women: the aged care royal commission’s final report. You may recall it received a brief window of media attention after being released by the prime minister, together with the health and aged care ministers, at short notice on a sunny Sydney day following a week of high speculation regarding the historical rape allegations against a current cabinet member. The final report was titled Care, Dignity and Respect, the antithesis of the interim report which had been titled Neglect.

In the months since, there has been significant public outrage, debate and national demonstrations regarding the rights, opportunities and wellbeing of Australian women. Members of parliament have been stood aside, and a major reshuffle within the federal coalition cabinet has resulted in an all-time high number of women sitting within the inner sanctum. These are all welcome changes. However, none are likely to impact on the one sector of society where women are the most vulnerable — the aged-care sector.
Women’s work

As is widely acknowledged, the aged-care sector is underfunded and so are the staff who work in it. Like childcare, aged care is traditionally ‘women’s work’. Women represent 87 percent of workers in the residential aged-care sector and 89 percent of workers in the homecare sector. Men represent just 12 percent of registered nurses in aged care and 14 percent of personal care workers. It is no wonder pay rates are so low. No one could seriously argue that funding and pay rates would be so low if aged care was traditionally ‘men’s work’.

Women live longer and need more aged care
Two-thirds (64 percent) of all people in receipt of aged care are women. Women live longer and require aged-care support for longer. While both sexes want to age at home, men are more likely to be able to do so. Reflecting stereotyped relationships, the typical pattern is of a wife looking after her husband until he dies before her. The older you are, the more likely you are to be a woman who lives on her own. Given this, no one should seriously expect demand for residential aged care to reduce into the future.

An increasing number of women are living for longer with no partner or family to look after them. This is already reflected in residential aged care. While women represent about half of people in aged care who are under 75 years, the female percentage increases steadily with age. There are more than 30,000 people aged between 95 and 106 years in aged-care homes this year. 78 percent are women.

Aged care is unsafe, especially for women
Aged care is unsafe for many residents, mostly women. While most incidents are between residents, residents are also assaulted by staff and visitors. Aggression can take many forms, including physical, verbal, sexual and material aggression. Extrapolating from a study of 178 services, the best available estimate is that there are close to 40,000 reportable incidents and 15,000 non-reportable incidents in aged-care homes each year. This equates to more than 100 reportable incidents every day.

The Aged Care Act 1997 requires providers to report allegations, or a suspicion, of a “reportable assault” on a resident. But the act allows for exemptions including when a reportable assault is “perpetrated by a resident with an assessed cognitive or mental impairment . . .” In this case, the home does not have to report the incident. This study reported that 4.4 percent of incidents were unlawful sexual contact. Extrapolating from that study, this equates to more than 1,700 cases of unlawful sexual assault per year or 33 cases every week.

This study further investigated incidents “displaying perpetrator behaviours of rape, sexual assault, including touching the resident’s genital area without consent” and specifically looked at the victim impact for these incidents. Extraordinarily, 58 percent of these were assessed by aged-care staff as having “no impact” on the victim. This is a shocking statistic. It is alarming in what it says about the culture of the aged-care sector.

Elder abuse in aged care
The recent aged-care royal commission tried to get to terms with this issue. They produced “experimental estimates of the prevalence of elder abuse in Australian aged care facilities”. They estimated that the prevalence of elder abuse in Australian residential care is 39 percent. This estimate only includes people reporting emotional abuse, physical abuse and/or neglect. They were unable to estimate the prevalence of financial, social, or sexual abuse.

They estimated the prevalence of neglect to be 31 percent. This included people who reported concerns about how they are helped with daily living tasks such as showering, eating, toileting and getting around. It also included concerns about how “medication is managed, wounds are looked after, catheters are used and/or pain is managed; concerns about accessing a GP, dentist, mental health services, and/or other allied health services; and/or care staff rarely being able to spend enough time attending to the person’s individual needs”.

The estimated prevalence of emotional/psychological abuse is 23 percent. This includes people who reported feeling “forced to be dependent on staff, treated like a child, forced to wear continence pads, being shouted at by staff, and/or not having their specific care needs thought about or listened to”. The estimated prevalence of physical abuse is five percent. This includes people being physically restrained against their wishes, not being allowed out of their bed/chair/room or outside, and/or being hurt or treated roughly by staff.

What will it take to get from neglect to care, dignity and respect?
The priority for additional funding is clear: more funding is required to make residential aged care safer and kinder. This requires adequate staff ratios, a better mix of skills, improved staff continuity and more effective clinical governance. At the same time, more funding is required to address the community aged-care waiting list. But these changes alone will not be sufficient. We need to understand that, just like women’s rights issues everywhere, systemic change is required. The task is to end decades of neglect due in large part to a culture underpinned by sexism and ageism.

The community is now standing in judgement waiting for the government to seriously address the systemic issues underpinning sexual assault and abuse in parliament house and in the broader community. In the same way, the community must now also stand in judgement waiting for the government to seriously address the systemic issues underpinning the abuse and neglect of women in the aged-care system.

• Professor Kathy Eagar is Professor of Health Services Research and Director of the Australian Health Services Research Institute (AHSRI) at the University of Wollongong; Anita Westera is a research fellow with the Australian Health Services Research Institute (AHSRI), University of Wollongong and has worked in aged care policy, research, advocacy and governance roles for over three decades.