Is caring for the elderly a valued role? The face of elderly care is changing as welfare and religious-run institutions are bought out by private companies wanting a commercial return. What does this mean for quality of care?

TERRI POTROZ is a straight-talking realist. Perhaps it's due to her rural Taranaki upbringing. Or her rule as a mother of five children. Or her experience as a public health nurse in south Taranaki working with a large Maori population. Or working with intellectually and physically disabled children. Or her struggles with the then Central Regional Health Authority to ensure the church-owned rest-home and hospital she managed got adequate funding to provide quality care and pay staff a decent wage.

Whatever the forces that have shaped her during her 40-year nursing career, Potroz has remained a staunch advocate of those whose voices are often muffled in the clamour for the health dollar, Her last role was as general manager of a 37-bed rest-home and 36-bed hospital and 59 cottages in Nelson, which employed 100 staff and was run by the Anglican Diocese. It brought her into conflict with the Central RHA as she refused to accept the funding constraints it tried to impose. But like many such religious and welfare institutions around the country, facing huge refurbishment costs, the business has been sold to a private company. At that point last year, Potroz decided to retire. She felt with a new owner, new philosophies and new blood were needed. But there is a sense she did not want to witness the possible erosion of standards she had put in place and protected during her time at Whareama. And she is sad many churches have got out of care of the elderly. "Churches have a role in care of the elderly because of their commitment to those who are vulnerable. It's ironic that now some church-run institutions see themselves as businesses and want commercial returns."

Do the entrepreneurs entering the industry have an understanding of the needs of the elderly? "Absolutely not, unless they get very good advisers they are prepared to listen to. There is a real tension between the needs of elderly people and the need for a commercial return. Some of the consequences of this can be lower staffing levels and lower expectations about standards of care. But the Ministry of Health's new health and safety standards [which Potroz helped develop] mean owners can't cut a lot of corners."

She says staff are already working incredibly hard in aged-care institutions and questions whether working smarter really means working even harder.

The private institutions mostly pay less than public hospitals and many face real problems in attracting staff. "The extreme shortage of registered nurses (RNs) means people's health, in all areas, is beginning to suffer. In elderly care it means managers are struggling to keep RNs on the floor and on occasions there are none. You can't get blood out of a stone. I often wished I'd had a packet of 'instant nurse mix' in the cupboard. The nursing shortage is a nationwide problem and needs to be addressed by the nation."

Potroz is also concerned at the rhetoric of valuing caregivers and the reality that means some are paid just $9.50 an hour. "What does that say about how we value women in our society and how we value the people they care for? We really squeeze our middle-aged women in this society. We need to look after their health as they are often working, caring for grandchildren and elderly parents. They are propping up both ends of the age spectrum."

She is also concerned about the implication of paying caregivers "bottom dollar". "There are very good and genuine people in care giving but if they continue to be paid poorly, who is going to be attracted to the work and what effect will that have on the elderly?"

Potroz has always been aware there is a direct correlation between staffing levels and patient outcomes and is pleased there in now hard research data produced by United States nursing researcher Linda Aiken to support that. "The outcomes of that research apply in elderly care."

Those entering rest-home and hospital care are no longer "genteel old ladies but people with significant health and disability issues who require more complex care".

She is a firm believer in the "valid and valuable role" of enrolled nurses (EN) but is concerned the lack of RNs may mean ENs and caregivers take on too much responsibility without the background knowledge needed to ensure safe care. "I don't have an answer. Certainly, conditions of work and salaries are important but money for health is not a bottomless pit. As a country we need to decide how we want our health dollars spent. Old people aren't respected, regardless of what we say."

She says many families whose elderly parent is entering residential care suffer from guilt and make decisions based on "brass and glass. They don't have the knowledge to look at staffing levels, recreational programmes, menus and other indicators of quality care".

Now, she does not want to be in a rest home when older but acknowledges increasing needs may change that. Her dream is for elderly people to stay in their own homes and get the care they need there. Or, if in an institution, for the residents "to own the front door and care comes in the back door. That means the place is like a home where family and friends can come and the provision of care doesn't intrude".

In the mean time, Potroz, in her latest role, continues to ensure the elderly get something approximating the care they deserve. She is now self employed, working with rest-homes that have not met their contractual obligations to put in place systems and processes to ensure they do. She finds it "tremendously satisfying to go in and fix things and work with staff to enable a better standard of care".

This work has affirmed her belief that most people want to do a good job. "I've been impressed by people's concern for older people. It's not the most glamorous job and you've got to have a genuine feeling for older people. But most people are keen to give a good standard of care to older people."