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After years of anecdotal reports (“They’re run off their feet”) and some disturbing incidents (nursing home fatalities related to bedsores), the Nova Scotia Nurses Union has called on the provincial government to increase staffing in long-term care (LTC) homes by 20%. That would translate into hiring about 600 additional nurses and 1400 more Continuing Care Assistants (CCAs). The cost? Upwards of $20 million a year.
The NSNU represents 1,200 RNs and Licensed Practical Nurses (LPNs) who work in nursing homes — just slightly more than the 1,000 nurses it represents at the IWK Children’s Hospital in Halifax. NSNU president Janet Hazelton suggests the comparison demonstrates how few licensed nurses actually provide care to the elderly nearing the end of their lives compared to those employed to care for the young.
“Everybody says we need more care in Long-Term Care,” Hazelton told journalists during a video news conference Friday. “There is only one way to get that, and that is money. And it is going to cost money, and people need to understand that. And people need to appreciate our seniors to say they are willing to pay that. The issue is money.”
The NSNU hired a reputable researcher to come up with a staff-to-resident ratio for LTC homes. The resulting paper — “Staffing Standards for N.S. Nursing Homes” — was commissioned before the COVID-19 pandemic and is authored by Charlene Harrington, Ph.D., RN, Professor Emeritus from the University of California San Francisco. Dr. Harrington is a renowned expert on long-term care staffing who has testified before the U.S. Senate’s Health Committee.
Harrington says Nova Scotia nursing home residents should receive 4.1 hours of care a day, with 1.3 hours provided by a registered or licensed practical nurse. The current standard is 3.45 hours of care per resident per day. If that sounds familiar, there’s a reason. Five years ago, a research paper for the NSNU entitled “Broken Homes” made precisely the same recommendation to improve care for residents and to working conditions for burned-out staff.
What’s different today is the lens through which conditions in nursing homes are being viewed. Of the total of COVID deaths in this province, 90% occurred in long-term care facilities. According to the Canadian Institute for Health Information, the national figure of COVID deaths among residents of nursing homes is 81%.
In a preface to the Staffing Standards paper, the NSNU’s senior researcher, Paul Curry wrote, “We expect and advocate for in-depth and independent reviews of the COVID crisis in long-term care, both in Nova Scotia and across the country.”
Curry cites as some particular concerns, “the hospital-inspired design of many long-term care facilities, and the continued use of shared rooms. We are not in a position to provide a full analysis of the situation, though we welcome the opportunity to participate in the coming months. However, as we present this work calling on reforms to the long-term care sector in Nova Scotia, it is incumbent on us to reflect on the cruel lessons the pandemic has taught us with respect to the issue of staffing in the long-term care sector.”
COVID Highlights Pre-existing Concerns
In his preface, Curry references dozens of deficiencies noted in recent inspection reports of nursing homes carried out by the Department of Health. He says these deficiencies show nursing homes do not have enough licensed nurses on staff with enough time to carry out regular health care assessments of residents — which are mandated by Health Department policy.
“A review of the reports reveals that in those completed in 2019 and 2020 (up until June), 16 facilities were cited for not meeting the minimum 24-hour RN coverage required by the regulations. Inspection reports reveal a total of 37 assessment-related citations in 2019 and 2020 (until June, Nova Scotia, 2020). Furthermore, a full care plan for a resident must be completed within 6 weeks of admission and reviewed annually at a minimum. There were 52 instances where aspects of this were not being met.”
Registered Nurse Glenda Sabine works at a 175-bed long-term care facility. She told journalists there is never enough staff (or time) to provide residents with the care she wants to provide.
“When we are short-staffed, it’s hard,” said Sabine. “It doesn’t make you feel good at the end of shift when you go home, and you know the residents deserve more than they are getting. We don’t have enough time to spend with them. What is not happening is we aren’t checking their skin as often as we would like. Even at full staff, its hard to watch a resident that is potentially physically or sexually aggressive. When you have only three Continuing Care Assistants looking after 23 people on a unit, and then you have somebody that’s behaving aggressively, that’s a whole other ballgame. It’s dangerous. You have more people off on stress leave. Before COVID, it wasn’t good when we were at full staff. Now this pandemic has thrown a whole new spin on everything.”
Would More Staff Prevent Future COVID Outbreaks?
Both Northwood and Shannex had infection control experts and occupational health and safety nurses on staff. In Northwood’s case, it’s accurate to say that once 100 staff were off sick or self-isolating, the organization did not have people available to backfill. But without an Inquiry, it’s unclear whether government funding to provide a better ratio of staff to residents could have prevented the rapid spread of the virus.
“This report is broader than the COVID crisis,” writes Paul Curry in his preface to “Staffing Standards for N.S. Nursing Homes.” “We aren’t here to say we have the answer to what happened at Northwood… but we do know looking at the broader picture of Long-Term Care across the country and internationally, there is a relationship between infection control and the number of nurses dedicated to long-term care. Yes, the staffing report is about infection control, but it is also about preventing bedsores, de-escalating behaviours, making sure medications aren’t missed. This crisis puts into stark relief what is a broader systemic issue. We think staffing is the most important thing that is going to help the sector.”
The Expert Panel on Long-Term Care commissioned by the province in 2018 and chaired by Janice Keefe, a respected gerontology researcher, refused to recommend a staff-to-resident ratio for long-term care homes. The Panel said it didn’t have enough information and there are not enough nurses or CCAs available to hire.
But NSNU president Janet Hazelton says that is not the case for Registered Nurses. Hazelton says she has spoken to a number of recent Nova Scotia Nursing School graduates who have not yet been offered jobs. She maintains that the issue is money.
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I am 100% behind the work being done by the NSNU and its members to provide quality care to LTC residents. Their report provides excellent data and analysis of the systemic issues in LTC that I hope will also be looked at by those investigating the outbreak at Northwood. However, one thing I have noticed in many presentations by the nurses’ union and their members, is that they sometimes (inadvertently I am sure!) stigmatize and present very negative stereotypes of LTC residents. For example, the quote regarding the need for nurses to deal with any “resident that is potentially physically or sexually aggressive”. These references are scattered throughout their research. Unfortunately, those both outside and inside the LTC system have a tendency to demonize and ‘Other’ those living with complex cognitive or memory issues, who need love and support instead of control, surveillance and compliance. Perhaps the nurses should change the way they frame these issues, providing a more sensitive view of the residents as real people rather than hard-to-control ‘problems’.