Unsung Heroes

They say “a rising tide raises all boats.” But the waves of the pandemic have raised public awareness of partially submerged boats which have been floating in and out of political view for decades: income inequality, the precarious economic status of women, and weak spots in our health care system, to name a few. 

Add to that list the state of long-term care in Canada, and specifically, in Nova Scotia. With some exceptions, COVID-19’s ravages in nursing homes have led to descriptions of the system which include “inadequate” and “shocking.”

Now, thanks to a recent grant of $97,412 from the Nova Scotia Health Research Fund (administered by Nova Scotia Health), Dr. Janice Keefe and two investigators will interview people about working conditions in eight nursing homes across the province. The project described as “The Unsung Heroes, Long-Term Care staff’s quality of work life” is expected to report next spring — a year from now. 

But anyone who has been paying attention to news coverage of issues in the province’s LTC system — especially over the past five or six years — might be forgiven for saying, “Huh?” 

The cost of the latest study is chump change when you consider 46% of the entire provincial budget goes to Health. Janice Keefe, a PhD and director of the Nova Scotia Centre on Aging at Mount Saint Vincent University, is a highly qualified and recognized expert on geriatric care. In fact, the province appointed Keefe to chair the Expert Panel on Long-Term Care a few years ago. Submitted to government in December 2018, the report made 22 recommendations.

If you were to sit down and read it today (only 21 pages if you skip the title and glossary), you might be hard-pressed to imagine what else could be added to its pointed recommendations for the province to act in the short-, medium-, and long-term.

Keefe was also a member of the Royal Society of Canada’s Working Group on Long-Term Care. Its “Restoring Trust” report, released in July 2020, said there is an urgent need “to solve the workforce crisis” by setting national standards that will require more federal and provincial funding to pay people adequately to do the work. The prime minister has since tasked the health minister to work with the provinces to develop such standards. Meanwhile, it’s fair to question what new information a year-long study in Nova Scotia could generate that hasn’t already been documented. 

“My first thought was, really?” said Nova Scotia Nurses Union president Janet Hazelton. “We have plenty of evidence staffing levels in long-term care homes are inadequate. We don’t need to study it again!” 

Hazelton said you only have to look at the injury rates among people who work in home care and long-term care to see they are the highest in the province. “This is because there aren’t enough staff hired to do the work,“ said Hazelton, “so the people dealing with heavy workloads get sick and injured on the job more often.” 

In December of 2015, the Nova Scotia Nurses Union published a report called “Broken Homes,” which included survey responses from 200 registered nurses (RNs) and licensed practical nurses (LPNs) working in long-term care facilities. Two-thirds said they had considered quitting in the past year. Staffing levels and workload emerged as the top contributors to work-life dissatisfaction. Half the nurses said their long-term care facilities regularly or often did not meet minimum staffing levels prescribed by the Homes for Special Care Act — a finding which raised serious questions about the rigour of provincial inspections and enforcement at the time. 

The NSNU has been urging the provincial government since 2015 to legislate minimum staffing levels to reflect best practices elsewhere. This would involve increasing the amount of care residents receive from 3.5 hours to 4.1 hours a day — an extra 36 minutes. This change would require hiring more Continuing Care Assistants (CCAs) who clean, dress, and feed residents, and hiring more licensed nursing staff responsible for medication, wound care prevention, and treatment associated with bedsores.

So far, the Liberal government has consistently refused to amend the Homes for Special Care Act to increase staffing levels — even after 57 nursing home deaths in the first wave of Covid-19 exposed glaring weaknesses in the system. And by the way, the aforementioned 2018 Expert Panel flagged the problems with the outdated, three-decades-old Act with this comment: “…given the number of times that it was mentioned in our consultations we would be remiss not to recommend that the government consider this review and invest in significant modernization of the legislation.”

In this latest study, Keefe and her investigators plan to interview staff who consent to participate and whose job classifications range from Continuing Care Assistants (CCAs) to senior managers. “This is an opportunity to provide some evidence about the value of the work that these individuals are doing for us as a society,” Keefe told CBC News earlier this month, “so we get a sense of what is the experience of the workers, and that will be very useful, I think, to be able to understand issues around recruitment and particularly retention.”

 No shortage of reference points

Keefe may want to review a three-point plan the Canadian Union of Public Employees (CUPE) submitted to the Nova Scotia government and opposition leaders. CUPE represents 5,700 CCAs and dietary workers in nursing homes and residential care facilities across the province. Point Number One in the plan was, “Address chronic staff shortages for Continuing Care Assistants by increasing their pay from $18.96 an hour. These workers are often forced to work overtime and denied vacation.”

“The solution is not the creation of another unskilled CCA assistant that is paid at a lower rate,” said Govind Rao, a researcher for CUPE’s Atlantic region. Nevertheless, the Nova Scotia government has budgeted $10.3 million this year for nursing homes to hire and train people to help CCAs with feeding and transporting residents. This was envisioned as a stop-gap or temporary measure by the Expert Panel in 2018 to ease the “crisis” in front line staffing. Rao said the way to attract more workers is to increase their pay, as both Quebec and British Columbia have, with both provinces now paying more than $20 an hour.

Eight publicly and privately owned nursing homes have agreed to participate in the “Unsung Heroes” study, even though last July, the Nursing Homes Association of Nova Scotia went public for the first time with a position paper called “Enough Talk.” As the paper’s title suggests, the nursing home operators requested urgent action from the province to change the way homes are funded and to come up with a plan to address chronic shortages for both front-line workers and nurse managers. 

Unlike the Nurses Union, nursing home operators do not support a minimum number of hours of care, because they fear they will lose the flexibility to choose what mix or classification of workers to hire and pay. (The latest provincial budget added $6.4 million to implement an Expert Panel recommendation to hire more physio- and recreational therapists, and $5.4 million to hire nurse practitioners and doctors.)

“This research study is supported by our association with eight of our members participating,” said Michele Lowe, executive director of the Nursing Homes Association of N.S. “While you may ask why a study of this nature needs to be conducted, the fact is, long-term care continues to be underfunded and these projects seem to be necessary to demonstrate the impact. Janice has continued to advocate for our sector and the staff who work so hard to provide quality care.”

But Gary MacLeod finds it difficult to see how yet another study will effect meaningful change for people living — and working — in long-term care. He founded a group called Advocates for Care of the Elderly (ACE) more than a decade ago. He has observed the Liberals’ 2015 promise to deliver a long-term care strategy evaporate. This years’ budget includes $500,000 to develop “a blueprint” for long-term care. 

Asked what he thinks of the latest $94,000 study for working conditions in nursing homes, MacLeod was blunt. “I was appalled when I saw the report of another ‘study’ headed by Dr. Janice Keefe. I have a lot of respect for Dr. Keefe, but this is the third study in less than three years she has been involved in,” said MacLeod.

“There is no shortage of reports and studies for what is wrong with long-term care, and no — we certainly do not need more waste of taxpayer money for another study. The recent Liberal budget has no clear plan to improve the quality of care for long-term care residents, who have to endure sitting in soiled incontinence pads for long periods of time and one bath a week, all due to staffing shortages. Who needs another study to know that?”

When the Unsung Heroes study’s recommendations are released next year — perhaps after provincial or federal elections in which other hot-button issues tend to swamp weaknesses in long-term care — it may be interesting to compare its closing statement with the report from the 2018 Expert Panel on Long-Term Care:

It is our hope that the recommendations outlined here, many of which have been previously suggested in other LTC reports, will provide important first steps to improving conditions in LTC to the benefit of both residents and workers.

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