Ontario has been remarkably resistant to the idea of staffing standards in long-term care.
Staffing is a major determinant of quality in long-term care – something even the most casual observer should understand.
Such standards are not uncommon in other jurisdictions – many have based regulations on a comprehensive U.S. Department of Health and Human Services study that stated a daily minimum of 4.1 hours of total nursing time (including personal support workers) is required to avoid common quality of care problems such as bedsores, weight loss, and loss of bodily functions for long-term care residents. That was in 2002.
There is not general agreement on how nursing home staffing is measured in Ontario, making it difficult to directly compare existing data to this benchmark. However, experts suggest that Ontario is hovering somewhere below three hours of direct care per resident per day based on average acuity.
Writing for the Centre for Policy Alternatives in 2008, York University’s Pat Armstrong has highlighted how so many of the issues in long-term care flow from inadequate staffing.
“Residents, for example, often become violent towards care providers because they are frustrated beyond endurance with the lack of care,” she writes. “They sit in soiled diapers for hours because there are no workers available to answer their call. They are rushed through dinner because there are too many who need to be fed. Or they miss their bath because there are not enough staff to get everyone adequately bathed. And they sit in their rooms without exercise or conversation because the workers have no time to chat, to explain, or provide social support.”
During the 2008 election then Health Minister George Smitherman told a long-term care forum that such a standard was on its way. It was up to his appointee, Shirlee Sharkey, to determine what that would be.
Sharkey instead sidestepped such standards and issued a series of difficult to enforce recommendations around “outcomes.” She did however urge the province to strengthen staff capacity. That never happened.
Following another round of bad press over scandalous conditions in long-term care, Health Minister Deb Matthews convened a task force in 2012 into resident care and safety.
The task force was blunt in its final report. Without setting a specific enforceable standard they did come back to Sharkey’s recommendations: “Recognize that there are not enough direct-care staff to meet the needs of all long-term care residents safely, (emphasis added) the Long Term Care Task Force on Resident Care and Safety strongly recommends that the Ministry of Health and Long Term Care implement recommendations of the Sharkey report on strengthening staff capacity for better care.”
In December of 2012 Matthews also received a report from Dr. Samir Sinha, Provincial Lead for Ontario’s Senior Strategy.
Sinha recognized the pressures Ontario’s nursing homes are under.
“Over the last three years, the care needs of those being admitted to long-term care have risen substantially, so that long-term care homes are now increasingly meeting the needs of very frail older adults who cannot be cared for elsewhere.”
Sinha notes that 78 per cent of admissions are coming from hospital at the two highest assessment levels.
“The sector predicts that virtually all those admitted to long-term care homes in the future will soon be from these two highest needs categories,” he writes.
The Canadian Institute for Health Information notes that three-quarters of Ontario’s long term care residents are either totally dependent or require extensive assistance with their activities of daily living. Just over three-quarters are cognitively impaired, while one-third have responsive behaviours, and over a half show signs of health instability.
So where is the staffing response to these changes?
While the Minister likes to talk about how many new hires there have been in the sector, the reality is most of these staff have allowed Ontario to expand the number of beds, not enhance quality of care.
Unfortunately Sinha is reluctant to make specific recommendations around staffing standards, but notes that the changing nature of long-term care will “require enhancing the sector’s ability to recruit and retain staff, advance the knowledge and skills of its direct care staff, increase the efficiency of long-term care business processes, and leverage existing investments in health human resources.”
Retention becomes an interesting question when workload becomes impossible.
“Workers become injured because they rush to provide service,” writes Pat Armstrong. “Or they come to work when they are injured or sick because they know that otherwise there will be no one there to provide care. They work unpaid hours to make up for the care deficit. They go home physically exhausted because they looked after far too many residents, or they go home emotionally drained because they could not provide the care they knew should have been provided but couldn’t be in spite of their best efforts.”
In March the death of a Scarborough long-term care resident prompted new calls for enhanced staffing.
That call led to an increase in the number of inspectors after it was learned the Scarborough long-term care home had not had a thorough inspection since 2009.
The Registers Nurses’ Association of Ontario called for both an inquiry and new money to address the staffing shortage in the spring budget.
Instead they got neither. The sector actually received a smaller increase than the year before – down to 2 per cent. In 2012 the increase was 2.8 per cent.
The RNAO noted that Ontario’s per capita funding for long-term care was lagging behind all but two other jurisdictions in Canada. Proportionately Ontario only spends 58.3 per cent of what Manitoba does on long-term care.
Deb Matthews doesn’t need any more reports to ignore.
The evidence is clear that Ontario must address staffing. This fall a number of organizations are set to push hard on this issue, including a planned campaign by the Ontario Health Coalition.