A new report, "Long-term Care in Ontario: Fostering Systemic Neglect," shows that understaffing contributes to a host of problems for residents of Ontario's long term care (LTC) homes. A group of 42 personal support workers (PSWs) and registered practical nurses (RPNs) from LTC homes in Guelph, Blind River, Ottawa, Minden, and Toronto participated in this focus group study presented by the Ontario Council of Hospital Unions.
This is one of several reports that have been released lately about problems and failures in our health care system. (see our post on advancing home and community care in ontario from a couple of weeks ago)
The participants said they continued working at their jobs because they love the work and are committed to helping the residents, but they are frustrated by lack of time to deliver quality care, excessive paperwork, and employer rules and government policies that encourage a “warehouse atmosphere” in nursing homes.
Chronic low staffing levels allow neglect and abuse to flourish:
- Injuries – Vulnerable residents are at greater risk of falling or being injured by other residents with dementia or behavioural issues when no staff is available to help them. When there is no one watching them who can divert them, they must be restrained for their own and others’ safety.
- Infection – Lax standards for infection control, and delayed testing for common infections contribute to higher incidences of disease in people who have lowered ability to fight infection because of substandard care in the first place.
- Hygiene – Residents receive fewer baths and frequently must sit in wet or soiled diapers for long periods of time. Bedsores become more common when there is not enough staff to reposition residents who cannot turn themselves in their beds. Beyond the discomfort, this allows infections to grow, and most worrisome, takes away what little dignity the residents might have had.
- Incontinence – Residents who would be able to toilet themselves, if only they had help getting there, are forced to use their adult diapers when there is no one to assist them. Over time, they stop asking. It's as if they were actually being encouraged to become incontinent.
- Mobility – Residents who can move with help, and can’t without it, end up over time losing their mobility altogether when they don’t get the chance to even try. Some residents require a two-person assist to get them out of bed. If two PSWs aren’t available at the same time, they stay in bed, alone.
- Mixed levels of care – A single PSW’s patient assignment may include residents with varying levels of care: total care, palliative care, two-person care, convalescent care and minimal care. Their assignment on any given day may include elders with dementia or Alzheirmer’s, elders with mobility issues, younger adults with mental health problems, and older adults with difficult behaviours such as aggression or wandering.
- Emotional issues – The residents see and understand the stress and strain of staff trying to do the jobs of two or three. They feel sorry for overworked staff and don’t ask for things they need because they don’t want to add to the PSW’s burden. They are stuck alone for long periods of time. The consistently tense atmosphere is not good for either residents or staff. Staff are on a strict timeline, so have no time to care for emotionally distressed residents.
- Care vs. documentation – Every incident – falls, injuries, bedsores, arguments between residents – has to be written up. Lack of time to prevent problems means there will be more problems, which means there will be more paperwork, which means there is less time to prevent problems.
- Unexpected events – When there are not enough staff members to handle the everyday load, what happens if there is an emergency? When an incident occurs staff is expected to respond, no matter what they are doing. If they are all handling the emergency, who is on the floor to maintain safety?
Every one of these issues infringes on, if not downright disregards, patients’ rights. The Ontario Patients’ Bill of Rights includes: respect and dignity, no abuse, no neglect, proper care, a safe and clean home, privacy, consent to treatment, independence, lifestyle choices, and much more. (View the full Patients’ Bill of Rights here.) When staff do make the choice to help a resident that puts them behind their schedule, they are reprimanded by management.
Ways to Make it Better
Several changes in the structure and delivery of care would make a huge difference in the quality of life for those in Ontario’s LTC homes:
- Staff to patient ratio – The maximum ratio should be 1 staff per 8 residents, with higher staffing at peak times, such as wake-up, mealtimes and bedtime.
- Minimum hours of care – The minimum hours of care should be raised to 4 hours per day, up from the current 2.8. (The government maintains that the average number of direct care hours is 3.4.)
- PSW training – PSWs should have training to specialize in types of care: behavioural care, palliative care, or dementia care, for example. More training means residents get better care.
- Care-appropriate units – If people with similar issues stayed together in units within the LTC home, PSWs trained for those issues could provide a higher level of care. It would also allow for better distribution of staffing, with higher staff to patient ratios in units with higher needs.
It’s an unfortunate fact that the amount and range of health care services provided by the government depends on political, economic, and social factors. Perhaps we cannot expect totally comprehensive care, that is, everything anyone would like to have, but we can expect a reasonable level of care, respect, and dignity for our seniors who worked hard all their lives and deserve a comfortable old age.