The Registered Nurses’ Association of Ontario (RNAO) is calling on the government to take immediate and concrete action to address the long-standing shortfalls in long-term care (LTC) homes made blatantly evident in the Canadian Armed Forces’ (CAF) report, released on Tuesday. Although the province announced May 19 it would set up an independent commission to examine conditions residents are experiencing in LTC, first expected to begin its work in September and yesterday moved to July, RNAO says the litany of serious and egregious issues outlined by CAF cannot wait another day. Rather than only relying on a future commission, the immediate step is to start implementing the recommendations from past inquiries and commissions.
“Seniors are dying, LTC staff members are disheartened and exhausted, and families and communities are devastated that such a horrifying debacle can happen in our rich province,” says Dr. Angela Cooper Brathwaite, RNAO president. “The CAF report Operation Laser - Joint Task Force Central Observations in LTC Facilities in Ontario has validated critical shortfalls and is a clarion call for immediate action,” stresses Cooper Brathwaite.
RNAO is gratified that Premier Ford sees the health and safety of residents and staff in LTC as the number one priority, and is fully prepared to work with his government to “fix the long-term care system in Ontario.” RNAO says such action should begin right away since Minister of Long-Term Care Dr. Merrilee Fullerton is expected to deliver a report on the adequacy of regulated staffing in LTC to the legislature on July 31. This is a requirement in the recommendations of The Long-Term Care Homes Public Inquiry led by Justice Eileen Gillese, in 2019.
RNAO wants Minister Fullerton to recommend and immediately implement substantial measures and funding to address the current regulated staffing crisis that permeates all nursing homes. Such a move will show the public that Premier Ford’s government is ready to act with urgency. Acting on a past commission’s recommendations will demonstrate that Premier Ford is intent on implementing the recommendations of a future one.
“Although staffing is only one component of what needs strengthening in our long-term care system, it is a central one. Adequate overall levels of staffing, as well as strengthening the skill mix between regulated and unregulated staff alongside the funding to make it real will go a long way to start addressing the damage done to nursing home residents, their families and their staff,” says RNAO’s CEO Dr. Doris Grinspun. “RNAO is bringing a concrete evidence-based proposal for Minister Fullerton to adopt in her July 31 report to the legislature, and implement immediately thereafter. RNAO’s proposal is well-known to government since it took office in June 2018 and addresses the dangerous levels of staffing and skill mix currently found in LTC,” Grinspun adds.
RNAO is proposing a basic formula to address the crisis of staffing in LTC to include: (a) adequate numbers of staff, and (b) the proper skill mix of regulated and unregulated staff – including larger utilization of nurse practitioners (NP), registered nurses (RN) and registered practical nurses (RPN), allocated follows:
Basic staffing formula:
- Each resident shall receive four (4) hours of direct nursing and personal care each day, as follows:
- 0.8 hour of RN care (regulated)
- 1 hour of RPN care (regulated)
- 2.2 hours of personal support worker (PSW care) (unregulated)
- In addition, there should be one (1) NP per 120 residents, and
One (1) infection prevention and control specialized nurse (preferably an RN), per home.
In 2017, the government committed to providing four (4) hours of direct care per day per resident. This target was based on a 2008 report by RN Shirley Sharkey. Shockingly, to this day, the four (4) hours of direct care per day per resident has not been implemented leaving residents short of staff to meet their needs. Equally worrisome, is that current legislation in Ontario does not specify ratios for RNs, RPNs and PSWs; it only assigns one RN on-site per shift, which is gravely inadequate, as the CAF report shows. Added to these deficiencies is the fact that only a small number of nursing homes have NPs and most must do without any. In short, the current standard fails on two counts: the overall number of hours of care is too low, and there is no requirement that a certain number of those hours of care be provided by an NP, RN and RPN (regulated staff).
The proposed RNAO standard also recognizes the specialized nature of LTC and the need to have a nurse (preferably RN) dedicated to lead on-boarding, orientation, mentoring, and staff development, as well as infection prevention and control, as part of the mandatory staffing required.
The CAF report provides multiple examples to understand the profound impact of these numbers:
Inadequate overall levels of staffing: The indications are everywhere in the CAF report: “Morale and well-being of staff at risk. Many are overworked, seem burned out and have no time off (some have not seen their families for weeks).” The staffing is such that it is impossible to provide care at a pace that is appropriate to each resident or allow them any kind of independence.”
Inappropriate standards of care due to the absence of regulated nursing staff: For example, a resident requiring palliative care was not given hydromorphone injection since an RN was unavailable (page 4). The presence of regulated staff is essential since PSWs have short, hands-on oriented training with little to none (depending on the program) theoretical background. For example, CAF reports that “PSWs can be task focused and do not always report discovered abnormalities to registered staff” (page 5).
Negative implications of lack of RNs: The CAF Senior Nursing Officer (SNO) notes the lack of RNs and the impact on safety: “No (civilian) RN in the building other than SNO during weekends. SNO and Executive Director (also an RN) only RNs on site on numerous occasions during the week. Significant resultant safety concerns regarding patient ratios (1 RN for up to 200 patients)” (page 8).
RNAO says the issues identified in the five long-term care homes supported by the military represent many of the long-standing issues that have existed and have never been addressed in this sector, in particular issues related to inadequate levels of regulated staffing. “Report after report including the 2005 Coroner’s Inquest into the Casa Verde home in Toronto, have called for urgent action and nothing has happened,” insists Grinspun.
RNAO calls on the Ford government to:
- Adopt the basic staffing formula presented above.
- Release on July 31, 2020 a plan of action for implementation of the new staffing formula to be completed within 6 months – by the start of 2021.
RNAO has been raising staffing concerns for years and now is calling for immediate action to avoid adding harm to the damage already done. “Minister Fullerton has a golden opportunity to deliver on a first installment of building public trust. The shortfalls of staffing have been discussed and examined and the time to act is July 31, when the minister must table the results of her consultations in response to Justice Gillese recommendations in the long-term care public inquiry report, released on July 2019. One of her key recommendations ̶ #85 ̶ called on the government to increase the number of registered nursing staff in long-term homes by undertaking a study and tabling its results in the legislature by July 31, 2020.
The Canadian Armed Forces report reinforced once again that key staffing issues must be immediately addressed. There is no need to wait for a new commission and – once again – delay addressing staffing issues. “Premier Ford – here is your opportunity to fix the system, as you have promised, and we are eager to help you do so,” offers Grinspun.
The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses’ contribution to shaping the health system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit our website at RNAO.ca or follow us on Facebook and Twitter.