Sustainable staffing is critical to long-term care

A history of staffing issues

In 2018, an Ontario staffing study found that 59 per cent of the staff employed in LTC homes were personal support workers (PSWs), 17 per cent were registered practical nurses (RPNs) and 8 per cent were registered nurses (RNs). That means, on average, less than half of the staff in a given Ontario LTC home have the qualifications to perform clinical duties such as health assessments and administering medication. With such a low percentage of nurses, the time that nurses spend with each resident is often severely limited because of the sheer quantity of residents requiring nursing care. PSWs are able to carry out certain tasks delegated by nurses and assist residents with their daily living activities; however, as with nurses, the ratio of PSWs to residents in their care can be overwhelming.

Issues related to the recruitment and retention of care staff pose a major challenge to the sector, jeopardizing both continuity and quality of care. This is especially the case for PSWs, who typically have lower salaries, limited occupational benefits, and physically and psychologically demanding work. The same staffing study found that about 40 percent of PSWs leave the healthcare sector within one year of training. Only about 50 per cent of PSWs remain in the field within five years of joining, with 43 per cent leaving due to stress and burnout related to staffing shortages.

Such problems have persisted silently for years within the LTC system. However, with the onset of COVID-19, there is now national acknowledgement of these issues and their impact on the wellbeing of residents.

COVID-19 and the road ahead

Since COVID-19 reached pandemic status back in March 2020, the effects of the already dire conditions within the provincial LTC sector reached a new level of devastation. Staffing shortages were exacerbated, and in some facilities, limited supplies of personal protective equipment (PPE) put both staff and residents at risk of contracting the virus. Measures that were put in place to curb the spread of the virus — such as mandating that care providers work in only one location to reduce the risk of COVID-19 transmission between facilities, frequent testing and adequate PPE — were introduced late in the first wave. Situations arose where residents, already vulnerable to the virus due to their older age and prevalence of pre-existing conditions, were left alone and unable to care for themselves. This eventually reached such a level of crisis that the Canadian Armed Forces were called upon to provide some level of relief in LTC homes experiencing severe staffing shortages.

Currently, as the second wave of the pandemic continues, the situation in LTC remains dire. Outbreaks and COVID-related deaths have been rampant. Although the first wave of the vaccine rollout has targeted LTC residents and staff, the underlying issues within LTC exacerbated by the pandemic will continue unless sustainable long-term solutions are implemented now.

In December, the Ontario Premier’s office released an LTC staffing plan that promised four hours of direct care  for LTC residents by 2024-25, with an investment of up to $1.9 billion annually aimed at creating more than 27,000  jobs in the sector. The plan also identified five other action areas: expanding education and training, supporting staff development, improving working conditions by increasing full-time employment, promoting effective leadership, and using performance indicators to evaluate progress.

This plan offers great potential given the challenges the LTC sector is facing. However, the timeline has received criticism from groups like the Registered Nurses Association of Ontario (RNAO). The RNAO welcomes the plan, but argues that four years is much too long to reach four hours of care per resident per day, and would allow issues within LTC to perpetuate for years. Instead, the group’s Nursing Home Basic Care Guarantee proposes a minimum of four hours of direct care per resident per day, including at least 48 minutes of RN care, 60 minutes of RPN care and 132 minutes of PSW care. It also calls for:

• hiring more care workers in order to increase the amount of care time per resident;
• reducing staffing inconsistencies related to varying salaries, benefits and staff-to-resident ratios, which can affect quality of care;
• bringing the salaries of nurses and PSWs in line with salaries for the same positions in different care facilities (e.g. hospitals); and
• creating full-time jobs with benefits, so that workers would not need to work in multiple locations.

These amendments would be a positive step toward improving recruitment and retention. This is especially the case for PSWs: As of 2018, 48 per cent of PSWs worked part-time, and many worked in multiple locations to support themselves. A set of standard benefits could better protect these workers, potentially decreasing their levels of stress and burnout and allowing them to stay in the field longer. However, the province’s proposal remains vague about such benefits for PSWs.

While improving working conditions for staff should be a clear priority area when it comes to tackling the LTC crisis, ensuring that this is not only done efficiently, but also sustainably, is paramount. In addition to implementing the action areas highlighted by the province and the RNAO in a timely manner, methods to track the progress of such initiatives are also needed to ensure that positive outcomes are actually being achieved and maintained. This could include regular inspections of Ontario LTC homes to guarantee that appropriate infection prevention and control measures are in place, as well as to ensure that the needs of both staff and residents are met.

Building a strong and sustainable foundation of dedicated and compassionate care teams within Ontario LTC homes is vital to improving the quality of care for residents. More support for staff can translate into staff who are better equipped to care for residents — a lesson that COVID-19 has taught us the hard way.