By Brenda Pearce,
RN
I recently
watched the W5 program on abuse in Long Term Care (LTC) homes across the
country. If you have not seen it, then I URGE you to watch it right now by
clicking this link:
http://www.ctvnews.ca/w5/w5-nursing-home-investigation-reveals-1-500-cases-of-staff-to-resident-abuse-in-one-year-1.2321287
http://www.ctvnews.ca/w5/w5-nursing-home-investigation-reveals-1-500-cases-of-staff-to-resident-abuse-in-one-year-1.2321287
To give some background, I am an Ontario Registered RN with over 3 decades of experience in healthcare. I have taught Personal Support Workers (PSWs) and Registered Practical Nurses (RPNs) at the Ontario College level. I have been a part of an implementation project with the Ministry of Health and Long-Term Care (MOHLTC) in Ontario, and I have worked in both the hospital sector and to this day have worked in 10 LTC homes. I work as a part time RN in LTC right now. I am writing this blog from a place of knowing. I only speak from my experience.
Watching the CTV
program at first blush is very shocking. There are things that happen and are
seen in it that should never ever happen. There are actions that people do out
of becoming disenfranchised and burned out, and are inexcusable. I feel for the
families, the residents and the staff. I too have aging parents and part of my
quest of working in so many LTC homes is to eventually find where I would place
my parents when and if the time comes. I am still looking.
Many people
coming into long term care are very complex. Their needs are escalating as the
problem lists are expanding. People are not just the elderly. There is a
growing population of younger and younger people who cannot be housed and
assisted as home options dwindle and their complexities increase. There
are more and more mentally ill people being admitted along with the cognitively
and physically declining elderly. The baby boomer population has not peaked yet
and as we peak, we will see the co-mingling of people at various states of age
and complexity increase.
The focus of the
W5 show is on unregulated care providers (UCPs) known as PSWs or previously
known as HCAs (Health Care Aides). It shows a variety of people providing
damaging, derogatory and disrespectful care. All of it should NOT be occurring.
What I want to focus on is the instances of direct care where 1 UCP is
providing direct care to 1 resident, or where 2 UCPs are making snide remarks
and being directly disrespectful to a resident. Treating these clients like
unwanted baggage is totally wrong. I will not justify the behaviour. I
will justify that with heavy workloads, decreased coverage of care during times
of breaks, where less staff are taking care of residents’ requests and needs are
at high demand at times, these behaviours are symptoms of a system based on
minimum care standards that are set by our Ministry of Health, and multiplied
throughout the country. In Ontario, the symptoms are magnified from home
to home. Some are a little better, but the minimum standards provide homes a
benchmark that they often do not exceed as funding by the MOHLTC sets the
envelopes that each home receives. Many
homes are businesses and as such need to provide profits to shareholders and
corporations in order to continue to be in business.
There are for profit
homes, charitable homes and municipal homes. These homes need to be run in the
black, not the red. These homes belong to one of two provincial
associations. The OLTCA is for profit homes and the other association is
for not-for-profit homes. Many residents who come into these homes are filling
semi-private and private rooms and have nothing more than their basic pensions.
Or they fill these beds in interim until the appropriate level of beds become
available. New build regulations in Ontario are doing away with the traditional
3 and 4 bed ward rooms, but many homes have not yet been able to rebuild or
implement these changes, or are on a list within their respective corporations
to rebuild as able or allowed.
There are
standards that must be met to maintain a license to operate. There are annual
compliance officer visits, audits, and there are accreditations and generally a
lot of hoops to jump through and rules and regulations to remain in the LTC
business. A lot of costs are incurred to meet all of these standards of care.
However, the MOHLTC
sets the minimum care requirements. They set the funding to these homes, and
they set the ratios of UCPs to resident. Homes are going to ensure that the
minimums are met, but providing more than that may or may not occur. You can
also be assured that there are checks and balances from a corporate level that
do not provide incentives to move beyond that to ensure corporate costs and
profits are also maintained. In short, the resident is in the middle of this
tug o' war. I feel these vulnerable people are being shortchanged, and we are
often not aware of this until we are made aware of all of the shortcomings.
There are
physical conditions that may make an innocent bump turn into a black eye as the
skin tissues thin and the collagen slackens. But, when can an innocent
situation and an actual physical contact of abuse appear differently? One only
knows. I also know that cognitively impaired people can also become abusive towards
a well-intended and compassionate caregiver. Hygiene is a basic requirement
of incontinence and goes hand-in-hand with declining cognition. In the W5
episode where the 1 caregiver is trying to turn and attend to the provision of
hygiene and applying a brief, I can honestly say that this occurs because of
the minimum staff ratio as set out by the MOHLTC. Many residents, minimal
staffing and high needs of declining cognitive elderly results in quick care
provision and the need to get moving to the next resident as the needs are many
and the time to provide care is minimal. It really looks awful on video and, in
short, should not have to be this way.
I see the direct
care providers in LTC, the UCPs, become burnt out because the high demands of
the job. There is also a need to ensure that documentation is complete, and
this is extensive. There is reduced staffing while breaks and meals are taken. There
are often times that UCPs are working short on shift due to lack of ability to
cover call-ins. Why? Many UCPs work 2 or 3 part time jobs in order to afford to
live! They may go from one 8 hour shift to another 8 hour shift back-to-back. They
may work 10-12-14 days in a row including different shifts, lack of sleep
during these long stretches in order to meet the demands of scheduled and
unscheduled shifts. There is a basic undercurrent of not wanting to let any of
their bosses down. They set themselves up for injury because of the heavy work
demands. Different employers under different collective agreements have
different levels of pay for the same job. The number of full time jobs is
declining because it is more affordable to the LTC homes to move more and more jobs
to part time staff. Part time staff that count on the number of scheduled
shifts to ensure their income base, take on more part time employers because they
cannot count on the call in shifts. Thereby, when a call in comes to them they
turn it down as they prefer to go to where they are scheduled, or have a scheduled
shift already in place. It is a huge problem which is evident in EVERY LTC home
I have worked for. Some employers will not call-out for part-time staff until
the 2nd call-in for the shift comes in. This ensures that homes that employ
that strategy are always working short. Working short adds more workload to an
already overloaded workload based on minimum staffing levels.
This does not empower
the staff to provide the care that they really do want to provide, and when
caught on camera as they have been, makes them look like villains, abusers, and
criminals. I will not and do not ever feel that blowing ones nose in a sheet,
or making out in a room with another staff member, or spraying water on a
residents face or throwing them in a chair, or any of these behaviours as seen
in the video, are symptoms of the system. They are simply inexcusable. I simply
feel that they would be lessened in a system that raises the bar of minimal
staffing, where people feel less stressed and have the staffing and
resources to provide the care they really do want to provide.
The
implementation of a comprehensive assessment system known as RAI MDS was
implemented more than a decade ago to improve resident outcomes and provide
funding to enable residents to improve abilities through nursing rehab, and to create
a team approach from all disciplines. I was part of the Provincial
implementation program. Homes were elated to know that by providing more
programs to help their residents become healthier, stronger and feel more
engaged, they could access funding and create the programs that would increase
what is known as the CMI level for each resident. Well, the homes went crazy
with implementation, and then the MOHLTC decided that they could not afford to
support the implementation of these programs and now there is no funding for
nursing rehab, which has led to a significant reduction in the number of
programs.
People who are
coming into LTC homes walking are ending up in wheelchairs and losing their
abilities, making them frail, more dependent and more at risk for the
appearance of abuse during the provision of care. With low minimum staffing
ratios, there is less staff to assist people who want to maintain their levels
of ability, and the dependency grows.
Turning and
positioning frequently for bed-bound residents is the way to reduce pressure
ulcers. Allowing better communication and time to provide care to residents
allows for better outcomes and reduction of pressure ulcers and provision of
care by the Registered Staff who treat the breakdowns, chart and monitor them,
and involve the MD in the care needs of the resident. When the ratio on a night
shift is 2 PSWs to 60 residents, you can be assured that it is difficult to
make frequent rounds to turn and re-position.
This is a growing
problem, and not just in Ontario. Here are some solutions:
- Create a division of the College of Nurses of Ontario to regulate UCPs - Colleges are regulatory bodies that ensure protection for the public. Each Province has a similar regulatory college.
- Contact the Minister of Health. Dr. Hoskins in Ontario, or your own Minister in the Province in which you reside. In Ontario you can connect through this link - http://www.health.gov.on.ca/en/common/default.aspx?hc_location=ufi
- Demand elected officials and those running for office to be aware of this situation and to lobby for better outcomes for those who reside in LTC, and their families.
- Be informed well before the time of need to access the system of LTC.
- Ensure better health outcomes by employing integrative approaches to better nutrition, and employing health practices such as massage therapy, Reiki, reflexology and demanding that these continue well into other health residences, including LTC.
- Be active in PRIM, CARP and voice your concerns. Being proactive and advocating for change are very important.
