“Increasing staff at the point of care is needed immediately to assist with the activities of daily living.” That’s the plain language advice in the report submitted by the expert panel on long-term care to the provincial government more than a year ago. But in that time, what has changed to improve life for residents and caregivers?
“We heard over and over from residents and their families that staff do not have time to provide appropriate care because they are ‘working short,’” stated the report.
The panel, chaired by gerontologist Janice Keefe at the Centre for Aging at Mount Saint Vincent University, recommended two things the government could do as a stop-gap until it developed a recruitment and retention strategy: one was fast-tracking the process to import internationally trained workers, and another was creating a new “temporary assistant” position to lighten the load of continuing care assistants who feed, bathe, and provide personal care for residents. But as of last June, there were still 300 vacancies across the province, mostly for casual or part-time workers.
Both Michele Lowe, who speaks for the Nursing Homes of Nova Scotia Association, and Josie Ryan, executive director for Northwood Inc., say a change to regulations allowing internationally trained registered nurses and licensed practical nurses to work as continuing care assistants while they re-certify has been a big help. Ryan estimates as many as 40 to 50 new continuing care assistants a month have come in since October at several facilities owned or managed by Northwood. India and the Philippines have become sources for additional healthcare workers.
Hiring people to assist continuing care assistants with housekeeping duties and escorting residents, however, has had less impact and resulted in fewer hires. That said, Ryan says two people hired as temporary assistants at the Shoreham Village home in Chester have chosen to take the two-year continuing care assistant program offered by the Nova Scotia Community College. As recommended by the panel report, the provincial government is now paying tuition for students who enrol in the continuing care assistant course.
The panel also recommended the province prepare a long-term human resources strategy by November of 2020. That hasn’t surfaced, despite the retirement of hundreds of continuing care assistants and family doctors anticipated over the next three to five years. The Health Department declined a request to interview the senior executive director of long term care. Instead, it provided a progress report that shows work on all 15 recommendations is underway, with five having been implemented, including a province-wide policy to prevent and manage pressure injuries or bedsores.
Working short on shifts
“We haven’t seen much change,” says Louise Riley, a continuing care assistant who chairs CUPE’s Long-Term Care Committee. “We are still working short and we are still being mandated (i.e. forced by the employer) to work overtime. We have lots of people out sick or on Workers’ Compensation claims. We need more CCAs in nursing homes - period.”
Since the panel reported, continuing care assistants got a raise. Wages currently range from $18.64 to $20.12 an hour to start. Riley says the reintroduction of training bursaries, immigration changes, and temporary assistants are all welcome but are still only “temporary fixes.” She says internationally trained nurses don’t stay long in continuing care assistant jobs and temporary assistants aren’t trained to do the type of personal care that is most required.
The Department of Health is now surveying nursing homes every three months to find out how many vacant positions they have. Michele Lowe of the Nursing Homes Association of Nova Scotia, a group (including Shannex) that provides about 85 percent of all the province's nursing home beds, says a better question would be: how many vacancies exist on each shift? Lowe says that’s because many homes are funded for 0.2 or 0.6 of a position, and that means as many as five to six people could be sharing one full-time job.
“On paper, our members say it looks as if they have no vacancies,” says Lowe. “The challenge is many of the individuals they have hired are casual or part-time. The homes say, ‘My vacancies are in my shifts: people are off on disability, sick time’ - all that stuff.”
Lowe says absenteeism is a big challenge and in 2019-2020, the Health Department will spend $72.2 million on claims, disability, and time lost by healthcare workers, many of whom care for the elderly.
Both Lowe and Ryan say nursing homes are working to resolve some of these stubborn challenges. In December, the Health Department made $3 million available through an innovation fund to test pilot projects. For example, Lowe says homes have teamed up to request funding so they can share services and receive more frequent visits from professionals such as nurse practitioners, recreation, physio- and occupational therapists. If homes can demonstrate their residents experience fewer falls or “do better” as a result of getting these services, the Health Department has committed to making some permanent changes.
Janice Keefe, who still sits on the Committee monitoring the implementation of the panel’s recommendations, says she is encouraged by initiatives taken by homes themselves.
“When people say ‘We need more beds or better quality of life for residents,’ my suggestion is we need to get it right before we just throw more beds at the problem,” says Keefe, “because we are still going to have lack of staff and not enough care. Where I still have a big concern is staff morale. You can’t attract people unless you value them, and nurses in long term care are not valued for the extent of the experience they have dealing with so many chronic illnesses. We have to break that circle.”
Another problem on near horizon
While the authors of the panel report called for more money and more front-line staff, they stopped short of prescribing a new staff-to-resident ratio for either nurses or continuing care assistants, in part because there aren’t enough people to hire. The current legislated ratio of one registered nurse for every 30 residents was established more than three decades ago before the establishment of homecare, which allows people to receive support in their homes for a longer period before admission. But by the time elderly Nova Scotians are admitted to a nursing home these days, their physical, mental, and medical needs are more acute and complex than they were in the 1990s.
“What is in our face right now is access to primary care for our residents,” says Michele Lowe. “We have three homes that stopped taking patients because they have no physician. Under the Homes for Special Care Act, it puts the responsibility for that client at the foot of the home administrator. The government has provided some homes with access to a nurse practitioner, which is working beautifully. But we have other homes where the doctor providing coverage is well into his or seventies, and when they retire, there will be more long-term care homes left without an attending physician.”
Health Minister Randy Delorey recently said about 19 nursing homes have some access to a nurse practitioner. But while the government is committed to training and hiring more nurse practitioners, its focus has been to get them working as part of collaborative care centres in communities where everyone can access their help.
Once again, nursing homes find themselves competing with other parts of the health care system for trained staff.
