Over 100,000 patients are cared for in Alberta and Ontario’s nursing homes every year.

Many residents and families are quite happy with the care provided in nursing homes. However, news reports from home and abroad remind us that not all nursing home residents receive the same quality of care.

Ontario has launched several quality initiatives for long term care in recent years, and the Ministry of Health and Long Term Care has recently announced that it will be hiring 100 additional inspectors to monitor the long term care sector.

However, while more inspectors can help ensure minimum standards are being met, they do not address some of the root causes of low quality, which include low staffing levels, inadequate training and a failure to engage all front-line staff in quality improvement.

Staffing levels in Ontario nursing homes lower than Alberta, Canadian average

“There is no doubt that we don’t have enough staff;” says Gail Donner, who chaired Ontario’s Long Term Care Task Force on Resident Care and Safety, “It’s past even talking about – you just have to go to a long term care facility to see that.”

“There’s good evidence that staffing level is a prerequisite for quality care in nursing homes,” says Margaret McGregor, a family doctor and research scientist at the University of British Columbia. Below a certain threshold, she explains, care staff just don’t have time to complete all the routine activities – dressing, feeding, grooming, repositioning, toileting, changing wet clothes, etc. – required for quality care.

According to data from Statistics Canada, staffing levels in Ontario’s nursing homes have historically been below the national average (behind only British Columbia for the lowest staffing levels in the country).

While Ontario legislation requires there to be a nurse on duty at all times in nursing homes, Ontario has not legislated a minimum staffing ratio – the ratio between the number of nursing home staff (nurses and non-nurses) compared to the number of patients they care for.

Statistics Canada data shows the average staffing ratio in Ontario nursing homes was 4 hours per resident day in 2010 (the last year for which data is available). This was 25% less than in Alberta, where nursing homes averaged 5.3 hours per resident day. (This is only a measure of the hours paid to all staff in nursing homes, not of the actual time care staff spend providing care ‘at the bedside.’)

“Many nursing homes don’t have enough Personal Support Workers (PSWs),” says Miranda Ferrier, President of the Ontario Personal Support Worker Association. “Even when facilities aren’t short-staffed [due to illness or injury], staff are stretched too thin to provide quality care to all residents. When they are short-staffed, it’s even worse.”

Candace Chartier of the Ontario Long Term Care Association agrees, saying “there is simply not enough funding to staff appropriately for the kinds of patients who are now residing in long term care.”

Staffing levels relatively stable, despite rising patient complexity

Staffing levels in nursing homes are a concern not only because they are low, but they may not be increasing fast enough to meet the rising medical complexity of patients in nursing homes.

Data from the Canadian Institute for Health Information shows that between 2008 and 2012, the proportion of residents in Canadian nursing homes with disease diagnoses increased for every category of disease.

Proportion of residents in Candian nursing homes with specific health conditions
Disease type	2008	2012
Endocrine/Metabolic/Nutritional Diseases	31.3%	38.7%
Heart/Circulation Diseases	61.1%	70.6%
Musculoskeletal Diseases	50.4%	55.7%
Neurological Diseases	73.6%	77.7%
Psychiatric/Mood Diseases	32.0%	36.8%
Pulmonary Diseases	14.0%	17.0%
Sensory Diseases	20.9%	23.9%
Other Diseases	45.3%	52.2%

Dementia is also increasingly common among Canadian nursing home residents, with over three quarters of residents having some level of cognitive impairment. More than one in four residents suffers from severe dementia.

As a result, the care needs of nursing home residents have grown. In Ontario, care needs are assessed using the Method for Assigning Priority Levels (MAPLe) scoring system. The system ranges from a score of 1 (low needs) to 5 (very high needs). In 2012, 85% of new admissions from the community and 78% of admissions from hospital were in the High or Very High (MAPLe 4 and 5) clinical needs categories. Less than 1% of admissions were in the low and mild (MAPLe 1 and 2) clinical needs categories. Projections from the Ontario Long Term Care Association suggest that soon virtually all patients admitted to nursing homes will be from the two highest need categories.

The increasing needs of nursing home residents in Ontario has been driven in large part by the shift from letting individual nursing homes choose their residents, to having Community Care Access Centres determine who is in greatest need of long term care, says Dr Samir Sinha, lead for Ontario’s Senior Strategy. Prior to this change, he says, some nursing homes were caring for patients who didn’t need long term care at all, but would have been better cared for in their own homes. Now that the process has been standardized, he believes the patients cared for in long term care are only those who need to be there – those with the highest care needs.

Alberta has experienced a similar shift in the needs of its nursing home residents, says Bruce West, Executive Director of the Alberta Continuing Care Association. This has largely been driven by Alberta’s development of publicly-funded supporting living centres, which care for residents who can no longer live at home, but who do not require 24 hour nursing care, he explains.

Meeting needs of today’s nursing home residents will require updated “skills, knowledge and attitudes”

While Cheryl Knight, Executive Director of Seniors Health for Alberta Health Services says that nursing homes need a certain number of staff to provide quality care, she is clear that “staffing levels alone do not ensure quality.”

Donner agrees, saying that “while we need more staff in long term care, just establishing an arbitrary number for staffing ratio isn’t the solution.”

These experts stress that it’s equally important to look at how much time staff are able to spend directly with residents, and whether they have the training they need to provide quality care. Given the increasing needs of long term care residents, Sinha explains that “we have to make sure the staff working in our long term care facilities are equipped with the knowledge, skills and attitudes to care for the residents we have today, rather than the residents we had ten years ago.”

Ontario moves to find efficiencies and increase staffing and skills

Ontario has begun to increase both the number and skill sets of nursing home staff, while also trying to find efficiencies to free up more staff time for direct patient care.

“One of the most promising initiatives to date has been Behavioral Supports Ontario (BSO),” says Sinha. The BSO initiative is province-wide, and has funded the hiring of 604 new staff (194 nurses, 272 PSWs, and 138 other health care professionals, such as social workers) with specialized skills in caring for and supporting residents with complex and challenging behaviors, such as violence.

BSO-funded staff are located both within individual nursing homes, as well as in mobile outreach teams. Mobile BSO teams provide support to their colleagues in nursing homes, by helping develop care plans and strategies to help manage residents with challenging behaviors. (Quarterly reports and an interim evaluation are available on the BSO website.)

Ferrier believes the BSO initiative is an important step in the right direction, but stresses that PSWs also need more direct training in caring for patients with dementia and in crisis management. “The BSO teams are a great help,” she says, but if a crisis breaks out at night when a PSW is alone, they need the training to manage it.

Sinha also thinks there is opportunity to increase the amount of direct care that staff can give to residents, without having to spend more on hiring more staff. “We need to make sure our care staff aren’t doing unnecessary assessments or clerical paperwork, so that we can release more of their time for direct care,” he says. “We’ve seen some real successes with this approach, like at the Mon Sheong nursing home in Richmond Hill, where they used some Lean methodologies to look at all the work their clinical staff were doing, and they were able to reduce unnecessary administrative tasks and free up 12,000 more hours a year of front-line time for direct care.”

Alberta researchers and policy makers aim to engage Health Care Aids in quality improvement

Researchers and policy strategists in Alberta believe another key to improving quality in nursing homes is to engage Health Care Aides (HCA in Alberta is the rough equivalent of a PSW) as full members of the care team.

Carole Estabrooks, a Professor of Nursing at the University of Alberta has been researching the engagement of HCAs in quality improvement for the last several years. She believes that too often, HCAs are not treated as members of the care team. “Care Aides typically have the least amount of formal training, and as a result doctors, nurses and others too often assume they have nothing to offer,” she says. Frequently, this means they have little input into the care plans they are expected to carry out.

“Rather than just telling Care Aides what to do, Knight believes medical and nursing staff should recognize that care aids often have valuable insight. “Care Aides spend the most time with residents, they know the residents best”, says Knight. “If we’re having trouble getting a resident to drink enough fluids to stay hydrated, just telling a Care Aide to ‘make sure Ms. Jones drinks more’ isn’t going to help. I’ll get a lot farther asking the care aid ‘have you noticed if there’s something Ms. Jones really likes to drink?’ Now we’re collaborating – we’re working together to identify strategies to improve care for Ms. Jones.”

Estabrooks’ research indicates that “Care Aides on the front-lines are an untapped source of quality improvement – when you put them in a position where they can help develop solutions, and support that work, they can be very innovative.” (Results of Estabrooks’ research are currently in press with the European Journal for Person Centered Healthcare.)

Ferrier believes this approach has enormous promise, and describes similar experiences in Ontario, particularly at Wellington Hospice in Guelph: “They have a phenomenal team ethic – the PSWs, the nurse, the dietician, the doctor – everyone is part of the team. The PSWs participate in care meetings, because they recognize that PSWs know the residents best, and so have important information to contribute.”

Ferrier also notes that the PSWs who work at the Wellington Hospice are much more invested in wanting to enhance their training. “That environment has made them want to be the best they can be,” she says.

Changing the culture of elder care

While staffing levels, training and engagement all play important roles in determining the quality of long term care, there is broad agreement among experts that effort must be made to change the culture of elder care in Canada.

“We currently place value on a life ‘to be lived’, not on a ‘life lived’” says Estabrooks.

Donner agrees. “Our whole society doesn’t value elders – we’ve started to think of elders as ‘takers’. As long as we think that way, it will be a self-fulfilling prophesy. If all of society devalues our elders, it can’t help but reflect in the care they get. How can professionalism grow in our care workers if they can’t feel pride in what they do because society doesn’t value it?”