Improving quality in Canada’s nursing homes requires “more staff, more training”

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



Endocrine/Metabolic/Nutritional Diseases



Heart/Circulation Diseases



Musculoskeletal Diseases



Neurological Diseases



Psychiatric/Mood Diseases



Pulmonary Diseases



Sensory Diseases



Other Diseases



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?”

The comments section is closed.

  • Jennifer Miller says:

    Long term care requires stricter regulations including
    • minimum staff to resident/patient ratios,
    • minimum staff time per resident/patient,
    • staff training to properly address dementia and other complex needs, and
    • unannounced inspections per year

  • Rebecca says:

    I’m an American LPN geri-psyc-skilled. I have been 47 years in long-term care. I have worked in 6 states. You people have it great. I had never any less than 23 residents to 180, that’s right.
    The worst place I worked was Texas. We have TPN, vents wound-vacs tube feedings in our facilities. There were times when we shared O2 concentrators, IV poles, and at times could not find a needle to give an IM. Really, you all have it much better.

  • Kyla says:

    This was an articulate and well-thought out article. It illustrates a lot of the issues we face everyday. I made the switch from being a PSW into Early Childhood Education as it’s a much better regulated and standardized system. I truly enjoy working with seniors but long-term care homes and hospitals only offer dismal prospects and stressful jobs. There is no true oversight and abuse runs rampant in these homes when both residents and staff feel bitter. Enforcing a ratio of 1:8 would be an excellent first step and PSW’s with extra knowledge should be assigned to the more complex-needs residents (please pay for their experience accordingly). Our seniors need help and they deserve quality care.

  • Jim says:

    It seems to me that the problem is not enough hours by the employer as most emploees have to have more than one job. If more hours were offered more employees would be glad to work.

    • Kyla says:

      Great point! A lot of employers offer really inconvenient ‘lines’ with only a few hours a week. I believe since it is 24 hour work we should work on rotation like most other emergency services do (police, paramedics, etc.) with the exception of people signing up to work a straight afternoon or night shift. They have problems staffing because they either offer no hours or an inconvenient shift time for the majority of women who are doing the job (most PSW’s I know are moms) and want to be home in the evenings with their children or can’t find childcare to work overnight.

  • Alyson Flood says:

    This was well written! I agree completely. Most nursing care staff or aides dont set out with intent to harm or do the least for their patients. But society and govefnmentsl constraints or resources have set them up for failure. Without the support sttucture or empowerment of the leadership or patient advocates to provide continuous consistent quality care, we have failed our elderly after they have given do much of their lives and selves over their productive years. So what are we to do? I recommend pooling and sharing resources across continumn of thr otovinces. Veterans and residents are intermixed in nursing homes with PTSD and violence tendencies abd these added dynsmics on the staff or are not trained for example, have also been ignored due to “no places to be placed to meet their needs” so assaults and unsafe conditions and frail elderly women being choked or assaulted are common occurances that are not often addressed. I have witnessed these in person and feel for all the parties involved. Thankfor looking at this critical issue and increading community awareness. As a society we have to share in finding solutions and honoring our elders. They are at our mercy and depend on our support & deserve a safe and nurturing loving environment to live out their final days.

    • Suzanne Wade says:

      I totally agree with you! We need to take better care of the elderly in nursing homes. We have to be advocates for them as they are not able to speak for themselves in most cases. Remember that we will all be in their situation one day too.

  • J Del Giacco says:

    I work in a nursing home , we are always understaffed, often working 2 staff for over 30 residents some of which are fall risks, more and more staff members are getting injured on the job myself included ,(I now have a life long knee injury) Our home claims they try to replace but staff say they never get a call. Management thinks if they extend a short shift we are ok, but we are still down physical bodies, not to mention having to still due baths and working under stressful situations and being denied vacation time off. Management continues to “promise” family members unrealistic expectations and staff ,are unable to adhere to these demands with then no backing from our management team. We are told we are a “dmd a dozen”. The surprising thing is when Ministry comes down we are fully staffed, only to be told in the past that it is not in “the budget” to replace or extend shifts. Union is helpless and often times neglectful to deal with this matter even after pointing out that this is a form of harassment, unrealistic goals in a unrealistic time frame.

  • Marla osborne says:

    HCAs need an associaton just like LPNs and RNs…..To be treated fairly

  • Jennifer says:

    If I have concerns regarding my mother’s medication or her pain in her lower quad.Not able to see the catscan results
    To be told that they are not able to tell you what’s wrong. I need to call the POA.In North Carolina. How can I get info regarding her health when I am sitting right there beside her

  • sarah says:

    I work in a rest home that has close to 100 residents in it…I am a psw and work with only one other psw and a nurse on the night shift…we are in charge of 75 residents , and have 18 of them who need product changes, walks to the bathroom, frequent checks to fall risk residents. As alot of the 18 of these residents need at least 2 people to assist with changes, and walks to the bathroom it spreads us very thin if there is an emergency in the building. We would not be able to help if we are both stuck with a resident who requires at least 20min help with changing, etc…The nurse of course is doing her nursing duties….very frustrating…constant pleading with management becoming a headache, a waste of time…families expressing their concern to me about this issue….If there also is a fire , heaven forbid…but this situation is not fair at all for the elderly or the workers….pleading for change….the rights of the residents and the psws who are struggling with this issue, also paid, just enough to pay bills…heartbreaking that rest homes are aloud to run their businesses like this…very very sad…..

  • Mary skjonsby says:

    How do I see quality assurance report for a particular nursing home?

  • Darla says:

    PSW’s are sadly looked down apon by management and registered staff and under appreciated!! We are bull workers with a ridiculous work load. We are just a number!! We do everything that a nurse does except meds etc so how can you call a “NURSE”a nurse when they do no hands on with anything with the resident in long term care? It’s rather sickening!! Staffing is 1 to 11 residents in the facility I work in and when we work short like usual we are working 1 to 16 residents! Tell me how that is even safe or fair to the residents!! For sure there is no “quality care” given as it’s impossible!! Surprised if the residents are getting hot meals due to the high number of feeders compared to the Skelton number of employees on each shift. Sure hope this changes!! Unfair to the elderly as well as the staff!! One wonders why there is so much burn out and injuries!!

  • Tim H says:

    I work in long term care as a clinician and manager. As a clinician, I am often 3-4 weeks behind on URGENT medical consults, and as a manager I am usually 2-3 weeks behind on audits, reports, etc. that are urgently required by regulation agencies and RHAs. The reason why many LTC facilities are top heavy in administration is quite simple: LTC is heavily and overly regulated with governments and RHAs requiring an unsustainable and ridiculous amount of paperwork to flow upward to them. Unfortunately, if this data collected by managers and nurses would not flow upward so that more positions for PSW’s could be created then “heads would roll”. Again, this is unfortunate and is a problem created at the top. Homes are just scrambling and panicking to try to keep both the Residents healthy while scrambling on the other end of the spectrum to keep the “data monsters” in the government and RHAs fed. In the end, the Homes just cannot sustain this incredible level of work rate and inevitably Residents are overlooked in serious ways. I see this everyday. The public has no clue as to what truly is happening inside most Homes and the level of neglect which occurs on all shifts. Irregardless of this issue, the primary, and most important way to address this issue is to provide adequate numbers of PSWs on the ground floor-there is absolutely no way around it!

  • John Barr says:

    I believe all potential powers that be, that are looking to build new LTC homes, should have one thing in mind. As I remember a resident that spoke to me as I was on a team that was looking into building 2 new homes and to collect ideas by visiting other new homes, she said, “when you build your new home try building it for the resident and not for visitors or family attraction for the potential of their loved ones. Build for the resident. She was right, making it more like a hotel with lush front entrance and corridors with dining rooms on the ends (pods) so when residents finish their meals they sit and look at walls. Have them sit where they can see what is going on mind stimulation is absolutely essential. Private homes have a habit of this, making it look very attractive for potential residents, but not really giving the family member what they need visible stimulation, activation of others around them, company, laughter, attention, and I am here. Of course they need the care, and medication but what they want day to day is just “people”

  • Kevin Bates says:

    As a PSW in a Long Term Care Home in Ontario, I can tell you the stretching of the PSW is becoming worse. We have become a province that warehouses some of our most vulnerable citizens and gives them assembly line care. We are seeing more and more closing of acute care beds in hospitals and downloading of thes patients to LTC. Younger with psychiatric diagnosis mixed with elderly dementia is not a great combination and the expectation that 2 PSWs can take care of 75 residents on a midnight shift. We constantly hear they are in bed but they are not they wander around need to be redirected but instead of increasing staffing they increase charting which takes away from care time for residents. There is a great video at:

  • Sherry says:

    My heart goes out to you and your family as well…as a nurse in a LTC facility in Alberta we have staffing ratios of 2:26…try getting up 26 frail elderly people in the morning in 90 minutes. As well after supper they are exhausted, weak, frail, often sundowning and again 2 HCA to 26 residents. ABSOLUTELY IMPOSSIBLE to do adequate care….no matter what anyone says. I dare management to do the job of an HCA for one week…or even the job of aunit nurse…how can we properly give medications, care, assessments, WOUND CARE for 26 people in a shift??? SHAME SHAME SHAME on both government’s lack of funding and top heavy administrations! We have challenged our management about our ratios telling them no other facilities operate in this manner and they have lied to our faces….said that is the norm for LTC. 2:26??? LIARS! This is not an SL1

  • cheryl wouters says:

    This us hard for me, my mom recently died in a nursing home due to septicaemia, could this have been prevented? Answer; YES! Why? Lack of staff, education, support for nurses, to much money spent in management! Most importantly the sunday doctor? Everything can wait till sunday! No assessments!
    My mother was treated for gout, yet she had a necrotic area to her foot! No assessment, no blood work, no assessment, no doctor, till it was to late! If my mom could have called a doctor she wone so. I had called the home several times, requesting a doctor to look at her, yet was never seen, i called her doctor begging her to go see her. I asked the home for there sunday doctor to see her, not seen. I received a phone called from the home indicating her blood pressure had dropped, and were thinking of sending to hospital???? I told them no you are going to send her for it appears it has something to do with her blood, infection, and or gout med!
    Surprising she went to ER, presenting with a fever, lower flank pain, decrease appetite, drecrease out put, yet because she from a nursing home there approach to the elderly is decreased. Did bloid work and sent her back? Septic Shock??? No they decease her gout med, did they assess the foot? No!
    Morning comes, we get a call from doctor, what is your moms DNR? Finally doctor see her, to late, nothing can be done. My mom of 69, asks us to do everything to keep her alive, telks doctor its sbout time you came! She died shortly after that.
    I learnt later my mom lied in bed with pain to her foot, and lowere back, decrease appetite, fever, extremly tired, decrease urine out put, vomiting and we were not told of thses changes. I tried calling my mom, no answer, call home and they said she was doing fine! Asked them to look at her phone, for we talk sometimes 4 tines a day and I was worried!
    My moms death at 69 was and is to me grouse neglect! Owners are criminals, its about making money off of the most fragile population! Shame on the goverment of Canada.
    Most nursing homes in Canada, have more management then nursing staff, they hire cheap labour, in the promise of educating them. Most edlerly who come into facilities now are a lift and require more care! Care aides have 8 to 12 patients to get up in one hour and half, pkus bath two of them in the morning as well tend to ADLs of the patients! Things get missed! This has to stop! People are living at home longer, and the baby bommers are flooding the system. Nursing homes get more money for someone who reqiures more care, and homes are attracted to this and fill there homes and this put on those poor care aides!
    People need to stand up and fight back! Demand better care for seniors! I wish I did! There one thing to die of natural causes, but to die of a infection is another story!

    • dd says:

      My heart felt condolences to you . I agree with you that nursing home is very short staffed . Being a rpn at a nursing home I agree that with three PSW and one RPN how can the home with 32 resident unit run ? Lots of things gets missed out even if a nurse or a PSW wants to spend time with a resident she can’t because there are 8 others waiting . Shame on canada ‘ health care. Residents are paying 2500 Plus per month and get only less that 40 mins care in total a day . Totally getting ripped off paying pension plans and taxes.

    • KeriAnn says:

      Cheryl I am so sorry this happened to you and your mother. I, too, ran into a similar problem with my father. My sister who lives three thousand miles away did not tell anyone in the nursing home that he was having chest pain while he was vomiting. The staff thought it was simply the flu…so they gave him gravol and cough syrup for his sore throat. Within less than 48 hours, he died with a heart attack.

      I would never point a finger at the floor staff because they have not been taught to recognize symptoms of heart problems. My issue is with the communication breakdown throughout all nursing homes between those on the floor and those who would recognize symptoms (RNs, Doctors) … despite his age my father wanted to live … and NO ONE could see what was happening with his heart.

      The system itself is broken and needs an overhaul. e.g. respecting and responding to what the floor staff reports to administration or supervisors

      Again, I’m very sorry for your loss and your experience.

  • Anne says:

    I have been informed today by the charge nurse that the nurse to patient ratio in my Aunt’s facility is 2 nurses/psw for 32 patients. I don’t know how that translates into hours but how does this compare to other Ontario sites?

  • Mark Weitz RSW says:

    Looks like a great ezine and congratulations on getting mentioned in 2013/06/22 Saturday Star re LTCHs staffing issues.

  • diane carruthers says:

    Yes I have to agree. Working short is a serious matter And it happens way too much. When you cannot even stop and have a break you get pretty frustrated and that’s not good for anyone!! We seriously need to hire more ESP when there’s a high risk person that needs constant care. And were getting more and more residents that are more complexed and angry and very dangerous! Sometimes i wonder how long I can stay where i work due to circumstances that are out of my control

  • Ardonna Symes says:

    You can initiate as many programs as you want the real issue is that there are not enough “hands on care” staff. This issue is skirted around all the tme. Even when funding comes down it most often goes elsewhere. Ministry, come in and talk to your PSWs and get the real issue. We dont need more inspectors, we need more “hands on care”. Please listen to us!

  • Paul Curry says:

    %featured%A staffing ratio may not be THE solution, but it would certainly help. To be sure, the problems facing the long term care sector are multi-faceted, but we also need some simple and concrete steps to begin addressing these problems.%featured% Research by Hyer et al. (2009, 2011) details the positive influence of staffing ratios on quality of care in the US. This is a good place to start.

  • Sue says:

    %featured%finally, we are getting on the same page. We need more psw’s Take away all the things that have been loaded on the poor psw’s and let someone else do it. Let the psw’s look after their residents, and yes their knowledge is invaluable.%featured% Everyone can learn from them. They are the ones that are with them the most. I know Miranda Ferrier and she is going to talk at our concerned citizens meeting on June 26 in Mitchell, Ontario. My hope is that all nursing homes will start to come around and listen to the ones that know.

    • Rachelle Galloway says:

      I’ll get right to the point, “WHY CAN’T WE LOCK OUR DOOR” in nursing homes?, so many wonders, and nobody watching them. I’ve been in this nursing home since 2011 and I’ve had my leather jacket stolen, my computer mouse stolen. I’m very scared now to leave my room.


Jeremy Petch


Jeremy is an Assistant Professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation, and has a PhD in Philosophy (Health Policy Ethics) from York University. He is the former managing editor of Healthy Debate and co-founded Faces of Healthcare

Mike Tierney


Mike is the Vice President of Clinical Programs at Ottawa Hospital.

Greta Cummings


Greta is the Dean of, and a Professor in, the Faculty of Nursing at the University of Alberta.

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