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WHAT’S MISSING FROM DISCUSSIONS ON NURSING HOMES

Pat Armstrong and Sharon Strauss | May 21, 2020

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Pat Armstrong is a Distinguished Research Professor in Sociology, Fellow of the Royal Society of Canada and teaches at York University.

Sharon Straus is a geriatrician and Physician in Chief, St. Michael’s Hospital-Unity Health Toronto.

Calling in the army to work in nursing homes is just one indicator of our failure to recognise and adequately support the skilled nature of the work in these settings. 

This is often the case even among those of us who work in health care. Nursing homes are at the bottom of the clinical hierarchy with wages to match. 

As one nurse described to us, long-term care is a more complex environment than her colleagues recognize:  

“ ‘Oh you’ll lose your skills,’ they told me. You’re joking. Anyone who tells you long-term care is easy is lying. Or they haven’t worked in long-term care…I have a guy who’s having a heart attack over there, a stroke over there, this one’s got a picc line, this one’s got this … like all sorts of complex [care]… so I’m running my own blood work, x-rays and everything else…so I’m actually operating in a sense at a higher level than you would as a hospital nurse.”

The irony here is that long-term care residents are becoming increasingly medically complex – for example, many need dialysis or tracheostomy care amongst other things. Most have dementia in addition to their other chronic conditions. 

There is also increasing diversity with regard to language amongst both the staff and the residents, further complicating the need for and delivery of care. 

In addition to dealing with multiple clinical issues, nurses are also required to do a growing amount of reporting and paperwork that takes time away from care. 

Their workload is further increased during an outbreak when the care required per resident increases by 2 to 3 fold; donning and doffing personal protective equipment (PPE) alone increases workload substantially. Changes to workflow - such as ensuring medication administration and clinical assessments are consolidated to optimise PPE conservation – also increase the burden of care.

What this means is that personal support workers (PSWs) or care aides provide the bulk of the work caring for these residents with quite complicated needs. It bears mentioning that such work is too often seen as a ‘woman’s job.’ And almost all of those who do this work are women, many of them new to Canada.  The tasks they perform sound simple enough: PSWs have to get residents out of bed, toileted or changed, bathed, dressed, fed and engaged in activities. But these tasks require an underestimated amount of skill when they are carried out in a nursing home environment. 

For example, bathing is critical to care, especially for the large number of residents who are either in bed most of the day or in a wheelchair. Without proper and regular bathing, various complications can develop. The process is about much more than applying water to skin. Residents must be talked into allowing someone to provide such intimate care. Bathing must be carried out with attention to the particular frailties, fears and preferences of the resident. It requires physical and social skills, as well as knowledge of the individual. A holocaust survivor, for instance, may be terrified of the shower; a resident with dementia may become violent if their face is not washed first. For some, a bath means being put in a lift and lowered into the water. In a Manitoba home, the in-house training for nurses and care aides required them to bathe each other using the lift. One employee reported how incredibly vulnerable he felt, even though he was allowed to wear a bathing suit. 

Similarly, helping a resident to eat is no simple task. Residents frequently need to be convinced to eat. Understanding particular preferences is important, as is knowing who can chew, who has difficulty swallowing, who may spit out their food, and who has a violent reaction to having green beans on their plate. And like bathing, eating can be a risk to the resident, with choking just one possible consequence. In a pandemic, this becomes more challenging with the requirement for PPE and the need to avoid communal dining.

The sheer number of patients each employee cares for adds additional challenges. Unlike in a hospital, where the patient to nurse ratio is around six to one, nurses may look after 30 to 40 patients and PSWs may care for 10-15 patients at a time, depending on the shift. That breaks down to less than an hour of care per patient per shift. It is undoubtedly difficult to be expected to performed skilled labor when volumes are this high. 

The need for specialized skills particular to the nursing homes is not limited to those providing direct nursing care. Cleaning, as is obvious during this pandemic, is critical to our health. For frail older adults in long-term care, rigorous cleaning of both individual and communal spaces is even more important for infection prevention and control. Cleaners need to know what chemicals are required for different circumstances, the risks involved in their use, the special considerations needed with particular surfaces and equipment, and how to respond to the frequent accidents that leave urine, saliva and feces on chairs and floors. Moreover, cleaners have to know how to interact with residents and are frequently called on by residents for assistance, requiring them to know when and how to respond. 

Long-term care, contrary to what many assume, requires both skilled medical and social care across many professional disciplines. While in times of crisis it may be a case of all hands on deck, we need to make sure that those hands have the necessary skills and are supported in receiving the training required. We can’t expect that health care workers from acute care hospitals can simply be redeployed to long-term care without some training and support.

Beyond this pandemic, we must recognize, support and respect the skilled labor that happens in nursing homes in the same way we support our military. Let’s use COVID-19 as an opportunity to shine a spotlight on the specific needs of long term care residents and consider their needs when planning for future health care challenges.

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