Working with seniors in long-term care requires specialized knowledge

Today, once again, our focus is on long-term care.

The tragedy in long-term care defies description. Of Ontario's official toll of 713 COVID-19 deaths, 72%, or 516 of those deaths, have occurred in long-term care facilities. There are currently outbreaks in 132 nursing homes, or just over a fifth of the 626 homes province-wide, and there are outbreaks in 63 retirement homes. Some 2,189 nursing home residents have been infected by the novel coronavirus, while 1,058 staff members have tested positive – which is about 70% of all the staff infected across all sectors (about 1,500). These numbers severely underestimate the real numbers of infected persons as testing has been very limited. As part of its action, the government has finally announced they plan to test all 78,000 residents and 56,000 health-care workers in long-term care homes – a measure RNAO has repeatedly asked for since April 10. When will this universal testing begin to happen and how long it will take to complete is not clear. The government is now also seriously addressing the PPE shortages across the sector. You may say that RNAO’s CEO sounds angry, and you are right: All nurses in our province are furious, heartbroken and devastated!   

Meanwhile, RNAO’s VIANurse program, launched on March 13, has already registered 283 NPs, 1,016 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 7,277 RNs for virtual and clinical care. RNAO is continuously responding to requests from health organizations. So far, we have served 226 organizations, of which almost 170 are LTC or senior’s homes. RNAO has also offered the government to identify NPs and RNs who can help manage LTC organizations that are in crisis, and assist with urgent interventions where severe outbreaks are ongoing. RNAO’s long-term care coordinators are engaged in around-the-clock support to organizations in the sector that require help. Some of their activities can be found in this page.

Earlier today we launched a new survey for RNs, NPs and nursing graduates urging them to register for work in nursing homes that have an outbreak. This will fasten even more the matching of nursing staff to homes in dire need. Today we responded, within hours, to the staffing needs of 10 nursing homes with an outbreak. Please retweet the following urgent tweet.

For those of you ready to work in a nursing home with an outbreak -- we need you -- please CLICK HERE and complete our survey. We need your response as soon as possible given the rapidly evolving situation, and the urgent need in nursing homes across the province.

RNAO was surprised to hear that premier Ford has called for military backup for five of the hardest-hit nursing homes, though the province has not announced which facilities those will be. This, at a time when RNAO has the resources required to support these homes and has repeatedly offered to assist, as mentioned above. Earlier, in Quebec, premier Legault was pleading for medical specialists and family physicians to lend a helping hand to nurses and orderlies in hard-hit nursing homes and senior residences. Nurses in Quebec also found this to be a peculiar request.

The references in the media to efforts to bring medical specialists prompted a RN who works with seniors to write, brilliantly detailing the specialized knowledge required to work in long-term care. She prefers to remain anonymous. Please know that I am deeply appreciative for your willingness to share your exquisite knowledge and commitment. My RN colleague wrote the letter last week, before we heard about the invitation for military backup in Ontario nursing homes. Her arguments are relevant also in reference to the role of the army.

I have extensive background in long-term care (LTC), where I have spent most of my 25-year career. I have worked at the bedside, in support, as well as management of homes, and currently as a case manager in geriatric psychiatry.

I watched the news this morning [about bringing medical specialists to LTC homes] with mixed feelings, probably like many RN colleagues. They need help in LTC, for sure. It is a horrible situation, which no doubt was preventable with proper use of PPE. That PPE is, at least, in place now, so that will help in those homes lucky enough to have no outbreaks so far.

I am concerned about the deployment of “specialists” to LTC. I use quotations since LTC itself is a specialty. As much as I would not be qualified or safe to work in ICU, a step down cardiology unit, or even in acute care – how do they think a “specialist” will manage in LTC?  No disrespect to them – I am sure most of them do a wonderful job in their specialty. However, physicians don’t receive basic training on how to feed, transfer, bathe, do skin assessments, or administer medications (often to as many as 60 people at a time). The actual medical care requirements of sick patients are limited. I expect many of the COVID-19 patients would be palliative or at least bedridden, and their biggest need is a sitter and support. A health provider with training in palliative care would do this job more effectively (at far less cost to an already taxed health care system).

Dementia is prevalent in LTC, and dementia care is a specialty. Would medical specialists in other fields have good understanding of dementia? This includes how to deal with responsive behaviours, how to convince someone with dementia to eat when they do not want to, or get dressed or bathe or shower when they are agitated. Would they be trained in de-escalation techniques, or would know non-pharmacological techniques to use to soothe a person with dementia who is crying and wanting “to go home” or looking for their parents?  Would a specialist, despite their best intentions, know what extra-pyramidal side effects are? Or which medications (as a last resort) to prescribe, for which behaviours, to elicit the least side effects? These are just a few of the specialized skills care workers apply in LTC. I have similar concerns with the deployment of hospital nurses to LTC, as I would with LTC nurses assigned to the hospital sector. However, they have basic nursing skills and, by listening to their peers and accepting direction from them, are likely to do better.

We must recognize that LTC is a different environment – for example, we use no restraints. One often hears people misjudge that LTC does not require a skill set. I heard early in my career, from other nurses, that I was “wasting my degree working in that nursing home,” and have been taunted that “all you do is wipe asses.” In each case, I responded they would know better if they worked there – there is a significant skill set and there is in-depth expertise. These remarks signify something different: that there is alarming discrimination against seniors and the staff that house and protect them.

Finally, I want to address the cries for more regulation of the LTC sector. Inspections have their place but are not sufficient for quality care. Does the public know that government inspectors, in a manner similar to LTC, do not inspect hospitals? What LTC needs is funding for staff – not more inspections. When I worked as a director of care in LTC I spent my time writing policies that I knew we didn’t have the staff to uphold. To my colleagues: LTC needs adequate staff – please help us advocate for this. We require more RNs and higher staffing ratios. Also newer homes with single rooms would have gone a long way towards changing the outcomes in some of the hardest hit homes.

RNAO’s response: Thanks for your thoughtful contribution and for your expertise – explicit in every phrase. RNAO has advocated since at least 2003 for changing the funding formula and archaic staffing in nursing homes.