Focus&Group&Study&Report&!!!

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Focus&Group&Study&Report&

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Long3Term&Care&in&Ontario:&

Fostering&Systemic&Neglect&

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Fall$2014$

__________________________________________________________________________________________________________$

Ontario$Council$of$Hospital$Unions/CUPE$

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TABLE!OF!CONTENTS!

! FOCUS!GROUP!STUDY!SUMMARY!...!3" ! EXECUTIVE!SUMMARY!...!4" ! INTRODUCTION!...!6" ! METHODOLOGY!...!7" FOCUS"GROUP"INSTRUMENT"DEVELOPMENT"..."7"

SITE"SELECTION"..."7" PARTICIPANT"RECRUITMENT"..."7" FOCUS"GROUPS"..."7" ! DEMOGRAPHICS!...!8" ! FOCUS!GROUP!DISCUSSION!RESULTS!...!13" I."PATIENT"ASSIGNMENT"..."13"

II."STANDARD"LEVELS"OF"STAFFING:"UNDERSTAFFED"..."17"

III."CONSEQUENCE:"UNWORKABLE"WORKLOAD"..."23"

IV."CONSEQUENCE:"COMPROMISED"CARE"..."30"

V."CONSEQUENCE:"INJURIES"TO"STAFF"AND"RESIDENTS"..."39"

VI."CONSEQUENCE:"RESIDENT@TO@STAFF"AND"RESIDENT@TO@RESIDENT"ABUSE"..."41"

VII."CONSEQUENCE:"UNSAFE"PRACTICE"..."47"

VIII."WHAT"WOULD"BETTER"CARE"LOOK"LIKE?"..."50"

! CONCLUSION!...!57" ! RECOMMENDATIONS!...!58" ! APPENDIX!A:!FOCUS!GROUP!DISCUSSION!GUIDE!...!60" APPENDIX!B:!PARTICIPANT!INFORMATION!SURVEY!...!64"

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FOCUS!GROUP!STUDY!SUMMARY!

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The"intent"of"this"study"–"Long%Term*Care*in*Ontario:*Fostering*Systemic*Neglect"–"was"to"speak" directly"to"Personal"Support"Workers"(PSWs)"and"Registered"Practical"Nurses"(RPNs)"working"in" long@term"care"(LTC)"in"Ontario"about:" " • what"kind"of"care"they"are"currently"able"to"provide"residents;" • any"barriers"presently"impeding"delivery"and"quality"of"care;" • what"better"care"would"look"like,"and"what"resources"would"be"necessary"in"order"to" ensure"its"delivery." " The"data"in"this"report"comes"from"the"knowledge,"experiences,"observations"and"feedback" shared"by"PSWs"and"RPNs"during"focus@group"discussion." " In"November"2013,"five"focus"groups"were"conducted"with"35"PSWs"(which"made"up"83"per" cent"of"the"study"participants)"and"RPNs"(17"per"cent"of"the"participants)"working"at"facilities" located"in"Guelph,"Blind"River,"Ottawa,"Minden"and"Toronto."57"per"cent"of"the"homes"were"in" urban"areas"and"43"per"cent"were"in"rural"communities."89"per"cent"of"the"participants"were" female"and"11"per"cent"were"male,"and"the"vast"majority"(81"per"cent)"were"between"35@64" years"of"age."69"per"cent"have"worked"in"LTC"for"a"long"time,"between"6@20"years."57"per"cent" worked"full@time"hours,"while"40"per"cent"said"they"worked"part@time." " " The"Ontario"Council"of"Hospital"Unions"(OCHU)"is"a"bargaining"council"that"represents"30,000" CUPE"(Canadian"Union"of"Public"Employees)"healthcare"workers"across"Ontario,"including"PSWs" and"RPNs"providing"medical"care"and"supports"to"LTC"residents."" " In"addition"to"OCHU’s"role"as"bargaining"council,"OCHU"campaigns"in"defence"of"a"universally" accessible"healthcare"system."It"is"OCHU’s"mandate"to"defend"healthcare"in"every"community."

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EXECUTIVE!SUMMARY

! PSWs"and"RPNs"told"frank,"powerful,"often"heartbreaking"accounts"of"how,"despite"their" outmost"efforts"and"dedication,"they"are"forced"to"provide"what"amounts"to"substandard"care" to"residents.""" " Based"on"their"accounts,"provincial"indifference"to"care"levels"and"the"quality"of"care,"policies" and"funding"allocations"for"LTC,"are"fostering"systemic"neglect."Routine"understaffing"and" chronically"low"staffing"levels"are"resulting"in"lonely,"isolated"and"often"depressed"residents." PSWs"and"RPNs"simply"do"not"have"adequate"time"to"provide"residents"with"the"social"and" emotional"care"they"desperately"need." "

Key!Findings!!

" 1. Dangerously"high"resident@to@staff"ratios:"up"to"15"residents"per"PSW"on"dayshifts"and" up"to"42"residents"per"PSW"on"nightshifts;"30@42"residents"per"RPN"on"both"day"and" nightshifts." " 2. Chronic"understaffing""and"shortstaffing"that:" • is"fueling"a"barrage"of"injuries,"infection,"bedsores,"abuse"and"unsafe"work" practices" • is"hastening"incontinence"and"loss"of"mobility"in"residents"because"there"are"not" enough"PSWs"to"toilet"residents"as"needed"–"this,"the"PSWs"and"RPNs"say,"is"the" ultimate"indignity"for"residents" • often"results"in"“nobody"on"the"floor”"in"emergencies,"including"in"cases"of" evacuation,"threatening"the"safety"of"residents"and"staff" " 3. An"impracticable"workload"that"adversely"impacts"the"level"and"quality"of"care"PSWs" and"RPNs"are"able"to"provide"residents,"and"has"significant"implications"for"staff"and" resident"safety"(including"injury,"abuse"and"unsafe"practice)." " 4. Lax"infection"control"because"residents"are"not"immediately"screened"for"common"

infections"such"as"C*difficile,"MRSA"and"VRE."Resident"isolation"is"minimal"and"frontline" staff"do"not"have"adequate"time"to"take"precautions"like"wearing"gowns,"masks"and" gloves,"to"minimize"the"spread"of"germs. 5. 91"per"cent"of"the"focus"group"participants"said"they"do"not"feel"satisfied"with"the"level" of"care"they"are"able"to"provide"for"the"residents"in"their"patient"assignments." " 6. 97"per"cent"of"participants"identified"not"enough"staff"and"heavy"workloads"as"the"key" reasons"they"cannot"provide"quality"care." "

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7. All"of"the"PSWs"and"RPNs"interviewed"said"they"had"residents"suffering"from"dementia" and"almost"all"(97"per"cent)"said"they"had"residents"in"their"assignments"with"cognitive" behaviours"such"as"aggression,"wandering,"and"hoarding." " Fed"up"with"provincial"government"indifference,"PSWs"and"RPNs"are"speaking"up,"giving"voice" to"the"many"residents"who"have"no"family"to"advocate"for"better"quality"care"and"a"mandatory" staffing"ratio"of"8"PSWs"per"resident." "

Recommendations!

! 1. Implement!mandatory!minimum!staffing!ratios!–!1!PSW!per!8!residents!(1:8)!–!based! on!acuity!levels!of!residents.!This"is"consistent"with"a"mandatory"(and"legislated)"daily" care"level"of"4"hours"(average)"per"resident"that"includes"both"increased"PSW"and"RPN" staffing"levels."At"present,"patient"assignments"are"unrealistic"and"unsafe,"and"PSWs"and" RPNs"are"unable"to"provide"better"care"for"their"residents."Care"should"never"be"rushed," compromised"or"denied."There"should"never"be"“no"one"on"the"floor”"to"provide" resident"care"and"to"ensure"safety"during"emergencies." " 2. Create!segregated!units!for!violent!residents,!and!staff!accordingly.!At"present,"violent" residents"co@habit"with"non@violent"residents."This"critically"impacts"resident"safety"–" both"physically"and"emotionally." " 3. Implement!pre3placement!infectious!disease!testing!and!provide!staff!time!to!take! best!practice!precautions!like!gowns,!masks!and!gloves!to!minimize!outbreaks.!At" present,"residents"are"rarely"tested"for"infectious"disease"pre@placement,"and"most" often,"it"takes"weeks"and/or"months"post@placement"before"such"tests"are"run."! ! 4. Establish!acuity!levels!for!current!and!incoming!residents.!Assess"and"determine"which" residents"require"heavier"levels"of"care"and"why"(e.g.,"mental"status,"mobility,"medical" condition,"documentation"requirements,"etc)"and"staff"and"train"accordingly." " 5. Implement!care3appropriate!units!(heavier"care;"minimal"care;"locked"units"where" necessary)!to"ensure"residents’"safety"and"minimize"injury"and"abuse.!" "

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INTRODUCTION!

" Since"the"mid@1990s"when"a"mandatory"daily"LTC"resident"care"level"was"eliminated"by"the"then" provincial"government,"staffing"levels"have"not"kept"pace"with"the"ever"increasing"complex"care" needs"of"residents,"the"majority"of"whom"are"over"80"years"old."" " Respected"academic"research"has"consistently"shown"that"increasing"staffing"levels,"particularly" PSW"and"RPN"staffing,"results"in"better"resident"care,"less"incidents"of"violence"and"falls,"and" fewer"bedsores"and"wounds."The"fact"is,"higher"staffing"results"in"improved"outcomes"for" residents"who"are"not"mobile"and"who"have"complex"medical"conditions,"often"along"with" cognitive"impairment."" " Many"European"countries"have"heeded"the"research"and"provide"a"better"quality"of"resident" care."However,"Ontario’s"provincial"government"is"ignoring"the"mounting"evidence"that"clearly" links"care"quality"and"staffing"and"fostering"system"neglect"of"vulnerable"LTC"residents."" " Frontline"PSWs"and"RPNs"working"at"five"Ontario"LTC"homes,"interviewed"in"a"series"of"focus" groups"(within"the"last"year)"believe"this"needs"to"change."" " "

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METHODOLOGY!

Focus!Group!Instrument!Development!

" The"focus"group"discussion"guide"(Appendix"A)"was"developed"by"an"elected"subcommittee"of" the"OCHU’s"Long@Term"Care"Committee."The"subcommittee"built"the"guide"out"of"preliminary" recommendations"provided"by"the"Long@Term"Care"Committee." " A"participant"information"survey"containing"demographic"and"workplace@related"questions"was" also"developed"(Appendix"B)."The"survey"was"distributed"upon"participants’"arrival"at"each"focus" group,"and"completed"prior"to"focus"group"discussion."" "

Site!Selection!!

" The"Long@Term"Care"Committee"elected"to"conduct"focus"groups"in"the"following"Ontario"cities:" Guelph,"Blind"River,"Ottawa,"Minden"and"Toronto."Private"meeting"rooms"were"secured"by"local" union"presidents"and/or"the"Long@Term"Care"Committee"representative"specific"to"the"region." "

Participant!Recruitment!

" Participants"were"recruited"by"local"union"presidents"and/or"the"Long@Term"Care"Committee" representative"specific"to"the"region."Due"to"time@constraints,"participants"were"recruited" directly"rather"than"via"screeners."Participants"were"recruited"with"an"emphasis"on"diversity"of" experience,"including"but"not"limited"to:"job"classification"(PSWs/RPNS),"employment"status" (full@time/part@time),"shifts"worked"(days/evenings/nights/weekends),"and"years"of"service."To" incentivize"focus"group"attendance,"potential"participants"were"told"that"they"would"receive"a" $50"honorarium"for"taking"part"in"focus"group"discussion."" "

Focus!Groups!

" Between"November"5@22,"2013,"focus"groups"were"conducted"in"Guelph,"Blind"River,"Ottawa," Minden"and"Toronto."In"total,"35"people"participated"in"the"focus"groups."Focus"groups"were" either"conducted"late"morning"(11"a.m."@"2"p.m.),"or"late"afternoon"(4"p.m."@"6"p.m.)." " 11/05/2013:"Guelph" " 7"participants" 11/12/2013:"Blind"River" 9"participants" 11/14/2013:"Ottawa" " 7"participants" 11/15/2013:"Minden" " 6"participants" 11/22/2013:"Toronto" " 6"participants" " Each"focus"group"lasted"approximately"two"hours."All"focus"groups"were"conducted"by"the"same" facilitator"and"the"same"note@taker."Focus"group"discussion"was"audio@recorded"and"later" transcribed.""

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DEMOGRAPHICS!

" In"total,"35"people"took"part"in"the"focus"groups."Each"of"these"participants"completed"a" participant"information"survey"upon"arrival."The"information"collected"from"these"surveys" delineates"the"demographic"profile"of"the"participants"(presented"via"tables,"below)."" " Table"1"identifies"the"participants’"age"range."Participants"ranged"in"age"from"18@64"years." (Percentages"add"to"101,"due"to"rounding.)""" " Table!1:!Participants’!Age!Range! Age!Range! Percentage! 18@24"Years"of"Age" 9%" 25@34"Years"of"Age" 11%" 35@44"Years"of"Age" 23%" 45@54"Years"of"Age" 29%" 55@64"Years"of"Age" 29%" " Table"2"identifies"the"participants’"gender"identification."The"majority"of"the"participants"were" female."" " Table!2:!Participants’!Gender!Identification! Gender!Identification! Percentage! Female" 89%" Male" 11%" " Table"3"identifies"the"participants’"cultural/ethnic"identification."The"majority"of"the" participants"were"Caucasian"and"Anglophone." " Table!3:!Participants’!Cultural/Ethnic!Identification! Cultural/Ethnic!Identification" Percentage! Francophone" 17%" Person"of"Colour" 26%" Aboriginal/Indigenous" 9%" " Table"4"identifies"the"participants’"job"classification."The"majority"of"the"participants"were" PSWs.""" " Table!4:!Participants’!Job!Classification! Job!Classification! Percentage! PSW" 83%" RPN" 17%"

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Table"5"identifies"the"type"of"community"in"which"the"participants’"place"of"employment"was" located."Though"a"significant"number"of"the"participants"worked"in"facilities"that"serve"rural" communities,"most"of"the"participants"worked"in"facilities"that"serve"urban"communities." " Table!5:!Participants’!Facility!Location/Community!Served! Community!Served! Percentage! Urban" 57%" Rural" 43%" " Table"6"identifies"the"participants’"years"of"service."Participants’"years"of"service"ranged"from"0@ 29"years."(Percentages"add"to"101,"due"to"rounding.)" " Table!6:!Participants’!Years!of!Service! Years!of!Service! Percentage! 0@5"Years"of"Service" 17%" 6@10"Years"of"Service" 23%" 11@15"Years"of"Service" 26%" 16@20"Years"of"Service" 20%" 21@25"Years"of"Service" 6%" 26@29"Years"of"Service" 6%" Undisclosed" 3%" " Table"7"identifies"the"participants’"employment"status."Though"a"significant"number"of"the" participants"were"part@time"staff,"most"of"the"participants"were"full@time"staff.""" " Table!7:!Participants’!Employment!Status! Employment!Status! Percentage! Full@Time" 57%" Part@Time" 40%" Undisclosed" 3%" " Table"8"identifies"the"type"of"shifts"–"days,"evenings,"nights,"weekends"–"that"the"participants" worked."The"majority"of"the"participants"worked"a"combination"of"days,"evenings,"nights"and/or" weekends."(Percentages"add"to"101,"due"to"rounding.)"" " Table!8:!Participants’!Type!of!Shifts!Worked! Type!of!Shifts!Worked! Percentage! Days" 17%" Evenings" 9%" Nights" 3%" Days,"Evenings,"Nights"&/or"Weekends" 69%" Undisclosed" 3%"

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Table"9"identifies"how"many"hours"the"participants"worked"in"a"given"shift."The"majority"of"the" participants"worked"8@hour"shifts."" " Table!9:!Participants’!Hours!Worked!Per!Shift! Hours!Worked!Per!Shift! Percentage! 8@Hour"Shifts" 60%" 12@Hour"Shifts" 11%" 8@Hour"&"12@Hour"Shifts" 23%" Undisclosed" 6%" ! Table"10"identifies"the"type"of"unit/floor"on"which"the"participants"worked."While"a"number"of" the"participants"worked"on"open"units,"most"of"the"participants"worked"on"locked"units." (Percentages"add"to"101,"due"to"rounding.)" " Table!10:!Type!of!Unit/Floor!Worked! Unit/Floor!Worked! Percentage! Locked"Unit" 46%" Open"Unit" 29%" Mixed"" 23%" Undisclosed" 3%" " Table"11"identifies"the"types"of"residents"in"the"participants’"patient"assignments."Every"single" participant’s"patient"assignment"included"residents"suffering"from"dementia."Almost"all"of"the" participants"also"had"residents"with"behaviours"(e.g.,"aggression;"wandering;"hoarding)"in"their" patient"assignments." " Table!11:!Types!of!Residents!in!Patient!Assignment! Residents!in!Patient!Assignment! Percentage! Stable" 89%" Dementia" 100%" Palliative"Care" 91%" Convalescent"Care" 57%" Complex"Care" 74%" Behaviours" 97%" " The"final"three"questions"on"the"participant"information"survey"asked"participants"to"indicate:"if" they"felt"satisfied"with"the"level"of"care"they"are"able"to"provide"to"every"patient"in"their" assignment;"any"obstacles"standing"in"the"way"of"their"ability"to"provide"better"care;"any"on@ the@job"injury"(emotional/mental/physical)"they’ve"experienced"as"a"result"of"attempting"to" work"around"these"obstacles." " The"following"tables"display"the"participants’"answers"to"these"questions.""

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Table"12"identifies"the"participants’"responses"to"the"question:""Do*you*feel*satisfied*with*the* level*of*care*you’re*able*to*provide*to*every*patient*in*your*assignment?"The"majority"of"the" participants"did"not"feel"satisfied"with"the"level"of"care"they"are"able"to"provide"to"every" resident"in"their"patient"assignment.""" " Table!12:!Satisfaction!With!Level!of!Care!Provided!to!Every!Patient!in!Assignment! Satisfaction!with!Level!of!Care" Percentage! Yes" 6%" No" 91%" Sometimes" 3%" " Table"13"identifies"the"participants’"responses"to"the"question:"What*are*some*of*the*things* preventing*better*care?"The"majority"of"the"participants"identified"heavy"workload,"not"enough" staff,"and"working"short"as"barriers"preventing"the"delivery"of"better"care."" " Table!13:!Barriers!Preventing!the!Delivery!of!Better!Care! Barriers!to!Delivery!of!Better!Care! Percentage! Heavy"Workload" 97%" Unrealistic"Patient"Assignment" 69%" Not"Enough"Staff" 97%" Working"Short" 91%" Unrealistic"Policies/Procedures" 71%" " Table"14"identifies"the"participants’"responses"to"the"question:"Have*you*experienced*any*of*the* following*ills*due*to*workload,*working*short,*and/or*unrealistic*policies*and*procedures?"Every" single"participant"indicated"that"they"have"experienced"stress"and"over"half"of"the"participants" indicated"that"they"have"suffered"work@related"injuries,"due"to"heavy"workload,"working"short," and/or"unrealistic"policies"and"procedures." " Table!14:!Ills!Experienced!Due!to!Heavy!Workload,!Working!Short,!and/or!Unrealistic! Policies/Procedures! Ills!Experienced! Percentage! Stress" 100%" Burnout" 74%" Fatigue" 89%" Work@Related"Injuries" 66%" " Results"from"participant"information"survey"questions"#14"(On*average,*how*many*patients*are* in*your*patient*assignment?),"#15"(During*an*average*shift,*what*is*the*ratio*of*residents*to* PSWs*&*RPNs?)"and"#17"(In*a*given*shift,*how*many*hours*to*you*spend*on*each*of*the*following* tasks?)"are"not"available."Because"the"answers"to"these"questions"are"dependent"on"the"type"of" shift"worked"(day/evening/night),"responses"were"compromised."Also,"in"regards"to"#17,"in"

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most"cases,"hours"noted"didn’t"add"up"to"or"exceeded"total"shift"hours."These"questions"were" explored"in"focus"group"discussion,"and"the"resulting"data"is"present"in"the"Discussion"Results."

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FOCUS!GROUP!DISCUSSION!RESULTS!

" In"conducting"these"focus"groups,"we"found"that"PSWs"and"RPNs"are"confronted"with"two"key" challenges"on"a"regular"basis:"demanding"patient"assignments,"and"routine"understaffing."" " These"issues"make"for"an"impracticable"workload"that"adversely"impacts"the"level"of"care"PSWs" and"RPNs"are"able"to"provide"residents."Furthermore,"these"issues"have"significant"implications" for"staff"and"resident"safety"(including"injury,"abuse"and"unsafe"practice)." "

I.!Patient!Assignment!!

" Each"PSW"and"RPN"has"a"patient"assignment"–"a"cluster"of"residents"who"are"under"their"care" for"the"duration"of"their"shift."The"number"of"residents"within"a"given"patient"assignment"varies" from"facility"to"facility,"and"increases"as"day"shift"turns"into"evening"shift"turns"into"night"shift.""" " PSW!Patient!Assignment:!Staff3to3Resident!Ratios!! " Among"the"participants,"the"lowest"number"of"residents"in"a"dayshift"patient"assignment"was" nine;"the"highest"number"of"residents"in"a"dayshift"patient"assignment"was"15."" " As"day"turns"to"night,"the"number"of"residents"per"patient"assignment"increases."Among"the" participants,"the"lowest"number"of"residents"in"a"nightshift"patient"assignment"was"18;"the" highest"number"of"residents"in"a"nightshift"patient"assignment"was"42."" " For"example,"in"one"facility"there"are"36"residents"on"the"floor."During"the"day,"four"PSWs"are" on"shift"(a"ratio"of"four"PSWs"per"36"residents)."Each"of"these"PSWs"is"responsible"for"providing" care"to"nine"residents"(a"ratio"of"one"PSW"per"nine"residents)."Overnight,"two"PSWs"are"on"shift" (a"ratio"of"two"PSWs"per"36"residents)."Each"of"these"PSWs"is"responsible"for"providing"care"to" 18"residents"(a"ratio"of"one"PSW"per"18"residents)." " RPN!Patient!Assignment:!Staff3to3Resident!Ratios! " Among"the"participants,"the"lowest"number"of"residents"in"a"patient"assignment"was"30;"the" highest"number"of"residents"in"a"patient"assignments"was"42."" " Some"facilities"staff"one"RPN"on"the"floor"during"the"day."Some"facilities"staff"two"RPNs"on"the" floor"during"the"day."At"night,"there"is"generally"only"one"RPN"on"the"floor."" " Where"there"are"two"RPNs"on"the"floor,"both"RPNs"share"the"same"patient"assignment,"with" each"RPN"providing"different"elements"of"RPN@related"care"to"every"single"resident"in"the"unit." For"example,"in"one"facility,"there"are"40"residents"on"the"floor."If"there"are"two"RPNs"staffed," one"RPN"is"primarily"responsible"for"administering"medications"to"all"40"residents,"and"the" other"RPN"is"responsible"for"all"other"RPN@related"care"for"the"40"residents."

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! Combination!Levels!of!Care:!“It!takes!a!lot!more!time!to!get!everything!done”! " Each"patient"assignment"is"comprised"of"a"mix"of"residents"who"require"varying"levels"of"care:" total"care,"complex"care,"palliative"care,"two@person"care,"convalescent"care,"and"minimal"care." Some"have"dementia"or"Alzheimer’s;"some"are"younger"adults"with"mental"health"issues;"some" have"behaviours"(e.g.,"aggression;"wandering;"hoarding)."This"makes"for"a"challenging" assortment"of"care"needs."" " Each*assignment*has*a*combination*of*all*different*levels*of*care.*Out*of*42*residents,* there’s*probably*only*two*that*you*can*depend*on*them*being*pretty*much*self%sufficient,* but*still*have*to*be*supervised.*The*rest*of*them*are*a*lot*of*care.** * The*level*of*care*we*have*to*give*people*is*getting*more*–*there*is*more*difficulty*–*more* people*are*total*care,*that*kind*of*thing.*It*takes*a*lot*more*time*to*get*everything*done.** * What*we’re*experiencing*now*is*a*lot*more*residents*coming*in*who*have*behavioural* issues*who*are*a*very*heavy*workload,*and*then*they*have*mental*health*issues.*And*I* believe*that*a*lot*of*us*PSWS*haven’t*really*had*the*full*training*for*people*who*have* mental*health*and*psychiatric*problems.** * We’re*getting*more*younger*people*with*behaviours.*So*we’re*getting*these*little*old* ladies*and*we’re*getting*people*that*are*more*violent,*and*it’s…*It’s*not*a*good*mix.* * They’re*accepting*people*that*are*younger,*stronger,*they*want*to*scrap,*they’re*very* aggressive,*they’re*noisy.* * I*think*the*population*is*getting*older*and*staying*home*longer.*And*so*by*the*time*they* come*here,*they’re*in*worse*shape*than…*Years*ago,*they*came*in*with*their*suitcase*and* they*were*able*to*walk*and*communicate.** * Some*units*have*huge*age*ranges*–*from*35*to*105*years*old.*To*cater*to*somebody* who’s*45*years*old,*their*needs*are*a*lot*different*than*somebody*who’s*105*years*old.** " Uneven!Care:!“You’re!not!able!to!give!equal!care!to!all!of!your!residents”! " Some"residents"require"heavier"levels"of"care."These"residents"include:"those"who"are"total"care," palliative"care"or"two@person"care;"those"who"have"dementia,"Alzheimer’s"or"behaviours;"those" who"refuse"care;"those"who"are"demanding"and/or"have"demanding"families."" " A*person*with*behaviours…*They*might*have*a*soiled*pad*and*they*need*to*be*cleaned* and*changed,*but*they*give*you*a*hard*time,*they*swing*at*you*when*you’re*trying*to* clean*them*up*–*so*it*takes*a*bit*more*time.** *

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If*you*tell*a*resident*with*dementia*to*roll*over,*they*don’t*know*what*you’re*talking* about,*they*don’t*get*the*message.*So*you*have*to*use*a*different*approach.*You*have*to* spend*some*time,*get*creative.** ! Searching*for*residents*who*wander*takes*time.*You*can*easily*guide*them*out,*but*it’s* the*time*it*takes*to*find*that*person*and*bring*her*back*to*her*room*or*keep*her*in*the* dining*room.* * There’s*one*resident*who*is*constantly*on*the*call*bell*for*unnecessary*things,*like,*‘Grab* me*a*Kleenex,’*and,*‘What*time*is*it?’*This*is*stuff*that*she’s*capable*of*doing*on*her*own.* But*there’s*not*really*much*to*be*done*about*the*situation,*because*if*a*resident*rings* their*bell,*we*have*to*answer*that*bell*no*matter*what,*because*we*don’t*know*why* they’re*ringing.*And*you*can*easily*spend*a*couple*of*hours*running*back*and*forth*when* someone’s*ringing*every*15*minutes.*" " Because"some"residents"take"more"time"than"others,"this"necessarily"results"in"uneven"care."" ! There’s*always*a*resident*in*your*assignment*who*suffers.*You*hate*to*do*it,*but*that’s* just*being*honest.*There’s*one*who*doesn’t*get*the*proper*care*because*you*just*don’t* have*time.** " The"participants"overwhelming"indicated"that"they"are"consistently"forced"to"“poach”"time"from" one"resident"in"order"to"meet"the"needs"of"another"resident." " Some*residents*take*longer,*like*residents*with*dementia.*It*takes*longer*to*get*things* done*with*them.*So*you’re*spending*maybe*an*hour*with*that*person.*Which*means*that* another*resident*is*getting*short*time,*maybe*five*minutes.*So*you’re*not*able*to*give* equal*care*to*all*of*your*residents.** * If*someone*is*walking*down*the*hall*naked*with*a*big*mess*on*them,*you’re*going*to* have*to*deal*with*that*–*you*don’t*have*a*choice.*So*somebody*else*is*going*to*go* without.* * I*have*nine*patients.*And*the*two*that*are*cognitive*and*able,*I*kind*of*go,*‘Okay,*well,*I* can*steal*10*minutes*from*this*one*because*she*can*take*care*of*herself.*I’ll*put*her* towels*in*there*for*her,*but*I*can*steal*10*minutes*from*her*and*give*it*to*this*resident* because*he*needs*more*hands%on*care.*So*I’ll*spend*20*minutes*with*him.*But*now,*I*need* another*10*minutes;*I*have*to*get*10*minutes*from*somebody*else*because…* * For*residents*who*are*minimal*care,*when*you*go*in*there*for*the*five*minutes*of*care* you*have*available*for*them,*they*want*you*to*stay.*They*want*their*15*minutes,*even*to* socialize,*to*tell*you*something*that*happened*with*their*day.*They*say,*‘It’s*my*time* now.’*And*I*understand*that’s*her*15*minutes.*But*you*don’t*have*that*15*minutes.*So* somewhere*you*have*to*cut*back*in*order*to*give*her*that*15*minutes.*But*you*can’t*do*

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that*every*shift.*The*next*day,*unfortunately,*you*can’t*give*her*15*minutes,*because*you* have*a*demanding*resident*you*have*to*go*to.* * The"residents"who"tend"to"receive"the"least"care"include:"those"who"are"total"care;"those"who" are"minimal"care"and/or"independent;"those"who"are"less"demanding"and/or"have"less" demanding"families;"those"who"don’t"or"can’t"speak"up." ! Independent*people*–*those*who*can*do*most*of*the*stuff*for*themselves*–*get*neglected.* Because*if*we*don’t*have*to*do*anything*with*them*right*away,*we*might*not*see*them* all*day,*really.* * The*ones*who*are*in*a*Broda*chair*that*are*total*care*–*they*actually*get*less*care,* because*you*get*them*done*and*get*them*safe*in*their*chair,*and*that’s*pretty*well*it*for* the*day.*And*then*you’re*more*dealing*with*the*people*with*the*behaviours.* ! The*ones*who*can’t*speak*for*themselves*are*losing*out*on*care.*They’d*be*your*heaviest,* the*ones*that*really*require*the*care*–*and*they’re*not*getting*it.* * The*person*you*don’t*have*the*time*for*is*the*resident*that’s*sitting*in*a*Broda*chair*who* won’t*ask*you*for*a*single*thing.*First*of*all,*he*doesn’t*want*to*bother*you,*second*of*all* he*knows*you’re*busy,*you*know,*and*he*thinks*he’s*fine.*But*the*guy*that*can*ring*that* buzzer*to*see*what*time*of*day*it*is*or*to*empty*his*garbage,*or*to*pass*him*something,* even*though*he’s*already*rang*15*times…*It*leaves*you*feeling*really…*It’s*inadequate.** ! Allocation!of!Assistance:!“There’s!nobody!around”! ! During"the"day,"each"PSW"is"“partnered”"with"a"fellow"PSW."In"theory,"PSW"partners"assist"one" another"as"needed."In"reality,"PSWs"struggle"to"assist"one"another"because"their"own"patient" assignments"are"equally"as"demanding."" " There’s*not*really*anybody*–*you*have*a*partner*but*that*partner*has*just*as*much*of*a* load*as*you*have,*so*the*whole*trick*is*to*try,*you*know,*to*get*your*timing*right,*so*that* you*can*actually*use*that*other*person*to*help*you*do*two%person*transfers,*lifts,* whatnot.*That’s*a*policy.*If*we*don’t*abide*by*it,*we*do*get*in*trouble.*Well,*there*are* times*when*you*don’t*always*get*to.*You’ll*be*so*far*behind*you*think*you’re*first.*So*you* just*are*doing*unsafe*things.*I’m*being*honest;*it’s*happening.*Everyday.* * You*go*into*a*room,*you*get*the*person*all*ready*to*go.*You*stick*your*head*out*the*door* to*find*help*and*there’s*nobody*around.*The*only*person*you*see*is*the*PSW*down*the* hall*in*the*other*section.*But*if*you*go*down*there*to*ask*for*help,*you*get*stuck*helping* them.*Then*you’re*20*minutes*behind*coming*back*to*your*section*in*the*morning.** * The*reality*is,*we’re*working*by*ourselves*to*get*the*job*done.* !

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Depending"on"the"facility,"PSWs"don’t"always"have"a"nightshift"partner."If"PSWs"do"have"a" nightshift"partner,"these"two"PSWs"are"responsible"for"care"of"the"entire"floor"(among"the" participants,"this"ranged"from"36@40"residents)."If"PSWs"don’t"have"a"nightshift"partner,"a"single" PSW"is"responsible"for"the"care"of"the"entire"floor"(among"the"participants,"this"ranged"from"30@ 42"residents)."" " RPNs"are"not"allocated"any"assistance."While"some"facilities"staff"two"RPNs"during"the"day,"each" of"these"RPNs"is"responsible"for"different"RPN@related"care"for"the"entire"floor."Many"facilities" staff"just"one"RPN"during"the"day."And"at"night,"there"is"generally"only"one"RPN"on"the"floor." Some"facilities"encourage"RPNs"to"assist"PSWs"where"needed."Other"facilities"do"not"allow"RPNs" to"assist"PSWs."Either"way,"RPNs"have"their"own"workload"and"are"typically"unable"to"assist" PSWs"even"if"such"assistance"is"encouraged." " Some"facilities"also"employ"additional"staff"–"for"example,"BSO"(Behavioural"Supports"Ontario)" staff"and"RAI"(Resident"Assessment"Instrument)"coordinators"–"but"these"staff"have"their"own" specialized"roles;"they"are"not"assigned"assistance"for"PSWs"and"RPNs."" " And"while"some"facilities"might"staff"a"floater"PSW,"and/or"have"a"volunteers"on"hand"for"a"few" hours"at"a"time,"the"participants"overwhelmingly"expressed"that"there"is"not"enough"help"to"go" around."" * Our*manager*told*us*to*get*the*residents*out*of*bed*and*put*them*in*wheelchairs*–*don’t* wash*them*all*right*away*–*because*we*have*one*hour*to*get*nine*people*up*on*each* section.*She*told*us*to*leave*the*residents*in*the*hallway,*that*somebody*would*bring* them*down*to*the*dining*room,*because*us*PSWs*are*busy*going*down*the*line.*She*said,* ‘All*hands*on*deck.’*Well,*seven*heads*gone*and*five*PSWs*left*in*the*morning.*All*the* residents*are*sitting*in*the*hallway.** * We’re*all*busy.*Everybody*has*something*to*do.* * We’re*lucky*if*we*have*some*volunteers*to*come*and*help*us*feed*the*residents.*We’re*so* lucky*if*that*happens.** * We*don’t*have*the*manpower.*Everyday*is*like*that.*We*don’t*have*the*manpower.* There’s*12%14*people*starting*out*in*the*morning,*but*there’s*only*five*of*us*that*are* really,*really*doing*this*work.* *

II.!Standard!Levels!of!Staffing:!Understaffed!

! All"of"the"participants"indicated"that"these"standard"levels"of"staffing"are"sorely"inadequate."" " We*should*more*than*welcome*government*people*to*come*in*and*shadow*us*for*a* week,*a*month,*or*whatever,*and*see*what*these*people*are*lacking*because*of*the* deplorable*staff%to%resident*ratio.*It*just*sickens*me.**

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" Care!Plans:!“It!doesn’t!really!mean!somebody!is!available!to!look!after!these!people”! " Insufficient"staffing"has"serious"consequences"for"resident"care"plans."Without"enough"staff"to" go"around,"it’s"impossible"for"care"plans"to"be"truly"actualized."" " When*residents*are*admitted,*a*care*plan*is*set*up*for*them,*so*that*they*can*get*the* care*that*needs*to*be*provided*to*them.*Also,*the*Ministry*of*Health*sets*up*some* standards,*expectations,*that*so*much*time*is*being*given*to*each*one*of*these*residents.* Everyday,*every*time*of*the*day,*anytime*that*they*need.*But*it’s*not*necessarily*so.*It* doesn’t*really*mean*somebody*is*available*to*look*after*these*people.** * You*might*have*a*care*plan*that*says*this*one*individual*is*to*be*toileted*on*demand.* Well,*what*if*that*resident*requires*a*mechanical*lift*and*it*takes*two*people*to*toilet* them?*Because*the*Ministry*has*certain*regulations*with*these*lifts.*So*you’re*required*to* have*a*minimum*of*two*people.*But*there’s*one,*a*genie*lift,*and*it*requires*four*people* to*use*that*lift.*Imagine*if*that*four*staff*are*the*only*staff*you*have*on*the*floor?** * On*the*floor*I*work*on,*out*of*20*residents,*15*require*the*two%person*mechanical*lift.* And*you*only*have*two*PSWs*on*that*side.** " Safety!Implications:!“Now!there’s!nobody!on!the!floor”! " Limited"staffing"also"threatens"the"safety"of"residents"and"staff."Between"breaks,"emergencies," and"attending"to"residents,"there"are"often"times"when"there"is"“nobody"on"the"floor.”" ! When*I*first*started,*I*always*looked*at*it*like*this:*How*many*men*on*the*ice?*Where*is* everybody?*So*we’ve*got*five*PSWs.*Three*of*them*are*gone*on*a*break;*I’m*on*the*floor,* and*the*other*PSW*is*over*there.*The*RPNs*are*busy.*And*this*is*the*only*time*I’ve*got*to* give*this*resident*a*shower.*So*I’m*in*the*shower*–*if*something*comes*up*and*that*PSW* has*to*leave*the*floor,*passes*me*her*pager*–*now*there’s*nobody*on*the*floor.*Unsafe.* What*if*somebody*falls?*I*can’t*answer*a*call*bell*–*I*can’t*leave*this*person*in*the* shower.*How*many*men*on*the*ice?*This*happens*everyday,*more*than*once*a*day.** * At"one"facility,"PSWs"take"their"breaks"on"the"floor"to"ensure"safety."They"do"this"despite"the" fact"that"they’re"not"allowed"to"take"their"breaks"on"the"floor." " We*take*our*breaks*on*the*floor,*at*the*back.*Because*the*bells*are*going,*and*the*staff* on*the*other*side,*we*don’t*want*to*leave*them*alone.*Like*the*other*day,*I*was*taking*my* break*on*the*floor,*and*I*heard*this*screaming.*I*didn’t*know*what*was*going*on.*I*found* the*patient*on*the*floor.*I*had*to*leave*my*break*and*go*get*the*RPN*to*help*me.*And* we’re*not*supposed*take*our*breaks*there.*But*if*I*hadn’t*been*there,*what*would*have* happened*to*this*resident?*I*don’t*know*how*long*she*would’ve*been*on*the*floor.* *

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Working"beyond"scope"of"practice"is"also"a"risk"factor."Yet"at"one"facility,"the"RNs"are"largely" unavailable,"so"the"role"of"the"RN"falls"to"the"RPN."" " As*the*RPN*on*the*unit,*we’re*considered*the*‘leaders.’*I*don’t*know*where*the*RN*is,*now* they*have*them*locked*away*doing*MDS,*so*basically,*we’re*supervisors,*we’re*leaders,* we’re*doctors*–*we’re*everything*on*the*floor*right*now.*They’ve*never*come*out*and*told* us*that*we’re*‘charge*nurse,’*but*that’s*exactly*what*we’re*doing*–*we’re*taking*on*the* responsibility*of*the*RN,*not*knowing*exactly*or*being*able*to*work*within*their*scope,* because*we*know*our*scope*–*but*what*happens*when*it*goes*beyond?*Who*do*we*call?* What*do*we*do?*We’re*just*working*together*and*trying*to*make*it*through*the*day.** * Overworked!and!Unable:!“I!can’t!be!here!and!here!at!the!same!time”! ! These"substandard"levels"of"staffing"mean"that"staff"are"overloaded,"and"must"struggle"to"meet" the"demands"of"a"given"day."" * As*the*RPN*on*the*floor,*I’m*expected*to*monitor*36*residents*every*hour,*on*the*hour.* And*I*don’t*know*how*I’m*supposed*to*do*that*between*everything*else.! * I’m*literally*standing*in*the*middle*of*this*assignment*going,*‘Okay,*I’ve*got*to*get*this* one*up*because*he’s*crawling*out*of*bed,*and*this*one*over*here*is*going*to*crawl*out*of* bed,*and*I’ve*got*a*two%person*lift*over*there,*and*that*one’s…’*You*know,*you’re*like*–* there’s*not*enough*time*for*me*here.*And*I*can’t*be*here*and*here*at*the*same*time.* * The*compliance*advisor*[from*the*Ministry*of*Health]*said*we*need*more*staff.*She*said* to*me,*‘Do*you*realize*tonight,*during*the*dinner*hour,*you*were*doing*the*work*of*five* people?’*I*don’t*know*that*she*meant*like,*five*people,*but*that*I*was*doing*the*work*of* more*than*just*myself.*I*said,*‘Do*you*know*what?*I*am*well%aware*of*that.*And*that*is*an* every*day*and*every*night*occurrence.’*She*goes,*‘I*don’t*know*how*you*do*it.’*I*said,* ‘Well,*you*just*saw*it*–*I*did*half*and*half*and*half*–*I*didn’t*do*it*the*way*it*should’ve* been*done.’*A*compliance*advisor*acknowledged*the*fact*that*what*I*was*doing*was* beyond*what*should*be*expected*of*me.** * And*you*can’t*do*fill*ups,*so*the*next*shift*has*got*to*do*twice*the*amount*of*work* because*I*didn’t*have*time*to*do*that.* * I*spent*an*hour*and*a*half*from*the*time*I*left*work,*thinking*about*what*I*could*have* done*better,*what*I*could*have*maybe*switched*up,*done*differently.*And*the*conclusion* at*the*end*of*it*was*that*there*really*wasn’t*anything*I*could’ve*done*differently,*because* I*was*stretched*to*the*max*already.* " I’m*the*first*one*who’ll*help,*like*with*the*lift,*but*when*that*happens,*my*job*as*an*RPN* isn’t*getting*done.*My*documentation*isn’t*getting*done,*all*this*stuff*the*government’s* added*onto*us*that*we*have*to*complete*if*this*happens*or*that*happens.*But*you*feel*

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bad*because*the*buzzers*are*going,*so*you*leave*what*you’re*doing*and*answer*a*buzzer,* and*then,*oh,*so%and%so*needs*a*hand,*so*I’ll*go*help*her,*and*then…*So*we*need*more* staff.*But*ultimately,*if*we*can’t*document*correctly,*we’re*not*going*to*get*the*funding,* so*we’re*not*going*to*get*extra*staff.** * At*what*pace*should*a*person*be*expected*to*work?*Because*we’re*dealing*with*people,* we’re*not*dealing*with*cardboard*boxes.** * In"fact,"one"participant"revealed"that"she"goes"into"work"early,"in"attempts"to"get"a"head"start" on"the"shift"at"hand.""" " I’m*usually*come*in*30*minutes*early.*I*check*–*sometimes*the*shift*before*wasn’t*able*to* get*everything*completed,*like*stocking*carts.*So*I*stock*my*cart.*I*check*on*all*my* residents.*I*do*this*on*my*own*time,*before*my*shift*has*started.** * Strain!and!Stress:!“The!residents!know!when!we’re!stressed”!! " Inadequate"staffing"also"results"in"significant"strain"and"stress"for"both"staff"and"residents." Many"of"the"participants"noted"that"residents"respond"to"this"charged,"hectic"environment"by" attempting"to"“take"care”"of"overloaded"staff."" " The*residents*know*when*we’re*stressed.** * The*residents*can*feel*it,*and*that’s*sad.* * They*know.*And*it*affects*them.*The*poor*patient.*One*resident*said*to*me,*“I*feel*so* sorry*for*you.*Go*home*and*have*a*good*night*and*come*back*tomorrow.”* * They*see*you*working*and*they*say,*“Did*you*have*your*breakfast?*Did*you*get*your* lunch?*Go.*Leave*everything.”* * I’ve*had*my*cognitively*impaired*residents*ask*me,*‘Are*you*okay?’*They*can*see*it*in*your* face,*the*way*you*walk.** " The"participants"revealed,"however,"that"when"they"raise"concerns"about"staffing"levels"and" workload"with"management,"their"concerns"are"ignored."In"fact,"at"many"facilities,"shifts" continue"to"be"cut"from"the"floor."" " We*used*to*have*one*PSW*leaving*at*1:30*p.m.,*but*they*took*away*another*1.5*hours*so* now*we*have*two*PSWs*leaving*at*1:30*p.m.*That*really*leaves*us*short*on*the*floor.*We* voiced*our*opinion,*we*said,*‘Look,*bring*it*back.’*‘Oh*no,*we*can’t*do*that;*it’s*set*in* stone*now.’*We’ve*been*trying*to*work*with*it,*but*we*still*can’t*get*around*it.*At*1:30*in* the*afternoon*during*the*week,*fill%ups*aren’t*done,*the*cart’s*not*full,*you*got*to*take* care*of*all*these*residents…*It*gets*overwhelming.**

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* They*removed*all*the*four%hour*shifts*in*the*morning.*Most*of*the*floors*in*the*building* were*getting*an*extra*four%hour*shift*from*6:30%10:30*a.m.*It*was*basically*a*float*shift* that*used*to*come*in*and*assist*with*all*the*baths*–*she*would*do*five*or*six*baths*–*she* would*maybe*ask*for*help*if*somebody*was*hard.*But*now*that*shift*is*gone*from*the* floor.*So*what*does*that*mean?*The*two*remaining*PSWs*have*to*try*and*fit*in*those* baths*or*showers.*We*don’t*have*enough*time,*we*don’t*have*enough*staff*to*do*all*this* work.*Instead*of*implementing*an*extra*four%hour*shift,*they*took*it*away*from*us.*

" Working!Short:!“We’re!working!short!everyday”!! " As"we’ve"seen,"standard"levels"of"staffing"are"pitifully"insufficient."Yet"in"addition"to"this"already" scant"staffing,"participants"overwhelmingly"revealed"that"they"consistently"work"short@staffed."" " We’re*always*working*short."" * The*first*thing*I*think*about*when*I*get*up*in*the*morning,*before*I*even*get*to*work,*is* that*I’m*hoping*we*are*fully*staffed.*That’s*the*first*thing*I’m*hoping*for*because*that’s* been*a*major*issue.** * A*huge*issue*that*we’re*having*right*now*is*that*they’re*not*replacing*the*first*sick*call*of* the*shift,*days*and*evenings.*So*we’re*working*short*everyday.*All*week*we’ve*worked* short.*Every*single*day*this*week,*there’s*been*a*sick*call,*and*every*single*day,*either*on* days*or*evenings,*they’ve*worked*short,*with*one*complete*less*person.** * One*of*the,*I’m*going*to*say,*‘strong%willed,’*PSWs,*last*night,*she*was*almost*in*tears* when*she*left*because*it*was*three*evenings*in*a*row*that*she*worked*short.*And*she* can’t*do*it*anymore.** * I’ve*been*told,*‘We*called*everybody.*No*one*can*come*in.’*And*I’ll*text*all*the*part%timers* to*check*–*and*not*one*of*them*has*been*called*to*come*in.* " Less!Care:!“Residents!stay!in!bed!for!their!meals,!don’t!get!up,!don’t!get!baths”!! ! In"an"already"understaffed"environment,"working"short"even"further"complicates"the"ability"to" provide"care."" * Ultimately,*our*job*is*here*for*the*residents,*and*we’re*supposed*to*be*resident%focused.* Not*replacing*these*shifts,*no*matter*how*much*money*it’s*saving,*it’s*not…*That*means* residents*stay*in*bed*for*their*meals,*don’t*get*up,*don’t*get*baths,*don’t…*It’s*sad.* * Both*floors*currently*–*over*half*of*both*floors*are*mechanical*lifts,*and*they*require*two* people.*So*if*you’re*by*yourself…*And*yet,*it’s*your*job.** *

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It*really*depends*on*who*you*have*with*you,*if*the*registered*staff*on*shift*is*someone* who*will*come*along*and*help*you*with*things.*Otherwise*you*have*to*rely*on*the*two* PSWs*upstairs,*for*one*of*them*to*leave*their*partner*and*come*help*you.*And*that*then* screws*up*what*they’re*doing.*Last*night,*I*was*by*myself*from*6:30–10:30*p.m.*And* residents*were*asking*to*go*to*bed.*So*I*went*to*my*RN,*and*he*said,*‘They*can*wait*until* 10:30*p.m.*when*the*next*staff*member*comes*in*and*can*help*you.’*And*I*said,*‘But* they’ve*been*up*since*5:00*or*6:00*a.m.*They’re*tired.*They’re*exhausted.*And*they’re* probably*sitting*in*a*wet*diaper.*They*need*to*be*changed*and*washed.’*It’s*just*always*a* fight.*I*just*feel*like*it’s*always*a*fight.** * The"pressure"of"working"short"–"of"being"unable"to"meet"residents’"needs"–"is"further"intensified" by"the"fact"that"staff"are"not"allowed"to"tell"residents"the"reason"care"is"unavailable."" * We’re*not*allowed*to*tell*residents*or*their*families*when*we’re*short%staffed.* * Management*doesn’t*want*us*to*tell*residents*when*we’re*working*short,*that*the* reason*they*can’t*have*their*bath*tonight*is*because*I’m*the*only*one*here.*Management* wants*me*to*tell*residents*that*when*I*get*help,*I’ll*be*back.*Well,*seriously,*that*might*be* three*days*from*now.*I’ve*always*cared*about*the*residents,*and*I’m*not*going*to*lie*to* them.*I’m*not*going*to*say,*‘You*know*what,*when*I*get*help,*I’ll*get*you*in*the*tub.’* Because*that*might*be*Saturday*and*today’s*only*Tuesday.*So*I’m*going*to*tell*the*truth,* and*if*they*want*to*reprimand*me*for*that,*they*can*go*right*ahead.*I’ll*take*a*chance*on* that*as*opposed*to*lying*to*a*resident.*I*had*to*deal*with*it*again*today.*A*resident*said*to* me,*‘Can*you*tell*me,*is*something*wrong?’*And*I*said,*‘Well,*for*the*last*two*evenings,* the*girls*have*worked*short*so*there*hasn’t*been*that*extra*person*–*there*might*have* been*two*people*to*get*you*up,*but*there*wasn’t*going*to*be*that*second*person*until* 10:30*p.m.*to*put*you*to*bed.’*She*said,*‘You*know,*I’d*rather*you*tell*me*that,*because* I’m*okay*with*that.*I*don’t*expect*you*to*do*it*by*yourself.’** * Residents!Bearing!the!Burden:!“They’re!afraid!to!ask!for!assistance”! " Working"short"also"results"in"stress"for"residents,"wherein"they"deny"themselves"care"in" attempts"to"“take"care”"of"overworked"staff."" * The*residents*know*we’re*short*and*we’re*stressed*out,*because*if*they*need*something,* they’ll*say,*‘No,*I’m*fine.*No,*I’m*okay.’*And*that’s*not*fair*to*them.*They’re*just*making* that*decision*because*they*don’t*want*to*be*a*burden,*which*is*a*shame.* * They’re*afraid*to*ask*for*assistance.*One*of*our*residents*rang*three*times*because*she* had*to*go*to*the*bathroom,*but*didn’t*want*to*ring*to*get*washed*up*or*have*her*teeth* brushed*because*she’d*already*rang*three*times.*You*know,*it’s*sad.* * The*one*night*I*came*back*and*worked*a*night*shift,*and*a*resident*said*to*me,*‘Didn’t* you*get*me*up*this*morning?*And*now*you’re*here*putting*me*to*bed?’*And*I*said,*‘Well,*

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I’ve*been*home*for*a*few*hours*and*now*I’m*back.’*And*she*said,*‘Oh,*I*don’t*know*how* you*girls*do*it,*but*I*sure*appreciate*it,*and*I*promise*I*won’t*bother*you*for*the*rest*of* the*night.’*And*I*said,*‘Well,*I’m*here*all*night,*anyways.’*And*she*said,*‘No,*you*put*your* feet*up.’** "

III.!Consequence:!Unworkable!Workload!

" As"all"of"the"participants"reported,"demanding"patient"assignments"and"inadequate"staffing"– both"routine"understaffing"and"routine"short@staffing"–"make"for"an"unworkable"workload."" ! Between"patient"care,"constant"call"bells,"unexpected"events"(falls;"outbreak;"et"cetera),"the" demands"of"each"facility’s"daily"schedule"and"policies/procedures,"documentation,"and"other" job"duties,"PSWs"and"RPNs"are"constantly"rushing"and"multitasking."" * You*arrive,*you*walk*in*a*running*mode,*and*you*don’t*stop*for*eight*hours.*And*you*do* everything*you*can*do*in*that*eight*hours,*and*it’s*still*not*enough.* * It’s*just*go,*go,*go,*get*it*done.** * And*I’m*trying*to*find*somebody*to*help*me.*‘No,*I*can’t*come*over*there*right*now;*I’m* behind,’*or,*‘I’ve*got*two*people*to*lift*up,*too.’** * Between*that,*you’ve*got*bells*ringing,*ringing,*ringing.** * You*could*say*your*bells*are*12*hours.*Because*you’ve*got*to*answer*them*for*12*hours.** * We’re*just*totally*always*walking*on*marbles,*tripping.* " You*feel*like*you’re*always*half*doing*everything,*like*you’re*never*completing*anything.** * Resident!Care!Vs.!Timing:!“Our!day!is!not!based!on!patient!care.!It’s!based!on!timing”!!! * Each"facility"has"daily"schedule"requirements"(e.g.,"dining"schedules;"bathing"schedules;"task" schedules)"and"various"policies/procedures"that"must"be"followed."Given"the"lack"of"staff," however,"these"demands"are"increasingly"impractical,"and"adversely"impact"residents."" " Our*day*is*not*based*on*patient*care.*It’s*based*on*timing.*** * Our*Director*of*Care*has*devised*a*new*time%chart*for*us*and*it’s*every*15*minutes,*in* increments*of*15*minutes*–*this*happens,*that*happens,*this*happens,*that*happens.*And* it’s*completely*unrealistic*because*this*isn’t*how*long%term*care*works.*Things*constantly* change*–*somebody*doesn’t*want*to*get*up*out*of*bed,*somebody*has*an*accident…*So*

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this*chart,*it’s*totally*unrealistic.*With*long%term*care,*you*cannot*go*by*structure*alone.* You*have*to*have*the*element*of*compassion.*And*that’s*been*taken*out.*It’s*gone.** * These*policies*and*procedures*that*are*in*place*are*so*unrealistic.*If*they*can’t*provide* the*people*to*help*us,*they*shouldn’t*have*these*policies*and*procedures.*It’s*just* unrealistic.*But*we*encounter*that*everyday.** * For"example,"in"the"morning,"staff"are"under"extreme"pressure"to"get"residents"into"the"dining" room"on"time."" " Our*manager*wants*everybody*out*there*by*8*a.m.* * We*have*to*have*everyone*in*the*dining*room,*all*set*up*and*ready*to*eat,*by*8:30*a.m.* We*start*at*7:15*a.m.*Our*dining*room*doesn’t*close*till*9:30*a.m.,*but*our*boss*figures* 8:30*a.m.*is*the*almighty*hour.*The*whole*floor*has*to*be*there*or*we*get*shunned.*If*you* come*in*at*8:40*a.m.,*it’s*like,*‘Oh*my*god.*You’re*not*doing*your*job.’*And*that’s*where* the*stress,*everything*comes*right*then*and*there,*because*then*you*got*to*deal*with*that* the*rest*of*the*day.* " Given"this"dining"schedule,"staff"are"faced"with"a"impossible"time"crunch"that"results"in"roughly" seven"minutes"of"morning"care"per"resident"in"a"given"patient"assignment." " In*the*morning,*there’s*an*hour*to*get*these*people*up.*And*if*you*figure*it*out,*that’s* seven*minutes*almost,*per*person.*Now*I*don’t*know*about*you,*but*when*I*do*my* morning*routine*–*and*I*can*walk*to*the*toilet,*and*I*can*do*this*kind*of*stuff*–*it*takes*me* a*lot*more*than*seven*minutes.* * We*have*seven*minutes*max*per*resident*in*the*morning,*and*that’s*pushing*it.** * Seven*minutes,*but*realistically*it’s*not*even.*Because*a*bell*will*go*off.*A*Tabs*alarm.* You’ve*got*to*check*on*that*person*because*they’re*going*to*fall,*they’re*getting*out*of* bed*or*whatever.*You’ve*got*to*go*get*your*supplies.*You’ve*rolled*somebody*over*to* change*their*pad*and*lo*and*behold,*there’s*a*sore*so*you’ve*got*to*record*that,*run*to* your*nurse.*Maybe*somebody*is*vomiting*or…*so*you*don’t*really*have*seven*minutes.** * I*just*can’t*get*over*the*fact*that*you’re*giving*me*seven*minutes.*I’m*spending*five* minutes*going*to*look*for*somebody*to*help*me*do*a*two%person*transfer*on*a*sling*lift.* * As"the"participants"revealed,"these"scheduling"demands"are"at"odds"with"residents’"rights."" " I’m*doing*this*seven%minute*morning*care.*I’m*looking*at*the*clock,*I’m*thinking,*holy* crap.*The*dining*room*opens*at*8:15*a.m.,*so*you’ve*got*15*minutes*to*get*them*all*in* there*for*8:30*a.m.*So*I’m*getting*this*cognitive*elderly*person*out*of*bed*and*I’m*saying* to*them,*‘Sorry,*you’re*going*to*go*down*to*the*dining*room*in*your*nightgown’*–*and*

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let’s*hope*that*you*can*actually*change*that*person*from*their*soiled*pad*because*you* don’t*have*time,*I*don’t*have*time*–*and*I’m*trying*to*smile*and*say,*‘No,*we*don’t*have* time.*We*have*to*go,’*because*I’m*going*to*get*written*up.*‘Put*that*brush*down.*You* can’t*comb*your*hair*right*now.*Yeah,*don’t*comb*your*hair.*You*look*fine,*you*look*fine.’** * That*bill*of*rights,*they*may*as*well*throw*it*out.*Because*whatever*their*mission,*their* mission*statement*out*there,*it’s*not*true.*‘I’m*sorry,*Mrs.*So%and%So,*you*don’t*have*the* right*to*say*if*you’re*coming*to*the*dining*room*this*morning.*You’re*coming.’** * I’ve*got*residents*who*are*refusing.*One*particular*resident*–*he*will*not*go*to*the*dining* room*if*he*is*not*cleaned.*So*he*refuses*breakfast.** * We’re*dragging*99%year%olds,*97%year%olds*out*of*bed,*because*it’s*their*rule*to*have* them*in*the*dining*room*for*8:30*a.m.*It’s*so*against*what*they’ve*got*posted*at*the*front* door,*their*rights,*their*bill*of*rights.*It’s*all*against*that.*It’s*supposed*to*be*their*home.* *** I*had*this*resident*that*didn’t*sleep*all*night*or*whatever*the*case*may*be.*She’s*old*and* she*was*sleeping.*So*I*went*to*my*RPN*–*it*depends*who’s*working*–*and*I*said,*‘This*lady* is*sleeping.*I*can’t*wake*her.’*And*she*said,*‘Well,*you*better*get*in*there*and*wake*her* right*now,*it’s*8:40*a.m.,*chop%chop,*get*her*out*of*bed.’*I’m*picking*up*this*lady*who’s* sleeping.*I*felt*awful.*I*felt*like*I’m*abusing*her,*really.*I’m*infringing*on*her*rights.*I* picked*her*up,*and*she*says,*‘Oh,*no,*no,’*and*she’s*in*pain.*I*put*her*in*the*wheelchair,* brought*her*down,*and*she*slept*the*whole*time*through*her*breakfast.*How*sad*is*that?* " Mealtimes"–"breakfast,"lunch"and"dinner"–"are"equally"as"rushed,"due"to"time"constraints"and" insufficient"staffing."" * You*have*a*time*limit*to*feed*the*residents.** * At*8:30*a.m.,*the*servery*is*there.*There’s*42*residents*in*the*dining*room.*We*have*to* drop*all*our*other*jobs.*We*have*to*serve*those*plates,*we’ve*got*to*clean*up,*and*we* have*to*make*sure*everyone*is*fed.*In*half*an*hour.*Two*at*a*time.*At*9:00*a.m.,*they* have*to*be*out*of*there.*If*they’re*not*out,*we’re*told.*We*have*to*remove*them*from*the* dining*room.* * Feeding*two*people*at*one*time.*It’s*awful.* * You*know,*I*don’t*want*to*eat*if*you’re*rushing*me.*‘Hurry*up.*Hurry*up.’*And*then*you* wonder*why*they’re*not*eating*and*drinking.** * You’ve*got*maybe*eight*residents*to*feed.*By*the*time*you*get*them*their*meal,*it’s*cold* or…*You’re*just*shoveling*it*in*their*face.*You’re*running*over*and*feeding*two*at*a*time*–* at*the*least.*And*probably*trying*to*get*someone*else*to*sit*down*at*the*table*behind*you*

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that’s*now*gotten*up*and*is*trying*to*get*through*the*dining*room.*And*keeping*an*eye* on*everybody*else*to*make*sure*that*they’re*eating.** * Some*people*who*are*isolation*don’t*get*fed*until*two*hours*after*the*meal.*One*resident* didn’t*get*fed*until*8*o’clock*one*night.*Because*we*don’t*have*the*staff*to*deal*with* everyone*in*the*dining*room*and*at*the*same*time,*be*going*down*to*the*halls*to*feed* everybody.*We*can’t*do*it*all.*And*then*we’ve*got*to*get*people*to*bed,*too.*Because*they* all*want*to*go*to*bed*now.** * Everybody*has*to*be*at*the*table*before*anyone*can*eat.*Residents*have*to*sit*and*wait* until*everybody*is*there*before*they*can*eat.*So*you*have*someone*who*has*an*insulin* dependency*and*they*have*to*wait*because…*And*then*you*get*mad*because*this*PSW*is* late*bringing*in*one*of*her*residents*–*so*you’re*stuck*waiting*and*you’ve*got*stuff*to*do*–* and*it’s*not*her*fault.*It’s*because*she*can’t*find*anyone*to*come*help*her*because*we’re* all*sitting*in*the*dining*room*and*we*can’t*leave.*It’s*ridiculous.** " Bathing"schedules"are"also"in"effect."Each"resident"is"allowed"to"have"two"showers"(or"baths)" per"week,"as"per"their"individual"bathing"schedule."Scant"staffing"and"the"rigors"of"the"day," however,"make"bathing"schedules"a"challenge"to"execute."" * We*try*to*shower*two*residents*a*day.*But*we*can’t*get*into*the*shower*until*10:00*a.m.* So*at*10:00*a.m.,*five*PSWs*are*fighting*for*two*shower*rooms.** * We’ve*been*told*that*Sunday*is*a*no%bath*day.*It’s*to*be*a*catch%up*day.** * Basic*care*is*9:30%11:30*a.m.*That’s*the*deadline*to*get*them*all*showered*and*ready.* * We*often*have*to*pass*the*baths*onto*the*next*shift.** * If*it’s*their*hairdressing*day,*or*if*there’s*activities*they*want*to*go*to,*you*have*to*have* them*cleaned*and*dressed*and*ready*by*10:30*a.m.*This*just*throws*a*wrench*into* everything.** * We*just*got*new*bathing*assignments,*where*sheets*are*supposed*to*be*changed*on* certain*days*of*the*week*as*opposed*to*their*first*bath*day,*and*also,*for*each*and*every* resident,*which*day*is*their*bath*day.*If*we*are*the*people*taking*care*of*these*people,* shouldn’t*we*be*doing*the*bath*list*so*that*we*can*actually*make*sure*that*they’re* comfortable,*that*it*goes*with*their*care*plan,*that*it*goes*with*hair*appointments,*going* out*with*their*family?* " Say*it’s*your*shower*day.*Well,*I*can’t*give*you*a*shower*right*now*because*I*don’t*have* time.*This*is*your*shower*day*but*I*have*to*tell*you*when*you*can*take*a*shower*and*it’s* probably*not*going*to*be*until*11:15*a.m.,*because*that’s*the*only*time*I*have*to*do*it.*So* that*resident*is*stuck*in*her*nightgown*until*11:15*a.m.**