As we search for ways to deal with COVID-19 in nursing homes, and to prevent such tragedies in the future, it seems obvious that we need to begin with staffing. British Columbia (BC) began its efforts to control the spread of the virus in these homes (Harnett 2020); Ontario called in the military (Mialkowski 2020); and Quebec will attempt to hire and train 10,000 healthcare workers (Campbell and Ross 2020). Yet, there are those who still argue that there is insufficient evidence, linking staffing levels and quality of care, or on appropriate staffing levels to establish enforceable standards.

We beg to differ. First, research demonstrates that adequate staffing is a necessary pre-requisite for delivering high-quality care (Harrington et al. 2016). As is the case with all research – especially when it explores complex social phenomena – there are some mixed findings but the overall results are clear.

Second, we have the extensive research commissioned by the US Congress on minimum necessary numbers of staff (Centers for Medicare and Medicaid Services 2001). Conducted almost two decades ago, the resulting reports included time-motion studies to measure how many minutes it takes to cater to the essential needs – toilet, feeding, bathing – of a resident in a given day. Researchers contributing to this report also looked at both the threshold staffing level below which adverse events occurred and the staffing level past which there appeared to be no further improvements. The research led to a call for an enforced standard, setting the minimum staffing level at 4.1 hours of nursing staff per resident per day, with at least .75 registered nurse (RN) hours per resident per day. Although we do not have the same kind of extensive research on staffing in Canada, it is reasonable to assume the US-based research is transferable, given the similarities in both the resident populations and the nursing home labour force.

Third, in the years since that research was done, multiple studies have reinforced the need for such standards, while documenting the increasing frailty of residents that mean even higher staffing levels are required just to meet their needs. Recent US research by Harrington and colleagues (2020) shows a clear link between staffing levels and COVID-19 outbreaks. By providing details on the number of staff in each occupational category, Harrington and colleagues also demonstrate the need to develop minimum staffing levels based on the assessed needs of residents. This research takes us well over the 4.1 hours of nursing care per resident per day previously established as necessary to address residents’ needs and to provide quality care. It demonstrates that while these minimums must be enforced, they are not enough. The lack of such preliminary studies is one reason why we do not have equivalent research in Canada. Moreover, as the BC Seniors’ Advocate points out, the data we do have from managers on staffing is not verified in ways that public accountability requires (Mackenzie 2020).

Fourth, appropriate staffing levels are a necessary but not sufficient condition to ensure safe, quality care. Team-based care, relevant, ongoing training, nursing leadership, staff feeling that managers respect and value their work, union protection, sufficient resources and the values of the organization providing care are all contributing factors. Decent working conditions, as the recent military reports make clear, are essential (Mialkowski 2020). Workload is a major element of working conditions and there is good evidence of the association of high staff turnover with both lower staffing levels and poor quality of working conditions.

Fifth, quality means understanding the importance of relational care. Here, the work of Ramage-Morin – one of the few researchers to have measured this – found that positive self-perceived health among Canadian seniors was associated with a lower risk of mortality and could be developed by having a close relationship with at least one staff member (Ramage-Morin 2006). Staff continuity and sufficient time are critical components in building such relationships. So should there be minimum staffing levels? Absolutely. Will meeting a minimum staffing level automatically result in high-quality care? Not without the many other elements that comprise the “secret sauce” of high-quality relational care. But there is no doubt that failure to meet the minimum staffing levels will result in inferior care and that we need to do better for our most vulnerable seniors. 

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