Staffing for Nursing Home Care: COVID-19 and Beyond
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.
About the Author(s)
Pat Armstrong, Phd, FRSC, is a Distinguished Research Professor of Sociology, York University. She was principal investigator of a ten-year study titled “Reimagining Long-term Residential Care: An International Study of Promising Practices”.
Charlene Harrington, Ph.D., RN, is Professor Emeritus, Department of Social and Behavioral Sciences, University of California, and a widely recognized international expert on staffing in nursing homes.
Margaret McGregor, BA, MD, CCFP, MHSc, COE, is a family physician and Director of Community Geriatrics at the University of British Columbia, Department of Family Practice. She co-authored multiple studies on staffing, quality and ownership in nursing homes.
Campbell, E. and S. Ross. 2020, June 3. After Announcing It Will Hire 10,000 Orderlies, Quebec Gets 69,000 Applications. CTV News. Retrieved July 10, 2020. <https://montreal.ctvnews.ca/after-announcing-it-will-hire-10-000-orderlies-quebec-gets-69-000-applications-1.4968115>.
Centers for Medicare and Medicaid Services. 2001, December 24. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Report to Congress: Phase II Final, Volume I. Retrieved July 10, 2020. <https://theconsumervoice.org/uploads/files/issues/CMS-Staffing-Study-Phase-II.pdf>.
Harrington, C., J. F. Schnelle, M. McGregor and S. F. Simmons. 2016, April 12. The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes. Health Serv Insights (9): 13–19. doi: 10.4137/HSI.S38994.
Harrington, C., L. Ross, S. Chapman, E. Halifax, B. Spurlock and D. Bakerjian. 2020, July 7. Nurse Staffing and Coronavirus Infections in California Nursing Homes [online ahead of print]. Policy Polit Nurs Pract. doi: 10.1177/1527154420938707.
Harnett, C. E. 2020, April 10. Long-Term Care Workers Limited to One Facility Only Under New Rules. Times Colonist. Retrieved July 10, 2020. <https://www.timescolonist.com/news/local/long-term-care-workers-limited-to-one-facility-only-under-new-rules-1.24116171>.
Mackenzie, I. 2020. A Billion Reasons to Care: A Funding Review of Contracted Long-Term Care in B.C. Office of the Seniors Advocate. Retrieved July 10, 2020. <https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2020/02/ABillionReasonsToCare.pdf>.
Mialkowski, C. J. J. 2020, May. Op Laser – JTFC Observations in LTCF Ontario Long Term Care Homes. Scribd. Retrieved July 10, 2020. <https://www.scribd.com/document/463110038/Op-Laser-Jtfc-Observations-in-Ltcf-Ontario-Long-Term-Care-Homes>.
Ramage-Morin, P. 2006, February. Successful Aging in Health Care Institutions. Health reports / Statistics Canada, Canadian Centre for Health Information = Rapports sur la santé / Statistique Canada, Centre canadien d'information sur la santé 16(Suppl): 47–56.
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