Focus&Group&Study&Report&!!!

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1 Focus&Group&Study&Report& Long3Term&Care&in&Ontario:& Fostering&Systemic&Neglect& Fall$2014$ $ Ontario$Council$of$Hospital$Unions/CUPE$

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3 TABLEOFCONTENTS FOCUSGROUPSTUDYSUMMARY...3 EXECUTIVESUMMARY...4 INTRODUCTION...6 METHODOLOGY...7 FOCUSGROUPINSTRUMENTDEVELOPMENT...7 SITESELECTION...7 PARTICIPANTRECRUITMENT...7 FOCUSGROUPS...7 DEMOGRAPHICS...8 FOCUSGROUPDISCUSSIONRESULTS...13 I.PATIENTASSIGNMENT...13 II.STANDARDLEVELSOFSTAFFING:UNDERSTAFFED...17 III.CONSEQUENCE:UNWORKABLEWORKLOAD...23 IV.CONSEQUENCE:COMPROMISEDCARE...30 V.CONSEQUENCE:INJURIESTOSTAFFANDRESIDENTS...39 VII.CONSEQUENCE:UNSAFEPRACTICE...47 VIII.WHATWOULDBETTERCARELOOKLIKE?...50 CONCLUSION...57 RECOMMENDATIONS...58 APPENDIXA:FOCUSGROUPDISCUSSIONGUIDE...60 APPENDIXB:PARTICIPANTINFORMATIONSURVEY

4 FOCUSGROUPSTUDYSUMMARY Theintentofthisstudy Long%TermCareinOntario:FosteringSystemicNeglect wastospeak directlytopersonalsupportworkers(psws)andregisteredpracticalnurses(rpns)workingin whatkindofcaretheyarecurrentlyabletoprovideresidents; anybarrierspresentlyimpedingdeliveryandqualityofcare; whatbettercarewouldlooklike,andwhatresourceswouldbenecessaryinorderto ensureitsdelivery. Thedatainthisreportcomesfromtheknowledge,experiences,observationsandfeedback InNovember2013,fivefocusgroupswereconductedwith35PSWs(whichmadeup83per centofthestudyparticipants)andrpns(17percentoftheparticipants)workingatfacilities locatedinguelph,blindriver,ottawa,mindenandtoronto.57percentofthehomeswerein urbanareasand43percentwereinruralcommunities.89percentoftheparticipantswere TheOntarioCouncilofHospitalUnions(OCHU)isabargainingcouncilthatrepresents30,000 CUPE(CanadianUnionofPublicEmployees)healthcareworkersacrossOntario,includingPSWs andrpnsprovidingmedicalcareandsupportstoltcresidents. InadditiontoOCHU sroleasbargainingcouncil,ochucampaignsindefenceofauniversally accessiblehealthcaresystem.itisochu smandatetodefendhealthcareineverycommunity. 3

5 EXECUTIVESUMMARY PSWsandRPNstoldfrank,powerful,oftenheartbreakingaccountsofhow,despitetheir outmosteffortsanddedication,theyareforcedtoprovidewhatamountstosubstandardcare toresidents. Basedontheiraccounts,provincialindifferencetocarelevelsandthequalityofcare,policies andfundingallocationsforltc,arefosteringsystemicneglect.routineunderstaffingand chronicallylowstaffinglevelsareresultinginlonely,isolatedandoftendepressedresidents. PSWsandRPNssimplydonothaveadequatetimetoprovideresidentswiththesocialand emotionalcaretheydesperatelyneed. KeyFindings 1. nightshifts. 2. Chronicunderstaffingandshortstaffingthat: isfuelingabarrageofinjuries,infection,bedsores,abuseandunsafework practices ishasteningincontinenceandlossofmobilityinresidentsbecausetherearenot enoughpswstotoiletresidentsasneeded this,thepswsandrpnssay,isthe ultimateindignityforresidents oftenresultsin nobodyonthefloor inemergencies,includingincasesof evacuation,threateningthesafetyofresidentsandstaff 3. AnimpracticableworkloadthatadverselyimpactsthelevelandqualityofcarePSWs andrpnsareabletoprovideresidents,andhassignificantimplicationsforstaffand residentsafety(includinginjury,abuseandunsafepractice). 4. Laxinfectioncontrolbecauseresidentsarenotimmediatelyscreenedforcommon infectionssuchascdifficile,mrsaandvre.residentisolationisminimalandfrontline staffdonothaveadequatetimetotakeprecautionslikewearinggowns,masksand gloves,tominimizethespreadofgerms percentofthefocusgroupparticipantssaidtheydonotfeelsatisfiedwiththelevel ofcaretheyareabletoprovidefortheresidentsintheirpatientassignments percentofparticipantsidentifiednotenoughstaffandheavyworkloadsasthekey reasonstheycannotprovidequalitycare. 4

6 7. AllofthePSWsandRPNsinterviewedsaidtheyhadresidentssufferingfromdementia andalmostall(97percent)saidtheyhadresidentsintheirassignmentswithcognitive behaviourssuchasaggression,wandering,andhoarding. Fedupwithprovincialgovernmentindifference,PSWsandRPNsarespeakingup,givingvoice tothemanyresidentswhohavenofamilytoadvocateforbetterqualitycareandamandatory staffingratioof8pswsperresident. Recommendations 1. Implementmandatoryminimumstaffingratios 1PSWper8residents(1:8) based onacuitylevelsofresidents.thisisconsistentwithamandatory(andlegislated)daily carelevelof4hours(average)perresidentthatincludesbothincreasedpswandrpn staffinglevels.atpresent,patientassignmentsareunrealisticandunsafe,andpswsand RPNsareunabletoprovidebettercarefortheirresidents.Careshouldneverberushed, compromisedordenied.thereshouldneverbe nooneonthefloor toprovide residentcareandtoensuresafetyduringemergencies. 2. Createsegregatedunitsforviolentresidents,andstaffaccordingly.Atpresent,violent bothphysicallyandemotionally. 3. Implementpre3placementinfectiousdiseasetestingandprovidestafftimetotake bestpracticeprecautionslikegowns,masksandglovestominimizeoutbreaks.at 4. Establishacuitylevelsforcurrentandincomingresidents.Assessanddeterminewhich residentsrequireheavierlevelsofcareandwhy(e.g.,mentalstatus,mobility,medical condition,documentationrequirements,etc)andstaffandtrainaccordingly. 5. Implementcare3appropriateunits(heaviercare;minimalcare;lockedunitswhere necessary)toensureresidents safetyandminimizeinjuryandabuse. 5

7 INTRODUCTION provincialgovernment,staffinglevelshavenotkeptpacewiththeeverincreasingcomplexcare needsofresidents,themajorityofwhomareover80yearsold. Respectedacademicresearchhasconsistentlyshownthatincreasingstaffinglevels,particularly PSWandRPNstaffing,resultsinbetterresidentcare,lessincidentsofviolenceandfalls,and fewerbedsoresandwounds.thefactis,higherstaffingresultsinimprovedoutcomesfor residentswhoarenotmobileandwhohavecomplexmedicalconditions,oftenalongwith cognitiveimpairment. ManyEuropeancountrieshaveheededtheresearchandprovideabetterqualityofresident care.however,ontario sprovincialgovernmentisignoringthemountingevidencethatclearly linkscarequalityandstaffingandfosteringsystemneglectofvulnerableltcresidents. FrontlinePSWsandRPNsworkingatfiveOntarioLTChomes,interviewedinaseriesoffocus groups(withinthelastyear)believethisneedstochange. 6

8 7 METHODOLOGY FocusGroupInstrumentDevelopment Thefocusgroupdiscussionguide(AppendixA)wasdevelopedbyanelectedsubcommitteeof theochu alsodeveloped(appendixb).thesurveywasdistributeduponparticipants arrivalateachfocus group,andcompletedpriortofocusgroupdiscussion. SiteSelection Guelph,BlindRiver,Ottawa,MindenandToronto.Privatemeetingroomsweresecuredbylocal ParticipantRecruitment directlyratherthanviascreeners.participantswererecruitedwithanemphasisondiversityof experience,includingbutnotlimitedto:jobclassification(psws/rpns),employmentstatus incentivizefocusgroupattendance,potentialparticipantsweretoldthattheywouldreceivea $50honorariumfortakingpartinfocusgroupdiscussion. FocusGroups MindenandToronto.Intotal,35peopleparticipatedinthefocusgroups.Focusgroupswere 11/05/2013:Guelph 7participants 11/12/2013:BlindRiver 9participants 11/14/2013:Ottawa 7participants 11/15/2013:Minden 6participants 11/22/2013:Toronto 6participants Eachfocusgrouplastedapproximatelytwohours.Allfocusgroupswereconductedbythesame transcribed.

9 DEMOGRAPHICS Intotal,35peopletookpartinthefocusgroups.Eachoftheseparticipantscompleteda participantinformationsurveyuponarrival.theinformationcollectedfromthesesurveys delineatesthedemographicprofileoftheparticipants(presentedviatables,below). Table1identifiestheparticipants (Percentagesaddto101,duetorounding.) Table1:Participants AgeRange AgeRange Percentage 9% 11% 23% 29% 29% Table2identifiestheparticipants genderidentification.themajorityoftheparticipantswere female. Table2:Participants GenderIdentification GenderIdentification Percentage Female 89% Male 11% Table3identifiestheparticipants cultural/ethnicidentification.themajorityofthe participantswerecaucasianandanglophone. Table3:Participants Cultural/EthnicIdentification Cultural/EthnicIdentification Percentage Francophone 17% PersonofColour 26% Aboriginal/Indigenous 9% Table4identifiestheparticipants jobclassification.themajorityoftheparticipantswere PSWs. Table4:Participants JobClassification JobClassification Percentage PSW 83% RPN 17% 8

10 Table5identifiesthetypeofcommunityinwhichtheparticipants placeofemploymentwas located.thoughasignificantnumberoftheparticipantsworkedinfacilitiesthatserverural communities,mostoftheparticipantsworkedinfacilitiesthatserveurbancommunities. Table5:Participants FacilityLocation/CommunityServed CommunityServed Percentage Urban 57% Rural 43% Table6identifiestheparticipants yearsofservice.participants 29years.(Percentagesaddto101,duetorounding.) Table6:Participants YearsofService YearsofService Percentage 17% 23% 26% 20% 6% 6% Undisclosed 3% Table7identifiestheparticipants employmentstatus.thoughasignificantnumberofthe Table7:Participants EmploymentStatus EmploymentStatus Percentage 57% 40% Undisclosed 3% Table8identifiesthetypeofshifts days,evenings,nights,weekends thattheparticipants worked.themajorityoftheparticipantsworkedacombinationofdays,evenings,nightsand/or weekends.(percentagesaddto101,duetorounding.) Table8:Participants TypeofShiftsWorked TypeofShiftsWorked Percentage Days 17% Evenings 9% Nights 3% Days,Evenings,Nights&/orWeekends 69% Undisclosed 3% 9

11 Table9identifieshowmanyhourstheparticipantsworkedinagivenshift.Themajorityofthe Table9:Participants HoursWorkedPerShift HoursWorkedPerShift Percentage 60% 11% 23% Undisclosed 6% Table10identifiesthetypeofunit/flooronwhichtheparticipantsworked.Whileanumberof theparticipantsworkedonopenunits,mostoftheparticipantsworkedonlockedunits. (Percentagesaddto101,duetorounding.) Table10:TypeofUnit/FloorWorked Unit/FloorWorked Percentage LockedUnit 46% OpenUnit 29% Mixed 23% Undisclosed 3% Table11identifiesthetypesofresidentsintheparticipants patientassignments.everysingle participant spatientassignmentincludedresidentssufferingfromdementia.almostallofthe participantsalsohadresidentswithbehaviours(e.g.,aggression;wandering;hoarding)intheir patientassignments. Table11:TypesofResidentsinPatientAssignment ResidentsinPatientAssignment Percentage Stable 89% Dementia 100% PalliativeCare 91% ConvalescentCare 57% ComplexCare 74% Behaviours 97% Thefinalthreequestionsontheparticipantinformationsurveyaskedparticipantstoindicate:if theyfeltsatisfiedwiththelevelofcaretheyareabletoprovidetoeverypatientintheir veexperiencedasaresultofattemptingto workaroundtheseobstacles. Thefollowingtablesdisplaytheparticipants answerstothesequestions. 10

12 Table12identifiestheparticipants responsestothequestion:doyoufeelsatisfiedwiththe levelofcareyou reabletoprovidetoeverypatientinyourassignment?themajorityofthe participantsdidnotfeelsatisfiedwiththelevelofcaretheyareabletoprovidetoevery residentintheirpatientassignment. Table12:SatisfactionWithLevelofCareProvidedtoEveryPatientinAssignment SatisfactionwithLevelofCare Percentage Yes 6% No 91% Sometimes 3% Table13identifiestheparticipants responsestothequestion:whataresomeofthethings preventingbettercare?themajorityoftheparticipantsidentifiedheavyworkload,notenough staff,andworkingshortasbarrierspreventingthedeliveryofbettercare. Table13:BarriersPreventingtheDeliveryofBetterCare BarrierstoDeliveryofBetterCare Percentage HeavyWorkload 97% UnrealisticPatientAssignment 69% NotEnoughStaff 97% WorkingShort 91% UnrealisticPolicies/Procedures 71% Table14identifiestheparticipants responsestothequestion:haveyouexperiencedanyofthe followingillsduetoworkload,workingshort,and/orunrealisticpoliciesandprocedures?every singleparticipantindicatedthattheyhaveexperiencedstressandoverhalfoftheparticipants and/orunrealisticpoliciesandprocedures. Table14:IllsExperiencedDuetoHeavyWorkload,WorkingShort,and/orUnrealistic Policies/Procedures IllsExperienced Percentage Stress 100% Burnout 74% Fatigue 89% 66% Resultsfromparticipantinformationsurveyquestions#14(Onaverage,howmanypatientsare inyourpatientassignment?),#15(duringanaverageshift,whatistheratioofresidentsto PSWs&RPNs?)and#17(Inagivenshift,howmanyhourstoyouspendoneachofthefollowing tasks?)arenotavailable.becausetheanswerstothesequestionsaredependentonthetypeof shiftworked(day/evening/night),responseswerecompromised.also,inregardsto#17,in 11

13 mostcases,hoursnoteddidn tadduptoorexceededtotalshifthours.thesequestionswere exploredinfocusgroupdiscussion,andtheresultingdataispresentinthediscussionresults. 12

14 FOCUSGROUPDISCUSSIONRESULTS Inconductingthesefocusgroups,wefoundthatPSWsandRPNsareconfrontedwithtwokey challengesonaregularbasis:demandingpatientassignments,androutineunderstaffing. TheseissuesmakeforanimpracticableworkloadthatadverselyimpactsthelevelofcarePSWs andrpnsareabletoprovideresidents.furthermore,theseissueshavesignificantimplications forstaffandresidentsafety(includinginjury,abuseandunsafepractice). I.PatientAssignment EachPSWandRPNhasapatientassignment aclusterofresidentswhoareundertheircare forthedurationoftheirshift.thenumberofresidentswithinagivenpatientassignmentvaries fromfacilitytofacility,andincreasesasdayshiftturnsintoeveningshiftturnsintonightshift. PSWPatientAssignment:Staff3to3ResidentRatios Amongtheparticipants,thelowestnumberofresidentsinadayshiftpatientassignmentwas nine;thehighestnumberofresidentsinadayshiftpatientassignmentwas15. Asdayturnstonight,thenumberofresidentsperpatientassignmentincreases.Amongthe participants,thelowestnumberofresidentsinanightshiftpatientassignmentwas18;the highestnumberofresidentsinanightshiftpatientassignmentwas42. Forexample,inonefacilitythereare36residentsonthefloor.Duringtheday,fourPSWsare onshift(aratiooffourpswsper36residents).eachofthesepswsisresponsibleforproviding caretonineresidents(aratioofonepswpernineresidents).overnight,twopswsareonshift (aratiooftwopswsper36residents).eachofthesepswsisresponsibleforprovidingcareto 18residents(aratioofonePSWper18residents). RPNPatientAssignment:Staff3to3ResidentRatios Amongtheparticipants,thelowestnumberofresidentsinapatientassignmentwas30;the highestnumberofresidentsinapatientassignmentswas42. SomefacilitiesstaffoneRPNonthefloorduringtheday.SomefacilitiesstafftwoRPNsonthe floorduringtheday.atnight,thereisgenerallyonlyonerpnonthefloor. WheretherearetwoRPNsonthefloor,bothRPNssharethesamepatientassignment,with Forexample,inonefacility,thereare40residentsonthefloor.IftherearetwoRPNsstaffed, onerpnisprimarilyresponsibleforadministeringmedicationstoall40residents,andthe 13

15 CombinationLevelsofCare: Ittakesalotmoretimetogeteverythingdone Eachpatientassignmentiscomprisedofamixofresidentswhorequirevaryinglevelsofcare: SomehavedementiaorAlzheimer s;someareyoungeradultswithmentalhealthissues;some havebehaviours(e.g.,aggression;wandering;hoarding).thismakesforachallenging assortmentofcareneeds. Eachassignmenthasacombinationofalldifferentlevelsofcare.Outof42residents, there sprobablyonlytwothatyoucandependonthembeingprettymuchself%sufficient, butstillhavetobesupervised.therestofthemarealotofcare. Thelevelofcarewehavetogivepeopleisgettingmore thereismoredifficulty more peoplearetotalcare,thatkindofthing.ittakesalotmoretimetogeteverythingdone. Whatwe reexperiencingnowisalotmoreresidentscominginwhohavebehavioural issueswhoareaveryheavyworkload,andthentheyhavementalhealthissues.andi believethatalotofuspswshaven treallyhadthefulltrainingforpeoplewhohave mentalhealthandpsychiatricproblems. We regettingmoreyoungerpeoplewithbehaviours.sowe regettingtheselittleold ladiesandwe regettingpeoplethataremoreviolent,andit s It snotagoodmix. They reacceptingpeoplethatareyounger,stronger,theywanttoscrap,they revery aggressive,they renoisy. Ithinkthepopulationisgettingolderandstayinghomelonger.Andsobythetimethey comehere,they reinworseshapethan Yearsago,theycameinwiththeirsuitcaseand theywereabletowalkandcommunicate. Someunitshavehugeageranges from35to105yearsold.tocatertosomebody who s45yearsold,theirneedsarealotdifferentthansomebodywho s105yearsold. UnevenCare: You renotabletogiveequalcaretoallofyourresidents Someresidentsrequireheavierlevelsofcare.Theseresidentsinclude:thosewhoaretotalcare, palliativecareortwo@personcare;thosewhohavedementia,alzheimer sorbehaviours;those whorefusecare;thosewhoaredemandingand/orhavedemandingfamilies. Apersonwithbehaviours Theymighthaveasoiledpadandtheyneedtobecleaned andchanged,buttheygiveyouahardtime,theyswingatyouwhenyou retryingto cleanthemup soittakesabitmoretime. 14

16 Ifyoutellaresidentwithdementiatorollover,theydon tknowwhatyou retalking about,theydon tgetthemessage.soyouhavetouseadifferentapproach.youhaveto spendsometime,getcreative. Searchingforresidentswhowandertakestime.Youcaneasilyguidethemout,butit s thetimeittakestofindthatpersonandbringherbacktoherroomorkeepherinthe diningroom. There soneresidentwhoisconstantlyonthecallbellforunnecessarythings,like, Grab meakleenex, and, Whattimeisit? Thisisstuffthatshe scapableofdoingonherown. Butthere snotreallymuchtobedoneaboutthesituation,becauseifaresidentrings theirbell,wehavetoanswerthatbellnomatterwhat,becausewedon tknowwhy they reringing.andyoucaneasilyspendacoupleofhoursrunningbackandforthwhen someone sringingevery15minutes. Becausesomeresidentstakemoretimethanothers,thisnecessarilyresultsinunevencare. There salwaysaresidentinyourassignmentwhosuffers.youhatetodoit,butthat s justbeinghonest.there sonewhodoesn tgetthepropercarebecauseyoujustdon t havetime. Theparticipantsoverwhelmingindicatedthattheyareconsistentlyforcedto poach timefrom oneresidentinordertomeettheneedsofanotherresident. Someresidentstakelonger,likeresidentswithdementia.Ittakeslongertogetthings donewiththem.soyou respendingmaybeanhourwiththatperson.whichmeansthat anotherresidentisgettingshorttime,maybefiveminutes.soyou renotabletogive equalcaretoallofyourresidents. Ifsomeoneiswalkingdownthehallnakedwithabigmessonthem,you regoingto havetodealwiththat youdon thaveachoice.sosomebodyelseisgoingtogo without. Ihaveninepatients.Andthetwothatarecognitiveandable,Ikindofgo, Okay,well,I cansteal10minutesfromthisonebecauseshecantakecareofherself.i llputher towelsinthereforher,buticansteal10minutesfromherandgiveittothisresident becauseheneedsmorehands%oncare.soi llspend20minuteswithhim.butnow,ineed another10minutes;ihavetoget10minutesfromsomebodyelsebecause Forresidentswhoareminimalcare,whenyougointhereforthefiveminutesofcare youhaveavailableforthem,theywantyoutostay.theywanttheir15minutes,evento socialize,totellyousomethingthathappenedwiththeirday.theysay, It smytime now. AndIunderstandthat sher15minutes.butyoudon thavethat15minutes.so somewhereyouhavetocutbackinordertogiveherthat15minutes.butyoucan tdo 15

17 thateveryshift.thenextday,unfortunately,youcan tgiveher15minutes,becauseyou haveademandingresidentyouhavetogoto. Theresidentswhotendtoreceivetheleastcareinclude:thosewhoaretotalcare;thosewho areminimalcareand/orindependent;thosewhoarelessdemandingand/orhaveless demandingfamilies;thosewhodon torcan tspeakup. Independentpeople thosewhocandomostofthestuffforthemselves getneglected. Becauseifwedon thavetodoanythingwiththemrightaway,wemightnotseethem allday,really. TheoneswhoareinaBrodachairthataretotalcare theyactuallygetlesscare, becauseyougetthemdoneandgetthemsafeintheirchair,andthat sprettywellitfor theday.andthenyou remoredealingwiththepeoplewiththebehaviours. Theoneswhocan tspeakforthemselvesarelosingoutoncare.they dbeyourheaviest, theonesthatreallyrequirethecare andthey renotgettingit. Thepersonyoudon thavethetimeforistheresidentthat ssittinginabrodachairwho won taskyouforasinglething.firstofall,hedoesn twanttobotheryou,secondofall heknowsyou rebusy,youknow,andhethinkshe sfine.buttheguythatcanringthat buzzertoseewhattimeofdayitisortoemptyhisgarbage,ortopasshimsomething, eventhoughhe salreadyrang15times Itleavesyoufeelingreally It sinadequate. AllocationofAssistance: There snobodyaround Duringtheday,eachPSWis partnered withafellowpsw.intheory,pswpartnersassistone anotherasneeded.inreality,pswsstruggletoassistoneanotherbecausetheirownpatient assignmentsareequallyasdemanding. There snotreallyanybody youhaveapartnerbutthatpartnerhasjustasmuchofa loadasyouhave,sothewholetrickistotry,youknow,togetyourtimingright,sothat youcanactuallyusethatotherpersontohelpyoudotwo%persontransfers,lifts, whatnot.that sapolicy.ifwedon tabidebyit,wedogetintrouble.well,thereare timeswhenyoudon talwaysgetto.you llbesofarbehindyouthinkyou refirst.soyou justaredoingunsafethings.i mbeinghonest;it shappening.everyday. Yougointoaroom,yougetthepersonallreadytogo.Youstickyourheadoutthedoor tofindhelpandthere snobodyaround.theonlypersonyouseeisthepswdownthe hallintheothersection.butifyougodowntheretoaskforhelp,yougetstuckhelping them.thenyou re20minutesbehindcomingbacktoyoursectioninthemorning. Therealityis,we reworkingbyourselvestogetthejobdone. 16

18 Dependingonthefacility,PSWsdon talwayshaveanightshiftpartner.ifpswsdohavea nightshiftpartner,thesetwopswsareresponsibleforcareoftheentirefloor(amongthe thaveanightshiftpartner,asingle 42residents). RPNsarenotallocatedanyassistance.WhilesomefacilitiesstafftwoRPNsduringtheday,each staffjustonerpnduringtheday.andatnight,thereisgenerallyonlyonerpnonthefloor. SomefacilitiesencourageRPNstoassistPSWswhereneeded.OtherfacilitiesdonotallowRPNs toassistpsws.eitherway,rpnshavetheirownworkloadandaretypicallyunabletoassist PSWsevenifsuchassistanceisencouraged. Somefacilitiesalsoemployadditionalstaff forexample,bso(behaviouralsupportsontario) staffandrai(residentassessmentinstrument)coordinators butthesestaffhavetheirown specializedroles;theyarenotassignedassistanceforpswsandrpns. AndwhilesomefacilitiesmightstaffafloaterPSW,and/orhaveavolunteersonhandforafew hoursatatime,theparticipantsoverwhelminglyexpressedthatthereisnotenoughhelptogo around. Ourmanagertoldustogettheresidentsoutofbedandputtheminwheelchairs don t washthemallrightaway becausewehaveonehourtogetninepeopleuponeach section.shetoldustoleavetheresidentsinthehallway,thatsomebodywouldbring themdowntothediningroom,becauseuspswsarebusygoingdowntheline.shesaid, Allhandsondeck. Well,sevenheadsgoneandfivePSWsleftinthemorning.Allthe residentsaresittinginthehallway. We reallbusy.everybodyhassomethingtodo. We reluckyifwehavesomevolunteerstocomeandhelpusfeedtheresidents.we reso luckyifthathappens. Wedon thavethemanpower.everydayislikethat.wedon thavethemanpower. There s12%14peoplestartingoutinthemorning,butthere sonlyfiveofusthatare really,reallydoingthiswork. II.StandardLevelsofStaffing:Understaffed Alloftheparticipantsindicatedthatthesestandardlevelsofstaffingaresorelyinadequate. Weshouldmorethanwelcomegovernmentpeopletocomeinandshadowusfora week,amonth,orwhatever,andseewhatthesepeoplearelackingbecauseofthe deplorablestaff%to%residentratio.itjustsickensme. 17

19 CarePlans: Itdoesn treallymeansomebodyisavailabletolookafterthesepeople Insufficientstaffinghasseriousconsequencesforresidentcareplans.Withoutenoughstaffto goaround,it simpossibleforcareplanstobetrulyactualized. Whenresidentsareadmitted,acareplanissetupforthem,sothattheycangetthe carethatneedstobeprovidedtothem.also,theministryofhealthsetsupsome standards,expectations,thatsomuchtimeisbeinggiventoeachoneoftheseresidents. Everyday,everytimeoftheday,anytimethattheyneed.Butit snotnecessarilyso.it doesn treallymeansomebodyisavailabletolookafterthesepeople. Youmighthaveacareplanthatsaysthisoneindividualistobetoiletedondemand. Well,whatifthatresidentrequiresamechanicalliftandittakestwopeopletotoilet them?becausetheministryhascertainregulationswiththeselifts.soyou rerequiredto haveaminimumoftwopeople.butthere sone,agenielift,anditrequiresfourpeople tousethatlift.imagineifthatfourstaffaretheonlystaffyouhaveonthefloor? OnthefloorIworkon,outof20residents,15requirethetwo%personmechanicallift. AndyouonlyhavetwoPSWsonthatside. SafetyImplications: Nowthere snobodyonthefloor Limitedstaffingalsothreatensthesafetyofresidentsandstaff.Betweenbreaks,emergencies, andattendingtoresidents,thereareoftentimeswhenthereis nobodyonthefloor. WhenIfirststarted,Ialwayslookedatitlikethis:Howmanymenontheice?Whereis everybody?sowe vegotfivepsws.threeofthemaregoneonabreak;i monthefloor, andtheotherpswisoverthere.therpnsarebusy.andthisistheonlytimei vegotto givethisresidentashower.soi mintheshower ifsomethingcomesupandthatpsw hastoleavethefloor,passesmeherpager nowthere snobodyonthefloor.unsafe. Whatifsomebodyfalls?Ican tansweracallbell Ican tleavethispersoninthe shower.howmanymenontheice?thishappenseveryday,morethanonceaday. Atonefacility,PSWstaketheirbreaksonthefloortoensuresafety.Theydothisdespitethe factthatthey renotallowedtotaketheirbreaksonthefloor. Wetakeourbreaksonthefloor,attheback.Becausethebellsaregoing,andthestaff ontheotherside,wedon twanttoleavethemalone.liketheotherday,iwastakingmy breakonthefloor,andiheardthisscreaming.ididn tknowwhatwasgoingon.ifound thepatientonthefloor.ihadtoleavemybreakandgogettherpntohelpme.and we renotsupposedtakeourbreaksthere.butifihadn tbeenthere,whatwouldhave happenedtothisresident?idon tknowhowlongshewould vebeenonthefloor. 18

20 Workingbeyondscopeofpracticeisalsoariskfactor.Yetatonefacility,theRNsarelargely unavailable,sotheroleofthernfallstotherpn. AstheRPNontheunit,we reconsideredthe leaders. Idon tknowwherethernis,now theyhavethemlockedawaydoingmds,sobasically,we resupervisors,we releaders, we redoctors we reeverythingonthefloorrightnow.they venevercomeoutandtold usthatwe re chargenurse, butthat sexactlywhatwe redoing we retakingonthe responsibilityofthern,notknowingexactlyorbeingabletoworkwithintheirscope, becauseweknowourscope butwhathappenswhenitgoesbeyond?whodowecall? Whatdowedo?We rejustworkingtogetherandtryingtomakeitthroughtheday. OverworkedandUnable: Ican tbehereandhereatthesametime Thesesubstandardlevelsofstaffingmeanthatstaffareoverloaded,andmuststruggletomeet thedemandsofagivenday. AstheRPNonthefloor,I mexpectedtomonitor36residentseveryhour,onthehour. AndIdon tknowhowi msupposedtodothatbetweeneverythingelse. I mliterallystandinginthemiddleofthisassignmentgoing, Okay,I vegottogetthis oneupbecausehe scrawlingoutofbed,andthisoneoverhereisgoingtocrawloutof bed,andi vegotatwo%personliftoverthere,andthatone s Youknow,you relike there snotenoughtimeformehere.andican tbehereandhereatthesametime. Thecomplianceadvisor[fromtheMinistryofHealth]saidweneedmorestaff.Shesaid tome, Doyourealizetonight,duringthedinnerhour,youweredoingtheworkoffive people? Idon tknowthatshemeantlike,fivepeople,butthatiwasdoingtheworkof morethanjustmyself.isaid, Doyouknowwhat?Iamwell%awareofthat.Andthatisan everydayandeverynightoccurrence. Shegoes, Idon tknowhowyoudoit. Isaid, Well,youjustsawit Ididhalfandhalfandhalf Ididn tdoitthewayitshould ve beendone. AcomplianceadvisoracknowledgedthefactthatwhatIwasdoingwas beyondwhatshouldbeexpectedofme. Andyoucan tdofillups,sothenextshifthasgottodotwicetheamountofwork becauseididn thavetimetodothat. IspentanhourandahalffromthetimeIleftwork,thinkingaboutwhatIcouldhave donebetter,whaticouldhavemaybeswitchedup,donedifferently.andtheconclusion attheendofitwasthattherereallywasn tanythingicould vedonedifferently,because Iwasstretchedtothemaxalready. I mthefirstonewho llhelp,likewiththelift,butwhenthathappens,myjobasanrpn isn tgettingdone.mydocumentationisn tgettingdone,allthisstuffthegovernment s addedontousthatwehavetocompleteifthishappensorthathappens.butyoufeel 19

21 badbecausethebuzzersaregoing,soyouleavewhatyou redoingandanswerabuzzer, andthen,oh,so%and%soneedsahand,soi llgohelpher,andthen Soweneedmore staff.butultimately,ifwecan tdocumentcorrectly,we renotgoingtogetthefunding, sowe renotgoingtogetextrastaff. Atwhatpaceshouldapersonbeexpectedtowork?Becausewe redealingwithpeople, we renotdealingwithcardboardboxes. Infact,oneparticipantrevealedthatshegoesintoworkearly,inattemptstogetaheadstart ontheshiftathand. I musuallycomein30minutesearly.icheck sometimestheshiftbeforewasn tableto geteverythingcompleted,likestockingcarts.soistockmycart.icheckonallmy residents.idothisonmyowntime,beforemyshifthasstarted. StrainandStress: Theresidentsknowwhenwe restressed Inadequatestaffingalsoresultsinsignificantstrainandstressforbothstaffandresidents. Manyoftheparticipantsnotedthatresidentsrespondtothischarged,hecticenvironmentby attemptingto takecare ofoverloadedstaff. Theresidentsknowwhenwe restressed. Theresidentscanfeelit,andthat ssad. Theyknow.Anditaffectsthem.Thepoorpatient.Oneresidentsaidtome, Ifeelso sorryforyou.gohomeandhaveagoodnightandcomebacktomorrow. Theyseeyouworkingandtheysay, Didyouhaveyourbreakfast?Didyougetyour lunch?go.leaveeverything. I vehadmycognitivelyimpairedresidentsaskme, Areyouokay? Theycanseeitinyour face,thewayyouwalk. Theparticipantsrevealed,however,thatwhentheyraiseconcernsaboutstaffinglevelsand workloadwithmanagement,theirconcernsareignored.infact,atmanyfacilities,shifts continuetobecutfromthefloor. WeusedtohaveonePSWleavingat1:30p.m.,buttheytookawayanother1.5hoursso nowwehavetwopswsleavingat1:30p.m.thatreallyleavesusshortonthefloor.we voicedouropinion,wesaid, Look,bringitback. Ohno,wecan tdothat;it ssetin stonenow. We vebeentryingtoworkwithit,butwestillcan tgetaroundit.at1:30in theafternoonduringtheweek,fill%upsaren tdone,thecart snotfull,yougottotake careofalltheseresidents Itgetsoverwhelming. 20

22 Theyremovedallthefour%hourshiftsinthemorning.Mostofthefloorsinthebuilding weregettinganextrafour%hourshiftfrom6:30%10:30a.m.itwasbasicallyafloatshift thatusedtocomeinandassistwithallthebaths shewoulddofiveorsixbaths she wouldmaybeaskforhelpifsomebodywashard.butnowthatshiftisgonefromthe floor.sowhatdoesthatmean?thetworemainingpswshavetotryandfitinthose bathsorshowers.wedon thaveenoughtime,wedon thaveenoughstafftodoallthis work.insteadofimplementinganextrafour%hourshift,theytookitawayfromus. WorkingShort: We reworkingshorteveryday Aswe veseen,standardlevelsofstaffingarepitifullyinsufficient.yetinadditiontothisalready We realwaysworkingshort. ThefirstthingIthinkaboutwhenIgetupinthemorning,beforeIevengettowork,is thati mhopingwearefullystaffed.that sthefirstthingi mhopingforbecausethat s beenamajorissue. Ahugeissuethatwe rehavingrightnowisthatthey renotreplacingthefirstsickcallof theshift,daysandevenings.sowe reworkingshorteveryday.allweekwe veworked short.everysingledaythisweek,there sbeenasickcall,andeverysingleday,eitheron daysorevenings,they veworkedshort,withonecompletelessperson. Oneofthe,I mgoingtosay, strong%willed, PSWs,lastnight,shewasalmostintears whensheleftbecauseitwasthreeeveningsinarowthatsheworkedshort.andshe can tdoitanymore. I vebeentold, Wecalledeverybody.Noonecancomein. AndI lltextallthepart%timers tocheck andnotoneofthemhasbeencalledtocomein. LessCare: Residentsstayinbedfortheirmeals,don tgetup,don tgetbaths Inanalreadyunderstaffedenvironment,workingshortevenfurthercomplicatestheabilityto providecare. Ultimately,ourjobisherefortheresidents,andwe resupposedtoberesident%focused. Notreplacingtheseshifts,nomatterhowmuchmoneyit ssaving,it snot Thatmeans residentsstayinbedfortheirmeals,don tgetup,don tgetbaths,don t It ssad. Bothfloorscurrently overhalfofbothfloorsaremechanicallifts,andtheyrequiretwo people.soifyou rebyyourself Andyet,it syourjob. 21

23 Itreallydependsonwhoyouhavewithyou,iftheregisteredstaffonshiftissomeone whowillcomealongandhelpyouwiththings.otherwiseyouhavetorelyonthetwo PSWsupstairs,foroneofthemtoleavetheirpartnerandcomehelpyou.Andthatthen screwsupwhatthey redoing.lastnight,iwasbymyselffrom6:30 10:30p.m.And residentswereaskingtogotobed.soiwenttomyrn,andhesaid, Theycanwaituntil 10:30p.m.whenthenextstaffmembercomesinandcanhelpyou. AndIsaid, But they vebeenupsince5:00or6:00a.m.they retired.they reexhausted.andthey re probablysittinginawetdiaper.theyneedtobechangedandwashed. It sjustalwaysa fight.ijustfeellikeit salwaysafight. Thepressureofworkingshort ofbeingunabletomeetresidents needs isfurtherintensified bythefactthatstaffarenotallowedtotellresidentsthereasoncareisunavailable. We renotallowedtotellresidentsortheirfamilieswhenwe reshort%staffed. Managementdoesn twantustotellresidentswhenwe reworkingshort,thatthe reasontheycan thavetheirbathtonightisbecausei mtheonlyonehere.management wantsmetotellresidentsthatwhenigethelp,i llbeback.well,seriously,thatmightbe threedaysfromnow.i vealwayscaredabouttheresidents,andi mnotgoingtolieto them.i mnotgoingtosay, Youknowwhat,whenIgethelp,I llgetyouinthetub. BecausethatmightbeSaturdayandtoday sonlytuesday.soi mgoingtotellthetruth, andiftheywanttoreprimandmeforthat,theycangorightahead.i lltakeachanceon thatasopposedtolyingtoaresident.ihadtodealwithitagaintoday.aresidentsaidto me, Canyoutellme,issomethingwrong? AndIsaid, Well,forthelasttwoevenings, thegirlshaveworkedshortsotherehasn tbeenthatextraperson theremighthave beentwopeopletogetyouup,buttherewasn tgoingtobethatsecondpersonuntil 10:30p.m.toputyoutobed. Shesaid, Youknow,I dratheryoutellmethat,because I mokaywiththat.idon texpectyoutodoitbyyourself. ResidentsBearingtheBurden: They reafraidtoaskforassistance Workingshortalsoresultsinstressforresidents,whereintheydenythemselvescarein attemptsto takecare ofoverworkedstaff. Theresidentsknowwe reshortandwe restressedout,becauseiftheyneedsomething, they llsay, No,I mfine.no,i mokay. Andthat snotfairtothem.they rejustmaking thatdecisionbecausetheydon twanttobeaburden,whichisashame. They reafraidtoaskforassistance.oneofourresidentsrangthreetimesbecauseshe hadtogotothebathroom,butdidn twanttoringtogetwasheduporhaveherteeth brushedbecauseshe dalreadyrangthreetimes.youknow,it ssad. TheonenightIcamebackandworkedanightshift,andaresidentsaidtome, Didn t yougetmeupthismorning?andnowyou rehereputtingmetobed? AndIsaid, Well, 22

24 I vebeenhomeforafewhoursandnowi mback. Andshesaid, Oh,Idon tknowhow yougirlsdoit,butisureappreciateit,andipromiseiwon tbotheryoufortherestof thenight. AndIsaid, Well,I mhereallnight,anyways. Andshesaid, No,youputyour feetup. III.Consequence:UnworkableWorkload Asalloftheparticipantsreported,demandingpatientassignmentsandinadequatestaffing makeforanunworkableworkload. Betweenpatientcare,constantcallbells,unexpectedevents(falls;outbreak;etcetera),the demandsofeachfacility sdailyscheduleandpolicies/procedures,documentation,andother jobduties,pswsandrpnsareconstantlyrushingandmultitasking. Youarrive,youwalkinarunningmode,andyoudon tstopforeighthours.andyoudo everythingyoucandointhateighthours,andit sstillnotenough. It sjustgo,go,go,getitdone. AndI mtryingtofindsomebodytohelpme. No,Ican tcomeoverthererightnow;i m behind, or, I vegottwopeopletoliftup,too. Betweenthat,you vegotbellsringing,ringing,ringing. Youcouldsayyourbellsare12hours.Becauseyou vegottoanswerthemfor12hours. We rejusttotallyalwayswalkingonmarbles,tripping. Youfeellikeyou realwayshalfdoingeverything,likeyou renevercompletinganything. ResidentCareVs.Timing: Ourdayisnotbasedonpatientcare.It sbasedontiming Eachfacilityhasdailyschedulerequirements(e.g.,diningschedules;bathingschedules;task schedules)andvariouspolicies/proceduresthatmustbefollowed.giventhelackofstaff, however,thesedemandsareincreasinglyimpractical,andadverselyimpactresidents. Ourdayisnotbasedonpatientcare.It sbasedontiming. OurDirectorofCarehasdevisedanewtime%chartforusandit severy15minutes,in incrementsof15minutes thishappens,thathappens,thishappens,thathappens.and it scompletelyunrealisticbecausethisisn thowlong%termcareworks.thingsconstantly change somebodydoesn twanttogetupoutofbed,somebodyhasanaccident So 23

25 thischart,it stotallyunrealistic.withlong%termcare,youcannotgobystructurealone. Youhavetohavetheelementofcompassion.Andthat sbeentakenout.it sgone. Thesepoliciesandproceduresthatareinplacearesounrealistic.Iftheycan tprovide thepeopletohelpus,theyshouldn thavethesepoliciesandprocedures.it sjust unrealistic.butweencounterthateveryday. Forexample,inthemorning,staffareunderextremepressuretogetresidentsintothedining roomontime. Ourmanagerwantseverybodyoutthereby8a.m. Wehavetohaveeveryoneinthediningroom,allsetupandreadytoeat,by8:30a.m. Westartat7:15a.m.Ourdiningroomdoesn tclosetill9:30a.m.,butourbossfigures 8:30a.m.isthealmightyhour.Thewholefloorhastobethereorwegetshunned.Ifyou comeinat8:40a.m.,it slike, Ohmygod.You renotdoingyourjob. Andthat swhere thestress,everythingcomesrightthenandthere,becausethenyougottodealwiththat therestoftheday. Giventhisdiningschedule,staffarefacedwithaimpossibletimecrunchthatresultsinroughly sevenminutesofmorningcareperresidentinagivenpatientassignment. Inthemorning,there sanhourtogetthesepeopleup.andifyoufigureitout,that s sevenminutesalmost,perperson.nowidon tknowaboutyou,butwhenidomy morningroutine andicanwalktothetoilet,andicandothiskindofstuff ittakesme alotmorethansevenminutes. Wehavesevenminutesmaxperresidentinthemorning,andthat spushingit. Sevenminutes,butrealisticallyit snoteven.becauseabellwillgooff.atabsalarm. You vegottocheckonthatpersonbecausethey regoingtofall,they regettingoutof bedorwhatever.you vegottogogetyoursupplies.you verolledsomebodyoverto changetheirpadandloandbehold,there sasoresoyou vegottorecordthat,runto yournurse.maybesomebodyisvomitingor soyoudon treallyhavesevenminutes. Ijustcan tgetoverthefactthatyou regivingmesevenminutes.i mspendingfive minutesgoingtolookforsomebodytohelpmedoatwo%persontransferonaslinglift. Astheparticipantsrevealed,theseschedulingdemandsareatoddswithresidents rights. I mdoingthisseven%minutemorningcare.i mlookingattheclock,i mthinking,holy crap.thediningroomopensat8:15a.m.,soyou vegot15minutestogetthemallin therefor8:30a.m.soi mgettingthiscognitiveelderlypersonoutofbedandi msaying tothem, Sorry,you regoingtogodowntothediningroominyournightgown and 24

26 let shopethatyoucanactuallychangethatpersonfromtheirsoiledpadbecauseyou don thavetime,idon thavetime andi mtryingtosmileandsay, No,wedon thave time.wehavetogo, becausei mgoingtogetwrittenup. Putthatbrushdown.You can tcombyourhairrightnow.yeah,don tcombyourhair.youlookfine,youlookfine. Thatbillofrights,theymayaswellthrowitout.Becausewhatevertheirmission,their missionstatementoutthere,it snottrue. I msorry,mrs.so%and%so,youdon thavethe righttosayifyou recomingtothediningroomthismorning.you recoming. I vegotresidentswhoarerefusing.oneparticularresident hewillnotgotothedining roomifheisnotcleaned.soherefusesbreakfast. We redragging99%year%olds,97%year%oldsoutofbed,becauseit stheirruletohave theminthediningroomfor8:30a.m.it ssoagainstwhatthey vegotpostedatthefront door,theirrights,theirbillofrights.it sallagainstthat.it ssupposedtobetheirhome. Ihadthisresidentthatdidn tsleepallnightorwhateverthecasemaybe.she soldand shewassleeping.soiwenttomyrpn itdependswho sworking andisaid, Thislady issleeping.ican twakeher. Andshesaid, Well,youbettergetinthereandwakeher rightnow,it s8:40a.m.,chop%chop,getheroutofbed. I mpickingupthisladywho s sleeping.ifeltawful.ifeltlikei mabusingher,really.i minfringingonherrights.i pickedherup,andshesays, Oh,no,no, andshe sinpain.iputherinthewheelchair, broughtherdown,andshesleptthewholetimethroughherbreakfast.howsadisthat? Mealtimes breakfast,lunchanddinner areequallyasrushed,duetotimeconstraintsand insufficientstaffing. Youhaveatimelimittofeedtheresidents. At8:30a.m.,theserveryisthere.There s42residentsinthediningroom.wehaveto dropallourotherjobs.wehavetoservethoseplates,we vegottocleanup,andwe havetomakesureeveryoneisfed.inhalfanhour.twoatatime.at9:00a.m.,they havetobeoutofthere.ifthey renotout,we retold.wehavetoremovethemfromthe diningroom. Feedingtwopeopleatonetime.It sawful. Youknow,Idon twanttoeatifyou rerushingme. Hurryup.Hurryup. Andthenyou wonderwhythey renoteatinganddrinking. You vegotmaybeeightresidentstofeed.bythetimeyougetthemtheirmeal,it scold or You rejustshovelingitintheirface.you rerunningoverandfeedingtwoatatime attheleast.andprobablytryingtogetsomeoneelsetositdownatthetablebehindyou 25

27 that snowgottenupandistryingtogetthroughthediningroom.andkeepinganeye oneverybodyelsetomakesurethatthey reeating. Somepeoplewhoareisolationdon tgetfeduntiltwohoursafterthemeal.oneresident didn tgetfeduntil8o clockonenight.becausewedon thavethestafftodealwith everyoneinthediningroomandatthesametime,begoingdowntothehallstofeed everybody.wecan tdoitall.andthenwe vegottogetpeopletobed,too.becausethey allwanttogotobednow. Everybodyhastobeatthetablebeforeanyonecaneat.Residentshavetositandwait untileverybodyistherebeforetheycaneat.soyouhavesomeonewhohasaninsulin dependencyandtheyhavetowaitbecause AndthenyougetmadbecausethisPSWis latebringinginoneofherresidents soyou restuckwaitingandyou vegotstufftodo andit snotherfault.it sbecauseshecan tfindanyonetocomehelpherbecausewe re allsittinginthediningroomandwecan tleave.it sridiculous. Bathingschedulesarealsoineffect.Eachresidentisallowedtohavetwoshowers(orbaths) perweek,aspertheirindividualbathingschedule.scantstaffingandtherigorsoftheday, however,makebathingschedulesachallengetoexecute. Wetrytoshowertworesidentsaday.Butwecan tgetintotheshoweruntil10:00a.m. Soat10:00a.m.,fivePSWsarefightingfortwoshowerrooms. We vebeentoldthatsundayisano%bathday.it stobeacatch%upday. Basiccareis9:30%11:30a.m.That sthedeadlinetogetthemallshoweredandready. Weoftenhavetopassthebathsontothenextshift. Ifit stheirhairdressingday,orifthere sactivitiestheywanttogoto,youhavetohave themcleanedanddressedandreadyby10:30a.m.thisjustthrowsawrenchinto everything. Wejustgotnewbathingassignments,wheresheetsaresupposedtobechangedon certaindaysoftheweekasopposedtotheirfirstbathday,andalso,foreachandevery resident,whichdayistheirbathday.ifwearethepeopletakingcareofthesepeople, shouldn twebedoingthebathlistsothatwecanactuallymakesurethatthey re comfortable,thatitgoeswiththeircareplan,thatitgoeswithhairappointments,going outwiththeirfamily? Sayit syourshowerday.well,ican tgiveyouashowerrightnowbecauseidon thave time.thisisyourshowerdaybutihavetotellyouwhenyoucantakeashowerandit s probablynotgoingtobeuntil11:15a.m.,becausethat stheonlytimeihavetodoit.so thatresidentisstuckinhernightgownuntil11:15a.m. 26

28 ResidentCareVs.UnexpectedEvents: Youneverknowwhat sgoingtohappen Theparticipantsexpressedthatunexpectedevents(e.g.,falls;incidentsregardingresidents withbehaviours;incidentsbetweenresidents;diseaseoutbreak)areroutineoccurrences.given limitedstaffing,however,theseunpredictableyettypicaldisruptionsfurtherinterruptdelivery andqualityofcare. It shardtotellyouaboutthewholeday.youneverknowwhat sgoingtohappen. Youhopeandpraythattherearenoincidents. Multiplefallscouldhappenthroughouttheday three,four sowehavetoassess, report. We vejustbeeninoutbreak,sothatjustthrowseverythingoffandyoujustcan tkeep up.youjustcan t.sonowyouhavetotraypeoplesotheygettheirmealintheirroom, andsomeofthemyou llhavetofeedintheirroom Youhave,say,a37%year%oldwithamucholdermanwhohashoardingissues,andhe s goingintotheyoungerman spossessions.there salotofbehaviours.there snottoo manyfightserupting,butthere salotofarguments.sowe rebasicallysteppinginand policingpeoplealot. Youmighthavesomebodywho scompletelysoiled,orbedchanges,or andinbetween doingallthiskindofstuff,you reansweringbellsandwhatnot,andhelpingpeopleout. You rewitharesidentbutyou reinchingyourwayoutthedoorwhilethey retalking becauseyourbellisringing. What sthat?oh,hangon,igottogo. Napsareat1:00p.m.,butsometimesittakesanhourbeforeyou redoneeveryone it alldepends.thenyouhavetohavethemallupby3:00p.m.,togivethemtheir nourishment.butthere sonlythreepswsleftonthefloorbythatpoint.andthenyou havetogetthemallreadyagainforsupper. We vegottomonitorresidents.iftheyhaveabedsore,wehavetowriteitdownand monitorthem,turnthemeveryhalfhour.at7o clock,i mhere and, Oh,no,it s8 o clock.i vegottogoback. Yourmind slike,crazy. Andthenyouhavetodocument.Answeryourbells.Takeabreakifyou relucky. Someresidentsstartwakingupat2o clock,3o clockinthemorning,andstart wanderingthehalls.andsomeresidentsyouhavetokeepaneyeonbecausetheydon t knowwhichroomistheirs.they llcomeoutoftheirroom,they llcomesitinachair.and 27

29 becauseyou rebusyandnotabletokeepthemstimulated,they ll Okay,well,gonna gobacktobed.okay,well,gonnagointhisroom andpullthisresidentoutofbed, becausethat ssupposedtobehisbed.thishashappened.aresidenthaspulledanother residentoutofbed,nottodoanythingelsebuttogetintothatbed. There s36residentsthatwehavetogivemedsto,wehavetodoallthetreatments,do doctor sroundswiththedoctor,reviewlabreports,doassessments,greetvisitors.all internalandexternalphonecallscometousnow,notthern,totherpn sowemight begettingcallsfrompharmacies,families I mgivingmeds,gettinginterrupted Half thetimeican tevenanswerthephone,andwe reexpectedtoanswerthephone. Andoutofallthis,wehaven tevenmadebedsyet. ResidentCareVs.Documentation: EitherIdidmypaperworkorIchangedpeople Alloftheparticipants bothpswsandrpns notedthattheirdocumentationhasincreased considerably.oftentheonlywaytocompletedocumentationinagivenshift,however,isatthe expenseofresidentcare.tothatend,oneortheothernecessarilyfallstothewayside. Wehavemorepaperworkthanpatientcare. ItwaseitherIdidmypaperworkorIchangedpeople,andpaperworkaroundhereis whattheywantdone.theywantitalldone,butwecannotdoitall. DocumentationwhenI mworkingashift unlessit sanightshift isnullandvoid prettymuch.becauseyoudon thavetime.becausethatbuzzer sgoing.soamigoingto gogetthatbuzzer,oramijustgoingtogola%la%la,andcontinuewithmypaperwork? I mgoingtoandgetthatbuzzer. Ihadaconversationwithmymanageracoupleofweeksagoaboutapieceof documentation.isaid, Iwilltaketheblameforyesterdaybecauseonlypartofitwas done,buticantellyourightnow,wheniwasn tdoingdocumentation,iwasproviding hands%onresidentcare.thatmightnotbewhatyouwanttohear,butthat swhatiwas doing.theyweregettingwhattheyneeded.itmightnotsaythatonthatpieceofpaper, but Andthatwasmoreimportanttome. Now,theywantevenmorepaperworkdone.Andifyoudon thavetimetodoyour paperwork,yougetintotrouble.themanagercomestoyouandsays, Whywasn tthis done? Andyoutrytoexplaintothem,buttheydon twanttohearyourexplanation. Wedon thavethetimetodocument.there snotimeforregisteredstafftodo assessments,andifthey redone,they redonehalfway,orthey relate.wedon thave enoughstaff. 28

30 AverageHands3OnCarePerResident: Iwouldsay10minutes Confrontedwithinadequatestaffing,timeconstraints,anddemandingandunpredictable workloads allthewhilejugglingthevaryingcarerequirementsoftheresidentsinagiven patientassignment staffarenecessarilylimitedintheamountofcarethattheyareableto provide.theparticipantsrevealedthattheaverageresidentreceivesroughly10minutesof Ifyou retalkingaboutactualme%touching%you,hands%oncare,iwouldsay20minutes perpersonina12hourshift. There sneveratimeyoucansay, Oh,20minutesperperson, becausei mstealing10 minutesfromyoubecausei minajackpotoverhere. Iwouldsay10minutes. Iftheyringallthetime,theygetthebulkofthetime.Sojusttheaverageresidentwould be10minutes. Ifyouactuallysatdownandtriedtodoalittlebitofmath,Iwouldthink justfrommy lastthreedayshifts onaverage,outofmyeighthours,whatthey vegottenfrommeis 10minutes.Ifit stheirbathday,they dgetanextrafiveor10minutes.it snotaspa bath,that sforsure.it sinandout,washanddryandthereyougo. Onagoodday,we reabletospend10minutesperresident.that sgettingthemup, that stoileting,that sfeeding.atmaximum,15minutes ifyouhaveabath,or somebodywho shadanaccident.andthensomebodyelseisringing,soyou repulledin everydirection. Ihavefiveminutesforoneresidentand25minutesforanotherresident.Sometimesyou canonlyspendfiveminuteswitharesident.it sridiculous. Iwastoldbymanagementthatrightnowthere sabout2.5hoursofcaregivenper residentperday.andilaughed.becausehonestly,ifistartedaddingitallup,evenwith RNsgivingpills,andusfeedingthemandchangingthemandputtingthem Idon tthink they regetting maybeanhourtotal. minimumcare. Basiccare.Very,verybasiccare. 29