Today, Good Friday, April 10, focuses on long term care. I chose this as my report’s focus as their residents are most affected by COVID-19 – in their isolation from loved ones and in the devastating fatalities we as a society have experienced. For the families and friends of residents in nursing homes and retirement homes and especially those who have lost loved ones: our hearts are with you at this difficult time. We told you to stop visiting your loved ones so we could keep them safe. And, so far, we have failed you. For this, as a nurse and a health system leader: I apologize.
To residents in nursing homes and retirement homes, to their families and friends, and to all staff working so very hard: Know that RNAO will continue to pressure – without any stopping --that all necessary measures to protect residents in nursing homes and retirement homes be fully and immediately implemented. As we protect them, we also need to protect the staff, as the safety of one is the safety of the other.
We know, that even when all measures will be put in place – and they must – we will still have lives lost – but many will be saved, and families who were once told to stay away will be once again be able to reunite and embrace.
This blog is testament to the profound sadness at what’s happening and RNAO’s unwavering efforts to push for urgent interventions to save lives, help with the existing outbreaks and prevent new ones. We call on governments at all levels and their health officials – in the strongest possible terms – to act immediately and comprehensively.
In today’s report, we also describe the direct actions that RNAO is taking and for which we have full control, to support families and staff in nursing homes and retirement homes.
RNAO policy corner – Ontario’s tragedy in long term care homes and retirement homes
A tragedy of major proportions has been unfolding in front of our eyes in nursing homes and residential care in Ontario; the response so far has been slow, partial and ineffective. How many deaths are required until we start taking this horrific situation with the urgency, rigour and resources it requires? Words and promises do not suffice, what is needed – immediately – is action.
The outbreaks are spreading like fire in dry bush. We hear anecdotal evidence of terrible situations in some of the institutions. Many nursing homes are depleted of staff to start with, and now are facing dire lack of staff, many of which are sick or in isolation or unable to work, and we hear some reports of residents who are virtually abandoned in their rooms. Most nursing homes and retirement homes are doing heroic efforts to attend to their residents and provide dignified care under conditions they would have never imagined before and without the basic tools required, such as adequate staffing and PPE.
For the families, the situation is desperate. The homes and residences, rightly so, have limited visits so they are physically unable to visit their loved ones. They are also urged to have very difficult conversations given the clear message that treating the elderly and frail in hospitals may not be in their best interest. Are the LTC institutions set up to facilitate the passing away of so many residents, within the home, with dignity and the palliative care they deserve, and without the presence of family members? What will be the lasting trauma for families, staff and administrators who have to live through this nightmare?
The latest information we have is that there are over a 100 nursing homes in outbreaks and 40 or more retirement homes, across Ontario. Some of the information shows devastating scenarios, such as the Seven Oaks senior home in Toronto, with at least 16 deaths, 45 confirmed cases and 56 probable cases of COVID-19 among 249 residents. There were also 13 confirmed cases among staff members.
That the LTC sector is not prepared for this crisis is an understatement, and something all governments in Ontario have known for many years. The sector has been severely under-resourced, under-staffed and under-prioritized for decades. RNAO has repeatedly called for changing the provincial government formula for funding of nursing homes and for changing the staffing levels and mix. The changes so far, prior to the COVID-19 pandemic, have been minimal.
Indeed, these are the reasons why the sector was in a shambles during the 2003 SARS epidemic. RNAO was already saying then that the SARS outbreak was exacerbated by a “nursing workforce that battles with dangerously low staffing levels, high workloads, and an over-reliance on part-time, casual and agency staff.” Sadly, the only area where staffing has improved, in nursing, is that now we have a higher proportion of the workforce employed full-time. Nothing else has changed in any material way since 2003.
In RNAO’s report Mind the Safety Gap – released in 2016 and well known to past and current to past and current governments in Ontario – RNAO repeated its plea to increase the ratios of RNs, RPNs and NPs in nursing homes to the proper staffing skill mix. As recent as February 2019, RNAO recommended (see here and here) providing adequate staffing levels and an appropriate staffing skill mix in nursing homes. RNAO also recommended increasing the number of beds as well as changing the funding model to reward improvements in the wellness, quality of life and health outcomes of their residents. We repeated this plea, providing all the necessary evidence, in meetings and consultations with Minister of Health Christine Elliott and with Minister of Long-Term Care Minister Merrilee Fullerton, as late as March 11, the day that WHO called COVID-19 a pandemic.
During the current pandemic RNAO has been ferociously voicing for weeks our concern in every ambit possible: at daily morning briefings with Ontario’s Medical Officer of Health, with the Ministry’s Collaborative Table of associations, through these COVID-19 reports, through the media and of course with nurses and others who write to us in desperation.
Post COVID-19, RNAO will issue a report calling for a complete overhaul of the long term care sector to make it a priority for humane, dignified and safe care. For now, we must tackle ways to mitigate the utter devastation we are all experiencing.
The latest set of government measures for long-term care was announced yesterday, representing a step in the right direction. However, government must intervene immediately, fully and vigorously. RNAO has advised for key policy measures, some of which have been adopted fully or partially by government:
Late this evening, April 10, the government issued a new directive (see here), which appears to supersede the one issued earlier in the week. The new directive seems to limit the requirement of universal masking for all staff facing patients, since it states “In the event that the supply of PPE reaches a point where utilization rates indicate that a shortage will occur, the government and employers, as appropriate, will be responsible for developing contingency plans, in consultation with affected labour unions, to ensure the safety of health care workers and other employees.” We are waiting for further clarity from the Ministry and will provide updates as soon as they are available.
RNAO action – Supporting Long-Term Care
RNAO has been working since March 13, through its ViaNurse program here, to address human resource needs of nursing homes and retirement residences seeking RNs, NPs and PSWs. Nursing students in 2d, 3d and 4th year can legally work as PSWs. If you would like to register for work, or if you are an organization seeking help, please go here.
Nurse Practitioner Knowledge Exchange Webinars
We have already held several webinars with NPs working in LTC. This knowledge exchange Zoom forum centres on a wide range of needs and the identification of practice issues requiring more direction and tools, which we have quickly developed to support our colleagues in the field. We know these needs will continue to expand over the coming days, weeks and months, and we are eager, able and ready to respond. The new resources, tools and supports are summarized below:
Suggestions and Strategies for Isolating Residents in Long-Term Care
To our knowledge there is no current research evidence or best practice guidelines that directly address COVID-19 isolation measures in relation to the population and residents with dementia in long-term care. This document outlines suggestions and strategies for isolating residents in long-term care homes during the COVID-19 pandemic. RNAO has gathered this list of suggestions and strategies from a number of long-term homes, and has received endorsement from both AdvantAge Ontario and the Ontario Medical Association. For details, see here.
Palliative Care Delivery in Long-Term Care during the COVID-19 Pandemic
This summary of palliative care and end-of-life resources is for health care providers in Ontario long-term care homes to help them to quickly address the issues they are confronting during this COVID-19 pandemic. Recommendations for advanced care planning are based on the Ontario legal framework. For details, see here.
Mental Health and Well-being: Resources for Psychosocial Support during the COVID-19 Pandemic
Mental health and well-being is essential to our overall health. To maintain the safety of health care workers and their families during this pandemic, a list of recommended resources has been compiled to support you in getting the help you may need. We will continue to update this document as new resources are identified. For details, see here.
VIAFamily: RNAO LTC Support for Connecting Families
We recognize the profound impact social distancing is having on families and friends who have loved ones living in long-term care homes. Given the current visiting restrictions, RNAO established a Facebook Group the week of March 30th to provide a forum for families and friends of nursing homes and retirement homes residents to share stories and get support from others experiencing a similar situation. As of today, there are 150 members in the group. To join, go here.
Two emerging groups this week - we are responding to your needs – were launched yesterday!
Professional’s Peer-to-Peer Support During COVID-19
Sharing and Tackling Emerging Care Issues
This Group is for you, health workers - nurses and other colleagues - who are facing unprecedented challenges during the COVID-19 pandemic to raise concerns about practice issues affecting staff and/or the recipients of care and to offer mutual support that promotes safe, high quality care. You are encouraged to share your experiences and strategies to address practice concerns and cope with the challenges. To join, go here.
All three Facebook Groups will be moderated by RNAO staff, including registered nurses and policy experts. RNAO staff will direct participants to credible resources and identify unanswered questions, emerging issues and trends that require further action from us at RNAO and top officials in the province. You can join any of the groups through the links in RNAO’s Facebook page, here.
Update for nursing students – NCLEX Exam
In order to respond to student inquiries -- about the NCLEX Exam, access to a Temporary License, and completion of clinical placements -- we have contacted the College of Nurses of Ontario (CNO). They have advised that the NCLEX exam became available again on March 31st and more centres continue to become available as writing centres are able to open given current requirements for social distancing and cleaning. Students are registering to write the exam. Students with questions about the examination should access the CNO website at http://www.cno.org/students As we understand it, candidates can schedule their exams for appointments starting May 1st and beyond, if conditions allow.
A further issue is that many students are attempting to obtain a temporary license to enable them to become a part of the nursing and care team, having met all the requirements except that of a job offer. RNAO is working with possible employers and the CNO to expedite this process to enable students to join the workforce.
We have heard from many 4th year students who are concerned that they have been unable to complete their programs because their clinical placements are no longer being honored in the service setting at this time. RNAO is working with various heads of Schools of Nursing to clarify and help resolve the issues involved in facilitating students to meet program requirements through completion of their clinical placements. Again, these students are keen and ready to join their nursing colleagues in the battle against COVID 19.
Your messages: Voices and responses
Every day we welcome new readers to this daily report: thank you deeply for the work you do during this public health crisis, and also for keeping us well informed. You can see previous reports at RNAO updates and resources on COVID-19 for members and other health professionalsFeel free to share these updates with other health professionals at home and abroad. RNAO media hits and releases on the pandemic can be found here. Daily Situational Reports from Ontario's MOH EOC can be found here. Many of the articles you see here are posted in my blog, where you can catch up with earlier issues.
Thank you for your messages! Here are important items that respond to some of your questions and concerns in the past two days:
You can read earlier responses here.
MOH EOC Situational Report #76 here for Friday, April 10