Dear Colleagues:  Welcome to my Saturday, April 25, COVID-19 report – now in the fourth month of COVID-19 in Ontario. For the many resources RNAO offers on COVID-19, visit the COVID-19 Portal. In particular, VIANurse is your go-to page if you need to augment your nursing and personal support worker human resources. You can refer to earlier update reports here, including thematic pieces in my blog. Feel free to share this report or these links with anyone interested – they are public. Today, we continue to intensively address the unending tragedy in long-term care.

Seeking RNs, NPs and nursing graduates ready to work in nursing homes

RNAO launched on Friday a fourth survey for RNs, NPs and nursing graduates urging them to register for work in nursing homes that are on an active outbreak. This will fasten even more the matching of nursing staff to homes in dire need. Yesterday we responded, within hours, to the staffing needs of 18 additional organizations. Please retweet the following urgent tweet to have many more RN, NP and new graduates enrolled.  

For those of you ready to work in a nursing home with an outbreak – we need you – please CLICK HERE and complete our survey ASAP. We need your response as soon as possible given the rapidly evolving situation, and the urgent need in nursing homes across the province. The government has now improved the compensation, recognizing your critical role – see Ontario’s press release here.

So far we have got 141 responses: 19 NPs, 119 RNs – ready to go to nursing homes in an active outbreak - plus, 3 RNs who can do non-clinical work. These colleagues are being deployed as we speak, including over the weekend, and for that I want to thank Daniel Lau, RNAO’s director of membership & services working with several of the department’s awesome staff. I am not exaggerating when I say: You are helping save lives.  

I also want to give a big shout-out to RNAO’s long-term care coordinators led by associate director Heather McConnell. The team has been actively connecting with the nursing homes on daily basis, helping find solutions and developing fantastic resources. Please check here.  

Lessons learned through a COVID-19 nursing home outbreak

Wendy Dunn is one of the 60 nurse practitioners (NP) working in Ontario’s nursing homes as an Attending NP. Some of the readers will recall this is a role RNAO negotiated with government years ago and one we insist must expand to each nursing home in Ontario. As I spoke with Premier Ford early this afternoon, a lot needs to happen in nursing homes post-COVID-19 and the premier reinforced to me again that RNAO must and will be involved. Be assured that RNAO will insist on this.   

For now, let me share about Wendy’s work during the pandemic at two long-term care homes, Greenwood Court, Stratford, and Knollcrest Lodge, Milverton. Wendy shared with us her experiences at RNAO’s weekly webinar with NPs on the management of an outbreak at Greenwood Court. She has kindly put together some of the lessons learned through this challenging experience: 

• Teamwork – This is the one time when all must be flexible with routines and roles and must respect the high levels of anxiety that everyone is carrying.

• Communication – We have provided families or the resident’s assigned power of attorney with a “daily update” of what is happening within the Home, specifically commenting on swabbing (of both residents and staff) and our PPE supply. Kept track of frequently asked questions and addressed them for the whole group. Our Executive Director sends out her “One Call” daily. We share all the good news that are happening within the walls as the community support has been overwhelming. These updates are also shared with staff.
• I also recommend making one or two people the communicators for the families – our home is small so I have been that person; in a bigger home you would likely need more. Then the message is consistent and trustworthy for families.
• Staffing – We have been surprised by the number of staff who have not filled their shifts because of multiple issues. These include childcare, their own health issues, or issues within their family (children, spouse) that increase their risk of acquiring COVID-19. This could be other family members who will lose their job, or not be able to go to their work, if they were to have a positive COVID-19 swab or other respiratory symptoms. Staff in health care need to have a plan for how they are going to come to work and keep their families/home safe before an outbreak is declared. Would encourage employees to speak with their employers about this so there are no surprises.
• Do not let your guard down – Continue to don and doff PPE as if it is the first time; do not have staff come to work if they are symptomatic (even if it will cause chaos with staffing…); be on the watch for changes/new symptoms with residents. We made the decision to swab our residents who were positive and symptom free and past the 14 day isolation requirement and found they were still positive… reinforces the need to do that. We will be swabbing again.
• Need to remember that “we can do this” – LTC homes are very good at managing outbreaks. Draw on your past successes and do it even better!

RNAO: Thank you Wendy for sharing your expertise. We learn that there haven’t been any additional confirmed cases among Greenwood residents for two weeks. Huron Perth medical officer of health Dr. Miriam Klassen said on Thursday afternoon: “What we’re surmising is, because the staff have been using universal masking and more aggressive isolation and personal protective equipment and cleaning, etc., cases haven’t been transmitted to the residents,”. You can see and hear Wendy sharing her experience in a panel on Health Care Stories from the Front Lines here.

Letter from a retired RN to Premier Ford: The problems with LTC were evident long before COVID

Dear Premier Ford,

As a retired RN of 28 years, I’d like to provide some perspective on the Long-Term Care crisis. Although I speak of nurses and nursing, my comments also apply to personal support workers, who provide most of the daily care. Nurses do care planning, medications, and treatments.

Although your speech focused mostly on testing, that is a bit of a red herring. The fact is that the homes have been poorly staffed for years. This has nothing to do with COVID.

Nurses work in LTC because they find working with the elderly, with complex needs, intellectually stimulating, and emotionally rewarding. It is one of the highest ways to pay tribute to the people who have made our country such a wonderful place to live.  Unfortunately, any nurse who went into that branch of nursing because they enjoyed working with the elderly were quickly disabused of the notion of any meaningful contact with the residents. They leave because the working conditions are so bad. And there is no relief sight. They are physically and emotionally drained.

When one RN cares for 30 residents, interactions for both parties are disappointing and frustrating. When pressed for time, it is too tempting to take shortcuts and provide sub-optimal care. Nurses take pride in the quality of care they provide. It is disheartening to provide care that isn’t as good as you know it could be. This contributes to moving to a more rewarding situation.

The staffing ratios for PSWs are very low. PSWs care for people who need frequent and extended contacts. These are often people who can’t dress, toilet or feed themselves, and sometimes don’t understand why you won’t just leave them alone.  Caring for them takes long periods of time and a patient manner.  Both are in short supply when rushed. I’m sure before COVID there were people sitting in soiled diapers for extended periods. The elderly have complex needs and aren’t always able to articulate their needs.  Violence towards other residents and staff is high.

I suspect that before COVID many elderly died in part from being understaffed. A good experienced nurse will recognize the early onset of symptoms and take actions accordingly. This saves lives.

When few experienced nurses work in a situation, there is no-one to pass on knowledge, judgement and skill to novice nurses. There is no-one to remember how things were done during SARS, or no-one with the experience and skill to stand up to management to insist that things be done safely.

The lack of full-time positions in the LTC homes also plays a role. When a nurse/PSW sees the same resident for several days in a row, s/he can recognize when something is wrong, and take action. When a resident is seen occasionally by part-time or casual staff, subtle clues to health are not recognized.

Nursing involves teamwork.  You rely on your team to anticipate and respond to situations in a predictable way. When you don’t have a team because the staff keep changing, it is hard to feel safe and have confidence that situations can be handled well. This also leads to nurses leaving.

I won’t discuss the ethics of avoiding paying for benefits by keeping people in part-time positions. I will say it helps people feel unappreciated.

What is appalling, and verging on criminal, is that we knew from Italy and elsewhere that this virus was especially harsh to the elderly. And yet no resources were put in place – where were the allowances for extra space, protection of staff, segregation of people with the virus, and movement of the ill to the hospital for treatment? They were left to die. Shame on Ontario – at least Italy admitted they had to make tough decisions about who got care.

And care for the ones that didn’t have the virus - was extra equipment brought in for Skyping or Zooming with relatives?  Were extra volunteers vetted to be available to provide recreation and emotional support to the residents? There are ways for family to safely visit – it just takes the required staff and supplies. What emotional support was given as they watched their friends die and had no one to turn to? What a horrible way to spend your final years. Experienced nurses could have helped to suggest and implement these interventions.

By right, the for-profit homes should be sued for failure to provide care. But they would say their standard of care was the same as the public homes. Shame again.

In your speech, you made it sound as though these are problems that no-one knew about, that the problems are because of COVID. The problems with LTC were evident long before COVID. Nurses have known for at least 20 years how bad it is to work in LTC. The Ontario Nurses Association and The Registered Nurses Association of Ontario have been raising red flags for years. The newspapers reported on conditions in the homes. The violence, the rapes, the neglect – preventing these things all require good staffing. But somehow the LTC homes thought the care was good enough. It is especially appalling when a for-profit company says they don’t have the money to hire more staff.

So yes, Ontario has a big task ahead of itself.  A drastic change is required - one that will make nurses stay in their jobs. It starts with a good work environment.

Nurses need to see that:

• there are good, dependable, staffing levels,
• they won’t rush all day or night without a break,
• they won’t be consistently asked to work overtime,
• they won’t go home feeling bad about their quality of work,
• they are part of a team and can rely on that the team,
• they are valued, and
• they will be able to provide the level of emotional care that elderly residents require.

I suggest that you sit down and listen to the nursing associations mentioned above. They have Ontarians best interests at heart. After all, we will all be there someday.

Sincerely,

Diana Sebera

Your messages: Voices and responses

Each day we welcome new readers to this daily report: thank you deeply for the work you do always and especially 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 professionals. Feel free to share these updates with other health professionals and other organizations both 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. The COVID-19 Portal is here.

A special thanks to Catherine van Beek, a personal support worker who sent me the following note:

I wish to thank you for your comments showing your support of PSWs working full-time in one care setting or having their wages augmented. Many PSWs do what they do because of their clients. Ours is a difficult, unglamorous job that is undervalued with (mostly) abysmal pay, requiring us to work at several jobs. There is no governing body and most of the time no union to intervene on our behalf. I sincerely thank you for being a voice for us, the PSWs who are going into workplaces everyday despite the risks and challenges to provide care to our most vulnerable. Bless you, Catherine van Beek.

Together we can do it

MOH EOC Situational Report #90 here for Friday, April 24

Situation:

• 640 new cases were reported today in Ontario, bringing the cumulative total to 13,519 (this includes 7,087 resolved cases and 763 deaths).
• In Ontario, a total of 207,040 tests have been completed, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 5,414 tests under investigation.
• 910 patients are currently hospitalized with COVID-19; 243 are in ICU; and 193 are in ICU on a ventilator.

RNAO’s ViaNurse Program               

RNAO’s VIANurse program, launched on March 13, has already registered 284 NPs, 1,019 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 7,298 RNs for virtual and clinical care. RNAO is continuously responding to requests from health organizations. So far, we have served 254 organizations, of which almost 190 are LTC or senior’s homes. RNAO has also offered the government to identify NPs and RNs who can help manage LTC organizations that are in crisis, and assist with urgent interventions where severe outbreaks are ongoing. RNAO’s long-term care coordinators are engaged in around-the-clock support to organizations in the sector that require help. Some of their activities can be found in this page.

Staying in touch          

Please continue to keep in touch and share questions and/or challenges of any kind, and especially shortages of PPE. Send these to me at dgrinspun@rnao.ca. We are responding daily and are continuously solving your challenges. RNAO’s Board of Directors and our entire staff want you to know: WE ARE HERE FOR YOU!

Thank you deeply colleagues in the front lines; in administrative roles; in all labour, professionals and sector associations, and in governments in Ontario, in Canada and around the world. We are here with you in solidarity. These are stressful and exhausting times; the only silver lining is coming together and working as one people – for the good of all!

Together, we must redouble our efforts to tackle COVID-19 with the best tools at hand: accurate and transparent information, calmness, determination and swift actions. 

Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT
Chief Executive Officer, RNAO  

RECENT RNAO POLICY CORNER ITEMS:

23 April - Working with seniors in long-term care requires specialized knowledge – go here.

22 April - Shaking the stigma: We need a proactive COVID-19 response for mental health and addiction – go here.

21 April - We Require Expanded and Accessible COVID-19 Data in Ontario – go here.

20 April - Can Loss of Smell and Taste Help Screen for COVID-19? – go here.

18 April - COVID, Trump and the World Health Organization – go here.

16 April - A Home Based Model To Confront COVID-19 – The Case Of The Balearic Islands – go here.

15 April - COVID-19 and the Challenges in Homecare – go here.

14 April - Reprocessing Of N95 – An Update – go here.

14 April - A New COVID-19 Facility For Persons Experiencing Homelessness In Toronto – go here. 

13 April - Practical Tips for Safe Use of Masks – go here.

10 April - Ontario’s Tragedy in Long Term Care Homes and Retirement Homes – go here.

10 April - RNAO Action – Supporting Long-Term Care – go here.

10 April - Update For Nursing Students – NCLEX Exam – go here.

9 April - Celebrating Passover, Good Friday, Holy Saturday, Easter Sunday and the start of Ramadan during a pandemic – go here.

9 April - Guidance on use of N95 mask – go here.

7 April - Sentinel surveillance and on-site testing in the homeless service sector – go here.

7 April - Reprocessing of n95 – safe? – go here.

5 April - We must change the way we do testing and case definition – go here.

5 April - Ringing the alarm bells on critical care beds – go here.

4 April - COVID-19, stay at home and domestic violence – go here.

We have posted earlier ones in my blog here. Please go and take a look.

Information Resources

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers. 

Ontario’s health provider website is updated regularly with useful resources here.

Ontario’s public website on the COVID-19 is there to inform the general public – encourage your family and friends to access this public website. The WHO has provided an excellent link for you to share with members of the public here.

Please promote the use of Ontario’s COVID-19 self-assessment tool: It also has a guide where to seek care, if necessary. Its use will provide the province with real-time data on the number and geography of users who are told to seek care, self-isolate or to monitor for symptoms. Data will inform Ontario's ongoing response to keep individuals and families safe.

Health Canada's website provides the best information capturing all of Canada. It contains an outbreak update, Canada's response to the virus, travel advice, symptoms and treatment, and resources for health professionals.

The World Health Organization plays a central role in addressing the COVID-19 pandemic. See here and here.

You can find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE.

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