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. Indeed, that is where BC began their efforts to control the spread of the virus in these homes, why Ontario called in the military and where Quebec is going in its attempt to hire and train 10,000 health care workers. Yet there are still those who argue that there is not enough evidence of a link between staffing levels and quality of care or on appropriate staffing levels to establish enforceable standards. We beg to differ.
First, there is a host of research demonstrating that adequate staffing is a necessary pre-requisite for delivering high-quality care. As is the case with all research, especially when it explores complex social phenomena, there are some mixed conclusions but the overall results are clear.
Second, we have the extensive research commissioned by the US Congress on minimum necessary numbers of staff. Conducted almost two decades ago, the resulting reports included time-motion studies to measure how many minutes it takes to toilet, to feed, to bathe, etc. 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 at 4.1 hours of nursing staff per resident per day, with at least .75 RN hours per resident day. Although we do not have the same kind of extensive research on staffing in Canada, it is reasonable to assume the research from the US 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 research by Charlene Harrington and others shows a clear link between staffing levels and COVID-19 outbreaks. Further research by Harrington and colleagues also shows the need to develop minimum staffing levels based on the assessed needs of residents, providing details on the number of staff in each occupational category. 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. Moreover, this research demonstrates that it is not enough to set minimums. These minimums must be enforced, based on verified data. Indeed, the lack of such publicly available, detailed data is one reason why we do not have equivalent research in Canada. Moreover, as the Senior’s Advocate in BC points out, the data we do have from managers on staffing is not verified in ways that public accountability requires.
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 all contribute. Decent working conditions, as the military reports make clear, are essential. 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 poorer quality.
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 was associate with a lower risk of mortality and that having a close relationship with at least one staff member was one factor associated with positive self-perceived health. 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? Absolutely 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.
Pat Armstrong, Phd, FRSC is Distinguished Research Professor of Sociology, York University. She was Principal Investigator of a ten years study “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.
Dr. 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 has co-authored multiple studies on staffing, quality and ownership in nursing homes.
