A FRESH LOOK AT PSWs IN LTC HOMES
Prepared for the Conference of Family Councils
in the Waterloo Wellington Region of Ontario
on November 7, 2008
There is growing public concern about the quality of service in long-term care homes, and there have been several reports which emphasize the need for more resources, better quality, more planning, and improved reporting.
There are more projects under way now (see Appendix I), but insufficient attention has been paid so far to those who deliver most of the services directly to the long-term care resident – the staff usually known as “Personal Support Workers” or “PSWs”.
The purpose of this paper is to take a fresh – and I do mean “fresh” – look at the role of PSWs in LTC homes, and consider new ways to raise their profile, enhance their training, and attract more persons to this valuable profession. But first we must consider the overall nature of a LTC home, the context in which these persons deliver their services.
The Focus of Care: The Resident
In current Reports, there is often reference to “resident satisfaction”, and this is very well taken. However, it may not be an easy objective to achieve.
There is a danger that focussing on the system for operating a LTC home may take too much attention away from the satisfaction of residents. For example, if a general movement of staff is undertaken to diversify their experience, it may result in a significant dissatisfaction for the residents because of the unfamiliarity of a changing staff. This balancing act is not helped by the multiplicity of provincial standards for operating a LTC home, which may find the PSW spending time checking off extra items on a chart, rather than sitting down briefly to chat with a resident.The acid test for successful operation of a LTC home is its end effect on the resident.
On The Front-Line: The Personal Support Worker
At the front line in the flow of care are the Personal Support Workers. Not only that, but they constitute 2/3 of the work force and 2/3 of the time spent in personal health care of the resident. In other words, they carry (literally!) the bulk of the care in terms of time and closeness to the resident! They also have most of the contact with families and friends of the resident. Yet they do not seem to get the attention they deserve. Why is that?
Perhaps because much of their care is with activities of daily living, with which we are all familiar! However, helping someone who is physically or mentally handicapped is no mean feat, especially if it involves the use of complicated equipment. The PSW may also have to deal with emotions of the resident, to find cooperation and avoid violent reaction. And at the same time exude good humour and empathy for the resident! They would usually do this all on their own or with another PSW, without help from a nurse or doctor. Even though the regulated health professionals supply vital medical advice, from this perspective it sounds like the nurse and the doctor are the “support workers”!!
To give due respect for the care which is rendered directly and independently to residents, the title for this occupation should be changed, possibly to “Personal Care Worker”, or “PCW”.
Emotional Needs of Resident: It's a Home, Not a Hospital
In recent reports there is emphasis on the quality of care, meeting the individualized needs of the resident, and achieving resident satisfaction. There is also a suggestion that nursing guidelines should be used for administration of staff in a LTC home. This does not recognize the difference between a hospital and a LTC home.
In a hospital, the prime concern is to solve the medical problem; the emotional and spiritual concerns are important but secondary. The person is usually only there for a few days, and the objective is to get the medical problem dealt with and get back to normal living. The information card for the patient presumably summarizes medical facts, for passing on to the next medical professional.
A LTC facility is a home, where the person is a “resident”, and expects to be there a considerable length of time – possibly years. Medical problems are still vital, but emotional and spiritual aspects are just as important. These cannot be neatly summarized on an information card and passed on from one staff person to another. They are learned by spending time with the resident and creating a relationship, which requires continuity in staff. For quality care the PSW must be sensitive to the subtle emotional needs of the resident as well as alert to medical needs, and this cannot be readily passed on from one PSW to the next.
Substantial Continuity of PSWs for Each Resident – A Guiding Principle
If continuity of PSW for each resident is needed for quality of care, to what extent can it be achieved? Complete continuity is impossible. There are 3 shifts a day, changed twice a week, which means at least 6 different PSWs in a week. Then there is sickness, vacation, etc.
There will also be other factors which could make a change in assignment seem sensible: burnout, laxity in duties, incompatibility, simple need for a change, variety of experience, or balancing of workload within or between sections. There's quite a list of legitimate reasons! Would you like to work out the allocation of staff?! Obviously a high degree of continuity is almost impossible, and possibly even undesirable.
However, this does not mean that continuity should be abandoned as a guiding principle. It's extremely important not only for the resident but also the family, to have staff familiar with the resident. Furthermore, the needs for moving staff can be minimized by good supervision, staff training, and timely appraisals. Substantial continuity of PSWs for each resident should be adhered to as a guiding principle in staff allocations.
Measuring the Outcome: A Mathematical Degree of Continuity
Reports these days want to “measure outcomes” in terms of “resident satisfaction”, even though satisfaction is essentially immeasurable. Well, since continuity is important for the satisfaction of a resident, there is one simple arithmetic measure which would at least indicate a degree of continuity (like degrees of temperature on a thermometer).
Just tabulate the number of PSWs who have cared for a resident in 4 weeks. With perfect continuity, and 3 shifts a day, changing 2 times a week, 6 different PSWs would have cared for the resident in 4 weeks. If there was a complete change every two weeks, it would be 12; with a complete change every week, it would be 24 different PSWs in four weeks! In the search for measurable outcomes, there could be a mathematical measure of the degree of continuity of PSWs for a resident.
Qualifications of PSWs – Towards a Recognized Profession
Managing PSWs to provide consistent quality care to residents is extremely difficult at present because of two main factors:
1. The vast range of services provided by persons who are called “personal service workers”. These may range from helping with activities of daily living for a person living at home to carrying out diverse procedures for a resident in a long-term care home.
2. The great variety of educational experiences of the person, ranging from practical life experience, to high school courses, or college certificates. The college certificates, which at least meet basic government standards, can vary considerably in content, time and cost.
With these two difficulties, it is quite a challenge for management to judge how much further training and how much supervision is required to deliver quality service.
The possible regulation by Ontario of personal support services as a professional service was considered by the Health Professions Regulatory Advisory Council (HPRAC) and rejected in its report in September 2006, because there was an insufficient comprehensive body of knowledge, and not enough interest by persons in such occupation to organize and administer a profession. However in June 2007, the provincial minister of health asked HPRAC for its advice on whether a “self-regulatory model” would be appropriate for person service workers, in view of the “… extensive health care service provided by personal support workers in numerous environments”. It is understood that this project is to start late this fall.
Meanwhile progress continues to be made in the education and training of PSWs. In addition to the courses being provided by Ontario colleges, the National Association of Caregivers/Personal Support Workers (NACPSW) has developed a national standard of practical and academic requirements. In relation to a college certificate, this requires further time of about 500 hours. A graduate is a “Certified Caregiver/Personal Support Worker” and registered as a member, with continuing education being required to maintain membership. There are about 6,000 members across Canada, with about 3,000 in Ontario.
There is also the Personal Support Network of Ontario (PSNO), a division of the Ontario Community Support Association (OCSA), which commenced holding annual conferences in 2007. Their agendas include workshops for PSWs and PSW Supervisors, to share and advance techniques for long term care, in the home or in institutions.
With these continuing developments in the competence of PSWs, is there need for establishing a self-regulated profession? Do the variations in level of training not merely reflect the various circumstances under which the services are provided?
Still, the occupation is a form of “calling”, a hallmark of a profession, a special kind of dedication. Furthermore, there is a high level of public trust that an established level of competence can be expected. For these reasons, it appears that publicly establishing a new profession is essential in the long run. If so, the process should be started as soon as possible, to minimize transitional difficulties, and meet the rising demand for these services.
A brief sketch of a possible process would be as follows:
1. Adopt the objective of recognizing the occupation as a self-regulated profession, subject to consultations.
2. Consult with representatives of PSWs and existing institutions involved in educating PSWs. If favourable support is obtained, proceed as follows, with continuing input from and participation by these same parties.
3. Establish a credible institution to organize qualifications of the profession and procedures for its continuing operation in an efficient and ethical manner.
4. Decide on a designation for a successful graduate of the institution, such as Chartered Caregiver, or CCG.
5. Authorize the institution and the designation in government legislation, so long as the standards generally meet with minimum government objectives. The institution would be free to develop more advanced research and standards on its own.
6. Develop appropriate transitional measures for existing Personal Support Workers, such as:
(1) Designate another new level called a Personal Care Worker, or PCW.
(2) Accept some existing PSWs immediately as PCWs or CCGs by virtue of their present qualifications.
(3) Alternatively, an existing PSW could become a PCW by upgrading her or his qualifications. In turn, a PCW could become a CCG by upgrading her or his qualifications.
(4) Otherwise an existing PSW would remain a PSW.
7. Transitional financing by government to individuals (possibly scholarships) and LTC Homes (for upgrading time), to boost existing qualifications and attract more recruits.
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This “fresh look” at the role of “personal support workers” in the care of residents in long-term care homes, and the proposals made, may seem extreme. However, they are intended to reflect reality as seen by someone relatively new to the world of long-term care, and to provoke further thought and action.
Anyone who has spent some time in such a home will be impressed by the generous spirit with which the PSWs give very personal, diverse, services. They deserve more of our support and recognition, to efficiently raise the quality of long-term care in Ontario. If they took more pride in their occupation as a profession, they would help attract others to join them.
A. E. John Thompson, B Comm, CA
Co-Chair, The Elliott Family Council,
Guelph, Ontario, November 4, 2008
LONG-TERM CARE IN ONTARIO
Some Recent Reports
The Regulation of Personal Support Workers, by the Health Professions Regulatory Advisory Council (HPRAC), September 2006. Recommended against regulation of PSWs under the Regulated Health Professions Act.
People Caring For People, by Shirlee Sharkey, May 2008.
General recommendations for increased staff resources, improved staff planning, evaluation and accountability.
A Common Vision of Quality in Ontario Long Term Care Homes, released in July 2008, by MOHLTC, based on discussions held by the Seniors Health Research Transfer Network (SHRTN). Five themes emerged, including “a homelike environment for residents”.
Projects In Progress
1. Regulations Under the Long Term Care Homes Act, being drafted by the MOHLTC, for completion by January 2009. Some public consultations are still in process.
2. A Staff Planning Template, by Shirlee Sharkey and a committee, for completion in 2009. Intended to develop a staffing plan which could be applied under different circumstances. A Regional Chair for Family Councils is sitting on this committee.
3. Public Reporting on Resident Health Outcomes, by the Ontario Health Quality Council (OHQC). This may be based on “measurable outcomes” and surveys of residents and families.
4. Revision of the 400+ Standards for Operating LTC Homes, by the Ontario Ombudsman. A review of these standards to see if they could be simpler and more effective.