Just last week, the head of our local CCAC and a representative from CSCN met with our MPP to discuss the need to change legislation regarding the strangle hold that nursing has on funding for home care. Right now, the ombudsman of Ontario is in discussion with the ministry of health for the same reason. These things are happening because, for the last almost three years now, my husband (mostly) and I have been pushing for change.
I have posted a number of times on the situation. Currently, my daughter is eligible for 53 hours of nursing per week, as per home care legislation. The reality is that it is not possible to fulfill this mandate for a few reasons. First, there is a serious nursing shortage. Secondly, most nurses use home care as a quick stepping stone to the better paying postings in hospitals and long-term care facilities. Finally, few nurses care to do shift work in homes and fewer still choose pediatrics. Right now, most of the home care shift postings that can still be filled are, surprisingly (maybe not), night shifts...11PM-7AM. The bulk of home care nurses are visiting nurses only.
What I want to discuss here is the idea that the nursing model is fundamentally not appropriate for the home care situation. In fact, more appropriate care can be delivered with personal support workers and developmental service workers. In the end, this should result in higher satisfaction for home care clients, higher job satisfaction for home care workers and possibly....but not necessarily...savings for the government.
Let me start off with a quote from the 2004 study, " Addressing the Health Human Resource Challenge From a Home and Community Perspective: A Blueprint for Change", an excellent report, which, as far as I can tell, has not been implemented in any way, shape or form.
Due to these unique differences (drivers for homecare delivery), it is clear that the current government human resource strategies developed primarily to address institutionally-based human resource needs do not readily translate to the home care sector. Home and community care advocates must consistently suggest adaptations to human resource policies that are not designed to apply to home and community care delivery. (p.3)
This is exactly correct. In making the transition from institutionalized care to home care, the government did not come up with a new care paradigm. They just simply imposed the old model...hospital, institution...upon home care.
The end result is the funding structure that we have today, one that leans heavily on nursing care as a primary support care in the home.
It is important in developing human resource strategies that the uniqueness of the home and community setting be well understood, as all too often assumptions are based on an institutional framework. Many of the standard processes and procedures that work well in an institution do not translate easily into the privacy and complexity of an individual’s home environment. (p.8)
In addressing issues specifically related to pediatric care and those children deemed medically fragile and multiply disabled, thequoteabove rings particularly true. The nursing care model...a hallmark of institutional type care...falls flat in the home environment.
In the hospital environment, the nurse has control over the patient and the patient's environment, in the sense that s/he must assess what is going on, provide medication within specific guidelines, report to a physician, and manage personal care. The child is considered ill and is treated that way. Socializing with, or providing some sort of appropriate stimulation for the "patient" is minimal and not considered to be a major part of the nurse's job.
The tables are turned in the home environment. Here, the child is the client and no longer a sick person needing sick person type care. The parents are likely to be calling the shots, furthermore, with reporting both received from and given to them, rather than a doctor. The nurse should be taking on the role of support worker rather than traditional "nursing" care. This focuses more around personal care and social stimulation than the administration of drugs and recording of vital signs. In the home environment, therefore, the nurse's traditional skill set...medication, i.v.'s, injections, drawing blood, wound care, etc...is not only inappropriate for shift home care, it is rarely used. In fact, one of the main reasons for newly graduated nurses leaving the home care environment is fear of loss of skills.
I must point out, however, that in our personal experience, few nurses had the necessary skills to work effectively in our home. Most had no, or minimal g-tube training (the same can be said for management of tracheostomies), very little ability to properly position a physically challenged child in a bed or a wheelchair, no lift training, little ability to notice details in levels of comfort/discomfort in our daughter and few had the necessary training or comfort level to provide appropriate social/sensorial stimulation to a child with severe challenges. It was also clear that a nurse's traditional focus on illness was detrimental in the care of our child, as they were exceedingly uncomfortable handling situations typical to families like ours, without the supervision of a doctor, i.e., unforseen seizure activity, quick changes in health status, parental decision making as to timing/altering dosages of medication, understanding of their positions as helpers, rather than front line workers, in the home environment.
On page 10, the report notes that:
Within health care there is a great need for good personal care and support. However particularly in the autonomous work environment of home and community care, there is a need for critical thinking and in-depth knowledge, attributes typically acquired through the pursuit of formal education. The institutional-based paradigms of mixing highly skilled and educated staff with less skilled `affordable workers` is not necessarily an effective strategy given the unique practice issues in the home and community sector.
The point is well taken, however, we see here, once again, a clear bias toward nursing and a misrepresentation of the appropriateness of the nursing model and traditional skill set. The quote above implies that "highly skilled and educated staff" are nurses, or RN's to be specific and that DSW's and PSW's are "less skilled". What is not addressed here is that nursing skills, regardless of where or how they were acquired (university education), are fundamentally useless in the home environment. In actual fact, a PSW and better yet a DSW's skill set is far more appropriate and is, therefore, more valuable. Consider the following description of a college level DSW course:
The Developmental Services Worker supports people with a range of challenges including developmental and intellectual disabilities. Inclusion and empowerment are goals met by helping people be part of the community and making good choices. The DSW also teaches people various life and community skills and supports people to be healthy.This program will appeal to students who like working with people and appreciate and understand differences. They must be both patient and flexible, while showing a caring attitude and be able to work both independently and as a team member.Compare this with the description for nursing:The Nursing degree program is designed to prepare students to provide nursing care in a variety of settings. Graduates will work within the scope of nursing practice and in accordance with the regulations of the College of Nurses of Ontario. The practice of nursing is “the promotion of health and the assessment of, the provision of, care for and the treatment of, health conditions by supportive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal function” (RHPA, 1993). As a nursing student, you will be caring for individual clients or groups, including family members and significant others. You will make clinical decisions and exercise judgement in giving care to clients.Which would you prefer in your home with your challenged child? Speaking from experience, a DSW has far more appropriate skills and already a preference for this type of work. They also tend to have more hands-on work experience and require less in home training right off the bat.
The matter of learning how to use a g-tube or to suction a trach or to administer meds is a simple one for anyone with a modicum of common sense. None of these activities require a university education. As a matter of fact, parents do all of these things, all of the time. Furthermore, both in the past in institutions and currently in group homes, DSW's are the front line workers doing these types of activities. Acute care group homes are not staffed exclusively with nurses; they are usually there only in a supervisory capacity. The bulk of the daily routine for the care of the severely disabled is a carried out by PSW's and DSW's. They are more familiar with the vagaries of wheelchairs, the challenges with positioning and the sometimes odd behaviours of those with significant combined physical and cognitive disabilities. Neither do they consider it outside of their job description to provide activities and socialization to their clients.There needs to be a complete shift in thinking, therefore, from those creating home care legislation. They need to stop seeing kids in home care as sick people needing pseudo-hospital services. Nurses need only be involved in home care for acute situations like wound care, post-operative observations, setting up i.v.'s, and so on, in other words, the traditional role of the visiting nurse. The bulk of home care funding, particularly with pediatric shift work, should go toward DSW's and PSW's (PSW's can do things like bathe and feed a client, prepare meals and do light cleaning, which greatly assist the other members of the family). Here you are drawing from a pool of workers already interested in the field of disability support, all of whom have the appropriate training. This leads to greater job satisfaction for the nurses...who get to keep their skills...and for the front line workers who are fulfilling their personal desires to assist in the care and support of those with challenges.This represents a model for assisted living, rather than sick care.Does all of this save the government money? Yes and no. Significant wage disaparities exist between home care and hospital/long term care facilities. Certainly, even in home care, PSW's and DSW's are not as highly paid as RN's and RPN's. Right now, a service care provider bills the CCAC for $45 per hour for a nurse...but the nurse only makes $20, which is $10 less per hour than hospital nurses make (that doesn't even include benefits). PSW's take home around $10 to $12 per hour, whereas DSW's in a group home environment make around $15 up to $20 in a unionized environment. As of yet, DSW's have not been tapped to work in the home environment.For home care to attract and maintain quality people, there has to be some closing of this pay gap. In my opinion, home care workers with DSW qualifications should never make less than $20. That's the sort of pay that will provide optimal care and attract top notch people to the field.So, if the government wants to do it right, they will have to pay. Better home care will reduce hospitalization, however, and other critical care needs, so there will be some balancing out at that end.It is clear that home care needs to be understood not as "hospital in the home" but as supported living with people trained in the specifics of this type of assistance. Nursing care has a place, albeit a much smaller one in the home care scene. It goes without saying then, that current legislation needs to accommodate a new care paradigm and direct the bulk of funding to more appropriate care givers, i.e., personal support workers and developmental service workers.
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I have posted a number of times on the situation. Currently, my daughter is eligible for 53 hours of nursing per week, as per home care legislation. The reality is that it is not possible to fulfill this mandate for a few reasons. First, there is a serious nursing shortage. Secondly, most nurses use home care as a quick stepping stone to the better paying postings in hospitals and long-term care facilities. Finally, few nurses care to do shift work in homes and fewer still choose pediatrics. Right now, most of the home care shift postings that can still be filled are, surprisingly (maybe not), night shifts...11PM-7AM. The bulk of home care nurses are visiting nurses only.
What I want to discuss here is the idea that the nursing model is fundamentally not appropriate for the home care situation. In fact, more appropriate care can be delivered with personal support workers and developmental service workers. In the end, this should result in higher satisfaction for home care clients, higher job satisfaction for home care workers and possibly....but not necessarily...savings for the government.
Let me start off with a quote from the 2004 study, " Addressing the Health Human Resource Challenge From a Home and Community Perspective: A Blueprint for Change", an excellent report, which, as far as I can tell, has not been implemented in any way, shape or form.
Due to these unique differences (drivers for homecare delivery), it is clear that the current government human resource strategies developed primarily to address institutionally-based human resource needs do not readily translate to the home care sector. Home and community care advocates must consistently suggest adaptations to human resource policies that are not designed to apply to home and community care delivery. (p.3)
This is exactly correct. In making the transition from institutionalized care to home care, the government did not come up with a new care paradigm. They just simply imposed the old model...hospital, institution...upon home care.
The end result is the funding structure that we have today, one that leans heavily on nursing care as a primary support care in the home.
It is important in developing human resource strategies that the uniqueness of the home and community setting be well understood, as all too often assumptions are based on an institutional framework. Many of the standard processes and procedures that work well in an institution do not translate easily into the privacy and complexity of an individual’s home environment. (p.8)
In addressing issues specifically related to pediatric care and those children deemed medically fragile and multiply disabled, thequoteabove rings particularly true. The nursing care model...a hallmark of institutional type care...falls flat in the home environment.
In the hospital environment, the nurse has control over the patient and the patient's environment, in the sense that s/he must assess what is going on, provide medication within specific guidelines, report to a physician, and manage personal care. The child is considered ill and is treated that way. Socializing with, or providing some sort of appropriate stimulation for the "patient" is minimal and not considered to be a major part of the nurse's job.
The tables are turned in the home environment. Here, the child is the client and no longer a sick person needing sick person type care. The parents are likely to be calling the shots, furthermore, with reporting both received from and given to them, rather than a doctor. The nurse should be taking on the role of support worker rather than traditional "nursing" care. This focuses more around personal care and social stimulation than the administration of drugs and recording of vital signs. In the home environment, therefore, the nurse's traditional skill set...medication, i.v.'s, injections, drawing blood, wound care, etc...is not only inappropriate for shift home care, it is rarely used. In fact, one of the main reasons for newly graduated nurses leaving the home care environment is fear of loss of skills.
I must point out, however, that in our personal experience, few nurses had the necessary skills to work effectively in our home. Most had no, or minimal g-tube training (the same can be said for management of tracheostomies), very little ability to properly position a physically challenged child in a bed or a wheelchair, no lift training, little ability to notice details in levels of comfort/discomfort in our daughter and few had the necessary training or comfort level to provide appropriate social/sensorial stimulation to a child with severe challenges. It was also clear that a nurse's traditional focus on illness was detrimental in the care of our child, as they were exceedingly uncomfortable handling situations typical to families like ours, without the supervision of a doctor, i.e., unforseen seizure activity, quick changes in health status, parental decision making as to timing/altering dosages of medication, understanding of their positions as helpers, rather than front line workers, in the home environment.
On page 10, the report notes that:
Within health care there is a great need for good personal care and support. However particularly in the autonomous work environment of home and community care, there is a need for critical thinking and in-depth knowledge, attributes typically acquired through the pursuit of formal education. The institutional-based paradigms of mixing highly skilled and educated staff with less skilled `affordable workers` is not necessarily an effective strategy given the unique practice issues in the home and community sector.
The point is well taken, however, we see here, once again, a clear bias toward nursing and a misrepresentation of the appropriateness of the nursing model and traditional skill set. The quote above implies that "highly skilled and educated staff" are nurses, or RN's to be specific and that DSW's and PSW's are "less skilled". What is not addressed here is that nursing skills, regardless of where or how they were acquired (university education), are fundamentally useless in the home environment. In actual fact, a PSW and better yet a DSW's skill set is far more appropriate and is, therefore, more valuable. Consider the following description of a college level DSW course:
The Developmental Services Worker supports people with a range of challenges including developmental and intellectual disabilities. Inclusion and empowerment are goals met by helping people be part of the community and making good choices. The DSW also teaches people various life and community skills and supports people to be healthy.
This program will appeal to students who like working with people and appreciate and understand differences. They must be both patient and flexible, while showing a caring attitude and be able to work both independently and as a team member.
Compare this with the description for nursing:
The Nursing degree program is designed to prepare students to provide nursing care in a variety of settings. Graduates will work within the scope of nursing practice and in accordance with the regulations of the College of Nurses of Ontario. The practice of nursing is “the promotion of health and the assessment of, the provision of, care for and the treatment of, health conditions by supportive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal function” (RHPA, 1993). As a nursing student, you will be caring for individual clients or groups, including family members and significant others. You will make clinical decisions and exercise judgement in giving care to clients.
Which would you prefer in your home with your challenged child? Speaking from experience, a DSW has far more appropriate skills and already a preference for this type of work. They also tend to have more hands-on work experience and require less in home training right off the bat.
The matter of learning how to use a g-tube or to suction a trach or to administer meds is a simple one for anyone with a modicum of common sense. None of these activities require a university education. As a matter of fact, parents do all of these things, all of the time. Furthermore, both in the past in institutions and currently in group homes, DSW's are the front line workers doing these types of activities. Acute care group homes are not staffed exclusively with nurses; they are usually there only in a supervisory capacity. The bulk of the daily routine for the care of the severely disabled is a carried out by PSW's and DSW's. They are more familiar with the vagaries of wheelchairs, the challenges with positioning and the sometimes odd behaviours of those with significant combined physical and cognitive disabilities. Neither do they consider it outside of their job description to provide activities and socialization to their clients.
There needs to be a complete shift in thinking, therefore, from those creating home care legislation. They need to stop seeing kids in home care as sick people needing pseudo-hospital services. Nurses need only be involved in home care for acute situations like wound care, post-operative observations, setting up i.v.'s, and so on, in other words, the traditional role of the visiting nurse. The bulk of home care funding, particularly with pediatric shift work, should go toward DSW's and PSW's (PSW's can do things like bathe and feed a client, prepare meals and do light cleaning, which greatly assist the other members of the family). Here you are drawing from a pool of workers already interested in the field of disability support, all of whom have the appropriate training. This leads to greater job satisfaction for the nurses...who get to keep their skills...and for the front line workers who are fulfilling their personal desires to assist in the care and support of those with challenges.This represents a model for assisted living, rather than sick care.
Does all of this save the government money? Yes and no. Significant wage disaparities exist between home care and hospital/long term care facilities. Certainly, even in home care, PSW's and DSW's are not as highly paid as RN's and RPN's. Right now, a service care provider bills the CCAC for $45 per hour for a nurse...but the nurse only makes $20, which is $10 less per hour than hospital nurses make (that doesn't even include benefits). PSW's take home around $10 to $12 per hour, whereas DSW's in a group home environment make around $15 up to $20 in a unionized environment. As of yet, DSW's have not been tapped to work in the home environment.For home care to attract and maintain quality people, there has to be some closing of this pay gap. In my opinion, home care workers with DSW qualifications should never make less than $20. That's the sort of pay that will provide optimal care and attract top notch people to the field.So, if the government wants to do it right, they will have to pay. Better home care will reduce hospitalization, however, and other critical care needs, so there will be some balancing out at that end.
It is clear that home care needs to be understood not as "hospital in the home" but as supported living with people trained in the specifics of this type of assistance. Nursing care has a place, albeit a much smaller one in the home care scene. It goes without saying then, that current legislation needs to accommodate a new care paradigm and direct the bulk of funding to more appropriate care givers, i.e., personal support workers and developmental service workers.