Why are Quebec's nursing homes so understaffed, and what's being done about it?

Outbreaks of COVID-19 have been detected in dozens of long-term care homes in the province, leaving a mounting death toll that is staggering and end-of-life situations that are heartbreaking. 

The patient attendants (préposés aux bénéficiaires) at the homes haven't been able to cope. Already short-staffed before the pandemic, their ranks have been further decimated by infection, isolation and fatigue.

Authorities acknowledge there are now simply too few attendants to ensure residents are getting basic care. Along with the worrisome numbers of dead are reports of residents parched, unfed and left in their filth.

The Quebec government has taken increasingly drastic measures to try to remedy the staffing crisis.

Early on, it boosted the workers' pay — offering public-sector workers temporary pay increases of eight per cent. Those in private institutions, many of whom make little more than minimum wage, are getting an additional $4 per hour. 

It's shifting workers from hospitals to the long-term care institutions, known by their French acronym, CHSLDs. A new ministerial order allows teachers with health-care training to work in the homes.

Premier François Legault opened his news conference Tuesday with his most urgent plea yet for added help in CHSLDs.

"The only message I want to send is that we need extra pairs of hands," Legault said. "We need people with all sorts of medical training, whether they are family doctors or specialists or nurses."

Backbone of the system

The patient attendants are responsible for bathing, cleaning and feeding patients who have little autonomy. In many ways, they are the backbone of Quebec's long-term care system.

But even before the pandemic, CHSLDs across the province struggled to recruit enough attendants to provide quality care.

Quebec's ombudsman has repeatedly cited the staffing issue when examining the treatment of seniors in long-term care facilities.

Some CHSLDs have been forced to get creative in order to cope with the labour shortage. 

A CHSLD in Drummondville was using local volunteers to do some of the less-specialized tasks of attendants, such as cleaning tables or cutting up food. 

In the Mauricie region, managers have helped out on weekends when staffing dropped below critical levels. In Quebec City and elsewhere, CHSLDs have increasingly begun recruiting abroad. 

It is difficult to pinpoint the start of the staffing shortage. Some trace it to budget cuts that date back to 2003. But the problem has become demonstrably worse in recent years, according to François Aubry​, a professor of social work at the Université du Québec en Outaouais.

Aubry, who has conducted extensive research on patient attendants in Quebec, pointed to three key factors that help explain why it is difficult to both recruit and retain workers in long-term care homes, only 36 per cent of whom stay on the job longer than five years.

• Salary: The starting salary for a patient attendant in a publicly run long-term care home is $20.55 per hour. There are five rungs in the pay scale, which maxes out at $22.35 an hour. The pay is even lower in the private sector, where the starting salary is $13 an hour — barely above minimum wage.
• Precarity: Fewer than a third of Quebec's attendants have a stable, full-time job. Most of them work as casuals or on part-time contracts and must work at several different institutions to put together enough hours to make a living. "It is one of the most precarious jobs in Quebec," Aubry said.
• Workload:  Some unions estimate that before the pandemic, one attendant could be responsible for between 12 and 16 residents. Aubry says there is evidence this is unsustainable. Attendants have very high rates of absenteeism due to workplace injuries and psychological stress. This is compounded, Aubry said, by a "negative work environment," where managers can make overtime obligatory. 

What's being done to fix the problem?

These problems haven't gone entirely unaddressed. But solutions were either insufficient or too slow in coming to forestall what Legault himself calls "the crisis in the CHSLDs."

In 2018, then health minister Gaétan Barrette supported an initiative from the nurses' union to limit the ratio of nurses to patients in various health facilities, including CHSLDs.

By most accounts, that pilot project was a success, with nurses saying it allowed them to take more pleasure from their work and provide better quality care.

But before committing to putting that practice in place more widely, Legault's government wanted to include health-worker-to-patient ratios in ongoing negotiations with public-sector unions. Their current status is unclear.

"If we would have put in place these ratios in CHSLDs before the pandemic, we wouldn't be in this situation," said Denyse Joseph, vice-president of the Fédération interprofessionnelle de la santé du Québec, which represents nurses and other health-care workers. 

While promising to fix the staffing situation in CHSLDs, Legault said his desire to offer more permanent pay raises to public-sector patient attendants has been stymied by unions, who demand any pay increase be uniform across the board. 

"That was a cheap shot," said Jeff Begley, president of the CSN-affiliated federation of health and social services, which represents the patient attendants, as well as others in the health-care system.

What his union sought was an hourly pay increase of $3 for its members, instead of a percentage increase. That way those at the bottom of the pay scale — like the attendants — would get a higher percentage increase than those at the top. 

Begley said Legault's initial offer to health-care workers, before the pandemic, was a 1.75 per cent pay increase. That would have translated to a raise of less than 40 cents an hour for attendants.

Legault's other hope for solving the shortage of attendants is that Quebecers — newly unemployed from the downturn brought on by the pandemic — will seek out employment in CHSLDs

But Aubry, the social work professor, is not so sure that's a realistic premise, given the current working conditions.

"I don't think there will be a lot of people who will come forward," he said.