WCBA Season Debut: Personal Support Workers and Seniors

Some of these care providers work in hospitals, but the majority are employed by long-term care facilities and home care agencies. They also provide much of the care given to seniors at more than 650 privately-operated and largely unregulated retirement homes across Ontario.  These residences may also be known as assisted living as well as care homes.  It is at places like these that PSWs say they're expected to perform duties that go beyond their training and their scope of practice. The PSWs we spoke to are concerned that performing those duties may put their professional well-being and the safety or residents at risk. 

Health Canada estimates that there are 100,000 PSWs working in Ontario alone. There are no national standards for PSW training programs.  In Ontario, community colleges, private career colleges, Boards of Education, and Not-for-Profit training organizations operate PSW schools.  The courses - which range between 600 and nearly 800 hours in length - include theory plus supervised practical work experience.

In general, PSWs are trained to do personal care - everything from feeding to toileting - transferring seniors from bed to wheelchair, housekeeping, as well as social and recreational activities.  The Second edition of Mosby's Canadian Textbook for the Support Worker (published by Mosby Elsevier), a textbook used by many PSW training programs, warns students to never act beyond the limits of their role. The text also states that PSWs are never to perform a function or task that they have not been trained to do.

When it comes to seniors who take prescription drugs, the text states that PSWs can assist clients to take their own medications.  That means they may help seniors open pill bottles and blister packs.  According to PSW training, what they shouldn't do is measure medications and administer them to seniors.  Examples of administering a medication include placing pills or capsules in the resident's mouth, placing a medicated patch on the skin, or injecting medications.

"Administering medications is beyond your scope of practice." says the text.  Increasingly, they're being asked to that and more.

Jen - whom we're referring to by her first name only - works currently at a retirement home somewhere in Ontario.  On the program, Jen said she regularly had to perform duties that - in a hospital or a nursing home - would be described as nursing duties.

"We have to do all the medications," Jen told WCBA.  "So we're even dealing with handing out narcotics, pain patches, insulin."

"We actually do wound care as well."

When asked who trained Jen to perform nursing duties such as these, Jen replied "nobody". 
"We actually have to train each other," she told WCBA.  "When I started, it was another PSW that was on duty that was training me to do everything."

We wanted to find out whether Jen's story is unusual or typical of PSWs who work in retirement homes.  Natrice Rese is a retired PSW who speaks for the Ontario Personal Support Worker Association (OPSWA).  I asked her how often she hears stories like Jen's.

"Too often, almost daily," Rese told WCBA.  "We get phone calls, we get emails.   We have people saying 'Why can't you help us?'  We're being pushed beyond what our training is, and we're being told if we don't like it, we can leave."

Brenda Fowler is another PSW who says she was asked to perform more than she was taught to do at school.  In 2008, she graduated from a certified PSW program taught at a community college in Northern Ontario.  On April 2 of this year, Fowler was hired to work as a PSW at The Walford Timmins, one of six affiliated retirement residences operated by The Walford Management Group.

On WCBA, Fowler said she had to perform duties that included giving out medications including narcotics, providing wound care and injecting insulin.  In the case of one resident, Fowler said that her duties involved adjusting the dosage of insulin based on the blood sugar result obtained by the PSW.

"For the one resident, during my stay there, her insulin was adjusted by us," Fowler told WCBA.  We asked Fowler who taught her to adjust and administer insulin.
"No one," she told WCBA.  "It was written in the book.  If levels are between this and that, you dose that."

"I don't have any idea who wrote it," says Fowler.  "And I do understand it's a sliding scale, but it was never taught. It's just written."

It is the fear that harm may come to residents of retirement homes that has prompted PSWs to come forward. 

"I go home and I still worry about that place," Jen told WCBA.  "When I'm at home, I'm a nervous wreck because you're always thinking 'What's going on?  Did I forget to do something?'"

"Everybody that works there is burning out and it's getting pretty scary," says Jen.

"When a mistake happens, then it's the PSW's head that rolls," says OPSWA spokesperson Natrice Rese.  "PSWs are trying to do a job that's more than they are able to handle, and they are terrified to death."

Brenda Fowler told WCBA she was involved in a medical error that occurred while she was being trained by a fellow PSW to perform regular duties that included handing out medications to residents.  The fellow PSW was supposed to be giving out the medications that evening, but became engaged in a lengthy conversation with the family of a resident who had been transferred to hospital earlier in the day.  Brenda says she volunteered to give out medications to a husband and wife couple.   She says she mistakenly gave the husband's medications to the wife.  Fowler says although no harm came to the couple, the error haunts her.

"I knew the error.  I knew why.  I felt horrible," says Fowler.

In a letter to Fowler dated May 24, 2011, she was informed by Jessica Gervais, administrator in charge of The Walford Timmins, that she had been fired for "unacceptable performance during her probation period".  Fowler has denied the grounds for dismissal as described in the letter.  When asked for a response to Brenda Fowler's comments, Gervais told WCBA that management had "no comment".

It's important to stress that it's not illegal for PSWs to perform duties like injecting insulin or administering narcotics at retirement homes.  But the rules governing what PSWs like Jen and Brenda can do at retirement homes are unclear and open to disagreement.

In 2010, the Ontario Government passed the Retirement Homes Act.  It requires that the people licensed in the province to run retirement homes ensure all the staff employed there have the proper skills and qualifications to perform their duties and that they possess the prescribed qualifications.  However, the Act does not give specifics on what duties PSWs can and cannot perform.

In most provinces, injecting insulin and administering narcotics are duties known as 'controlled acts' which means they can only be done by licensed health professionals such as nurses - provided the duties fall within their scope of practice.  However, the laws that regulate health professionals do permit PSWs to perform some of these nursing-type duties provided they are part of the resident's routine activities of living.

For example, it's probably okay for a PSW to inject the same dose of insulin each day to a resident with well-controlled diabetes because that's part of the resident's daily routine.  But, it would not be permissible to inject insulin where the dose needs to be adjusted frequently.

Mosby's Canadian Textbook for the Support Worker, the text referred to above, says it is the employer's responsibility to ensure the PSW is properly trained, supervised and monitored by a registered staff member - meaning a nurse or other regulated health professional.  As well, permission for the PSW to perform a nursing duty under 'exception' provisions must be granted for each resident.  Receiving permission to inject insulin to one resident does not necessarily mean the PSW has permission to administer insulin to all residents.

Paul Williams, a health policy expert at the University of Toronto says little is known about what kind of medical care is delivered at retirement homes.  "There are no standards," Williams told WCBA.  "There are no quality guidelines."

"PSWs are not a regulated profession," he added.  "In fact, I can call myself a personal support worker."

Williams was part of an expert panel set up by the Ontario Government to consider how to regulate retirement homes.  He says he sees little appetite for tight regulation of retirement homes.

"If we start to regulate, if we put in quality improvement stuff, if we start to accredit along recognized lines, you're going to push the cost up," Williams told WCBA.  "People are going to go back into the public system."

"And that's why governments would like to regulate, but they fear to regulate because quite frankly they think it's going to cost some money here."

As for regulating PSWs like the provinces do nurses and physicians, Williams says that's just as unlikely.

"To call yourself a PSW doesn't mean anything in Ontario," says Williams.  "In fact, there was an attempt to professionalize PSWs - to put them under legislation.  The government doesn't think it's a good idea.  When you professionalize a group, you take responsibility for what they do. "

"Maybe there's a disincentive to governments to regulate PSWs because quite frankly, it will probably cost you more money.  You can't pay twelve dollars an hour (a typical wage for PSWs) to someone who is professionally regulated."

Last year, BC became the first province to set up a registry of PSWs, known there as care aides and community health workers.  The registry sets province-wide training standards and ensures a fair process for investigating complaints against front line workers.  Earlier this year, Ontario announced plans to set up its own PSW registry.

Since the provinces have responsibility for health care and for what goes on inside retirement homes, we wanted to interview Deb Matthews, who was Ontario's Minister of Health and Long-Term Care.  But, with the provincial election campaign now underway, she's busy on the hustings.  We'll put our questions to the next government - following the election.

In the meantime, if you're interested in moving to a retirement home, here's my advice.  Do your homework before saying yes.  Retirement homes should have a director of clinical care, typically an RN or registered practical nurse.  That person - not the PSW - is most responsible for taking care of you or loved one's healthcare needs.  If your preferred retirement home has PSWs injecting insulin, administering medications, or performing any other nursing duties, ask what sort of training they receive. The director of clinical care should be the one training PSWs to perform nursing like duties - not fellow PSWs.

The issue of who does what while caring for your loved ones will undoubtedly grow in the years ahead.  Given our aging population, would-be residents of retirement homes are increasingly likely to be frail seniors with dementia who require complex medical care.  They will need skilled, competent and well-educated professionals to meet their medical needs.