This week, White Coat, Black Art launched its new season with a look at duties performed by unregulated care providers at retirement homes in Ontario.  Known in this province as personal support workers or PSWs, these care providers are often asked by retirement homes (sometimes referred to as care homes or assisted living) to perform duties that - in a hospital or long-term care faciity - would generally be done by registered nurses or registered practical nurses.  The duties in question include injecting insulin to residents with diabetes (at times adjusting the dose of insuin based on the resident's blood sugar), administering narcotic pain relievers, and doing wound care.  In general, PSWs - who receive anywhere between 600 and 800 hours of theory and practical work experience - do not receive training in school on how to perform nursing duties.  After the show aired, we heard from you. 

Shannon Olden of Toronto writes: "As a retired nurse I strongly object to PSW's administering meds.  A huge part of an RN programme is learning drug categories, normal doses, bad interactions, and side effects.  Neither a PSW nor an LPN have this knowledge when it comes to things like insulin or other drugs that are given by needle.  Missing a diabetic insulin shock or morphine reaction can be catastrophic or worse, fatal.  The nurse is the last in a long line of professionals involved (doctors,pharmacists, pharmacy assistants).   If there is an error in prescribing or dispensing the nurse may be the one to catch it. Mistakes happen.  Learning the technique of giving an injection is the least of it.  One needs the background knowledge.  I would only allow an RN to give me my meds and even then I would be checking them first, according to what are known as 'the 5 rights':  the right patient, the right med, the right dose, the right time, and the right route (oral or otherwise.)   I once received a mail order medication that was the wrong dose!!   So I am back to trekking to the pharmacy for the blurb and the pills. I take very few medications so one mistake was a huge error statistically in my case.  Don't take a chance with your loved ones.  Let professionals do their job."

Noreen Bosnich sent this email:  "After listening to your broadcast today I wonder if most people realize that they will probably end up living in one of these homes someday!  Would you or they want someone with no training giving you drugs like narcotics and insulin?  If people feel that their health and last days are important at all they should lobby their provincial governments who are responsible for health to regulate nursing homes.  It is the responsibility of government to regulate health practices and workers in senior homes.  As a retired registered nurse, I am aghast at the leniency given to PSW workers and care aides to handle practices once only done by RN's."

We received this email from a woman from Calgary:  "Please do not read my name on air as I do not wish to negatively impact my mother's care.  I listened to your PSW segment with interest and I feel for these overburdened aides.  I come at this issue from the other side of the fence.  My mother is in a long-term care facility.  We often find that there are insufficient workers to provide timely care to the residents.  Hearing aids are neglected or not checked because, "we're not hearing specialists."  Neither are the family and yet we are capable of checking batteries, and ensuring that the devices work.  What kind of quality of life do hard of hearing residents have when they cannot hear?  Basic things like tissues (does the resident have some if their nose is running?), ear wax buildup (affecting hearing or comfort), and dry skin are non-medical and therefore can be safely disregarded until a family member complains.  Toiletting sometimes occurs in a timely fashion (i.e. when the call button is pressed), sometimes it is more convenient to change a diaper than to get someone on the toilet.   We recognize that medical issues take precedence, but our seniors live in these facilities, they are not just visiting.  That is their home and their life.  The priority in those facilities should be their comfort and well-being  We are not just warehousing our seniors like a boat wintering at a marina  They live in the facility.  I know the facility manager will happily dispense care-based homilies, but truly I do not believe they would enjoy spending a week in one of their long-term care beds.  We, as untrained and unskilled family members, should not be more observant or more skilled at care than the facility; whether this occurs due to a facilities lack of staff, resources, or desire.  I dread the day I require long-term care."

Some of you defended the practice of PSWs performing the duties in question.  Tanya M. Dion, a registered nurse sent this email:  "I work for Revera in a retirement home in Kingston. We have an excellent training program for unregulated workers who do give pre-poured meds in our home at times when nurses are not available.  I am the director of Health and Wellness and a PSW's care relies on my license as a registered nurse.  I take great pride on whom I train and whose care is reflective of my practice.  There is no difference between a PSW and a family member giving medications.  Healthcare has forced patients to go home, rely on family, friends and neighbours to care for family members, give them medications, insulins, do blood sugars and even do dressing changes.  There is no difference in this care other than the PSW is receiving additional training and education on some of the side effects of certain medications. This is not good quality healthcare but unfortunately there is no money in our government to keep RN's or RPN's in budgets. There is also a huge lack of nurses in Canada."

We received this email from a person in a position of authority who has asked that we not use her name:  "I'm an administrator of an organization that provides home care under contract with the home care services, and am deeply concerned about the trend toward having PSW's carrying out delegated acts such as injections, complex wound care and others that are normally seen as nursing duties.  There is no question they are not trained to do so.  While I'm proud of the service these dedicated PSW's provide, I'm ever aware of the risks involved.  PSW's provide care in a patient's own home, and are not supervised on site on a regular basis.  As in nursing homes, the client is often frail, sometimes with compromised capacity, and very often lives alone.  If there is a problem with treatment provided by the PSW, that may not be known until some time later.  In the community, the use of PSW's instead of RN's or RPN's provides a significant saving for the home care service and the regional health authorities.  Home care pays a fee for service at the rate for that particular service - PSW being the lowest of course.  If they can send a PSW instead of an RPN, they realize significant savings.  We are left with the concern about providing additional training and supervision at our own expense, as well as negotiating with a union that rightly claims that adding delegated acts significantly changes the PSW's level responsibility and therefore should attract a higher wage.  We'd like to refuse to provide these services, but are ever aware that the procurement of home care contracts is a competitive process, and there are plenty of other agencies that will agree to provide the service.  This is an issue that desparately needs intervention.  From a personal point of view, I'm hoping that happens before I find myself on the receiving end of delegated acts performed by unqualified caregivers.  Thanks for bringing attention to this very urgent issue!"

Sheena Sharp of Toronto sent this email:  "I am an architect who regularly ponders the unavailability of affordable housing, and the fact that seniors make up a significant portion of those who can't find any.  I'd like you to look at this from a slightly different perspective: yourself.  We are talking about how you will live the portion of your life when you start losing personal care independence. Where will you be?  Where will most Canadians be?  Seniors in the future will be different from those in the past:  we will be a lot less respectful of authority,  we will have higher expectations of life, and there will be a lot more of us.  Experts say that we can expect to spend a lot less time in long-term care (maybe the last 2 years of our lives) and that we need to build supportive housing which will, of course rely on the services of PSWs.  From your program, I can see some bright light at the ministry starting an expensive crusade to ensure that the rules are followed to absurdity.  Perhaps we need to start by defining a system that works, from a quality and cost point of view.  We need to think about the package of services required, and then train people to provide that package.  One of the problems is that people's needs can slowly change, and moving from one type of care has a long lead time.  We need to build that fact into the system, because that will cause pressure on the services of PSWs.  The regulation of architecture is done a bit differently than medicine.  As an architect, I am personally responsible for the activities of my employees,  which means their training is not an afterthought for me.  For surgery,  this would NOT work,  but for supportive housing, it might!  It's a complex issue!."

Even though this week's episode was set in Ontario, the issues raised clearly resonated across Canada.  Cayce Laviolette of Gibsons, BC sent us this:  "I am a social worker with Vancouver Coastal Health.  Here we call them (unregulated care providers) health care workers.  I have worked for agencies and in residential settings where medication is administered by health care workers, usually unsupervised by nurses.  In my experience, these workers do so with compassion and expertise and due diligence.  I would be more than comfortable sending my family member to be cared for by a health care worker at a site with no nurse present.  While burnout exists, sometimes in spades, this is more the result of poor management and a lack of support for the workers, not because workers themselves are not doing their jobs properly.  I have seen time and time again throughout my ten years in health care that certain technical tasks, especially medication administration, are guarded jealously by nurses.  The fact is any of us can give out medication properly, given appropriate systems and accountability.  Unfortunately, health care workers (or PSWs in Ontario) do not get the respect and support from either their own managers or from government simply because they are not 'professional'.  They do some of the hardest, most important and least recognised work in our health care system.  One solution to the dilemma suggested by your program is that health care workers get better pay and more support on the job.  This will have to come from provincial ministries of health, who unfortunately are balanced unevenly towards 'professions' such as nursing and medicine."

Finally, we received this email from Jennifer Brierley of Keswick, Ontario, who confirmed much of what we had to say in the show and more.  "I have to say that I'm happy you finally did a show on PSW in Retirement Homes so that the general public can know what is really happening in Retirement Homes.  I am a RPN in a retirement home, out of the six regular staff under the 'nursing' job, only two, including myself, are a Registered; the rest are PSWs or Unregulated Care Providers, as they are called when they give medications or workers who are Nurses in other countries.  For the PSW's who are in a nursing position, they are considered charge nurses, and are in charge of the whole facility (up to 36 people).  They will give insulin (no sliding scale is allowed), give narcotics, and give medications from the strips, vials and blister packs. They have applied medicated creams, dressings, put on stockings, and evaluated residents conditions daily  They take vital signs, go over doctors' visits, take care of Community Care Access (CCAC or home care) intake and even admissions and transferring residents to hospital.  As for the Director Of Care, we have one the comes in once a week and there has been times that staff have been unable to contact her other times during the week or on weekend when they have trouble.  As for who teaches the new people and the people who come, it is whoever works that shift, which means that most of the PSW are trained by another PSW.  They also have to watch a 15min DVD from our pharmacy.  As for the 2010 (Ontario) regulations, I think it's pitiful and sad.  It's more like self-regulation for the homes.  This is a business for money.  I have seen in the past at my work people kept on to live there when they most assuredly should go be transferred to a Nursing Home, but they are a bed filled with money."