N.L. long-term care needs more nurses, who need more time with residents

In the provincial election, parties are promising a lot of money for healthcare, and the hiring of more local nurses in particular. These local hires are meant to replace the travel nurses which healthcare authorities spent $241 million on between 2022 and June 2025. While it is good that everyone agrees we need to hire more local nurses, all of this will be for nothing if the government doesn’t increase hours of care and reduce nurse-to-patient ratios, which the Registered Nurses’ Union NL (RNU) has long called for. 

My mother is in a long-term care home in St. John’s. It is absolutely the best one my sister and I could find for her. The frontline staff and management have been open to working with us, but the lack of resources available to them has been a barrier. 

We try to visit at least once a day, usually at dinnertime because staffing levels drop after 4 p.m. Our mother tends to lose weight if we’re not there on a regular basis to help with her feeding. She’s forgetting how to use utensils, as dementia patients do. With so many residents requiring feeding assistance on her unit, staff don’t always have time to spend the full 45 minutes it takes for a full feeding with a dementia patient. 

Nurses are the backbone of the healthcare system and the ones who have the power to make the system caring and humane. Without adequate nursing resources, the system will always be deeply flawed for the public and provide poor working conditions for nursing staff. A lack of care is dehumanizing to patients, residents, nursing staff, family members and all of us as taxpayers who may one day end up in the system. 

My experiences with senior care in the province

Having a loved one in long-term care in Newfoundland and Labrador is an exercise in frustration. There are lost personal items, items missing from food orders, laundry that is put in someone else’s closet, missed items in care plans, and missed signage that directs staff on how to provide care. Families need to visit on a regular basis to check on loved ones because workers simply don’t have enough time to spend with residents. Medical issues can be missed, like pain management, advancement of a disease, and the need to change care plans. If you visit a loved one on a regular basis, you’re more likely to recognize when they are in pain, not eating, losing weight, in need of medication adjustments, or in need of more sleep. This leads to burnout for family members and deep resentment towards the system.

Staff run from issue to issue without much time to observe residents. It’s hard to see the entire human being when you’re constantly moving from task to task. Many of these problems would be resolved by budgeting for more nursing staff on the floor. Ideally, there should also be mostly permanent staff who regularly work in the same unit. 

Nursing staff are also required to spend increasing amounts of time charting and documenting, an important part of their jobs. Longserving nurses have advised me that resources haven’t kept up with the demands of increased paperwork. 

Based on discussions I have had with a resident care manager at my mother’s home, the Government of Newfoundland and Labrador provides assistance for 3.5 hours of care per resident, per day, on her particular unit. Late dementia care is considered Level III care. A healthcare administrator told me that five hours of patient care would be the ideal amount of time for a late dementia ward in this province. Dementia can manifest differently in alternate jurisdictions and require different levels of care. There are multiple kinds of dementia and they show up in different percentages of the population in different jurisdictions. For example, some jurisdictions have more Alzheimer’s Disease. Others have more vascular dementia. Others have more dementia that is induced by substance abuse. 

Having a family member in long-term care in Newfoundland and Labrador is like having a part-time job you don’t get paid for. Keep in mind that long-term care costs up to $2,990 a month. I often wonder what happens to residents who have no one to visit them in a province in which a lot of young people leave for work elsewhere. Because of my mother’s difficulty eating on her own, I have asked that she be weighed on a weekly basis. This is not the norm in long-term care facilities, which only have the staff resources for monthly weigh-ins. To their credit though, they will weigh my mother weekly if I call in and ask them to do so. 

Seniors need to keep moving or their capacity to walk can quickly decline. I’ve seen residents at the home sent to the hospital, only to return unable to walk because staff didn’t have the time to keep them moving. The resident then needs to be moved to a unit for bedridden patients. Nurses will tell you there are many stories like this in which someone didn’t get the care they needed because of a lack of nursing resources. 

There can also be a lack of understanding of geriatric care and dementia at hospitals, which is highly problematic in a province with an aging population. Most healthcare professionals don’t specialize in geriatric care or have much training in it. It takes a lot of experience dealing with a dementia patient to understand the disease. It manifests in ways that are generally not well understood by healthcare professionals outside of long-term care.   

When staffing in long-term care units is reduced around 4 p.m. each day, evening staff must feed the residents, get their own meal breaks, and administer evening medications while working with reduced numbers. Evenings are a time when seniors experience something nurses call “sundowning,” a state of increased confusion, often accompanied by aggression.This happens in both hospitals and long-term care facilities.

It is highly problematic that staffing in late dementia care units is reduced at a time of day when patients need more attention and care. I’ve seen nurses left to break up fights between residents experiencing sundowning, which strikes me as a dangerous situation for everyone involved. I’ve also seen nurses struggle to get their own meals and breaks, which is detrimental for their own health and for mitigating the risk of mistakes. It’s also not good for the retention of nurses. 

With staff shortages in long-term care, registered nurses can be responsible for up to 150 residents at a time. Registered nurses at my mother’s home cover two units, or 50-60 residents. At night there might be one RN for the entire home, with about 120 residents. Doctors are often not on site and nurses are often the highest-ranking medical professionals. A registered nurse working in a hospital will probably be responsible for five or six patients. 

My mother’s home has been advocating for an extra RN for her floor for months, and for clinical care coordinators at night. Clinical care coordinator positions are filled by RNs who also cover two units at night. I was told by the management team at my mother’s home that these positions had previously been filled but were cut through attrition, even though the people filling the jobs were busy and had a lot of work to do. Everyone agrees this must happen but approval processes are long. Nothing ever happens in a reasonable amount of time in the healthcare sector and approval for more resources can take years.  

In my experience, usually around half of the nursing staff on the floor are casual, which means they don’t have permanent jobs or even regular assignments. They move around to spaces where they’re needed to fill in for sick calls, others on leave, or to meet unexpected demands. Even though casual workers don’t have benefits, some career nurses have chosen this route to have more flexibility over when they work. There are simply not enough workers to guarantee time off for permanent nurses. This is an important quality of life issue. More jobs for permanent nurses should help with this. 

Originally, casualization was introduced as a money-saving measure, but there are costs to care. Casual workers are less familiar with the units they’re working on. They may not have expertise in the area they’re assigned to. They are also not familiar with the patients and families on the unit they may be assigned to. This means permanent staff carry a heavier load because casual workers look to them for guidance. There’s a noticeable difference when regular staff are not present. 

There are also increasingly fewer licensed practical nurses on the floors, as they have been replaced by personal care attendants who earn less money. So, not only are there not enough staff on the floor—skillsets are being reduced. 

Healthcare management systems are often reactive rather than proactive. Emails to management can be missed because they’re so busy, although management generally wants to hear from families about what’s happening on the floor. 

Families are asked to take urgent issues on the floor to the RN, even though there often isn’t an RN present. A generous estimate would put an RN on the floor of my mother’s unit of 26 residents for approximately nine hours a day. That’s about 38 per cent of the time, more than half of which is outside visiting hours. 

Solutions

Other jurisdictions in Canada have already moved to four hours of care per day in long-term care facilities, or are attempting to do so. Ontario has already attempted to move to four hours of care but narrowly missed the target. In 2023, it was reported that in Nova Scotia 30 out of 91 homes are now providing just over four hours of care and 36 more are preparing to do so. The Yukon appears to be the only jurisdiction in Canada already meeting this standard. One has to wonder why this is not already happening in Newfoundland and Labrador when nursing graduates are reporting they cannot find full-time jobs in the province. 

The most common thing I hear from nurses is, “No one listens to us.” It’s time to start listening to the frontline workers in our healthcare system and give them what they need to deliver quality care while still maintaining their own quality of life. 

Over-spending on travel nurses is money that could have been invested in providing more hours of care for our own residents and better working conditions for local nurses. This is the biggest travesty of the travel nurse scandal. 

That money could have been invested in our own province, on our own people, and one-third to one-half of it would have come back to governments through taxation. Local nurses pay taxes and spend their money here. Travel nurses pay their taxes in other provinces and are the very definition of a poor use of public resources, with large amounts of money going to outside corporations. This is just another form of extraction of our resources. 

More permanent hires in our healthcare facilities would ensure better quality of life for everyone. Retention of existing workers ensures continuity of care. Staff will be more familiar with residents and families and there will be more expertise because they know the facility and its practices. Nurses could better plan time off for family occasions like birthdays and weddings. 

What the parties are promising

In the provincial election campaign, many of the parties’ promises centre on hiring more healthcare professionals and improving working conditions for nurses. However, their responses to the RNU are telling. 

The Liberals say they’ve already hired 1,300 nurses and more than 160 doctors (though in a letter to the Registered Nurses’ Union, Premier John Hogan put the number of doctors hired at 140). They have promised signing bonuses, Come Home Year incentives, incentives for collaborative care teams, family practice startup funding, and tuition reimbursement for nursing work terms, with return to service agreements. The newly-released Liberal platform states that a core staffing review is currently underway. The Liberal response to the RNU does not address the issue of nurse-to-patient ratios. 

The Progressive Conservatives are promising to overhaul recruitment systems for nurses and to provide more permanent jobs. They are offering an expanded nursing school, paid work terms for nursing students, and free access to nurse practitioners for all residents. Leader Tony Wakeham has discussed implementing appropriate staffing models but it is not clear what this looks like. Again, no specifics have been provided on hours of care or nurse-patients ratios. In responding to the RNUNL they state they will “follow a robust and transparent Health Human Resource Plan.” Furthermore, they “want the union, and nurses themselves, to help lead the process of setting these ratios.”

The New Democratic Party is similarly promising recruitment of 1,000 healthcare workers, phasing out travel nurses, better home-care support, paid work terms for healthcare students, reduced administration for physicians, and the elimination of waitlists for mental health services. However, they have also offered to work closely with the nurses’ union in setting nurse-patient staffing ratios. Responding to questions from the union, they said the party “would consider only those ratios or ratio-setting frameworks backed up by research, supported by the RNU NL, and proven to result in nurse and patient safety.” The NDP also said it would “work collaboratively with appropriate stakeholders to enshrine the chosen ratios or frameworks in legislation, and find the resources to make sure that these ratios are then achieved by the end of a four-year term.”

While these are all important policies, only the NDP’s approach promises to engage with both the union and the research on nurse-to-patient ratios. Replacing travel nurses with local nurses will only tinker around the edges of the problems if the government doesn’t budget for more hours of care for patients and it is clear which parties are willing to do that. 

Nursing is the most gendered of professions. There is an expectation that nurses will be self-sacrificing and caring because nursing is a calling as much as it is a job. But when we as a society don’t take care of our caregivers, it puts us all at risk. The system will not be caring the way we want it to be until we provide the resources for more care. It’s as hard and as simple as that. Nurses. Residents. Patients. Families. Citizens. Taxpayers. Nurse managers. We all deserve a more humane healthcare system.