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Unfortunately, that's how many hospitals operate. Inadequate staffing is a nationwide problem, and with the exception of California, not a single state sets a minimum standard for hospital-wide nurse-to-patient ratios. Dozens of studies have found that the more patients assigned to a nurse, the higher the patients' risk of death, infections, complications, falls, failure-to-rescue rates and readmission to the hospital -- and the longer their hospital stay. According to one study, for every 100 surgical patients who die in hospitals where nurses are assigned four patients, 131 would die if they were assigned eight.

In pediatrics, adding even one extra surgical patient to a nurse's ratio increases a child's likelihood of readmission to the hospital by nearly 50 percent. The Center for Health Outcomes and Policy Research found that if every hospital improved its nurses' working conditions to the levels of the top quarter of hospitals, more than 40,000 lives would be saved nationwide every year.

Nurses are well aware of the problem. In a survey of nurses in Massachusetts released this month, 25 percent said that understaffing was directly responsible for patient deaths, 50 percent blamed understaffing for harm or injury to patients and 85 percent said that patient care is suffering because of the high numbers of patients assigned to each nurse. (The Massachusetts Nurses Association, a labor union, sponsored the study; it was conducted by an independent research firm and the majority of respondents were not members of the association.)

And yet too often, nurses are punished for speaking out. According to the New York State Nurses Association, this month Jack D. Weiler Hospital of the Albert Einstein College of Medicine in New York threatened nurses with arrest, and even escorted seven nurses out of the building, because, during a breakfast to celebrate National Nurses Week, the nurses discussed staffing shortages. (A spokesman for the hospital disputed this characterization of the events.)

It's not unusual for hospitals to intimidate nurses who speak up about understaffing, said Deborah Burger, co-president of National Nurses United, a union. "It happens all the time, and nurses are harassed into taking what they know are not safe assignments," she said. "The pressure has gotten even greater to keep your mouth shut. Nurses have gotten blackballed for speaking up."

The landscape hasn't always been so alarming. But as the push for hospital profits has increased, important matters like personnel count, most notably nurses, have suffered. "The biggest change in the last five to 10 years is the unrelenting emphasis on boosting their profit margins at the expense of patient safety," said David Schildmeier, a spokesman for the Massachusetts Nurses Association. "Absolutely every decision is made on the basis of cost savings."

Experts said that many hospital administrators assume the studies don't apply to them and fault individuals, not the system, for negative outcomes. "They mistakenly believe their staffing is adequate," said Judy Smetzer, the vice president of the Institute for Safe Medication Practices, a consumer group. "It's a vicious cycle. When they're understaffed, nurses are required to cut corners to get the work done the best they can. Then when there's a bad outcome, hospitals fire the nurse for cutting corners."

Nursing advocates continue to push for change. In April, National Nurses United filed a grievance against the James A. Haley Veterans' Hospital in Tampa, which it said is 100 registered nurses short of the minimum staffing levels mandated by the Department of Veterans Affairs (the hospital said it intends to hire more nurses, but disputes the union's reading of the mandate).

Nurses are the key to improving American health care; research has proved repeatedly that nurse staffing is directly tied to patient outcomes. Nurses are unsung and underestimated heroes who are needlessly overstretched and overdue for the kind of recognition befitting champions. For their sake and ours, we must insist that hospitals treat them right. ☐

"The sum of all the numbers is a tightening nursing labour market," Karima Velji, president of the Canadian Nurses Association (CNA), said in a statement. "Immediate action is needed to stave off the potentially long-lasting trend of a shrinking [registered nurse] work force and its consequences for population health." The CNA is a professional organization that advocates for nurse-friendly public policy.

Andrea Porter-Chapman, CIHI's manager of health work force information, said it is too early to say whether the dip in supply marks the start of a nursing shortage in Canada or a one-year blip thanks to a regulatory change in Ontario. Either way, health policy-makers will need to watch the trends closely over the next couple of years, she said.

"This is the first shift in almost two decades where we've seen a decline in the supply," Ms. Porter-Chapman said. "But the positive side of this is that our work force continues to increase. ... I think [the supply issue] is something that our health-care system just needs to be aware of and monitor."

When it comes to nursing in Canada, the term "supply" refers to the number of people holding active licences with the provincial bodies that regulate the profession.

But not all licensed nurses work in nursing. Some hold on to their licences after landing other jobs, going back to school or unofficially retiring. Last year, the College of Nurses of Ontario, the self-regulating body that oversees the profession in Canada's most populous province, put in place a new rule that effectively bars members from renewing their licences unless they have practised nursing in the province in the past three years. That contributed to an unusually high number of nurses formally exiting the profession in Ontario - 15,836 in one year.

Still, the CIHI report identified some underlying trends that suggest there is more at play. Across the country, a total of 27,757 nurses let their licences lapse last year, while only 25,397 registered anew with one of the provincial or territorial regulators - a net loss of 2,360.

The supply of nurses dropped in six jurisdictions: Newfoundland and Labrador (down 0.7 per cent), Prince Edward Island (down 3.5 per cent), New Brunswick (down 0.9 per cent), Ontario (down 2.6 per cent), British Columbia (down 0.9 per cent) and the Northwest Territories and Nunavut, which together saw a decrease of 3.2 per cent.

Canada's nursing schools are simply not graduating as many students. "We've seen the growth in the number of [nursing] graduates slow down, so it's just under 1 per cent now," Ms. Porter-Chapman said. "This is after five years where the growth was between 6 and 12 per cent."

As well, the number of students admitted to entry-level nursing programs actually fell between 2009-10 and 2010-11, the most recent year for which CIHI was able to obtain national figures. "Will the workplace feel it yet?

Perhaps not. It might take a year or two to see these changes trickle into work settings," said Linda McGillis Hall, a professor in the faculty of nursing at the University of Toronto. "I think this report will actually bring this issue to the forefront again."

Staffing levels in nursing homes are a concern not only because they are low, but they may not be increasing fast enough to meet the rising medical complexity of patients in nursing homes.

Data from the Canadian Institute for Health Information shows that between 2008 and 2012, the proportion of residents in Canadian nursing homes with disease diagnoses increased for every category of disease.

Dementia is also increasingly common among Canadian nursing home residents, with over three quarters of residents having some level of cognitive impairment. More than one in four residents suffers from severe dementia.

As a result, the care needs of nursing home residents have grown. In Ontario, care needs are assessed using the Method for Assigning Priority Levels (MAPLe) scoring system. The system ranges from a score of 1 (low needs) to 5 (very high needs). In 2012, 85% of new admissions from the community and 78% of admissions from hospital were in the High or Very High (MAPLe 4 and 5) clinical needs categories. Less than 1% of admissions were in the low and mild (MAPLe 1 and 2) clinical needs categories. Projections from the Ontario Long Term Care Association suggest that soon virtually all patients admitted to nursing homes will be from the two highest need categories.

The increasing needs of nursing home residents in Ontario has been driven in large part by the shift from letting individual nursing homes choose their residents, to having Community Care Access Centres determine who is in greatest need of long term care, says Dr Samir Sinha, lead for Ontario’s Senior Strategy

Ontario has begun to increase both the number and skill sets of nursing home staff, while also trying to find efficiencies to free up more staff time for direct patient care.

“One of the most promising initiatives to date has been Behavioral Supports Ontario (BSO),” says Sinha. The BSO initiative is province-wide, and has funded the hiring of 604 new staff (194 nurses, 272 PSWs, and 138 other health care professionals, such as social workers) with specialized skills in caring for and supporting residents with complex and challenging behaviors, such as violence.

Researchers and policy strategists in Alberta believe another key to improving quality in nursing homes is to engage Health Care Aides (HCA in Alberta is the rough equivalent of a PSW) as full members of the care team.

Carole Estabrooks, a Professor of Nursing at the University of Alberta has been researching the engagement of HCAs in quality improvement for the last several years. She believes that too often, HCAs are not treated as members of the care team. “Care Aides typically have the least amount of formal training, and as a result doctors, nurses and others too often assume they have nothing to offer,” she says. Frequently, this means they have little input into the care plans they are expected to carry out.

The number of "medical incidents" - hospital jargon for treatment errors - has spiked, said the nurse, who agreed to be interviewed on condition that his or her name not be published for fear of reprisals. The nurse said the hospital has prohibited stafffrom speaking to journalists about problems in the ER. In perhaps the most glaring case, a patient who was "gushing blood" arrived by ambulance in the ER and was supposed to undergo a transfusion immediately, but the blood supply was not ready even though it had been ordered in advance 30 minutes earlier, the nurse said. The girl ended up dying because of the severity of her injuries, not the delay in receiving the blood transfusion, but the case nonetheless illustrates the risks involved, the nurse added.

A second source described other "botched" cases, including a boy with a badly fractured femur "who sat in the ER for (eight) hours without it being set until someone actually looked at the X-ray." The are multiple causes for the problems, said the ER nurse and the second source - a lack of staff and unfamiliarity with the new medical equipment, lab technicians who haven't been trained in processing pediatric blood samples, and glitches in the facilities. And all those problems have occurred amid cost-cutting imposed by the provincial government.

"It's a zoo, it's dangerous," the ER nurse told the Montreal Gazette. "Before we moved in, we were told three things: the new ER was going to be more patient-centred; the doctors, nurses and clerks would be working better together; and it was supposed to be more comfortable. I haven't seen any of those things. Nobody works together because we're all preoccupied with our own things. We're running around like dogs. For me, it's falling apart. Patients' lives are in danger."

Officials at the Montreal Children's denied that lives are in jeopardy, but acknowledged that there have been problems in the processing of lab samples, some staffing shortages as well as glitches. At the same time, the medical team has been treating an unseasonably high number of patients with serious illnesses, said Dr. Harley Eisman, director of the emergency department. "I think we all recognize that moving to a new house is a big deal for everybody, and actually, our emergency department has had some significant cases," Eisman said. "We've dealt with many sick children over the past couple of weeks. We've had pretty brisk numbers as well. It hasn't been a quiet summer for us."

Lyne St-Martin, nurse manager at the Children's ER, said although "we have occasional shortages (of nurses), for the most part our quotas are met and our nursing staffis rather stable." Still, St-Martin warned that staff and patients will have to make adjustments for months to come at the Glen site, following the Children's move there from its old address on Tupper St.

"I do want to highlight that we transitioned three months ago, and that in speaking to other hospitals that have actually moved as well, they spoke about a one-year transition time where there is a very steep adaptation, and it will continue for several months to come," St-Martin said. "So none of this is surprising." Among the problems identified by the ER nurse:

At one point, water started pouring from a pipe in the ceiling of one of the treatment rooms. Staff closed the room and protected the medical equipment, but the leak hasn't been repaired yet. In the meantime, staffcan't use the sinks in the adjoining rooms to wash their hands. Eisman said there are other treatment rooms available and the ER flow hasn't been hampered. An emergency psychiatric room for agitated adolescent patients - some of whom are suicidal - has a bathroom that locks from inside and can't be opened by staff, the nurse said. There have been two cases where patients locked themselves in the bathroom and security was called but the guards arrived late. Eisman said that there is now a protocol in place to post a guard next to the bathroom in such cases. He added that glitches like the bathroom lock are being addressed quickly, although some parts are on back order.

Some of the lab techs, who used to work at the old Royal Victoria Hospital, have not been trained fully to process blood samples for children, resulting in delays as long as four hours for medical issues that must be addressed immediately, the nurse said. Eisman responded that "when we opened we certainly raised issues about lab performance. We opened a line of communication with the lab and were immediately on it and the lab performance has improved dramatically."

The Children's ER is consistently understaffed by nurses, and yet more than a dozen have not yet been fully trained to perform all tasks in the department, and there have been delays "in working up infants for signs of meningitis," the nurse said. What's more, many ER nurses are assigned to accompany patients on other floors, resulting in longer waits for emergency patients. As a consequence, frustrated parents have ended up shouting at nurses in the ER. Some of the nurses have reacted by seeking solace in the bathroom and crying in private for up to half an hour.

St-Marin said the ER nurses have been trained to deal with parents who are in crisis, and added "that our numbers show that (patients) are not waiting longer. In fact, we're tending to our sicker patients faster." She did not cite any statistics. The ER nurse accused the McGill University Health Centre of mismanagement, saying it had been planning the Montreal Children's move for years but has not trained staffproperly in using some of the new equipment. For example, some X-ray technicians continue to use portable X-ray machines rather than the new equipment in the ER. The MUHC has also balked at paying nurses to work overtime, yet the ER has ordered great quantities of rarely-used IV filters at $500 a box that sit mostly unused on shelves, the nurse added. aderfel@montrealgazette.com twitter.com/Aaron_Derfel

At Chartwell, a chain of 27 homes, chief operating officer Karen Sullivan said the pharmacy that services the chain, MediSystem, pays for "many additional valued-added services" such as employee education, nurse leadership sessions and conferences for leaders of homes. MediSystem also pays for Wi-Fi systems and therapeutic care equipment at the homes, Sullivan said in an email. The Star asked pharmacies what they are told the money is used for. Among the responses from pharmacies were "staff education," "resident programs" and payments toward Wi-Fi systems. Classic Care, a pharmacy, said the money it pays covers monthly rent of an area in the nursing home, staff education, technology and "donations and sponsorships" for conferences and other training. Other pharmacies, such as Rexall, say their fees have paid for diabetes education, for example. The largest pharmacies serving long-term-care homes in Ontario include Medical Pharmacies Group, MediSystem (owned by Loblaw), Classic Care (Centric Health) and Rexall. The fees are not new. Pharmacies have willingly offered money or agreed to demands for years. But there's a growing outrage among some who say homes are more interested in "inducements" than "clinical excellence" that pharmacies can provide seniors. Last year, after the Ontario government cut each dispensing fee by $1.26 (it is now $5.57 per prescription in nursing homes), sources said some pharmacies wanted to stop paying the fees. The problem was, the sources said, that the homes refused to give up the extra cash flow and other drug companies were willing to pay, so nothing changed.

It's usually the larger companies that can afford to pay. One insider said smaller pharmacies now ask the homes, "Do you want the money or do you want good service? Because we can't afford to give both." Sources said the Ontario Ministry of Health and Long-Term Care knows the money changes hands but does nothing to stop it. Instead, pharmacies are "held hostage" by the homes, the source said. One home that no longer charges the fees is John Noble Home in Brantford, a municipally operated 156-bed facility. The Star obtained a 2010 request for proposals (RFP) that noted "only proposals with a minimum rebate of $20,000 annually will be considered for the project." A spokesperson for the city said the RFP "references a previously approved practice employed by several long-term care homes." A recent RFP did not ask for a rebate, though some offered to pay. The city spokesperson, Maria Visocchi, said it chose a pharmacy that "demonstrated qualifications and experience, project understanding, approach and methodology, medication system processes and quality control." This pharmacy did not offer a rebate. Not all pharmacists pay. Teresa Pitre runs Hogan Pharmacy Partners in Cambridge and serves long-term-care homes that don't ask for money. Instead, she signed contracts with several homes in the People Care chain to provide a "highly personalized approach." Pitre sends a registered pharmaceutical technician into each home daily to relieve nurses of much of their work regarding medication, confusion over communications and extensive paperwork. Her company also puts a bookshelf-sized dispensing machine in each home, which holds medication (pain relievers, antibiotics or insulin) that residents need on short notice but, in the traditional system, often can't get for hours. "I really wanted our pharmacy to be a partner with homes instead of servicing them and just meeting the requirements," she said. Meadus says the added cost of bed fees means pharmacies have no reason to reduce their rates, either by lowering dispensing fees or not charging the $2 co-payment.

A recent Star story revealed that pharmacies serving nursing homes typically charge dispensing fees for drugs once a week, rather than once a month as they typically do in a community pharmacy. Long-term-care pharmacies told the Star they charge the weekly fee because the medication for frail residents can change weekly. That was a claim hotly disputed by some family members the Star spoke to, including Margaret Calver, who has spent years documenting the costs of dispensing fees at Markhaven Nursing Home, where her husband is a resident. "This needs oversight and that's the problem," she said. "Nobody is doing the checks and balances." Moira Welsh can be reached at mwelsh@thestar.ca.

The CDC is launching a public education campaign for nursing homes aimed at preventing more bacterial and viral infections from starting and stopping others from spreading. A similar effort was rolled out for hospitals last year.

"One way to keep older people safe from these superbugs is to make sure antibiotics are used appropriately all the time and everywhere, particularly in nursing homes," said CDC Director Tom Frieden in announcing the initiative. Studies have estimated antibiotics are prescribed inappropriately 40 per cent to 75 per cent of the time in nursing homes. Here's why that worries the CDC: Every time someone takes antibiotics, sensitive bacteria are killed but resistant bacteria survive and multiply - and they can spread to other people. Repeated use of antibiotics promotes the growth of antibiotic-resistant bacteria. Taking antibiotics for illnesses the drugs weren't made to treat - such as the flu and common colds - contributes to antibiotic resistance.

Antibiotics also wipe out a body's good infection-fighting bacteria along with the bad. When that occurs, infections like Clostridium difficile can get out of control. C. diff. leads to serious diarrhea that each year puts 250,000 people in the hospital and kills 15,000. If precautions aren't taken, it can spread in hospitals and nursing homes. Health-care facilities already have infection-control procedures in place, such as providing private rooms and toilets for infected individuals. But the CDC is pushing them to do more on the prescribing side, advising nursing homes to track how many and what antibiotics they prescribe monthly and what the outcomes were for patients, including any side-effects.

Other recommendations include placing someone, such as a consulting doctor or a pharmacist, in charge of antibiotics policies and training other staff in following them. Some of the CDC's suggestions could challenge nursing homes' culture and how staffs, residents and their families interact. While nursing home residents and staff are among the people most at risk for the flu, annual shots aren't mandatory. Nor do homes always track who gets them.

That's starting to change at Evangelical Lutheran Good Samaritan Society, a nonprofit that provides a spectrum of senior care services in many states. Starting this year, it will collect data on staff vaccinations at one of its 167 nursing homes and share the pilot project's results with other homes, said Victoria Walker, chief medical officer. But better handling of antibiotics in nursing homes may also require tactful communication with residents' families and nursing home doctors accustomed to treating antibiotics as a default remedy.

"There's a real fear of undertreatment and that it is better to err on the safe side, and that means treating with antibiotics but forgetting about all the harms. But giving antibiotics can be just as harmful as not," said Walker. Family members may push for an antibiotic treatment when they visit a loved one in a nursing home who seems sick, even if they don't know precisely what's wrong. Doctors and nurses may go along because they don't know either and it's easier to treat than not. "The family will check in and ask what the doctor did and the nurse will say 'nothing' because they don't see monitoring as doing anything," said David Nace, director of long term care at the University of Pittsburgh, who contributed to the CDC guidelines.

"Practitioners are guilty of saying, 'it's just an antibiotic.' ... We don't appreciate the real threat," he said. Antibiotics are routinely prescribed to treat urinary tract infections, which are common in nursing homes, but too often when a UTI is only suspected, not confirmed, studies have found. The Infectious Disease Society of America is developing guidelines to help institutions implement programs to better manage antibiotics. In addition to fostering antibiotic resistant bacteria and causing C. diff infections, antibiotics also can produce allergic reactions and interfere with other drugs a nursing home resident is taking. Those risks aren't always fully considered, says researcher Christopher Crnich, who has published articles on antibiotic overuse. He is a hospital epidemiologist at William S. Middleton Veterans Hospital in Madison, Wisconsin. "Bad antibiotic effects don't come until weeks or months later, and frankly all we [prescribers] see is the upside when we're dealing with a sick mom or dad," Crnich said.

The Centers for Disease Control in the United States has raised concerns about the use of antibiotics in nursing homes.

"It shows that people here really care about the Miramichi and it's too bad that politicians don't care about it as much," Driscoll said. "They want to privatize the nursing homes, they want to cut to the Education Department, their cutting the highway budgets and they're cutting to every service they can think of, so where are we going to go? They don't seem to think that matters." The Liberal government, come the fall, is expected to have a deal in place that will see all hospital food and cleaning services being outsourced to a private firm.

Government officials, including Health Minister Victor Boudreau have maintained that the changes are needed in order to help the province get its finances in order and will save the province millions of dollars through efficiencies that will be brought in under private management. Driscoll says those efficiencies, CUPE fears, are simply going to amount to job cuts at hospitals throughout the Horizon Health Network. The union learned from the province earlier in the summer that food and facilities management giants like Sodexo, Aramark and Compass Group are involved in the bidding process.

"If they privatize these services, then these corporations are going to come in and say 'you don't need all these people' ... we're going to cut because they're going to want to make at least a 20 per cent profit. Driscoll said the hospital is just one example of the trend toward the greater privatization of public services the union is seeing. Nursing home workers at Mount St. Joseph Nursing Home and the Miramichi Senior Citizens Home have been protesting at various points throughout the summer after learning the Department of Social Development would be using a private-public partnership (P3) model in building a new 280-bed nursing home that will replace both of the city's current facilities, which are run by a volunteer board of directors. Workers at both homes will have to reapply for positions at the new nursing home if that's what they choose to do and, with a private company running things, the membership has said it is concerned that those who do catch on at the new place could be subject to reduced pay and benefits.

The government is expected to open up a request for proposals (RFP) in the coming weeks to begin the process of determining which proponent will build and operate what will likely be New Brunswick's largest nursing home by the time it opens. Currently, each of the three privately run nursing homes in the province are owned by Shannex. The unions have also warned that the move to a P3 model would lead to a reduction in the level of community outreach programming offered to local seniors through things like Meals on Wheels and adult daycare. Tourism Minister Bill Fraser, the Liberal Miramichi MLA who advocated heavily for the new nursing home to be built and the man at the centre of much of the unions' ire, has shot down those concerns in previous interviews. Fraser has reiterated that regardless of whichever proponent emerges with the right to build and manage the structure, the initiative represents a major upgrade in terms of nursing home infrastructure.

He said the standards of care are dictated by the province and will remain, at the very least, on par with what has existed at the two current nursing homes over the last several years. Programs like Meals on Wheels, adult daycare and lifeline, would remain in place and potentially even enhanced and in terms of jobs, he said there will be provisions written into the RFP asking that priority be given to local applicants and that with an increase of 26 beds, even more staff will likely be required. As for pay and benefits, he said staff at two of the three Shannex properties have already unionized and the third was in the process of doing that.

Nursing home staff have called on the province to force the boards at the Mount and the senior citizens home to amalgamate together and operate the new facility using a model similar to what was undertaken in Edmundston when two nursing home boards melded into one in order to operate the new $48 million, 180-bed Residence Jodin. Danny Legere, the president of CUPE New Brunswick, was on hand for the vigil and urged the Miramichi workers to keep up the fight. "I want to congratulate the people of the Miramichi for taking a stand - the fight that you have started is a fight for all New Brunswickers," Legere said. "The militancy that you are showing is exemplary and it has to be carried on from one end of the province from one end to the other."

Andy Hardy, a Miramichi native and the president of CUPE 1190, said his sector is used to certain services being contracted out to private interests but when it comes to health and senior care, he said it was "flat out wrong." "You're looking after the most vulnerable people in that building right there," Hardy said. "When you privatize the food services and the cleaning services all it is is for profit - the service goes down and the profit goes up, and for nursing homes as well." Length: 1090 words

There is a crisis in our hospitals - we are dramatically understaffed and under-resourced in terms of both nursing staff and other health-care staff. But rather than trying to beggar their neighbours, we suggest that the RN association focus on working with all nurses and all health-care workers and the local community to increase the staffing of all nurses and health-care workers in Ontario hospitals. That is where CUPE Local 1974 will be putting our energies - and wherever possible we will do this with our registered nurse colleagues. Mike Rodrigues President, CUPE Local 1974

A number of other locals joined in on the demonstration, including representation from CUPE 1277 and 1256 of the Miramichi Senior Citizens Home and Mount St. Joseph Nursing Home, respectively, CUPE 1190, which acts on behalf New Brunswick's highway workers, the New Brunswick Federation of Labour and staff from Hebert's Recycling.

The Liberal government, come the fall, is expected to have a deal in place that will see all hospital food and cleaning services being outsourced to a private firm. Government officials, including Health Minister Victor Boudreau have maintained that the changes are needed in order to help the province get its finances in order and will save the province millions of dollars through efficiencies that will be brought in under private management. Driscoll says those efficiencies, CUPE fears, are simply going to amount to job cuts at hospitals throughout the Horizon Health Network. The union learned from the province earlier in the summer that food and facilities management giants like Sodexo, Aramark and Compass Group are involved in the bidding process.

"If they privatize these services, then these corporations are going to come in and say 'you don't need all these people' ... we're going to cut because they're going to want to make at least a 20 per cent profit. Driscoll said the hospital is just one example of the trend toward the greater privatization of public services the union is seeing. Nursing home workers at Mount St. Joseph Nursing Home and the Miramichi Senior Citizens Home have been protesting at various points throughout the summer after learning the Department of Social Development would be using a private-public partnership (P3) model in building a new 280-bed nursing home that will replace both of the city's current facilities, which are run by a volunteer board of directors. Workers at both homes will have to reapply for positions at the new nursing home if that's what they choose to do and, with a private company running things, the membership has said it is concerned that those who do catch on at the new place could be subject to reduced pay and benefits.

The government is expected to open up a request for proposals (RFP) in the coming weeks to begin the process of determining which proponent will build and operate what will likely be New Brunswick's largest nursing home by the time it opens. Currently, each of the three privately run nursing homes in the province are owned by Shannex. The unions have also warned that the move to a P3 model would lead to a reduction in the level of community outreach programming offered to local seniors through things like Meals on Wheels and adult daycare. Tourism Minister Bill Fraser, the Liberal Miramichi MLA who advocated heavily for the new nursing home to be built and the man at the centre of much of the unions' ire, has shot down those concerns in previous interviews. Fraser has reiterated that regardless of whichever proponent emerges with the right to build and manage the structure, the initiative represents a major upgrade in terms of nursing home infrastructure.

He said the standards of care are dictated by the province and will remain, at the very least, on par with what has existed at the two current nursing homes over the last several years. Programs like Meals on Wheels, adult daycare and lifeline, would remain in place and potentially even enhanced and in terms of jobs, he said there will be provisions written into the RFP asking that priority be given to local applicants and that with an increase of 26 beds, even more staff will likely be required. As for pay and benefits, he said staff at two of the three Shannex properties have already unionized and the third was in the process of doing that.

Nursing home staff have called on the province to force the boards at the Mount and the senior citizens home to amalgamate together and operate the new facility using a model similar to what was undertaken in Edmundston when two nursing home boards melded into one in order to operate the new $48 million, 180-bed Residence Jodin. Danny Legere, the president of CUPE New Brunswick, was on hand for the vigil and urged the Miramichi workers to keep up the fight. "I want to congratulate the people of the Miramichi for taking a stand - the fight that you have started is a fight for all New Brunswickers," Legere said. "The militancy that you are showing is exemplary and it has to be carried on from one end of the province from one end to the other."

Andy Hardy, a Miramichi native and the president of CUPE 1190, said his sector is used to certain services being contracted out to private interests but when it comes to health and senior care, he said it was "flat out wrong." "You're looking after the most vulnerable people in that building right there," Hardy said. "When you privatize the food services and the cleaning services all it is is for profit - the service goes down and the profit goes up, and for nursing homes as well." © 2015 Telegraph-Journal (New Brunswick)

“We need 16 to 17 per cent more RNs to catch up with the rest of the country,” he says. “Ontario hospitals are by far the leanest in the country, and the community and long-term care sectors are understaffed as well. More nurses should be going to the community to keep people out of hospitals. I think it’s one of those areas where the healthcare system finds it easier to cut back on nurses than cut back on money going to doctors. Right now family doctors are averaging $300,000 a year.” Full-time RNs make a base of $53,000 in their first year of work and up to $78,000 base if they have many years of experience. Overtime pay is typically one and a half times the hourly rate.

Fetterly said there could be violent blows and spitting from patients but also the threat of violence from visitors to a facility. "This kind of abuse has to stop and we'll be going to the provincial government to put some demands on to make some changes," she said.

"We have had nurses stabbed, beaten up, punched in the head, fallen to the floor, cracked their head on the floor, kicked, punched," Tracey Newton, a nurse at Providence Care and a chief steward with the Ontario Public Service Employees Union Local 431, said at the time. "Quite often, on a daily basis, nurses are subjected to violent assaults. We still have five nurses offwork with head injuries." Clayborne said the stories are the same where she works in Hamilton. "We've had quite a few incidents that have been brought to the public," she said.

Recently, according to the council, nurses have been attacked in Hamilton, North Bay, Cornwall and Kingston. Last November, about a dozen staff members from the Providence Care Mental Health Services site on King Street West held an information picket at the hospital entrance to bring public attention to what they say are dangerous conditions inside the building caused by having too few staffto deal with too many high-risk patients.

According to a news release from the union, its recommendations to the province include: increasing funding and staffing at least to the Canadian average in hospitals and long-term care facilities; beefing up legislation to protect healthcare workers from violence, giving health-care workers the same right to refuse unsafe work as other workers in the public sector; laying criminal charges against patients and family members who commit violence on health-care workers; and also improving security at these facilities.

In December, the hospital reported five attacks on staffby patients over a 10-day period. "We've had two nurses who were attacked: one left unconscious and suffered a severe concussion from a violent patient and another girl who had hot coffee thrown in her face on the forensic unit." Fetterly said about 85 per cent of RPNs in Ontario are women. Clayborne said St. Joseph's has five forensic units housing patients, some of whom have committed serious crimes and have mental health issues as well. "Short staffing led to those assaults," she said.

Clayborne said the patients know when the nurses are understaffed and take advantage of that. She said the nurses have to see patients without the benefit of security officers nearby. "The hospital has contracted out the security at our facility," she said. "The security guards make approximately $11.50 an hour and their job is to just show up and be there as a support, they're not supposed to put their hands on the patients." Nurses are trained in non-violent crisis intervention, Clayborne said, but when being attacked by a stronger and heavier person, the training doesn't help very much. Nurses wear panic alarms, but the alarms don't work all the time, Clayborne said.

"In violent situations, we press our alarms, nothing happens and nobody comes to help you," she said. When the alarms do work, there's a one-to three-minute delay before the call goes out. "That makes a big difference when you're being beaten before somebody comes to help you," After a violent incident, the RPNs often suffer from post-traumatic stress disorder, fear and anxiety before returning to work, and sometimes the incident also takes a psychological toll on the nurses' family members. Fetterly agreed that the issue should be considered a crisis.

Because of the funding and the funding freezes, we're working with less and less staffand the bed occupancy is at an all-time high," she said. Fetterly believes people will ultimately leave the profession. "Why should you go to work every day and be exposed to someone beating on you, intimidating you or spitting in your face. I didn't sign up for that. I signed up to give quality patient care." - With a file from Michael Lea ian.macalpine@sunmedia.ca Twitter.com @IanMacAlpine

Ian Macalpine, The Whig-Standard / Ontario Council of Hospital Unions officials Helen Fetterly, left, and Linda Clayborne attended a two-day conference on the safety of registered practical nurses in Ontario's mental health facilities.

The provincial government's statistics also show the length of stay at nursing homes is getting longer and the average age of residents is getting older.

The cash-strapped province is reviewing a five-year, $400-million infrastructure plan that would have replaced and renovated the stock of nursing homes.

Even nursing home projects that were already approved were reviewed to search for any possible cost savings and the remainder of the plan has been subjected to the internal review.

There are 4,140 residents in the province’s 65 nursing homes. But there are more than 700 seniors occupying hospital beds because there are no beds available in nursing homes. There were also 719 seniors on waiting lists for nursing homes on March 31, 2010, and those lists are expected to grow longer every year.

The infrastructure challenges being faced by the province's nursing homes are not new. The Department of Social Development's statistics show there were 73 infractions found during nursing home inspections in 2008. That number fell to 63 in 2010.

But the declining state of New Brunswick’s nursing homes burst into the open earlier this year when two facilities were forced to cope with mould outbreaks.

Mill Cove is like many other nursing homes in New Brunswick. It was constructed in the 1960s and it received a series of additions in the last 50 years to meet growing demands. The patchwork of upgrades has led to some of its current problems.

The costs of those ongoing battles to maintain the aging infrastructure, buy new equipment to improve the quality of life for residents and meet the standards of patient care are all adding up. “We are seeing the costs to maintain the facility go up each year,” Dickson said.

The facility’s chief executive officer said the myriad problems facing the nursing home prove a replacement building is not a luxury in an otherwise austere time. “It is a not a 'nice to have,' it is a 'must have' for us right now,” Dickson said.

For instance, the Ontario Nurses’ Association is supporting its members in challenging the CNO’s policies that discriminate against disabled nurses, including the branding of nurses as “incapacitated” on the CNO website, even though these nurses are able to work.

In fact, ONA has recently won an important commitment from the Ontario Human Rights Commission to discuss with the CNO the necessity of removing barriers that prevent nurses with mental health or addiction disabilities from accessing employment.

Over 12,000 nurses left the profession in Ontario alone, a decline of 2.6 per cent in regulated nurses, she said. "One of the factors driving the change in Ontario was a regulatory change (from) the College of Nurses of Ontario," she said.

Last year the college introduced a "declaration of practice requirement" - members can renew their membership only if they practised nursing in Ontario within the last three years or were registered or reinstated within the past three years.

Diane Clements, interim director of practice and policy for the Canadian Nurses Association, said her organization is "concerned" about the CIHI numbers, particularly when it comes to where nurses are working. The report finds retention rates were highest in hospitals, compared to community health agencies, nursing homes, long-term care facilities and other nursing workplaces.

Distribution of the workforce isn't where we'd like it to be, where we know Canadians and seniors are needing care," said Clements. "We know that 14 per cent of Canadians are 65 and older, and it's a number that's expected to double by 2036," she said. "Research has shown that age-related conditions, especially chronic diseases, are better managed in the community."

A spokesperson for Health Minister Dr. Eric Hoskins said the 2015 budget provides funding for an additional 80,000 hours of nursing care.

In the letter to Timmings, lawyer Michael Polvere of Siskinds wrote, "While we encourage all honest and fair debate on the issues, defamatory and untrue statements made of and concerning our client, the LHSC, will not be tolerated and will be met with swift action. The LHSC intends to hold both RNAO and yourself personally responsible for the conduct of this meeting." At the 6:30 p.m. meeting at Wolf Performance Hall in the Central Library, Timmings will lead discussion on a nurses' association report that claims cash-strapped hospitals are cutting registered nurses and replacing them with less qualified and lower-paid staff to the detriment of patients. "These (changes) are detrimental to Ontarians, to nurses, and to the future of health and health care in Ontario," conclude authors of the report Mind the Safety Gap in Health System Transformation: Reclaiming the Role of the RN. No one should be muzzled from discussing key health issues and LHSC's efforts should be addressed by Ontario Health Minister Eric Hoskins, Grinspun said. Hoskins couldn't be reached for comment Thursday. Nor could officials at LHSC. Earlier this year, Glendining refused to comment publicly on Burkoski's firing but defended the hospital in internal memos that insisted that the nurses' association had told a one-sided story and that safety was always a priority.

"What particularly alarms nurses is the lack of transparency on the part of the Ontario government when it comes to disclosing this ugly trend to the public," stresses Burkoski. Despite letters to both Premier Kathleen Wynne and Health Minister Eric Hoskins calling for a ban on medical tourism, the practice continues. "We hear that the government is investigating but in our view, there is nothing to investigate when there is clear evidence that hospitals are engaging in medical tourism," adding that even one is one too many. The Registered Nurses' Association of Ontario (RNAO) is the professional association representing registered nurses, nurse practitioners and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses' contribution to shaping the health-care system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit our website at www.RNAO.ca( (www.rnao.ca») ).You can also check out our Facebook page at (www.RNAO.org») (www.rnao.org») ) and follow us on Twitter at www.twitter.com/RNAO( (www.twitter.com») ) SOURCE Registered Nurses' Association of Ontario

The numbers underscore the need for improvements to hospital staff safety measures, something the Ontario Nurses' Association (ONA) has long been calling for to better protect health-care providers. "Violence isn't part of this job. It shouldn't be part of this job," said Andy Summers, vice-president of health and safety with ONA. "Eventually, somebody will get killed."

Summers called the current situation of violence against nurses in Ontario "completely unacceptable." At UHN, which includes Toronto General Hospital and Toronto Western Hospital, there has been a consistent increase in reports of assault in the past three years. The number of reported violent incidents doubled in two years, jumping from 166 incidents in 2012 to 331 in 2014, according to data provided to the Star. In 2014, 11 workers who were injured were unable to return to work for their shift following the assault. Spokeswoman Gillian Howard said changes in reporting standards probably account for the rise. The changes include a Behaviour Safety Alert, implemented at UHN in 2014, which requires staff to put an alert on patient records if the patient has aggressive or violent behaviour. Howard also said increased reporting could be attributed to the fact that unions are encouraging staff to report every incident: "a very good thing," she said.

"We do not want any staff member at risk from a patient, but given the care we provide, the medications used, the fact that some patients have cognitive impairment as a result of injury or aging, the impairment of some patients when they arrive, and the risks associated with some of the treatments, it is not likely that we will see a year with no incidents," said Howard, adding that UHN employs approximately 13,000 staff and has over one million patient visits per year. But ONA lashed out at this explanation, saying employers are trying to downplay the issue.

Erna Bujna, occupational health and safety specialist with ONA, said some employers "absolutely" still discourage staff from reporting incidents, by telling workers that violence is just part of the job. ONA wants to see a violence strategy implemented at hospitals across the province. The strategy would include mandatory reporting of every violent incident reported to the Ministry of Labour - currently, employers are only required to report fatalities and critical incidents to the ministry - mandatory risk assessment of every patient, increased security and more health-care providers hired. They also want the Ministry to charge individual hospital CEOs when workers are not adequately protected from violence.

He added that legislation requires employers to assess the risks of workplace violence, create workplace violence and harassment policies, develop programs to implement those policies, and take every precaution reasonable to protect workers from workplace violence. ONA's call for an updated safety strategy comes on the heels of a decision by the Ministry of Labour to lay charges against Toronto's Centre for Addiction and Mental Health (CAMH) in December 2014. The charges - made under the Occupational Health and Safety Act and relating to failure to protect workers from workplace violence - stem from a violent incident in January 2014 in which a nurse was dragged, kicked and beaten beyond recognition, according to ONA.

Toronto police later charged the patient, who was found guilty of assault causing bodily harm, according to court documents. "We don't want staff ever to feel that aggression is the norm," said Rani Srivastava, chief of nursing and professional practice at CAMH, in response to the comments. "We are committed to a culture of safety and recovery and that means safety for staff and patients." Jean Dobson, a nurse at University Hospital in London, Ont., said she's been strangled with a stethoscope, stabbed with a metal fork and spat at by patients over the course of her 42-year career. "People think that they can hurt a nurse and that's OK," she said. "We have to smile and take it."

In one incident, Dobson had her nose broken when she was kicked in the face by a patient. She was forced off work for weeks and suffered from PTSD, she said. Dobson said she's seen the frequency of patient-on-nurse assaults and the severity of violence increase during her career. At Sunnybrook Hospital, reports of abuse against staff by patients and visitors jumped from 140 in 2012 to 320 in 2013. The hospital attributes the increase mainly to their move to electronic reporting, which makes it easier to record violent incidents, a spokesperson told the Star. According to a 2005 national study from Statistics Canada, 34 per cent of nurses surveyed reported being physically assaulted by a patient in the previous year, and 47 per cent reported experiencing emotional abuse. For those working in psychiatric and mental-health settings, 70 per cent of nurses reported experiencing emotional abuse.

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Each year, the province spends $21.6 million for Nova Scotia’s three nursing schools and a total of 1,604 nursing seats. Given the pace at which the health system evolves, it’s critical that today’s students are offered every opportunity to be as “practice- ready” as possible when they graduate.

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