[Sharon]

Health Care Funding, Priority Setting and Allocation of Scarce Resources – choose from below for your discussion:

The following are some questions to consider and to guide discussions during WEEK 6:

• How are decisions regarding scarce resources made in Ontario’s health care system and at the organizational level?
• How should these decisions be made?
• Reflect on the process of allocation in your health field/organization.  Discuss and provide examples that demonstrate who makes the decisions and how do they decide?  Also comment on this process and ways that it could be improved.
• What measures would you use to determine that the allocation process was fair and equitable?
• Has your organization ever decreased services? If so, how was that decision made? How were RPNs involved in the decision? What would you need to know to assess the appropriateness of that decision?
• Share with us your approach to determining how much time to spend with each patient/client/resident.

[Jessica]

Unfortunately, Ontario is no stranger to scarce healthcare resources.
Decisions about reallocating resources such as funding, are typically made at multiple levels. Provincially, the Ministry of Health and Ontario Health determine funding priorities. At the organizational level, decisions regarding things like programs and service delivery come from senior leadership, finance departments, manager and directors.

One specific example I wanted to touch on was a recent change that occurred at my Organization. My organization announced the introduction and increased number of RPNs in specialized areas such as CCU, ED and Nurse run medication clinics. The decision to replace RN roles with RPNs was not welcomed with open arms, and I believe that had a lot to due with the lack of transparency when it was announced. There was not rationale behind the decision and there were a lot of unanswered questions in regards to scope and expectations.
In this situation, increased transparency regarding how the decision was made would have provided staff with a clear rationale and opportunities for feedback could have improved trust and acceptance of difficult allocation decisions such as this. While difficult decisions are unavoidable, processes that are transparent, evidence-based, ethically sound, and inclusive of frontline staff can help ensure resources are distributed fairly and effectively.
I think we could learn from this experience, but it is a great example of the pressure our healthcare system is currently facing and the decisions that need to be made because of it.

https://www.brantfordexpositor.ca/news/local-news/registered-nurses-protest-staffing-changes-at-brant-community-healthcare-system

[Jamie]

Jessica,

Thanks for your insight. It is interesting to see that other facilities are dealing with similar issues and that we are not alone in experiencing these changes. I have always felt that some of the floors that have traditionally been allocated as RN-only could potentially operate as a joint RN/RPN floor. I think this could be an effective way to make better use of the skills and abilities of both nursing roles while also addressing some of the staffing challenges organizations are facing.

I am excited about some of the changes and believe there is definitely more that RPNs can contribute to within the healthcare system. However, I am equally concerned about RPNs being expected to work in areas such as the ICU and CCU, where patient acuity is extremely high and specialized knowledge and skills are required. I think there needs to be careful consideration of the patient population, the complexity of care, and the education and experience required for each area.

Overall, I feel that we are progressing in the right direction by recognizing and utilizing the full scope of RPN practice. At the same time, I believe we still need RNs and should be thoughtful about where each nursing designation is most appropriate. Finding the right balance between RNs and RPNs could help organizations use their resources effectively while still maintaining safe, high-quality patient care.
Jamie

[Jessica]

Jamie,

I understand your concerns about RPNS working in areas such as ICU/CCU. I had strong feelings about this as well until a mentor of mine explained things in a way I hadn’t thought of. Some hospitals have ICU/CCUs where many of their Patients are waiting on the transfer list to move to another unit, many have step down units and some ICU/CCUs don’t always have “critically ill” patients. My mentor shared a story with me about working in the CCU in the North and the Patient she was assigned to was leaving the unit multiple times to smoke. ICU/CCU acuity depends a lot on the location, and what services they are able to provide. Some hospitals could definitely benefit from RPNs working in these areas as long as they remain working within in their scope of practice. I think that is going to be the more important educational piece. RNs and RPNs understanding the scope to understand the care they are able to provide safely. I think it could be a really great thing, as long as everyone is willing to work together… The buy in may be the tricky part.

[Mary Ann]

Hi Jessica, I agree with your post. I think transparency is very important when making changes that affect staff and patient care. If management clearly explains the reasons for the changes and listens to staff concerns, it can help build trust. In healthcare, difficult decisions are sometimes necessary, but staff should feel included and informed in the process.

[Jamie]

In my organization, we are currently going through significant changes in staffing and resource allocation. The organization is not necessarily eliminating RN positions outright; however, as RNs leave due to retirement, accepting new positions, or other reasons, some of these positions are being replaced with RPN positions. This change has not been met with open arms by staff. RPNs are also expected to work in specialty units, which has raised additional concerns among employees. The Ontario Nurses’ Association (ONA) is currently challenging these changes, so it will be interesting to see how the situation develops.

Another major change is that PSWs are now responsible for two units instead of one. This has significantly increased the workload for nurses on the floor. With fewer support staff available, many patient-care tasks that may not be considered immediate priorities are either left for the next shift or, unfortunately, are not completed at all. Families have also noticed these changes and have expressed concerns about the level of care their family members are receiving. These concerns are generally directed to management.

The reasoning provided by my organization for these staffing changes is that similar staffing models are being used at other facilities of comparable size and funding. The organization views this as the new standard and believes that, until the government provides additional funding, it must adapt to the available resources and staffing ratios.

While I understand that healthcare organizations have financial limitations and must allocate resources carefully, I believe staffing decisions should consider more than simply comparing staffing ratios with other facilities. Patient acuity, workload, the complexity of the unit, and the experiences of frontline staff should also be considered. Nurses and PSWs are in a unique position to identify how staffing changes are affecting patient care because they experience these changes firsthand.

I also believe there should be ongoing evaluation of the effects of these staffing changes. Patient and family complaints, missed or delayed care, staff workload, overtime, sick calls, and staff turnover could all provide valuable information about whether the new staffing model is actually working. Greater communication between management and frontline staff could also help ensure that decisions are made with both financial responsibility and patient safety in mind.

Overall, the current situation demonstrates how difficult it can be to balance limited healthcare resources with the need to provide safe, high-quality patient care. Although financial constraints are a reality, staffing decisions should not be based solely on what other organizations are doing. A more individualized approach that considers patient needs, staff workload, and patient outcomes could lead to better allocation of resources and improved care.

[Jessica]

After reading that PSWs are now responsible for two units instead of one, all I can think of is the increased risk for transmitting infections.
Are the PSWs going back and forth from one unit to another all day and assisting with Patients? If so, I am curious to know if your IPAC team has advocated against this?
As an infection control professional, we always think of the worst case scenario and I am picturing an uncontrolled outbreak spreading to multiple units and having to contact trace! haha

[Jamie]

Jessica,

I agree there is a large concern with increased risk of infection transmission and potential outbreaks. Since PSWs are moving between two units throughout their shifts and providing direct patient care, transfers, meal distribution, and other hands-on assistance, there is greater opportunity for infections to be carried between units, particularly during an outbreak or when additional precautions are required. This also raises IPAC (Infection Prevention and Control) concerns, as staff may have to move between units while trying to maintain appropriate precautions and prevent cross-transmission. With fewer PSWs available and no corresponding increase in nursing support, staff may become stretched thin, which could make it more difficult to consistently maintain infection-control practices while also meeting patient-care needs. I worry that this could increase the risk of an infection spreading and ultimately put both patients and staff at greater risk.

Jamie.

[Heather]

Thank you for your interesting post about staffing resources. I would also be concerned about cutting psw staff to such
an extent. I can’t help but wonder how they will keep up with this and how much more pressure will be on the nurse.
What about falls, skin conditions becoming worse are just a few things I can think of right now. There has been
much research about the benefits of having safe patient to staff ratios, which should also include psw’s. I have seen
so much of this in my career and I wish it would stop but resources are greatly affected by money.

[Marion Catherine]

Hi Jamie, Institutions and the facilities these buildings supply are clearly not in the people business. Your observations and the feedback from your facility show that health care is a business with an eye on the bottom line. There has to be a systemic change in how health care institutions and the governing bodies and legislative authorities carry out the business of health care. Clearly a must have “mandate” that each and every entity involved in any and all aspects of health care is required. The status quo is not bringing people back to a stable healthy condition. Quite the opposite is happening and numbers are increasing because the system is making the health care worker sick by maintaining the “do more with less” paradigm. That required mandate would have a requirement that the wellbeing of the health care worker MUST be upheld and safe working conditions regarding patient allocation be upheld.

[Heather]

I work in the community, and I am often having discussions with Care Coordinators to advocate for patients not to have their care hours cut back. Once in while I am able to delay the cutting back
of hours but often I am not. After having done the readings this week, I am not sure how decisions are made for how much care patients will receive in their home. It is the expectation of Ontario Health at Home that family and private care will fill the gaps, which is not an option for many patients.

As for RPN’s it seems they are being utilized to their full scope of practice in certain areas such a palliative care however I have noticed that Ontario Health at Home is slowly trying to put nursing tasks onto psw’s such as ostomy care, g-tube feedings which used to be visiting nursing tasks. I think that nurses should having a much greater role in deciding the services that patients need and how to safely deliver them through feedback from service provider organizations at regular intervals. It seems that finances are the driver of many decisions.

[Alhasan]

I agree that nurses should have a greater role in decisions about home care services. Nurses providing direct care often have the clearest understanding of a patient’s actual needs and the risks associated with reducing services. I also think the expectation that families will fill gaps can create inequities, as not everyone has family support or the financial ability to pay privately. Decisions may need to consider limited resources, but patient safety and individual needs should remain central to the allocation process.

[Sara]

Hi Heather, I liked the way you gave a perspective of a community nurse. When people think of cuts they often think hospital but some may argue those in the community may suffer more. When nursing tasks are passed onto PSWs, and nursing hours cut ; comlplications are more likely to happen.

[Alhasan]

Every day, nurses make decisions about allocating limited resources, whether it is time, staffing, or access to services. In my role, I am allotted 20 hours per week for case management for my assigned clients, so I must continuously prioritize competing demands to ensure those hours are used effectively. Factors such as client acuity, scheduled appointments, urgent health concerns, and changes in condition all influence how I allocate my time. While leadership determines overall staffing and resources, frontline nurses make ongoing decisions to ensure the most urgent health and safety needs are addressed first.

I believe allocation decisions should be based on fairness, clinical need, and evidence, rather than convenience or financial factors. The readings emphasize that no single principle is sufficient when allocating scarce resources, and that ethical decision making requires balancing factors such as need, prognosis, maximizing benefit, and treating people fairly.

In my own practice, I prioritize clients based on acuity while ensuring everyone’s essential needs are met. Some clients require more nursing time because of complex medical conditions, while others may only need brief interventions. A fair allocation process is one that is transparent, consistent, and focused on achieving the best possible outcomes for all clients. Decisions should also involve input from frontline staff, as they have the clearest understanding of clients’ day-to-day needs.

[Sara]

Ontario allocates scarce healthcare resources using provincial ethical frameworks that emphasize fairness, equity, and clinical need. Hospitals follow policies from the Ministry of Health. At the organizational level, managers use a variety of factors such as patient acuity, safety, and personal needs. There is not one factor that is considered “lone” when allocating resources
Hospitals are expected to avoid creating “second‑class citizens” or “VIP” patients by treating all patients equally, regardless of what is in their bank account.
The document reinforces this by noting that nurses must make decisions “without regard to payment sources.” Ideally, decisions prioritize patient well‑being, minimize harm, and uphold ethical principles.

[Mary Ann]

Hi Sara, I agree with your post. I think it is important that healthcare resources are allocated based on patient needs, safety, and clinical condition, rather than income or ability to pay. In long-term care, we also need to make sure that residents receive fair care based on their individual needs. When resources are limited, prioritizing residents with higher care needs can help reduce harm and promote equity. I also agree that no resident should receive better care simply because they have more money or influence.

[Mary Ann]

Reflect on the process of allocation in your health field/organization. Discuss and provide examples that demonstrate who makes the decisions and how do they decide? Also comment on this process and ways that it could be improved.

Answer: In my work in a long-term care home, resource allocation is mainly decided by the manager, nursing supervisor, and care team. They look at residents’ needs, staffing levels, and safety. For example, when there are fewer staff available, residents who need more help with bathing, feeding, toileting, or medications are given priority.
I think the process is fair when decisions are based on residents’ needs and safety. However, short staffing can make it difficult to provide equal care to everyone. I believe the process could be improved by having enough staff, better communication among the care team, and regularly reviewing residents’ changing needs. This would help ensure that resources are distributed fairly and that residents receive the care they need.

[Samantha]

Hi Mary Ann,

I completely relate to your experience. When I worked in long-term care, short staffing was a constant challenge (at times it felt like it was almost daily!)
PSW allocation usually prioritized units with heavier-care residents, which makes sense on paper to ensure safety. But,this creates an unfortunate tradeoff, residents requiring less hands on physical care receive less attention, even though they deserve equal care and quality time.

It often felt like a lose-lose situation. The staff left behind on the short-handed units had to handle an increased workload, leading to higher stress, resentment, frustration, and burnout. Balancing safety priorities with overall resident well-being remains one of the hardest parts of resource allocation in LTC in my opinion.

[Marion Catherine]

• How are decisions regarding scarce resources made in Ontario’s health care system and at the organizational level?
Decisions in Ontario regarding the allocation of scarce resources are based on fiscal responsibility and priority. These factors appear to be based on past and current political promises to lobbyists, who in turn fund election campaigns and consequent political party re-election.
It is the writer’s perspective that although well intentioned, political allocation of resources is a matter of a focus on popularity rather than actual need. Of course, if the politician can be re-elected then they have a better chance of fulfilling the wish list of balanced budgets and meaningful health care reform. But then this is the catch 22 of the political system we enjoy here in Ontario, Canada. There is much to be grateful for as a citizen of this province and country and yet there is so much left to be desired. Changing the “this is how the system has always worked” mindset to what would actually work is the matter under consideration.
• How should these decisions be made?
If it were possible to extract political ego, then health care decisions should be made according to the most fiscally efficient proposals that show extent of reach supporting the greatest number of citizens within each classification of health care needs. An example of a health care classification paradigm could be broken into 6 main categories; palliative care, elder care, maternity, disease, and prevention. Bringing formalized and proven practices of prevention under the umbrella of OHIP would allow citizens greater access to treatments that support wellness in the pre-disease state. This would stabilize costs to consumers, by splitting costs between OHIP funding and personal income for the practitioner.
• Reflect on the process of allocation in your health field/organization. Discuss and provide examples that demonstrate who makes the decisions and how do they decide? Also comment on this process and ways that it could be improved.
The health care facility where I provide RPN care is a non-profit, donations-based facility that is regulated by the RHRA. The decisions regarding the allocation of funds are clear from the onset. As this facility houses tenants as well as limited nursing care services, there are no funds allocated for the health care needs of the apartment tenants. However, there is financial support offered to all residents whose fiscal realities fall short of standard rent costs. This facility supports sustainable living for seniors by subsidizing rents for those tenants who are in need. The management team members filling positions of the executive director and community liaison discern how rent subsidies are allocated based on the tenant’s/resident’s fiscal disclosures. The allocation for health care needs is mainly focused on the nursing department’s services and as all departments in this facility provide an aspect of health care services, the dietary, housekeeping, maintenance and administration are also funded through the same pool of financial resources.
Improvements to how funds are allocated within this facility are being explored as the new management team looks to the future. At this time, as a new hire, less than one year with this facility as an RPN, I am not in a position to expand on how the process can be improved. But knowing that the donations-based model is precarious in times of economic strife within the greater society, fund raising is precarious and yet most necessary. The writer has proposals prepared to support this aspect of revenue generation.
• What measures would you use to determine that the allocation process was fair and equitable?
In a not so idealistic world, where there are alternatives to the mainstream health care system, there is much to be said for the application and the implications of evidence-based practices. The alternatives referred to here include the accepted practices of acupuncture and massage therapies. But what is missing is the enhancement of pre-disease wellness.
The approach presented here is not looking at the status quo and trying to figure out how to make it better, fair and equitable. This is already being studied by experts in this field. What is being offered, however, is the inclusion of alternative wellness practices that can provide evidence-based results showing the treatment plan and its outcomes. As mentioned earlier, acupuncture and massage therapies have been acknowledged however only through some private health insurance polies.
This proposal looks at including these and many other wellness modalities into the OHIP regime. This funding resource (OHIP) can be supplemented by a cost sharing of treatments whereby OHIP is paid a certain percent of the fee charged and the practitioner keeps the balance of the fee paid by the client. A systematic fee scale would be necessary so that fees are accessible to the vast majority of citizens.
• Has your organization ever decreased services? If so, how was that decision made? How were RPNs involved in the decision? What would you need to know to assess the appropriateness of that decision?
As far as I can tell, this facility has not decreased services, however, in the last couple of years, it came pretty close according to the disclosure from the executive director stating that staff bonuses were at risk of being discontinued. The new management team has been able to redirect the fiscal balance into a more stable path which seems to be effective.

[Samantha]

To further my reply to another student, Resource ( specifically staffing) in long term care often highlights the tension between triage based decision making and equal and fair care distribution among units. In my past experience working in LTC the choices were often determined by senior management based on resident numbers,acuity levels, safety and daily staffing availability. During short staffing shifts, staff are often moved to units with heavy physical care demands ( example more residents that have mechanical transfer needs or feeding needs) to prevent falls and maintain an acceptable level on care. While at the time it feels fair this inadvertently punishes the lower need residents and worsens the burnout of the other units who are left to manage overwhelming workloads with less staff. Improving this requires a shift towards proactive allocation strategies, such as real time acuity tracking tools, collaborative discussions among staff ( front line) and polices that account for emotional and social care alongside hands on physical care/task. Allowing front line staff to be apart of the solution or allowing them to hear the rationale for decisions would improve staff rapport and trust as well.

[Author]

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