A woman sings for residents at Idola Saint-Jean long-term care home in Laval, Que., Feb. 25, 2022.Graham Hughes/The Canadian Press
Carole Estabrooks, Faculty of Nursing, University of Alberta
Vivian Ewa, Department of Family Medicine, University of Calgary
Janice Keefe, Department of Family Studies and Gerontology, Mount Saint Vincent University
Sharon Straus, KT Program, Li Ka Shing Knowledge Institute, St Michael’s Hospital-Unity Health Toronto
In early COVID-19 waves, Canadians witnessed the pandemic’s devastating impact on long-term care home residents and staff. Photos of family members, pressed against windows, trying to connect with their loved ones in lockdown. Reports from staff and the military on the chaos and devastation they were seeing on the front lines. Many in Canada expressed outrage, because this crisis had been predicted based on population projections and hundreds of reports produced by policy makers and researchers in the 50 years leading up to the pandemic.
Now we must ask: what have we learned and will anything change for the hundreds of thousands of older adults who reside in long term care in Canada?
As we lay out in our recently published Series in The BMJ, Research identified critical factors contributing to the impact from COVID-19 in long-term care homes including chronic lack of funding and inadequate support for staff – neither of which kept pace with the increasing clinical and social complexity of residents. Individuals go to these homes much later in the trajectory of their chronic illnesses today versus 15 years ago, and have shorter lengths of stay. These factors result in highly compressed dependency and acuity of residents. And, they have not been adequately considered in the long-term care home work force model, where the estimated number of staff relative to the population aged 65 years and older is lower in Canada than the OECD (Organisation for Economic Co-operation and Development) average.
Failure to adequately support and pay staff compounded the situation during the pandemic. Long-term care home staff are paid less than their counterparts in acute care and typically didn’t receive sick pay pre-pandemic as many worked part-time across multiple homes and settings. Much of the workforce includes older, racialized women – overrepresented by 45% compared to the general population and the percent who are foreign-born is amongst the highest of any country. Compared with other health care workers, long-term care home staff diagnosed with COVID-19 were more likely to live in lower-income neighborhoods, with a higher household density and with other essential service workers. The pandemic also exacerbated staff burnout and retention. Given this tenuous workforce situation, it’s not clear how we will meet the 2023 Health Standards Organization’s recommended minimum of 4.1 hours of direct care per resident day in long-term care homes (a recommendation based on work done 20 years ago in the US). In Ontario alone, it was estimated that almost 30,000 staff will be needed to enter the market by 2035, and this estimate doesn’t include increasing direct care from 2.75 hours to 4.1 hours.
Lack of national data on the health workforce hampered pandemic efforts in long-term care. For example, no national data exist on staff intersecting demographics, such as race and language. Similarly, we have no comprehensive national data on the number of long-term care home staff or the hours of direct care received by residents. We can’t achieve or monitor change without these data.
Not all was dire during the pandemic. Interventions such as the prioritization of long-term care residents and staff for vaccination saved lives. Provincial sick pay and one-site work policies made a difference. Eliminating 4-bed rooms and enhancing ventilation impacted resident and staff wellness. The national standards recommendations on staffing and other areas that will affect staff retention and quality of life, if implemented and linked to funding and accountability, can achieve change. However, some pandemic policies have already been rescinded, including sick pay in some provinces. Four-bed rooms are coming back in some jurisdictions. And, we mustn’t forget that COVID-19 outbreaks (as well as other infectious outbreaks) are continuing in long-term care.
How can we ensure lessons are learned? Many countries called for pandemic long-term care inquiries – while some provinces conducted these, to date there has been no national inquiry or Royal Commission. In The BMJ series on COVID-19 in Canada, we posed several questions for a national inquiry, including the extent to which long-term care home residents, their essential care partners and staff were involved in policy and pandemic response? How did inadequate data on long-term care home quality of care, resident and staff quality of life and their social determinants of health, and staffing contribute to outbreaks? How did failure to support staff with a living wage and sick benefits contribute to pandemic morbidity and mortality? And, are long-term care homes and their workforce prepared for the next public health emergency?
We hope that inquiry results will lead to action. Specifically, along with the model of the Canada Health Act, we hope the federal government will use them to create a universal, national long-term care home plan – with adequate federal funding and cross-jurisdictional data sharing, which is linked to evidence-based outcomes (including staff outcomes) that hold homes and provincial governments accountable. We believe it is only through this approach that we will see transformational change with improved quality of life for long-term care home residents, their essential care partners and staff. Each of us can influence this agenda in Canada. How we care for older adults and those who care for them reflects our societal values – what do we want our long-term care home systems to say about us and what lessons we learned from COVID-19? We can use these lessons to inform our decision – we can do nothing, we can settle for incremental change, or we can undertake a transformation. It is a choice.