During the novel coronavirus pandemic which began in Canada in March 2020, the need for adequate staffing became a matter of life and death, as many seniors’ care facilities that had previously “managed” with bare minimum staffing levels were unable to provide even the most basic levels of care for their residents – with tragic consequences. The fundamental and painful lesson has been the way the virus exposed, exploited and exacerbated the long-standing fissures and flaws in the foundations of Canada’s social safety net. Nowhere has this been more poignant than in long-term care (LTC).
By March 2021, Canada suffered 22,238 deaths due to COVID-19 – 67 per cent of these in long-term care. Long-term care staff accounted for 25,276 confirmed cases of the virus. In Alberta, 64 per cent of COVID-19 fatalities – more than 1,200 – were seniors in LTC. Yet, even amidst this tragedy, the lesson has not been adequately learned: according to data from the Canadian Institute for Health Information
released in March 2021, COVID-19 cases among residents of LTC and retirement homes increased by nearly two-thirds during the second pandemic wave compared with the first wave.
Inadequate staffing levels and poor working conditions for employees has been widely acknowledged as a significant factor in the ability of Canada’s LTC facilities to respond to the pandemic and its concomitant public health restrictions. However, concerns about adequate staffing and the ability of LTC staff to meet the care needs of residents have been raised over and over again for decades in Alberta and across the country. Increased staffing of direct-care workers results in fewer negative health outcomes for residents. Inadequate staffing levels are strongly correlated to burnout among health-care workers, higher likelihood of workplace injury, and result in high rates of staff turnover – all of which impact the quality of care they can provide residents.
Despite the crucial role staffing plays in providing quality care, provincial data on staffing is scarce. The Government of Alberta has not undertaken any study of staffing levels and working conditions in the LTC sector. To effect substantive change in seniors’ care it is essential that front-line workers’ voices be heard, and their experiences learned from. To this end, in 2019 Parkland Institute researchers collaborated with the Canadian Union of Public Employees (CUPE-AB) to develop a survey of LTC staff in Alberta. The survey’s objective was to hear from workers about their own experiences in LTC and what challenges they face in providing care. Workers were asked about their experience of injury, violence and emotional distress in the workplace. We also asked workers about how these conditions impacted residents, and their own physical, mental and emotional well-being. The survey was distributed via CUPE-AB to their membership in LTC facilities. Responses were received between October 2019 and the end of March 2020, during the early days of the pandemic in Alberta.
Fewer Staff Means Less Time to Care
One of the most important objectives of this survey was to determine how much time LTC workers have in their work day to do their jobs, whether that time is sufficient to do their job to the highest standard, and whether they feel lack of time impacts residents of the facility in which they work. When asked, “If you had more time during your work day, what would you do?” workers spoke of time to complete necessary tasks which were too often left undone or deferred to the next shift.
Most poignantly, many respondents expressed their desire for additional time to provide emotional and social connection for their residents, and to complete basic physical care tasks in an unhurried way that preserved residents’ autonomy and dignity. Nearly half of respondents – 43 per cent – did not have adequate time to complete required tasks consistently every day. Only 24 per cent stated they never had essential tasks outstanding at the end of a shift. Consequently, staff are left with few options: leave important aspects of their job – including care tasks – undone, work through their breaks, or stay late to finish. Seventy per cent of respondents stayed beyond the end of their shift at least occasionally (occasionally, daily or once a week). Nearly one-quarter – 24 per cent – stayed late either daily or once per week.
It is clear from these responses that staying beyond the end of their shift to ensure all essential tasks are done is the norm for many LTC workers. Many respondents highlighted a concerning lack of time for cleaning. In the ongoing context of the COVID-19 pandemic, the lack of time to thoroughly perform cleaning tasks could have dangerous consequences as surfaces, linens and communal areas contribute to virus transmission if not properly sanitized. Respondents did not have the luxury of time because so many were working short-handed.
In total, 90 per cent of respondents reported their facility experiences short-staff at least occasionally. Almost half of the respondents – 44 per cent – reported they experienced short-staffing at least daily or weekly. Only one in 10 is never short-staffed. Pre-pandemic, this seems like an incredibly low bar. In the wake of the pandemic, this low bar will have been even more difficult to surmount.
Understaffing Harms Residents
Inadequate staffing means basic care needs of residents – essential to their physical well-being and personal dignity – are frequently delayed or missed entirely. Less than half of respondents felt the staff-to-resident ratio in their workplace was adequate to provide necessary care; 41 per cent felt it was seldom or never adequate to meet care needs. About half of respondents felt pressures on staffing were creating conditions of actual harm to residents whose calls went unanswered for longer than was ideal, who were not helped to the toilet in time, and who were not turned sufficiently. Around 40 to 45 per cent of respondents identified actual harm to residents due to delayed assistance with meals and – alarmingly - injuries to residents as the result of inadequate staffing. Incomplete walking and bathing of residents was identified by approximately one-third of respondents.
Understaffing Harms Workers
Survey participants responded about their experience of various injuries and illnesses sustained while working in LTC. Around 30 per cent of respondents experienced some type of illness or injury on the worksite daily or weekly. Survey participants reported experiencing a wide range of verbal, physical and sexual aggression from residents, residents’ family members, and also other staff. Disturbingly, 82 per cent experienced verbal abuse from residents, 57 per cent experienced physical abuse, and 37 per cent experienced sexual harassment.
Respondents were clear in linking additional staff to reduced incidence of violence among staff and residents. While 65 per cent of respondents believed more staff would prevent violent incidents, only four per cent did not believe more staff would prevent such incidents. More than half (53 per cent) experienced mental distress or post-traumatic stress symptoms at work at least occasionally; 22 per cent experienced mental distress at least once a week or daily. A further 21 per cent had taken stress leave, and 54 per cent knew of at least one co-worker who had taken stress leave. The gap between the high number of staff experiencing distress and those who took leave from their job suggests this level of stress is normalized within their workplace.
This was the status quo pre-pandemic. The ripple effects of COVID-19 – ill and isolating staff, increased care needs for infected residents, increased duties around symptom checks, sanitizing and personal protective equipment – further reduced the number of hands available for an unimaginable workload, and the time available to provide care. As the pandemic enters its second year, LTC and other health-care workers, already vulnerable to mental health impacts of their work, are now experiencing post-traumatic stress disorder in response to the staggering death tolls in their workplaces.
Profit Status of Facilities Affects Work Conditions and Care Provided
Profit status and the owner-operator model of facilities was also a significant factor in our survey responses. The broad consensus in seniors’ care research supports a correlation between profit status and quality of care. On average, for-profit facilities provide fewer hours of direct care per resident per day, and are more likely to have fewer staff per resident. Thus, residents in for-profit facilities are more at risk of adverse outcomes.
When asked whether their facility had adequate staffing to provide quality care for residents, a significant disparity could be seen across ownership/profit categories: 34 per cent of respondents based in for-profit facilities reported they never have adequate staff-to-resident ratios to meet resident needs, compared to just seven per cent for public facilities. Not-for-profit facilities fell in the middle, at 16 per cent. In the pandemic context, this correlation between profit status and quality of care has contributed to more widespread outbreaks and greater fatalities in for-profit facilities: those with chain ownership, older building design, multiple residents to a room, and/or lower staffing levels are more likely to be run for-profit.
Our survey affirmed alarming issues that similar studies in other provinces have raised, and that workers and unions have been flagging for years in Alberta and across the country. Staffing levels in LTC are rarely adequate to meet the increasingly complex needs of older, more vulnerable residents, and staff are stretched to their limits trying to square an impossible circle. Staff care about their residents. Staff want to provide individual, unrushed attention to their social and emotional needs as well as daily physical tasks. They want residents to be treated with dignity. LTC staff value doing their job to the best of their ability, but the conditions under which they work – even before the coronavirus pandemic – often made this impossible. Now the stakes are even higher. Workers, especially those delivering direct care, risk their health, their families’ well-being, emotional distress and even their own lives to provide the bare minimum of care. The pandemic has exacerbated all the long-standing challenges entrenched in LTC, and added new ones, while simultaneously reducing the available staff to meet them.
Based on these research findings, Parkland Institute recommends that:
- Alberta must increase staffing levels and consider staffing mix.
- Alberta Health needs to distribute the federally funded pandemic top-up pay to all LTC workers.
- LTC providers should offer equitable pay and benefits for health-care aides.
- LTC providers should create more opportunities for full-time positions.
- The proposed national staffing standards must be tied to funding and enforced through inspection and reporting.
- LTC providers should offer mental health supports for direct-care staff.
- LTC providers should ensure adequate staff on every shift to enable workers to take mandated breaks.
- Providers should empower direct-care staff to provide more input into resident care.
- Alberta Health should develop a relational care model to replace activity-based funding.
- Alberta must commit to building a resilient LTC workforce.
Quality of Care
- Remove the profit motive from care by phasing out for-profit ownership and delivery.
- Recognize that laundry, dietary, housekeeping, maintenance and therapy staff have essential roles in LTC – contributing to holistic care of the whole person and supporting a comfortable care environment.