More than half of the COVID-19 deaths in Canada are estimated to be among residents living in Canadian long-term care (LTC) homes, the highest percentage in the world. As well, a significant and growing proportion of the LTC workforce has been infected and forced to self-isolate. In some cases, front-line workers have died. Those remaining on the front lines are overworked, face a lack of protective equipment and receive a confusing and changing array of directives from provincial ministries. Amidst this, front-line staff have been deemed essential.

We are dismayed but not shocked that the LTC sector is the sector most vulnerable to the COVID-19 pandemic. It has always been the least visible part of Canada’s provincial health care systems, prone to underfunding, understaffing and poor working conditions despite high health and social care needs of its residents.

With the emergency orders, LTC work may be recognized as essential, but it is still essentially under-recognized work. The pandemic has exposed years of inattention from policy-makers, especially surrounding issues of insufficient and inappropriate staffing levels, and poor health and safety protections for staff. These issues need to be fixed before this pandemic is over.

Long term care environments require workers with unique skill sets

Not just anyone can “do” care work in LTC. Yet, the typical political response through the outbreak has been to “just get anyone in there.” The call has gone out to volunteers from specialist physicians on furlough, to teachers and educational workers not working due to school closures, to acute care facility staff and most recently to the Canadian Forces. True, in the short-term staffing levels need to be shored up, but the policy response belies the fact that LTC work is highly skilled and to not easily replaceable. This is not to say that these redeployed replacement workers are not highly skilled in their fields, but it overlooks how LTC is an environment that requires a unique skill set.

LTC is not a hospital, it is a place where people with complex medical and social care needs live often for the remainder of their lives. Because of the long duration of their care, care workers (personal support workers /care aides) and nurses, establish relationships with the residents, and the work should involve what we call relationship-oriented care. Care work has a critical psychosocial component and requires specific training to accomplish relationship-oriented care that extends beyond caring for someone’s bodily needs. It includes providing dining support; bathing someone with dignity; interpreting and recognizing when individuals who can’t speak are in pain; assessing how to sensitively and effectively support personal care especially for residents with dementia; engaging families; and generally bringing joy and comfort to residents’ lives.

In Canada, these skills are learned briefly in school but honed with front-line experience that involves knowing when to act and when to hold back despite the tremendous time pressures. Rushed or unresponsive care work approaches can lead both to bad outcomes for residents and injury of workers. Using skills requires knowing the person – their unique needs and habits – and the place.

Skilled care work involves the continual support of other essential workers such as cleaners in LTC who have very important knowledge and skills regarding infection control and residents’ preferences.  Importantly, cleaning in LTC is far different than cleaning a home, especially while in an outbreak situation. Cleaners are normally tasked with heavy workloads and only do “deep cleaning” of residents’ rooms once per week on a rotation. During an outbreak, more deep cleaning is required, more high touch surface cleaning such as with handrails and doorknobs, and more “accidents” to contend with. In addition, cleaners know how to chat with and engage residents with dementia. There are now even greater social care needs for residents who are isolated that cleaners can support.

In order for workers to use their skills, the most important condition is having enough time to safely carry out good quality relationship-oriented care work. It is hampered when faced with incontinuity stemming from staff shortages, under-staffing and too high a proportion of temporary and casual staff.  This is a large part of the reason why quality in long term care goes up when there is continuity of care.

In short, good working conditions create the potential for good quality relationship-oriented care.  Quality care is far less likely when staff are not working with their regular residents, when they are unsupported, and when their attention is stretched too thin. Given that COVID-19 presents in older adults with non-standard symptoms, knowing what is typical for a given resident has become more important than ever. Because care workers are the ones in closest and most frequent contact with residents, in a COVID-19 era we need to consider how we will create good working conditions and enhance care workers’ skills so that they are able to recognize and report on their residents’ symptoms.

Chronic understaffing leads to negative outcomes

Despite not being a hospital, work in LTC also includes professional health care work. Care workers require the support and supervision of nursing (including nurse practitioners) and rehabilitative staff (such as physiotherapists, occupational therapists, dieticians, and social workers). One recommendation is for provinces to ensure that there is an appropriate mix and ratio of professional-to-care workers in LTC since there is an ongoing rise in how sick people are when they enter long-term care and a complexity to the social care needs given the high proportion of residents living with some form of dementia. Furthermore, these ratios must be re-negotiated in light of the new COVID-19 circumstances. Long-term care facilities are dealing with the outbreak but don’t have the same staffing afforded to hospitals that are dealing with the same issues.

It’s no wonder that there have been so many negative health and workplace outcomes from COVID-19, but long-term care facilities were already dangerous places to work before the pandemic hit. Some of the highest rates of workplace illness and injury in any work sector are experienced by those working in LTC, who are often rushing because of under-staffing. COVID-19 has elevated the risk of illness and even death to very high levels for workers and for residents, but rushed or improper care has always led to serious, debilitating injuries for both parties. There is knowledge and skill in knowing how to care while at the same time knowing how to protect yourself while doing the work. This is not something that can be learned quickly. It is in part because of the difficulty of the work and in part because of its conditions that we see such high rates of turnover and attrition. We recommend that policy-makers immediately attend to the sector conditions – such as low pay, non-permanent work, precarity, under-staffing, and injury and illness – that create such high rates of attrition.

Proper compensation is key to decent work

Long-term care workers should be remunerated, and receive proper benefits and workplace protections. This must include access to full health benefits, including appropriate mental health supports and access to essential supportive services such as physiotherapy. Workers should also be allotted paid sick leave days equivalent to the number of paid vacation days due to the high risks of acquired infection at work. They should have access to permanent work with full-time hours if desired, and a much higher hourly wage rate in recognition of their essential skills. Access to protective equipment is simply not negotiable.

The lack of appropriate compensation and workplace protections creates poor working conditions, and has contributed to unsafe conditions and the rapid spread of COVID-19 infection.

We need a wholesale revalorization of the work in long-term care and an overhaul to the working conditions. Care workers in LTC have a unique, required and essential skill set. A step in the right direction includes the federal government’s recent commitment with the provinces of $4 billion to top-up low wage essential workers’ pay. But this is just short-term assistance, and applies to a limited aspect of the total compensation for work. Now that their work is recognized as essential, workers should be compensated with decent conditions in the same ways we protect and support other essential workers.

To protect these workers and residents, we need future-oriented solutions. There seems to be widespread consensus that COVID-19 exposed the fundamental flaws in the long-term care system in Canada. It is up to us to urge our political leaders to address these flaws that perpetuate the ongoing vulnerability of residents and workers. Part of the answer lies in addressing poor working conditions in long-term care – before the crisis is over – leading to more permanent improvements. Hopefully, fundamental changes to the care conditions will stem the high rates of attrition, attract people back to the sector, and ultimately attract new people to do this essential, important and meaningful work.

This article is part of the Facing up to Canada’s long-term care policy crisis special feature.

For related content, check out the IRPP’s Faces of Aging research program.

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Tamara Daly
Tamara Daly is a professor of health policy, equity and gender at York University; director of the York University Centre for Aging Research and Education; and director of the Imagining Age-Friendly “Communities within Communities” SSHRC Partnership.
Ivy Lynn Bourgeault
Ivy Bourgeault est professeure Ă  l’École des Ă©tudes sociologiques et anthropologiques de l’UniversitĂ© d’Ottawa et directrice du RĂ©seau canadien des personnels de santĂ©.
Katie Aubrecht
Katie Aubrecht is assistant professor of sociology, Canada Research Chair in Health Equity and Social Justice, and director of the Spatializing Care Lab at St. Francis Xavier University.

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