(This article has been translated into French.)

Out of the many tragedies of COVID-19, we must seize the opportunity to re-envision the nursing home system and make it work for women and for all Canadians. Women do the bulk of paid and unpaid caregiving around the globe – work that is systemically underpaid and undervalued. We must make the caregiving provided in nursing homes – and outside them – an economic priority, meaning providing adequate training, good pay, and esteem to these jobs.

It is no coincidence that caregiving is rarely valued as part of the productive economy. It’s too often invisible – even when it’s central to our economy’s function. In nursing homes, women represent more than two-thirds of residents and more than 90 percent of paid staff. More than 80 percent of unpaid family caregivers are women.

The first wave of COVID-19 news stunned the world. We saw nursing homes in Italy and Spain abandoned by care staff. Seniors with serious physical and mental challeges were left to fend for themselves – unfed, soiled and bewildered. Dead bodies lay in hallways and beds. It is the stuff of nightmares.

It can’t happen here, we thought. Until it did. It didn’t happen everywhere, but the extreme cases finally focused our attention on Canada’s nursing home system. This system has fallen into disrepair through decades of disjointed half measures and neglect. It holds together with the goodwill and deep ideals of caring from its largely invisible workers, paid and unpaid, most of them women and many of them racialized. We leave them to care for our aging spouses, siblings, parents, and grandparents.

They care for our loved ones in a system badly equipped to handle our aging population, in a society where family members often live far apart. People live longer with higher burdens of chronic disease – foremost Alzheimer’s disease and other dementias. The demand for care will increase exponentially in the coming decade as the first wave of boomers turns age 75 in 2021. Need for nursing home care keeps rising, but our essential resources of staff and supports are not keeping up. This gap widened until the COVID-19 crisis broke our system apart.

What do we know about women in the nursing home system?

Women’s caregiving in the home and community has tremendous, often unrecognized economic and social costs. Women’s paid caregiving (by front-line workers in nursing homes) is one of the lowest paid occupations with the highest risks for burnout, depression and job precarity.  Underlying this devaluing of their labour is that it is “woman’s work.” In both paid and unpaid caregiving, women do the majority of the heavy lifting of personal care and invisible emotional support.

Research around the world shows that front-line workers in nursing homes – Canada’s care aides or personal support workers – directly affect quality of care and quality of life for residents. For more than a decade, Translating Research in Elder Care (TREC) has collected data about care aides from more than 90 nursing homes in British Columbia, Alberta, Manitoba and Saskatchewan. We have learned that 67 percent of care aides are over 40 years of age and 61 percent speak English as a second language. A third of them work at more than one nursing home, often because nursing homes do not offer full-time hours for a living wage and benefits.

Their training is often inadequate for the complex care needed by nursing home residents with dementia. Their work is physically demanding, with high injury rates. It is psychologically demanding with emotional stress, verbal and sometimes racialized abuse. Our data show that care aides routinely report high rates of burnout, cynicism and exhaustion.

COVID-19 has made the work in nursing home more dangerous. Restrictions on family visitation have meant that front-line staff have to do more, including the emotional support at the end of life. Fear of infection and the trauma of losing so many residents with whom they have long-term relationships will have a long-lasting mental health impact.

Over the next three decades, costs of care in nursing homes and private homes are projected to more than triple, growing from $22 billion to $71 billion each year. Over the same time, changes in family composition – such as boomers having fewer children who also live farther apart – will result in 30 percent fewer close family members to give unpaid care. More older Canadians, and proportionally much more older women than men, will rely on institutional care. It is our responsibility to equip paid and volunteer staff to give essential human connection and care.

What to do?

We must consider gender in developing policy, systems and strategy. Voices at federal and provincial advisory group or task force tables must reflect the proportions of women working and living in nursing homes. These women know the system problems on the ground and their front-line experience should guide practical, immediate and positive changes.

Nursing homes, with appropriate support, must also better measure what goes on, recognizing that they are homes, not hospitals. We must assess more than quality of care and also routinely assess other essential dimensions of quality. For example, routine and regular quality of life assessment, directly from residents with dementia, who make up as many as 80 percent of residents. And quality of work life – the physical, mental, and emotional health of front-line workers, as well as the quality of the work environment. And then we must share what we measure transparently, reporting on what matters, acting to improve, and reviewing regularly.

An early goal must be addressing working conditions that include fair remuneration and benefits, healthy work environments, consideration of the childcare needs and that of older family members, and engagement in care decisions and planning. While several provinces have lifted the wages of front-line workers, much remains to be done – not only to determine longer term remuneration patterns, but also to address the issue of whether personal support workers/care aides should be a regulated group. Each of these areas requires the voices of government, operators, representatives of major workforce groups in policy-making processes – with a gender balance that is reflective of the gender balances in the paid workforce in LTC.

COVID-19 did not cause today’s tragedy in nursing homes, but it exposed deep and longstanding fault lines. In Canada, we accepted that “warehousing” our loved ones was good enough and without malice or ill intent, we took advantage of often voiceless older adults with dementia who wait for the voices of other, also vulnerable, to advocate. And that is shameful.

Caregiving is honourable work. Society and governments must make the caregiving provided in nursing homes an economic priority – to make this important work visible and decide its value to society. This means we must take a hard and serious look at what paying for caregiving appropriately and supporting the particular needs of women caregivers really means. Our communities and our nursing homes – our senior citizens – will flourish in a healthy society that considers caregiving worthy of adequate training, good pay, and esteem in our planning.

COVID-19 lays bare the nursing home crisis and its embedded crisis for women: we jeopardize the care of our most vulnerable – our moms and dads, our grandparents, our siblings and spouses, and our companions. Demographic aging in Canada may only heighten this crisis. We can and must do better.

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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Carole A. Estabrooks is scientific director of the pan-Canadian Translating Research in Elder Care (TREC) program and professor and Canada Research Chair in the Faculty of Nursing at the University of Alberta.
Janice Keefe is professor of family studies and gerontology, the Lena Isabel Jodrey Chair in Gerontology and director of the NS Centre on Aging at Mount Saint Vincent University. She is also a senior member of the TREC research program.

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