By Trina Thorne MN, NP and Eric KC Wong, MD FRCPC
The Policy Briefing Report for Long Term Care commissioned by the Royal Society of Canada describes a preferred future for the LTC sector in Canada, with a specific focus on COVID-19 and the long-term care workforce.
The deep operational cracks that have compromised our pandemic response have for some time been sabotaging the quality of care, quality of life, quality of work life for staff, health and safety of residents, caregivers, family and staff as well as the ability to provide a good death. These deficiencies are recognized as common across jurisdictions to differing degrees, and are underpinned by implicit negative attitudes on the value and need for expertise in LTC. The report summarizes the existing knowledge base for far-sighted and integrated solutions, articulates principles for action and provides recommendations for urgent action to overcome the challenges in the LTC sector.
Historically just managing
Canadian nursing homes have historically been able to just manage. However, COVID-19 has shown that quality of life and quality of care take second place to handle the surge. Exacerbating this is the paradigm of nursing homes as a public social place, inviting in the community, which has clashed sharply with nursing homes as a safe space for residents and staff under COVID-19. Although the risk of infection is reduced by closing doors, many of the visitors and family are relied upon to provide essential care. Specific findings and the context that created the COVID-19 crisis in LTC are explained in detail in the full report.
The report highlights 50 years of inquiries, panels, task forces, commissioned reports, media reporting and clarion calls for action to reform conditions in nursing homes and create a higher standard of care. There is ample sound evidence produced by social and health scientists globally on how to achieve this. We have the capacity, the knowledge, the resources and most importantly, a duty to take immediate steps toward restoring the trust we have broken.
There are 16 principles for action that are founded on our shared values as Canadians. These principles complement the urgent recommendations by offering guidance on funding models, monitoring and government oversight, regulations and standards, access to care, the environment and care integration in addition to workforce transformation. Taken together they will improve safety and quality of life for residents and staff of Canadian nursing homes.
The urgent recommendations cover longstanding issues in nursing home management, as well as several recommendations in response to the ongoing pandemic. Recommendations in response to COVID-19 include: • A national standard for pandemic management in nursing homes. • Infection control measures for direct care workers who are employed at multiple facilities, and mental health support for workers in the face of significant resident deaths in LTC. • The lack of a unified, national approach to standards for nursing home care led to recommendations to implement a consistent evidence-based approach across provinces. • Standardized education and routine data collection were also recommended to continuously improve care in nursing homes. The recommendations highlight a partnership between federal and provincial governments in funding and implementing change.
Hope for the future
While the Royal Society report brought clarity to the nursing home crisis in Canada, there is hope for the future. Part of the problem is nursing home building design. Most nursing homes built between 1950 and 1990 accommodated larger number of residents (200–400 per home) with communal bathrooms and dining spaces. These nursing homes resembled hospitals, with limited natural lighting and outdoor space. Infection control during a pandemic is particularly hard because of inability to physically distance infected residents. Modern nursing homes built in the past two decades offer private rooms with ensuite bathrooms, and generally house fewer residents per home (80–120). As older buildings get replaced by newer ones, the physical space can be designed to balance protection of residents and staff, while maintaining indoor and outdoor communal areas for socialization.
Even older buildings can be retrofitted with modern technology to help residents stay connected with family members during a pandemic. The installation of high-speed wireless internet in older homes allows the use of video calling technology so that patients can see and hear from their families, even when they are not allowed to visit. Future virtual reality technology may allow for a more immersive experience while patients are isolated physically. The main downside to these technologies is that people with dementia may not perceive people on a screen in the same ways a real person, leading to confusion or lack of interest.
Although the overall death rate in LTC in Canada is relatively high, there are Canadian regions where LTC outbreaks were well controlled, including Kingston (Ontario) and British Columbia. Experience from these places suggest the benefit of a coordinated approach between local hospitals and nursing homes to manage infected residents without compromising hospital capacity. Widespread testing and contact tracing of nursing home staff and residents were beneficial strategies. Adequate protective equipment, early isolation of infected residents, and limiting visitors were effective in preventing spread of the disease.
However, restriction of visiting family members impacts residents who depend on those caregivers. It is frightening for residents with dementia to see unfamiliar people with masks providing personal care such as toileting and bathing. A familiar face can go a long way in reducing anxiety and bringing comfort at a stressful time. Allowing visitors with appropriate testing and protective equipment may be an important way to ease staffing issues while policymakers work on the recommendations in the Royal Society report.
As the pandemic continues, it is important to recognize that LTC is integral to our society. Nursing home residents are the generation who made our modern way of life possible. We have a duty to combat ageism and provide the compassionate care that nursing home residents deserve. By coordinating a plan to systematically improve LTC across the country, we can pave the way for safe, equitable, and hospitable nursing homes for generations to come.v
Trina Thorne is a Nurse Practitioner and PhD student with a research focus on improving quality of life and quality of work life in continuing care settings.
Eric Wong is a Geriatrician and PhD student in Clinical Epidemiology and Health Care Research with a focus on improving the care of older adults.
Full report and 16 principles: roc-src.ca/en/restoringtrust-COVID-19-and-future-long-term-care.