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Personal support worker Vickram Sooknanan and Ryan Hicks, a law student turned volunteer orderly, have each had firsthand experience of the draining work and understaffed conditions in long-term care facilities in Ontario and Quebec, respectively.

Fred Lum and Christinne Muschi/The Globe and Mail

Patients overdrugged to reduce their anxiety. The smell of feces from unchanged diapers. Hair matted from lack of washing. Fallen seniors with no one to help them up.

These are scenes from long-term care homes, described by advocates and caregivers – before the COVID-19 crisis. Even in the years leading up to a global pandemic that cut a deadly swath through the facilities, a shortage of staff made conditions in many nursing homes unsanitary, undignified and unhealthy, critics say.

In Quebec there is no mandatory ratio of staff to patients in long-term care, but nurses caring for close to 100 patients during night shifts is routine, while cases of 160 patients to a single nurse were reported at the height of the pandemic.

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Similarly in Ontario, homes are only required to have one registered nurse on-site, no matter the size of the home – some have hundreds of patients – or the time of day. Personal support workers on overnight shifts may be responsible for as many as 32 residents, according a recent Ontario staffing report, which recommended a guideline of one support worker to eight residents during day and evening shifts.

A rampaging virus exposed and worsened the problem by an order of magnitude, especially in Ontario and Quebec, where COVID-19 hit hardest. Staffing – along with the outdated structure of homes – is seen as the critical piece to solving the problems of long-term care: high turnover of staff, poor resident care and spread of illness that came to the forefront during the COVID-19 pandemic. Now nurses, orderlies, patients groups and health reformers are calling for a lasting solution to understaffing in nursing homes.

Long-term care needs to be given pride of place in Canadian health care, through better funding and an image makeover that restores esteem to caring for older patients, argued Francine Ducharme, researcher and professor of nursing at the University of Montreal and co-author of a recent Royal Society of Canada report on long-term care.

“The measure of a society can often be taken by the fate of its elderly,” she said.

Some two decades ago, nursing homes were staffed mainly by nurses, while the facilities housed a much smaller share of the population, write the authors of the Royal Society report, Restoring Trust. But since then, an aging population and a push “to contain costs” drove the facilities to hire more low-paid workers, even as residents’ medical needs became more complex. (The system has grown into a patchwork of publicly and privately run facilities, regulated and partly funded by the provinces.)

Today, registered nursing staff make up 25 per cent of employees in Ontario’s long-term care sector, compared with 58 per cent personal support workers (PSWs). (The remaining staff include assistants, social workers and physical therapists, among other roles.) Personal support workers are unregulated and often suffer from workplace burnout, according to a recent staffing study, with half leaving before five years on the job. PSWs also receive far lower pay than nurses – as little as $12-an-hour in some parts of the country – according to the Royal Society.

Even as the composition of the workers changed, the total number has remained too low, critics argue, thanks in part to government underfunding and the difficulty of recruitment and retention in a challenging field. Everyone working in long-term care – including provincial governments – agrees: There is a staffing shortage that desperately needs to be filled.

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A worker looks out the window this past May at the Vigi Mount Royal seniors residence in Montreal.

Ryan Remiorz/The Canadian Press

A 2016 study by the Fédération interprofessionnelle de la santé du Québec (FIQ), a union that represents nurses and other health care workers, noted the Australian state of Victoria mandated a ratio of nurses to patients in long-term care at 1 to 7 in the daytime and 1 to 15 at night. A Quebec study the same year found the province’s ratios were often closer to double or triple that.

The result is less care for patients. Before the pandemic, British Columbia recommended 3.36 hours of nursing a day for long-term care patients, the highest in Canada. But experts call for a minimum of 4.1 nursing hours a day, according to the Royal Society panel.

Understaffing is not just a problem of too few nurses. Advocates say that there are shortages of all kinds of health workers, from physiotherapists and speech pathologists to orderlies. That meant seniors’ basic needs were often not being met even before COVID-19, said Paul Brunet, president of the Conseil pour la protection des malades, a Quebec patients group. Patients who were not incontinent were routinely put in diapers anyway, because there was no time to take them to the bathroom, a “complete violation of their dignity,” Mr. Brunet said. “The smell of soiled diapers is in the halls,” he said. “Families find their [relatives] stink, their bodies haven’t been properly washed. … Medications are badly managed.”

Caregivers themselves suffer from the understaffing as well. In the Quebec nursing profession, there is a permanent “battle against ratios,” said Nancy Bédard, president of FIQ, the health workers’ union. In the daytime, a nurse will often be responsible for multiple floors of a home, giving them no time for anything but to “run around.” On night shifts, there are routinely around 100 patients for every nurse, and sometimes dozens more in extreme cases, Ms. Bédard said.

For the better part of a decade, more nurses have been reporting difficulty giving quality care to their patients because of understaffing, Ms. Bédard said, which leaves many feeling physically and mentally exhausted. “The ratios are so not adequate that patients are often left alone for a long time,” she said. “A patient who falls, you’re supposed to see them within 15 minutes. Nurses tell us, ‘We don’t have time to do that. We cross our fingers.’”

COVID-19 played havoc with already overstretched long-term care staffing. Fully 75 per cent of recorded deaths linked to the virus in Canada have happened in long-term care. Outbreaks ravaged Ontario’s and Quebec’s nursing homes in particular. More than 1,800 residents and eight staff have died in Ontario, making up almost 64 per cent of all deaths in the province.

Vickram Sooknanan is a veteran employee at a Scarborough long-term care home that suffered a COVID-19 pandemic.

Fred Lum/The Globe and Mail

The spread of the virus took a toll on workers and thinned their ranks. Vickram Sooknanan, 36, had been a personal support worker for 12 years at Midland Gardens Care Community, a home in Scarborough, Ont., where 49 residents have died of COVID-19. He said the residence had staffing shortages before the pandemic because it was hard to recruit and keep people on temporary part-time contracts, but the coronavirus made matters worse.

In the mornings, there are supposed to be six PSWs, although there are sometimes only three or four, he said. In the evenings there are three staff who care for 20 residents each; if someone is away, they may handle 30 residents on their own.

Mr. Sooknanan tested positive for the virus in mid-May, more than a month after Midland’s first case, and has been off work ever since. At the time, he was living with his partner and his two-year-old son, as well as his mother – who is diabetic and underwent cancer surgery a year ago – and mother-in-law. He questioned why the home doesn’t pay for hotels for workers to self-isolate if they have COVID-19. (Sienna Senior Living, the for-profit company that runs the home, said it provides paid hotel accommodations to employees in homes with outbreaks, but the hotels will not allow employees who test positive for COVID-19 to stay there.)

Now, a lot of the staff are scared to return, he said. “I have this fear and anxiety about going back to work,” he said. “Am I strong enough to survive another reinfection?”

In Quebec, the numbers are even more staggering: As of July 26, the province’s long-term care homes have seen 4,856 deaths related to COVID, or about 85 per cent of Quebec’s total. At the height of the pandemic’s first wave, galloping outbreaks created an acute staffing crisis. By May 15, nearly 3,000 health care workers were absent from the homes because of infection or fear of infection. Many of those who remained grew exhausted from overwork, anxiety and grief.

“During the pandemic, we hit a wall, very, very, hard,” said Ms. Bédard of the health workers’ union. “It really put into light the conditions that care professionals had been decrying.”

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Ryan Hicks, shown outside his Montreal home, says nothing could have prepared him for conditions in the care home where he worked.

Christinne Muschi/The Globe and Mail

The Quebec government was quick to act, at least. In March, it launched a call for volunteers in the long-term sector and by April it had accepted 3,000 applicants. Ryan Hicks, a law student at McGill University, was among those who answered the call. (He was ultimately paid for his work as an orderly at a home in Montreal.) He witnessed the permanent staff of nursing homes pushed to the brink.

Mr. Hicks worked on the same floor as a PSW who had died from the virus. The home was riddled with “hot zones” of infection demarcated by a network of taped lines known as “the jungle.”

“Nothing could prepare you for what you see when you go in there,” he said.

For his first intervention, he had to change the full diaper of a screaming patient who suffered from dementia. From that point on, he and his new colleagues were run off their feet with work. Nurses routinely worked 16 hours straight to cover for colleagues who contracted COVID-19 or were afraid to come in. Laundry staff sometimes worked for 20 consecutive days. Burnout was rampant.

“It was so eye-opening, and physically draining, mentally draining, emotionally draining,” Mr. Hicks said. “And I remember at the end of that first shift thinking, ‘We need more help. We need those soldiers. Right now.’”

A soldier helps an elderly resident of the Vigi Queen Elizabeth long-term care home in Montreal this past May.

GENEVIEVE BEAULIEU/Canadian Armed Forces/AFP via Getty Images

The arrival of the military in Quebec was one of many government interventions designed to provide relief to long-term care workers that suffered in the rollout. The province wanted 1,000 military personnel to stay until September 15 but the deployment began leaving in June after a planned hand-off to the Red Cross that was itself short-staffed.

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Meanwhile, the government’s signature initiative of hiring 10,000 PSWs garnered more than six times that many applicants by June. But it also led to complaints from private care home owners anxious about their staff being poached by the $49,000 salary Quebec was offering. Even with thousands already enrolled in a fast-track training program, critics worry that it’s too little, too late.

“It’s suddenly during the COVID crisis that we want to hire people; we weren’t ready, and we did it late,” said Mr. Brunet, the patients’ advocate. “We’re late on hiring, we’re late on recruitment and we’re late on increasing wages.”

In any case, more PSWs alone will not solve the crisis in long-term care, Dr. Ducharme said. The complicated needs of elderly patients – many of whom are frail and cognitively impaired but living in nursing homes for many years – demands a hiring spree of other positions, such as psychologists, social workers and physiotherapists.

Meanwhile, one group was left out of the recruitment blitz: asylum seekers who worked in nursing homes during the pandemic, but still live in legal limbo and so fear applying. The federal government has signalled that it is open to regularizing the immigration status of these “guardian angels,” as they were known in Quebec, but thousands are still waiting for a formal announcement of the program, said Frantz André of the Comité d’action des personnes sans statut, a migrants-rights group.

“There are lots of little politics being played on the backs of people,” he said.

Even pandemic bonuses offered by Quebec and Ontario turned out to be fraught. Where the situation was most dire in Ontario, the $4-an-hour pandemic pay didn’t bring people back to work, said Donna Duncan, chief executive of the Ontario Long Term Care Association. She described the state of staffing as “precarious.”

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Ontario launched an online job-matching portal that saw more than 25,000 people sign up. But there were only 786 requests for staff made by long-term care homes, including nurses and PSWs, with 83.5 per cent of requests filled, a spokeswoman for Health Minister Christine Elliott said.

Compounding the struggle to find enough staff were rules in both provinces temporarily barring visitors to long-term care homes as a measure to prevent infection. Because family members often provide essential care for their loved ones, including feeding them, this left many elderly patients even more “abandoned,” Mr. Brunet said.

Ronald Gibara tries to say hello to his sister at the Vigi Mount Royal residence this past May.

Ryan Remiorz/The Canadian Press

The question now is how the long-term care work force can be bolstered in the future. One step urged by the authors of the Royal Society report is improving data collection in the sector to give a clearer picture of where work shortages exist and what kind of training is required in different provinces. “It is impossible using national data sources to tease out where the unregulated workers are actually working and in what numbers,” the authors write. “No data are routinely collected nationally or provincially on the characteristics of the care aide workforce or on the quality of their work life or on standards in each province for their training.”

Crucially, the report also calls for the establishment of national standards for long-term care, which don’t currently exist. The provincial patchwork and lack of regulation means that in some places, PSWs are paid minimum wage, which the report’s authors call “unacceptable” in normal conditions and “ridiculous” in the face of COVID-19.

Even with better pay, nursing homes simply need more skilled employees to provide more thorough care and curb the epidemic of overwork, argues Ms. Bédard, the union president.

“To make the field attractive, we have to ensure that it’s one where people can put their skills to use,” she said. “They need to be able to feel that they’re able to give adequate care to their patients.”

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Recruiting staff is a chronic challenge for nursing homes; many health professionals in particular prefer to work in more prestigious areas such as acute care. Rhonda Collins, the chief medical officer at Revera, one of Canada’s largest private long-term care companies, said she believes there needs to be more exposure to long-term care during nursing and medical school “so people can see this as a viable option for them.”

“Nursing staff are often dissuaded from coming into long-term care because they’re given the impression that they’re going to lose their skills. And that’s not true,” she said.

Miranda Ferrier, president of the Ontario Personal Support Workers Association, said long-term care is not seen as a “profession of choice.”

But she argues that regulation can help make the field more attractive. Ms. Ferrier is calling on the government to mandate staffing ratios of one worker for every eight residents. Currently, ratios are as high as 1 to 15, and even more on an overnight shift, she said.

She also wants a professional college for PSWs as well as standardized training across the province, where future PSWs could learn the complexities of caring for and communicating with patients suffering from cognitive decline.

“We need to make it into a profession of choice,” she said. “We need to take this profession seriously because without PSWs, the system will topple, it will definitely topple. It almost toppled in the pandemic.”

Nurses wave to a convoy of cars paying tribute to them outside a nursing home in Bobcaygeon, Ont., in April.

Fred Thornhill/The Canadian Press

The Registered Nurses’ Association of Ontario, which represents more than 40,000 registered nurses and nurse practitioners, has for years been pushing for a “nursing home basic guarantee.” The plan calls for an increase in nursing and personal care services to at least four hours a day per resident, and called on each home to have at least one nurse practitioner – along with other registered nurses – on staff. It also says a nurse should be hired in each home to focus on infection control, prevention and training, and homes should disallow staff from working in other facilities.

Doris Grinspun, the association’s CEO, said increasing direct care hours for residents would prevent the dehydration and malnourishment that occurred during the pandemic.

She said there have been 35 reports over the past two decades about staffing and funding recommendations for the sector, which are long overdue. “We don’t need more commissions, we don’t need more studies, we need action,” she said.

With a rising incidence of cognitive issues, caring for elderly patients has become more demanding over the years, said Dr. Ducharme, the nursing professor. A report from the Ontario Long Term Care Association last year notes that more than half of patients in the sector are over 85 and about two-thirds suffer from dementia.

Homes need orderlies but also trained professionals to manage these complex needs, Dr. Ducharme said – and that comes with a cost. Canadian society will simply have to decide whether long-term care, so often neglected in the past, is worth the investment.

“We find money when it’s a priority; I find [long-term care] has never been prioritized,” she said. “And now we’re waking up because of COVID.”

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