Abuse in Canadian long-term care homes: a mixed methods study.

OBJECTIVE: To examine reported cases of abuse in long-term care (LTC) homes in the province of Ontario, Canada, to determine the extent and nature of abuse experienced by residents between 2019 and 2022. DESIGN: A qualitative mixed methods study was conducted using document analysis and descriptive statistics. Three data sources were analysed: LTC legislation, inspection reports from a publicly available provincial government administrative database and articles published by major Canadian newspapers. A data extraction tool was developed that included variables such as the date of inspection, the type of inspection, findings and the section of legislation cited. Descriptive analyses, including counts and percentages, were calculated to identify the number of incidents and the type of abuse reported. RESULTS: According to legislation, LTC homes are required to protect residents from physical, sexual, emotional, verbal or financial abuse. The review of legislation revealed that inspectors are responsible for ensuring homes comply with this requirement. An analysis of their reports identified that 9% (781) of overall inspections included findings of abuse. Physical abuse was the most common type (37%). Differences between the frequency of abuse across type of ownership, location and size of the home were found. There were 385 LTC homes with at least one reported case of abuse, and 55% of these homes had repeated incidents. The analysis of newspaper articles corroborated the findings of abuse in the inspection reports and provided resident and family perspectives. CONCLUSIONS: There are substantial differences between legislation intended to protect LTC residents from abuse and the abuse occurring in LTC homes. Strategies such as establishing a climate of trust, investing in staff and leadership, providing standardised education and training and implementing a quality and safety framework could improve the care and well-being of LTC residents.

Innovative nursing employment initiatives to strengthen and sustain the health workforce in Canada.

Health systems worldwide are at a critical juncture due to an increasing demand for health services and a diminishing pool of health human resources. While COVID-19 exacerbated nursing deficits, the need to strengthen and sustain the health workforce in Canada was evident decades prior and supported by numerous studies that warned of significant shortages. Post pandemic, building health system capacity has become paramount. This article examines innovative nursing employment initiatives in Canada. It provides a snapshot of federal, provincial and territorial approaches, with a particular focus on Internationally Educated Nurses (IENs) due to burgeoning interest in and competition for their skills and services. However, recognizing that health human resource planning is a persistent challenge, further initiatives are suggested. These include complementary policy development to improve retention and policy frameworks that support proactive long-term strategies to address the cyclical shortage of nurses.

Work precarity, employment characteristics and health among Canada's long-term care and seniors' home workers during the COVID-19 pandemic.

Background: The COVID-19 pandemic has highlighted several issues among health care workers in Canada's long-term care and seniors' (LTCS) homes, including labour shortages, staff retention difficulties, overcrowding, and precarious working conditions. There is currently a lack of information on the health, well-being and working conditions of health care workers in LTCS homes - many of them immigrants - and a limited understanding of the relationship between them. This paper examines differences between immigrant and non-immigrant workers' health outcomes and precarious working conditions during the pandemic. Data and methods: The data were from the 2021 Survey on Health Care Workers' Experiences During the Pandemic, which collected information on LTCS home health care workers' (n=2,051) health, employment or work experiences, and working environment during the COVID-19 pandemic. Summary statistics and multivariable logistic regressions were conducted to examine the association between precarious work and workers' health (life stress, mental health and general health), stratified by immigrant status. Selected working characteristics were included in the regression models as covariates, namely occupation, number of locations worked, facility ownership status and number of years worked. Results: Immigrant health care workers were more likely than non-immigrant health care workers to experience precarious work in LTCS homes. Precarious work - characterized by income loss, reduced hours of work, and unpaid leave - was associated with stress and poor general health among immigrant and non-immigrant workers in the sector. Employment precarity was also associated with poor mental health for immigrant workers, but there was no association for non-immigrant workers. Interpretation: Employment precarity and the health and well-being of health care workers warrants further attention, in particular among immigrants employed in the LTCS residential care sector.

Factors associated with pressure ulcer and dehydration in long-term care settings in Ontario, Canada.

Pressure ulcers and dehydration are common conditions among residents of long-term care facilities that result in negative health effects. They have been associated with signs of neglect and increased 30-day mortality among LTC residents. However, they are both preventable and with proper care can be effectively managed and treated. We conducted a retrospective cohort study to examine factors associated with pressure ulcers and dehydration among long-term care residents in the province of Ontario, Canada. Results indicated that close to one-fifth of residents were dehydrated (17.3%) or had a pressure ulcer (18.9%) during the study period. Advanced age was significantly associated with the presence of pressure ulcers and dehydration for both men and women. However, men were more likely to present with a pressure ulcer while women were more likely to exhibit symptoms of dehydration. Study findings also demonstrate the presence of both conditions being higher in municipal and not-for-profit homes compared to for-profit homes. The significant differences observed in relation to home ownership which require further investigation to identify the most relevant factors in explaining these differences. Overall, pressure ulcers and dehydration are preventable conditions that warrant attention from policymakers to ensure quality of care and resident safety are prioritized.

Strengthening Community Roots: Anchoring Newcomers in Wellness and Sustainability (SCORE!): A protocol for the co-design and evaluation of a healthy active living program among a newcomer community in Canada.

BACKGROUND: The burden of childhood obesity and cardiometabolic risk factors affecting newcomer Canadians living in lower socioeconomic circumstances is a concerning public health issue. This paper describes Strengthening Community Roots: Anchoring Newcomers in Wellness and Sustainability (SCORE!), an academic-community research partnership to co-design interventions that nurture and optimize healthy activity living (HAL) among a community of children and families new to Canada in Hamilton, Ontario, Canada. METHODS/DESIGN: Our overarching program is informed by a socio-ecological model, and will co-create HAL interventions for children and families new to Canada rooted in outdoor, nature-based physical activity. We will proceed in three phases: Phase 1) synthesis of existing evidence regarding nature based HAL interventions among children and families; Phase 2) program development through four data collection activities including: i) community engagement activities to build trustful relationships and understand barriers and facilitators, including establishing a community advisory and action board, qualitative studies including a photovoice study, and co-design workshops to develop programs; ii) characterizing the demographics of the community through a household survey; iii) characterizing the built environment and HAL programs/services available in the community by developing an accessible real-time systems map; and iv) reviewing municipal policies relevant to HAL and sustainability; leading to Phase 3) implementation and evaluation of the feasibility of co-designed HAL programs. CONCLUSION: The etiology of childhood obesity and related chronic diseases is complex and multifactorial, as are intervention strategies. The SCORE! program of research brings together partners including community members, service providers, academic researchers, and organizational leaders to build a multi-component intervention that promotes the health and wellness of newcomer children and families.

The changing profile of the internationally educated nurse workforce: Post-pandemic implications for health human resource planning.

As part of its post COVID-19 recovery plan, the Canadian government is increasing the number of skilled immigrants, including Internationally Educated Nurses (IENs). However, pre-pandemic data show that IENs are underutilized and underemployed despite their education and experience. Focusing on the province of Ontario, this article explores trends in the IEN workforce and policies to address the nursing shortage. Barriers to IEN integration are reviewed and changes in the demographic and employment characteristics of IENs are analyzed. The disproportionate number of IENs employed in the Ontario long-term care sector, which has low wages and poor working conditions, emphasizes the need for policies that support the integration of IENs into the broader Canadian health system and increase their earning potential. To engage in strategic workforce planning and policy development, health leaders require access to nurse demographic and employment data that is timely and reflects the international and domestic labour supply.

The Crisis in the Nursing Labour Market: Canadian Policy Perspectives.

The labour market for care professionals has experienced significant changes, resulting in critical shortages globally. Nurses represent the largest share of health workers worldwide; nonetheless, an estimated 13 million more nurses will be needed over the next 10 years. Prior to the pandemic, the domestic supply of nurses in Canada had not kept pace with the ever-increasing demand for services. Pre-pandemic age- and needs-based forecasting models have estimated shortages in an excess of 100,000 nurses nationwide by 2030. While COVID-19 has accelerated the demand for and complexity of service requirements, it has also resulted in losses of healthcare professionals due to an increased sick leave, unprecedented burnout and retirements. This paper examines key factors that have contributed to nursing supply issues in Canada over time and provides examples of policy responses to the present shortage facing the healthcare system. To provide adequate care, the nursing workforce must be stabilized and-more importantly-recognized as critical to the health of the population.

COVID-19 and Long-Term Care: What Have We Learned?

The COVID-19 pandemic has led to thousands of deaths; of these, a disproportionate number has occurred in long-term care settings. The papers presented here deal with a number of issues highlighted by this crisis in several jurisdictions, including Ontario, Quebec and the Netherlands. Analyzing these may give us some insight into what is necessary to prevent this disaster from happening again.

Exemplars in Long-Term Care during COVID-19: The Importance of Leadership.

Early in the pandemic, many long-term care (LTC) homes struggled to manage resources and care for vulnerable residents. Using an appreciative inquiry approach, we analyzed exemplar homes in Ontario that remained free of COVID-19 in wave one and interviewed executive directors, directors of care and staff. Findings demonstrate the importance of leadership styles; clear, consistent communication; focusing on staff and resident safety; using a team-based approach; and adapting staff roles to meet care needs. The exemplar homes showed what works in practice. The decisions and approaches that they implemented could be used to develop standards to improve LTC and strengthen the sector.

Perspectives from the Netherlands: Responses from, Strategies of and Challenges for Long-Term Care Health Personnel.

The outbreak of the COVID-19 crisis severely afflicted the Dutch long-term care sector. To protect vulnerable residents of nursing homes the government took several measures, of which the complete nationwide visitors' ban was the most restrictive. These measures had not only a large impact on residents but they also greatly impacted nursing home personnel. Based on a descriptive review and a few interviews, this paper discusses the measures taken in the Dutch long-term care sector and the challenges healthcare personnel encountered in terms of workload and well-being. It further explores the strategies that were implemented to support personnel to cope with these challenges.

COVID-19 Issues in Long-Term Care in Ontario: A Document Analysis.

The COVID-19 crisis in long-term care in Canada has been characterized as a crisis upon a crisis. This study examines recent documents on the crisis in long-term care in Ontario, using document and thematic analysis to synthesize issues and recommendations from the perspectives of different groups and organizations. Thirty-three documents from 20 organizations were analysed and six thematic areas were identified: resident care; human resources; governance, leadership and management; financing; physical infrastructure and supplies; and training and preparation. The six common themes, as perceived by different perspectives, can inform policy makers on long-term care issues.

Frequency of Neglect and Its Effect on Mortality in Long-Term Care before and during the COVID-19 Pandemic.

Neglect of vulnerable adults living in long-term care (LTC) homes has been well documented. It often presents first in the physical symptoms of decubitus ulcers, dehydration and urinary tract infections (UTIs). A retrospective cohort study was conducted to examine the relationship between neglect and 90-day mortality among LTC residents in Ontario. An index of neglect was created. Of 106,765 residents, more than one-quarter were found to have at least one indicator of neglect: 13.1% had decubitus ulcers, 13.5% had dehydration, 6.2% had a UTI. Residents who exhibited clinical signs of neglect had higher risks of death within 90 days, both before and during the COVID-19 pandemic.

Inspection Reports: The Canary in the Coal Mine.

Neglect in the Ontario long-term care (LTC) sector is defined under section 5 of O. Reg. 79/10 of the Long-Term Care Homes Act, 2007. Allegations are monitored and investigated via inspections. Using an exploratory descriptive design, we analyzed reports of neglect in LTC homes from 2019 to 2020. The majority were in response to critical incidents, followed by complaints from family members or staff. Thematic analysis revealed four areas of neglect: (1) failure to provide treatment; (2) failure to provide care; (3) failure to attend to or assist residents; and (4) failure to investigate allegations. Study findings demonstrate that an accountability framework that includes consequences for institutions is needed.

Rights versus Risks: The Impact of Isolation on Residents and Families in Long-Term Care.

Early in the COVID-19 pandemic, the Ontario government created directives for long-term care (LTC) homes. As a result, residents were isolated in their rooms and visitors were banned. This commentary examines these practices and their impact on LTC residents and their families. A review of relevant documents showed the practices were unnecessary and physically and psychologically detrimental. Moving forward, family should be recognized as essential members of residents' care teams and allowed in LTC homes during outbreaks. This would entail providing them with the necessary protective equipment and adequate training to ensure infection prevention protocols are maintained.

COVID-19 excess mortality among long-term care residents in Ontario, Canada.

The coronavirus disease 2019 (COVID-19) has had devastating consequences worldwide, including a spike in global mortality. Residents of long-term care homes have been disproportionately affected. We conducted a retrospective cohort study to determine the scale of pandemic-related deaths of long-term care residents in the province of Ontario, Canada, and to estimate excess mortality due to a positive COVID-19 test adjusted for demographics and regional variations. Crude mortality rates for 2019 and 2020 were compared, as were predictors of mortality among residents with positive and negative tests from March 2020 to December 2020. We found the crude mortality rates were higher from April 2020 to June 2020 and from November 2020 to December 2020, corresponding to Wave 1 and Wave 2 of the pandemic in Ontario. There were also substantial increases in mortality among residents with a positive COVID-19 test. The significant differences in excess mortality observed in relation to long-term care home ownership category and geographic region may indicate gaps in the healthcare system that warrant attention from policymakers. Further investigation is needed to identify the most relevant factors in explaining these differences.

Diversifying the health workforce: a mixed methods analysis of an employment integration strategy.

BACKGROUND: Historically, immigration has been a significant population driver in Canada. In October 2020, immigration targets were raised to an unprecedented level to support economic recovery in response to COVID-19. In addition to the economic impact on Canada, the pandemic has created extraordinary challenges for the health sector and heightened the demand for healthcare professionals. It is therefore imperative to accelerate commensurate employment of internationally educated nurses (IENs) to strengthen and sustain the health workforce and provide care for an increasingly diverse population. This study aimed to determine the effectiveness of a project to help job-ready IENs in Ontario, Canada, overcome the hurdle of employment by matching them with healthcare employers that had available nursing positions. METHODS: A mixed methods design was used. Interviews were held with IENs seeking employment in the health sector. Secondary analysis was conducted of a job bank database between September 1 and November 30, 2019 to identify healthcare employers with the highest number of postings. Data obtained from the 2016 Canadian Census were used to create demographic profiles mapping the number and proportion of immigrants living in the communities served by these employers. The project team met with senior executives responsible for hiring and managing nurses for these employers. The executives were given the appropriate community immigrant demographic profile, a manual of strategic practices for hiring and integrating IENs, and the résumés and bios of IENs whose skills and experience matched the jobs posted. RESULTS: In total, 112 IENs were assessed for eligibility and 95 met the inclusion criteria. Twenty-one healthcare employers were identified, and the project team met with 54 senior executives representing these employers. Ninety-five IENs were subsequently matched with an employer. CONCLUSIONS: The project was successful in matching job-ready IENs with healthcare employers and increasing employer awareness of IENs' abilities and competencies, changing demographics, and the benefits of workforce diversity. The targeted activities implemented to support the project goal are applicable to sectors beyond healthcare. Future research should explore the long-term impact of accelerated employment integration of internationally educated professionals and approaches used by other countries.

Work readiness, transition, and integration: The challenge of specialty practice.

AIM: To determine how extended orientation enhances the work readiness of new graduate nurses as they transitioned to their professional role in a specialty care hospital. BACKGROUND: Given increased complexity of care and high-patient acuity, there is concern about the work readiness of new graduate nurses in specialty areas. DESIGN: Qualitative exploratory study using an inductive approach. METHODS: An integrative literature review was conducted to abstract characteristics of work readiness among new graduate nurses. Semistructured interviews were conducted with 41 participants from a large paediatric specialty hospital in Ontario, Canada, in 2014. The sample of nurses was stratified and included nurse managers, new graduates, and preceptors. Interview texts were interpreted using thematic analysis. RESULTS: A framework for enhancing work readiness of new graduates transitioning to specialty care was developed from the interview and literature findings. Interview data demonstrate an extended orientation that includes mentorship, a gradual increase in clinical responsibilities, and involvement in the professional role during the early stages of a nurse's career can enhance work readiness of new graduates. Four key areas of work readiness were identified in the literature: personal characteristics, clinical characteristics, relational characteristics, and organizational acuity. CONCLUSION: Based on the study results, new graduate nurses can be an integral part of the team in specialty care provided certain conditions are met during their transition to practice. Our study gives further evidence that extended orientation enhances new graduates' work readiness as they transit to their professional role.

Policy to practice: Investment in transitioning new graduate nurses to the workplace.

AIM: To analyse nurses' perceptions of the impact of an extended transition programme on key dimensions of care delivery 1-6 years after graduation. The dimensions included decision-making, communication, care management, system integration and commitment. BACKGROUND: Health care employers in Ontario, Canada, can apply for government funding to support an extended transition programme for new graduate nurses that includes orientation and mentorship. METHODS: A cross-sectional study design was used. Nurses who participated in the transition programme were compared with nurses who did not. A survey was administered to a convenience sample of 2369 nurses. RESULTS: There were statistically significant differences between the two groups. Nurses in the transition programme had higher mean scores on the key dimensions of care delivery. Results were confirmed when controlling for length of time since graduation. CONCLUSION: Extended transition benefits new graduate nurses. It has a lasting effect over time and impacts key dimensions of care delivery. It can also enhance workforce integration and reduce turnover. IMPLICATIONS FOR NURSING MANAGEMENT: Responding to the needs of new graduate nurses has potential long-term advantages for health care organisations and can influence both quality and delivery of care.

A government policy on full-time nursing employment in Ontario, Canada: An evaluation.

PURPOSE: To evaluate the impact of a government full-time employment policy targeting new graduate nurses in the province of Ontario, Canada, by comparing participants with non-participants. METHODS: The Policy Impact on Nurse Employment (PINEP) survey was administered in 2014 to nurses who graduated between 2007 and 2012. Backward multiple logistic regression analysis was conducted to determine the effect of participation in the policy on key outcomes: full-time employment, retention and perceptions of clinical proficiency. RESULTS: A total of 2369 nurses responded to the survey. Policy participants were 1.5 times more likely to be employed full-time and 2.3 times more likely to be retained in their initial position at the time of survey compared to non-participants. Participants also perceived their clinical proficiency to be higher. CONCLUSIONS: The evidence is converging around the importance of providing full-time employment to nurses to sustain the workforce, increase clinical proficiency and improve patient outcomes. In Ontario, the government created a policy to stimulate full-time employment for nurses. Results demonstrate that nursing employment has become more stable. Yet more needs to be done particularly in relation to the precarious employment trend.