Christine Fahim, PhD, MSc, Ayaat T. Hassan, MSc, Keelia Quinn de Launay, MSc, Alyson Takaoka, MSc, Elikem Togo, MPH, Lisa Strifler, MSc, Vanessa Bach, BPH, Nimitha Paul, MPH, Ana Mrazovac, MSc, Jessica Firman, MPH, Vincenza Gruppuso, PhD, Jamie M. Boyd, MSc, Sharon E. Straus, MD, MSc
Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto ONDOI: https://doi.org/10.5770/cgj.28.854
ABSTRACT
Background
COVID-19 exposed long-standing systemic challenges experienced by congregate settings and created a crisis for long-term care homes (LTCHs) and retirement homes (RHs). This study explored the pandemic-related challenges LTCHs and RHs faced and the strategies they used to mitigate them.
Method
Ninety-one key informant interviews were held with LTCH and RH leadership across 47 homes (33 LTCHs, 14 RHs) in Ontario, Canada from February 2021 to July 2022. Data were analyzed following the framework method.
Results
Findings confirmed evidence of three main challenges. First, leaders were challenged to implement infection prevention and control (IPAC) protocols and measures. Second, leaders required supports to facilitate COVID-19 vaccine access and to promote vaccine acceptance. Finally, LTCH/RH staff experienced well-being and mental health challenges in the face of COVID-19 pressures. Despite widespread attention and efforts to support these congregate settings, challenges persisted over one year into the pandemic.
Conclusions
Our findings reveal a plethora of strategies implemented by homes, with ranging reports of perceived success.
Key words: COVID-19, long-term care, retirement homes, infection prevention, vaccine uptake, staff well-being
The COVID-19 pandemic created a crisis in long-term care homes (LTCH) and retirement homes (RH). In Canada, LTCH, also known as nursing homes, are settings where residents are provided with supports for daily activities, including 24-hour nursing care. Residents of LTCH are individuals for whom care needs cannot be safely provided through home or community-based services (e.g., older adults with dementia). LTCH in Canada can be public or private, with privately owned LTCH including for-profit and non-profit organizations.(1) In the province of Ontario, applications to LTCH are managed through Ontario Health, a provincial government health agency.(2) In contrast, RH are typically better suited for individuals who are able to live independently but may require some daily supports, such as meals or grooming. Retirement homes in Ontario are regulated by the Retirement Homes Regulatory Authority (RHRA),(3) are usually privately owned, and are paid for directly by residents.
In the spring of 2020, >75% of COVID-related deaths in Canada were associated with LTCH and RH.(4,5) In Ontario, Canada, >230 LTCH had COVID-19 outbreaks and LTCH residents accounted for 77% of COVID-19 deaths.(6,7) LTCH and RH workers were also at risk, comprising a significant portion of Ontario cases and several deaths in early pandemic stages.(8,9)
COVID-19 exposed long-standing system gaps in the LTCH/RH sector.(10) A Royal Society of Canada report on COVID-19 and long-term care details these systemic failures including inadequate pay, training and protections for long-term care staff, insufficient staff mix, and environments that are not designed to care for residents’ increasingly complex medical and social needs.(10) Despite an abundance of evidence on the needed solutions, these gaps persisted for over five decades.(11) This was the context facing LTCH and RH staff, leaders, and residents at the onset of the COVID-19 pandemic.
In the initial months of COVID-19, Canada experienced a far higher proportion of total COVID-19 deaths in LTCH compared to its counterparts. These conditions were especially pronounced in the province of Ontario, due to coordination gaps between governments, hospitals and homes, funding shortages, and staff shortages.(12) In response, the Ontario Ministry of Health mandated that acute care hospitals support LTCH to implement Infection Prevention and Control (IPAC) protocols and mitigate outbreaks.(13) While not included in the mandate, RH were also encouraged to adhere to these protocols. Despite this support, LTCH and RH leaders were challenged to implement these IPAC protocols amidst a rapidly-evolving pandemic. It was in this context that we aimed to design a responsive support program for Ontario LTCH and RH to navigate COVID-19 challenges.
To inform the content of our program that was expected to be delivered over a 24-month period, we conducted a robust needs assessment with LTCH and RH in the province of Ontario, which is home to >600 LTCH and >780 RH,(3) and one of the Canadian provinces hardest-hit by COVID-19.(14) Specifically, our objectives were to: 1) explore the challenges faced by LTCH and RH leadership staff to navigate the pandemic; and 2) to identify supports currently in place to address COVID-19 challenges. In this article, we present the findings of our needs assessments, which were conducted using key informant interviews with LTCH and RH leaders.
We report our study findings using the Consolidated Criteria for Reporting Qualitative Research (COREQ). We conducted qualitative needs assessments using the Framework Method, which provides a systematic yet flexible approach that includes both inductive and deductive coding to generate qualitative themes.(15)
In Appendix S1 in the supplemental material, we describe our process of designing this study, including the COVID-19 context at time of study initiation.
We conducted semi-structured needs assessment interviews with LTCH and RH leaders to explore pandemic-related challenges, experiences implementing strategies to address these challenges, and needed supports. We used a rapid analysis approach to analyze our data in order to facilitate timely development of the support program.(16)
Our study was conducted in the province of Ontario (population 15.5 million), Canada. The Greater Toronto Area (GTA) is the most densely populated area in Ontario (population >6.2 million),(17) and was home to many “COVID hotspots” in the province.(18) Outbreaks in these hotspots were correlated with social determinants of health including income, level of education, higher proportions of visible minorities, housing density, and occupation.(19,20) We primarily sampled homes in the GTA and its surrounding regions. Homes were eligible to participate in our study if leaders 1) consented to participation, 2) were located in Ontario, and 3) designated a communication ‘point person’ within the home. Homes unable to meet these criteria were excluded from the study, as were Indigenous LTCH and RH, given that our study team did not have the appropriate expertise and resources to meaningfully support these partnerships.
Study advertisements were shared using study websites, our project partners, and social media. LTCH and RH leaders (defined as decision-makers responsible for day-to-day operations in an individual LTCH or RH) were eligible to participate in an interview.
We assembled a multidisciplinary study steering committee which included LTCH/RH organizations, caregivers, clinicians, and researchers. We held in-depth discussions with the steering committee to co-design an interview guide for the needs assessment.(21) While our initial goal was to identify challenges related to IPAC protocol implementation, the committee highlighted that homes were experiencing additional challenges. These included challenges keeping up to date with rapidly evolving COVID-19 public health policies and directives, supporting uptake of COVID-19 vaccines among residents and staff, and supporting staff who were experiencing burnout and mental health challenges amidst shortages and pandemic pressures. Using these insights, we developed an interview guide that first asked participants to describe their experiences working in LTCH/RH during the pandemic, identify challenges experienced during COVID-19, and describe solutions implemented to address these challenges. We then probed into the three identified challenge areas related to implementation of IPAC, vaccine, and staff well-being supports, to gain further insights on these themes identified by our steering committee.
Data were collected between February 2021 and July 2022. Participants took part in a 20- to 25-minute semi-structured interview (Table S1 in the supplemental material) via phone or Zoom (https://zoom.us/) conducted by an interviewer (AT, KQD, AH, JF, MSc or MPH) and note-taker (AM, VB, OS, BSc or BPH). Verbal consent and interviews were recorded. Notes were taken as close to verbatim as possible, in keeping with rapid analysis methodology.(16) Notes were reviewed for accuracy and supplemented using the recordings.(16) Participants were de-identified and assigned a unique study ID. Participants were not compensated.
Interviewers were research coordinators from the Knowledge Translation Program at St. Michael’s Hospital. They were all women and had experience in qualitative research, implementation, or community-based participatory approach research. A detailed reflexivity statement is provided in Appendix S2 in the supplemental material.
Using a rapid analysis approach in keeping with the framework method,(21) data were double-coded by research staff and trainees (KQD, LS, ET, AH, JF). First, the research team familiarized themselves with the data, then developed a codebook by double-coding five transcripts using open coding. The team double-coded fifteen interviews; remaining interviews were single-coded by two researchers (AH, MSc; LS, PhD). Following the indexing of the codes, the researchers and a scientist (CF, PhD) themed and interpreted the data.(15) We provided exemplar quotes for each illustrated theme to provide thick descriptions of the study data.
This study was funded by the COVID-19 Immunity Task Force and the John and Myrna Daniels Charitable Foundation via the University of Toronto. This study received ethics approval from the Unity Health Toronto Research Ethics Board (REB 20-347).
We conducted 91 key informant interviews with LTCH or RH leadership staff across 47 homes (33 LTCH and 14 RH) between February 2021 and July 2022. Our sample included privately owned for-profit homes (63.8%; 18 LTCH and 12 RH), as well as privately owned non-profit (17.0%; 6 LTCH and 2 RH), and publicly owned, non-profit homes (19.2%; 9 LTCH) (Table 1).
TABLE 1 Demographic characteristics of homes
The median number of floors in each home was three (range 1–8), with 128 beds (range 21–391) and 129 staff per home (range 10–528). The majority of the homes were located in the Greater Toronto and Hamilton areas (n=35).
We categorized our findings into implementation of IPAC protocols and measures, facilitation of access and uptake of COVID-19 vaccines, and addressing staff well-being. In Tables 1–4, we describe challenges pertaining to each of these categories and the strategies used by home leadership to address them.
TABLE 2 IPAC challenges and strategies implemented
TABLE 3 COVID-19 vaccine challenges
TABLE 4 Well-being challenges and implemented strategies
We identified ten challenges related to IPAC implementation during the COVID-19 pandemic (Table 2). These included insufficient resources and time to deliver IPAC education and preparation (e.g., mask fitting); lack of consistent IPAC implementation by staff and residents due to limited capacity to follow protocols (e.g., proper masking); difficulties keeping up with rapidly evolving COVID-19 protocols and mandates; resource shortages (including personal protective equipment [PPE] and COVID-19 rapid tests); impact of the physical home structure on IPAC implementation (e.g., lack of physical space to cohort and distance staff and residents); family pushback on IPAC protocols; staff PPE fatigue; and fears of returning to normal and loosening IPAC restrictions. To address these challenges, homes commonly leveraged external supports from hospitals and public health units to receive updates on COVID-19 mandates, protocols, and their implementation, in addition to physical (e.g., equipment), financial, and human resources. Homes found it useful to have a dedicated IPAC champion to provide advice, guidance, and staff support. Some homes implemented multi-pronged strategies (e.g., huddles, use of champions, handouts, training) to facilitate IPAC uptake; others also implemented routine audits. Other levers to IPAC implementation included having leaders who were committed to transparent and open communication, leaders with previous experience managing health emergencies, and homes with physical space conducive to IPAC cohorting and isolation.
Notably, participants reported that the majority of LTCH and RH staff were supportive of COVID-19 vaccines. However, we identified six challenges to COVID-19 vaccine uptake in LTCH and RH (Table 3). Barriers at the individual staff level included mistrust around vaccine safety, beliefs that COVID-19 boosters would not improve health outcomes, and beliefs that vaccine mandates were an infringement on labour laws and personal liberties. Some staff did not feel comfortable working with residents or colleagues who were unvaccinated, which led to workplace conflict and tension. Furthermore, family members concerned about vaccine safety did not provide consent for LTCH residents to receive the vaccines.
Also reported were logistical barriers, including a lack of knowledge or ability to access a vaccine clinic, challenges using the online booking systems, and lack of vaccine availability due to Canada-wide supply chain issues. In particular, some RH leaders reported that their homes, unlike LTCH, were not prioritized to receive the COVID-19 vaccines, and were challenged to advocate and secure doses for their staff members. Government-wide mandatory vaccination policies were perceived both as a barrier to uptake (some viewed it as an infringement on personal liberties) and a facilitator to uptake (led the majority of LTCH/RH residents and staff to receive the first two doses), though uptake of subsequent COVID-19 boosters remained a persistent challenge. Doubts about COVID-19 booster necessity was driven by beliefs that people had COVID-19 antibodies from their initial doses or from natural illness, and because COVID-19 case numbers were increasing despite high vaccination rates.
Enablers to vaccine uptake were also identified. Some staff believed that vaccine uptake (particularly the initial two doses) would facilitate a return to normalcy, for instance, by ending lockdowns and allowing staff to return to work in more than one home. Others became discouraged when public health mandates remained unchanged (e.g., lockdowns) and COVID-19 cases continued following uptake of COVID-19 vaccines.
In other homes, outbreaks drove staff, who were initially hesitant, to receive the vaccines. Participants reported the use of multi-pronged strategies to address vaccine misinformation and concerns, including one-to-one conversations with staff, engaging leadership to provide education about the vaccines, distribution of educational materials to address key concerns, and holding town halls with respected experts. Use of opinion leaders and respected vaccine champions were also found to be effective strategies to combat vaccine hesitancy, particularly when champions included members of historically marginalized populations and reflected the demographics of the LTCH/RH staff population. LTCH/RH policies such as provision of financial resources (e.g., transportation, parking coverage) and providing incentives to vaccination were perceived as effective strategies. Finally, homes used connections to IPAC supports, including IPAC hubs that included regional hospitals, to facilitate access to vaccine supply and appointments, particularly at the start of the vaccine rollout. Some sites overcame logistical barriers to vaccine access by supporting online appointment booking or hosting mobile or on-site vaccine clinics. Some homes also offered boosters to caregivers while they were visiting residents.
LTCH/RH leaders reported that frontline staff such as PSWs and nurses experienced a variety of challenges to well-being during the pandemic, and described significant experiences of burnout, low morale, and mental health challenges (Table 4). These were driven by working in a high-stress, high-risk environment, coupled with challenges outside of the workplace such as fear of transmitting COVID-19 to their families, colleagues and residents, childcare challenges, fears about vaccine safety, and general fears about the novel virus and its impacts (including health and economic impacts). Provincial policies aiming to curb COVID-19 spread prevented staff from working in more than one home, which led to staff shortages and increased burden on existing staff. Policies on social distancing prevented the implementation of social and activities programming for residents and increased resident isolation, which led to decreased social interaction and subsequent declines in residents’ physical and mental health. Participants reported that they and their staff felt helpless to address these concerns and were unable to support their residents’ needs.
Staff also became sick with COVID-19, saw colleagues and family members become sick with COVID-19, and witnessed the death of residents. As the pandemic continued, staff were expected to maintain high rates of compliance with IPAC protocols, including wearing masks when most of the province had lifted masking requirements. This led some staff to experience IPAC and PPE fatigue, which was compounded by emotional and physical burnout. Some staff refused to work with residents who had COVID-19, and others left their positions or chose to retire early due to burnout and feelings of ‘moral injury’ (i.e., feeling unable to care for residents in an optimal way while feeling unsupported by leadership). In turn, these challenges increased staffing shortages and pressures on remaining staff. For instance, role shifting was prevalent, with many frontline staff (and sometimes managers) taking on responsibilities outside of their traditional tasks (e.g., personal support workers implemented IPAC protocols, nurses became IPAC practitioners, and managers supported resident care), while many staff worked longer hours or double shifts to meet home and resident needs. When homes used agencies to address staff shortages, regular staff members worked alongside people they did not know or trust, which sometimes led to increased stress, workplace conflict, and reduced staff morale and team cohesion.
LTCH/RH leadership also faced a number of unique challenges. In addition to trying to maintain home functioning and staff morale, leaders were required to participate in daily or weekly calls with external organizations such as public health units or hospital IPAC hubs. System inefficiencies also challenged home leaders; for instance, some participants reported being forced to individually source PPE amidst the country-wide shortages. One participant reported having to source equipment from three medical providers, as the government had not yet developed its centralized system. Leaders also struggled to stay up to date on continually changing COVID-19 mandates, policies and guidance, and found it challenging to address questions about the nature of the virus or, as the pandemic evolved, COVID-19 vaccines. Participants also reported high levels of distrust directed towards them from by staff and by residents’ family members who were frustrated by IPAC protocols and lockdowns which limited or eliminated visits to loved ones.
Leaders reported feeling insufficiently equipped to provide resources to staff to address these challenges. At the height of the pandemic, they prioritized implementation of IPAC protocols and resident care, which left little capacity to develop and implement wellness programs to support staff. Some did report the implementation of well-being activities in the workplace; however, they were also reports of discontinuation of these activities due to a lack of capacity or funding to sustain them. Other participants implemented and encouraged mental health supports such as employee assistance programs, but noted little uptake among staff due to accessibility challenges and stigma associated with seeking these supports. Implementation of such strategies seemed largely dependent on leadership commitment to addressing staff well-being challenges (see Table 4). Some leaders used a co-development approach to develop and implement these strategies, such as the formation of a wellness committee or providing opportunities for leadership to listen to staff concerns.
The impact of COVID-19 on long-term care and retirement homes was devastating and received global attention and calls for immediate supports to maintain resident and staff safety.(22) Nearly one year into the pandemic, we conducted 91 key informant interviews with LTCH and RH leadership in 47 homes to assess their experiences navigating the pandemic, and to define ongoing challenges. Participants identified challenges associated with IPAC implementation, COVID-19 vaccine uptake, and staff well-being and mental health. At the onset of the pandemic, challenges were primary related to IPAC, including PPE shortages (e.g., masks, face shields) and difficulties implementing IPAC protocols. Many of these challenges were highlighted as significant concerns for congregate homes for decades.(10,11, 23) The pandemic exposed these vulnerabilities and created a crisis, leaving governments rushing to fill the gaps and provide supports. Despite these efforts, our study shows that IPAC implementation concerns continued to persist up to one year into the pandemic. Other contextual challenges unique to COVID-19 included supply chain shortages,(24,25) which limited access not only to PPE, but also to COVID-19 PCR testing (when rapid antigen tests had not yet become widely available).(26)
As PPE supplies became more available and IPAC protocols became more routine with the support of LTCH/RH leadership, hospital, and public health units, other IPAC challenges emerged including PPE fatigue and challenges to maintain stringent IPAC protocols while the rest of the province loosened restrictions. It was in this setting that COVID-19 vaccines entered our health system. In December 2020, home leaders advocated for early access for their residents and staff. While this prioritization was granted to LTCH, this was not the case for RH, creating equity imbalances.(11,26,27,28) Furthermore, home leaders contended with staff and family fears about vaccine safety and efficacy; these concerns further escalated with the Ontario government’s introduction of mandatory vaccination policies in the spring of 2021, which were seen by our participants as both a barrier and facilitator to vaccine uptake.(29)
Frequent changes to IPAC and vaccination policies posed further challenges. In both Canada and the United States, these included conflicting information about the safety of mixing vaccines, the safety of the AstraZeneca vaccine, vaccine schedules, and the speed at which vaccines were approved.(30,31) The absence of clear rationales and mixed messaging created confusion and eroded trust among staff and families, fostering fear, anger, and resistance to policies like vaccine mandates, family visitation, and masking.(27) These policies reinforced doubts about the vaccines and fueled mistrust of health organizations, especially among historically marginalized communities.(30) This context added significant strain on home leaders, who did not feel well-equipped or supported to navigate access, uptake, and morale challenges.(32,33)
Thus, it was not surprising that staff mental health and well-being challenges were identified as a strong theme across our interviews. Yet, unlike IPAC or vaccine challenges, there were few supports and limited capacity to address these challenges. Staff experienced stress, PTSD, and burnout.(34) While other health-care workers were being hailed as heroes, LTCH/RH staff, particularly staff in unregulated roles, such as Personal Support Workers, remained underpaid, underappreciated, and under-supported.(27,34–38) Mandates such as the ‘one-home policy’ requiring staff to only work in one home, coupled with province-wide shutdowns, directly impacted staff incomes and amplified needs for basic services such as childcare support and transportation.(39) Such challenges directly impacted well-being and mental health, and compounded the issues staff faced at work including ability to implement IPAC and vaccine programs. Racialized staff (estimated at >40% of the Ontario personal support worker workforce) also experienced intersecting challenges related to racism and workplace violence.(13,40,41) In our study, we identified few homes with robust employee support programs or supports; those that did have services available reported low uptake by staff due to lack of capacity to engage, lack of awareness, or concerns about stigma associated with seeking mental health supports.
Participants described a plethora of strategies that were used to mitigate these challenges. Leaders also described the benefits of the hub-and-spoke care delivery model.(42) which was implemented to allow hospitals to ‘partner’ with LTCH and provide supports; notably, these integrations were largely absent pre-pandemic.(10,11) Having effective leadership that was empathetic, collaborative, and engaged was consistently cited as a facilitator to combatting challenges related to IPAC, vaccines, and well-being. Despite the implementation of various strategies to address staff well-being, these were often deemed insufficient in the absence of government-wide policies such as paid sick leave for COVID-19 testing, vaccinations,(43) or illness and financial benefits.(44)
The COVID-19 pandemic put a spotlight on longstanding inequities and systems gaps for the LTCH and RH sectors and their workers.(10) Our findings are consistent with the well-documented challenges in LTCH and RH and other research conducted at this time in Canada and internationally.(11,45,46) However, our data also show that the systemic challenges reported by other researchers earlier in the pandemic continued to persist well through 2021 and 2022 despite massive media and government attention and efforts to address these challenges.(10,46,47) Our findings also show that, while challenges evolved during the pandemic, the available supports did not adapt accordingly.
Our study has limitations. It was limited to homes in Ontario, Canada, and mostly included homes located in the GTA.(48) We interviewed LTCH and RH leadership; however, the perspectives of LTCH and RH residents, caregivers, and staff are important voices missing from our assessment. Finally, we conducted these interviews over a 17-month period between February 2021 and July 2022. Thus, reported challenges facing homes in the early waves of the pandemic (March 2020–February 2021) may have been subject to a recall bias, though we anticipate the impact of this bias is limited, given consistency of our findings with other research reported during this time.(49)
LTCH and RH experienced significant challenges during the pandemic related to IPAC implementation, uptake of COVID-19 vaccines, and staff well-being and mental health. A plethora of strategies were used to address these challenges, yet over a year into the pandemic, significant gaps remained. These findings demonstrate the need for multi-level strategies to support LTCH and RH to prepare for and navigate future public health crises.
The authors wish to thank Chelsea Gao, Oswa Shafei, and Jane Dim for their contributions to data collection.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare that we have none.
This work was supported by the COVID-19 Immunity Task Force under Grant #2021-HQ-000143 and the John and Myrna Daniels Charitable Foundation via the University of Toronto.
Supplemental material linked to the online version of the paper (https://doi.org/10.5770/cgj.28.854):
• Appendix S1: Background & context
• Appendix S2: Reflexivity statement
• Table S1: Wellness hub needs assessment
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Correspondence to: Christine Fahim, PhD, MSc, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, E-mail: christine.fahim@unityhealth.to
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 28, No. 4, DECEMBER 2025