Creating safe environments in long-term care homes
While group-care settings have come to symbolize the worst of the COVID-19 pandemic, the practices they develop to protect residents and staff could provide guidance for workplaces across sectors.
By Meagan Gillmore
In some ways, the four long-term care homes operated by the Yee Hong Centre for Geriatric Care appear unscathed by the COVID-19 pandemic.
During the first wave, there were no reported cases at the homes across Toronto and the Greater Toronto Area that combined have 805 beds, said Dr. San Ng, Yee Hong’s CEO.
Less than five residents had died of the disease by the beginning of Sept. 2021.
“We have the utmost respect for seniors and caregivers, but also for each other,” said Ng, explaining the motivation of her staff.
The not-for-profit service organization supports seniors of Chinese and other ethnicities, and provides a range of community services from recreational activities, meals-on-wheels and medical clinics.
Staff began wearing masks before the pandemic was declared, and the organization implemented visitor restrictions and policies that restricted staff to working at one site early in the pandemic, said Ng.
“Diligence and catching things early have really helped our organization and prevented outbreaks,” she said. “That’s how we’ve been able to do it.”
It’s hurt, though.
Staff have been busy, setting up virtual visits and phone calls for residents. During lockdowns, public health guidelines required residents to be confined to their rooms.
Yee Hong workers from the community programs were reassigned to the long-term care homes; some staff have brought programming and virtual supports to residents’ rooms.
The isolation has “saddened” staff, Ng said. “It’s been really heart-wrenching.”
In that way, staff at Yee Hong resemble workers at all long-term care homes — risking their physical and mental health to ensure vulnerable individuals are safe.
Yet, while long-term care homes have come to symbolize the worst of the pandemic, the practices they develop to protect residents and staff could provide guidance for workplaces across sectors.
Risks vary; there’s no consistent standards
Workers at long-term care facilities face numerous hazards, ranging from exposure to diseases and dangerous chemicals, musculoskeletal disorders, to workplace violence, said Matthew MacLeod, an occupational health and safety specialist at the Canadian Centre for Occupational Health and Safety in Hamilton, Ont.
“Always consider the most effective controls first,” he said. “Those are controlling the ones at the source, followed by controlling the hazards along the path, and lastly those that provide protection at the worker level.”
This could mean closing non-essential spaces or allowing some administrative staff to work remotely. Changes to the physical environment, like upgrading ventilation or installing Plexiglas barriers and rearranging furniture, can also help. Finally, employers need to ensure staff have appropriate personal protective equipment.
“Even between long-term care homes, there’s going to be differences,” said MacLeod, emphasizing the importance of performing risk assessments for each task.
However, some say the sector needs consistent standards to improve conditions in long-term care homes. Provincial and territorial governments give guidelines about long-term care homes, which means that requirements in these facilities can vary greatly across the country.
While the Canadian Standards Association (CSA) Group has several standards for medical facilities like clinics or hospitals, there isn’t yet one specifically for long-term care homes.
“There’s actually no long-term care standard that any home or facility has to follow,” said Alex Mihailidis, chair of a CSA Group technical subcommittee that is developing a national standard for operation and infection prevention and control at long-term care homes.
This is why building and room designs aren’t consistent across the country, and neither are policies about visitors and infection prevention, he explained.
The new standard, still being developed, will look at building infrastructure and design elements that are important for infection prevention and control. This could include standards about ventilation and air conditioning, residents’ washrooms, and furniture fabrics, said Mihailidis.
But it also includes making sure long-term care homes can effectively use technology, like wireless internet and tablets, so residents can communicate virtually with relatives, friends and caregivers during future health crises.
Public review is scheduled for early 2022, with the final document scheduled to be published in Nov. 2022. Then, governments will decide if they will incorporate it.
“These standards need to be as inclusive as possible,” explained Mihailidis, who is also the scientific director and CEO of AGE-WELL, a Canadian network that develops technology to help individuals age in healthy ways. “We are going to design them for current homes, but also future builds, (and) also for homes in different parts of the country.”
Still, long-term care homes can improve their infection prevention and control practices now, said Doug Morton, vice-president of government relations for the CSA Group.
Hospitals and clinics often use the standards the CSA Group has on infection prevention and control, and facility operation, design and maintenance.
“They are equally useable in the long-term care setting if long-term care homes decided to use that,” explained Morton. “There’s lots that could be done now.”
The unique purpose of long-term care homes requires they be given focused attention.
“These are people’s homes,” said Mihailidis. “They’re not acute-care settings or hospitals. They are places where people come, most likely to be their last residence where they will live. We want to make sure that our standard takes that into account.”
Maintaining mental health
Workers’ mental health also needs to be improved.
The Health Standards Organization is currently working on a complementary standard, the National Standard of Canada for Long-Term Care Services, that will focus on resident and family-centred care, and emphasize dignity, respect, quality of life, and the health and competency of the workforce, states a press release about the standards.
The pandemic has greatly harmed the mental health of long-term care nurses, said Farinaz Havaei, a researcher at the University of British Columbia’s School of Nursing who is studying the topic.
“Before the pandemic, they were struggling with workload,” she said. “The pandemic just exacerbated things further.”
Visitor polices kept residents from seeing relatives, friends or caregivers. Other policies restricted staff from working at multiple facilities, and made it difficult for staff to take time off.
“Staffing levels dropped and workload increased,” she explained. “On top of that, they could not have family members’ whose care was, before the pandemic, really uncounted for.”
Employees need to know it’s acceptable to discuss their mental health and that other people are also struggling, Havaei said. That can be really “empowering,” she said.
Mandating vaccines must be done carefully
Vaccinations are becoming a prominent, yet controversial, part of protecting long-term care workers against COVID-19.
Some long-term care home operators require employees to be vaccinated against COVID-19. Governments across Canada have responded differently. Some have explicitly said that all long-term care workers — in some cases including volunteers — be vaccinated against the virus. Other jurisdictions, like Ontario, require long-term care homes to make policies about vaccination for workers.
The Ontario government announced in May that every long-term care home would need to have a policy that requires employees to do one of three things: show proof of vaccination; provide a written reason for why they can’t be vaccinated for medical reasons; or receive education about the benefits of vaccination. The government is not explicitly ordering long-term care workers to be vaccinated.
“Obviously, it’s kind of doing everything it can to encourage and push towards that conclusion, but it doesn’t go as far as to legislate it or mandate it,” said J. D. Sharp, a lawyer with Emond Harnden LLP in Ottawa, who represents employers.
“It’s not appropriate for every employer to implement a mandatory vaccine policy,” added Wade Poziomka, a lawyer with Ross & McBride LLP in Hamilton, Ont., who has advised many employers on vaccination policies. “It’s really time and context-specific.”
Employers need to consider factors like current health guidelines, the prevalence of COVID-19 in their community, and the type of work that happens at their workplace, he explained. They should review policies as public health information changes.
“You don’t want to have more restrictive policies in the workplace than are necessary,” said Poziomka. “You do want to have policies that promote health and safety.”
Employers also need to consider human rights implications.
“Because the human rights code has quasi-constitutional status, it’s a more difficult one necessarily to reconcile with the Occupational Health and Safety Act,” said Sharp.
“I will always take the position of protecting health and safety in the workplace, and that being forced to do something that may not support that would be undue hardship.”
“The duty to accommodate an employee who doesn’t want to get a vaccination or can’t get a vaccination is only triggered when you have a human rights ground,” said Poziomka, for example a “legitimate creed claim, or disability.”
Not every political belief or opinion about vaccines can be called a creed, he said. “A creed has to be either a fundamental religious view, or it can be non-religious, but it’s a worldview that’s integral to someone’s well-being, decision making and the way that they view the world.”
Employers should ask employees to explain what belief prevents them from receiving the vaccine and how that belief connects to their overall identity, sense of well-being, conduct and decision-making.
However, legitimate human rights exemptions don’t necessarily mean that unvaccinated employees can continue to work the same way as before, said Poziomka.
“But that doesn’t mean that just because they’ve established a creed and you’ve accepted it, that you need to let them work at the workplace without a vaccination.”
Employers are only obligated to comply up to the point of undue hardship. In some workplaces, alternative working arrangements can be created.
Employers need to discuss potential policies with different stakeholders. In a unionized workplace, policies should not contravene the collective bargaining act, while in a non-unionized setting, they should not fundamentally change the terms of employment, explained Sharp.
“It’s difficult to apply a one-size fits-all approach,” he said. Employers need to make policies, but “seeking feedback is never going to hurt.”
Most of Yee Hong’s staff are vaccinated, and vaccinations were not mandatory, said Ng.
It won’t be helpful to completely go back to the way things were before the pandemic, or to keep seniors in long-term care homes away from loved ones, she said.
“I think either extreme isn’t healthy,” said Ng. “We must strike a balance between keeping people safe and allowing them to live their lives.”
Across health and safety and long-term care sectors, many hope the pandemic will lead to improved conditions for residents and staff.
“Theoretically, things should have been preventable,” said Mihailidis. “But practically, this whole thing came upon us so quickly that I think it was tough for a lot of homes to manage. The resources just weren’t there.”
“If we can take any bright light out the pandemic, it is now in the public eye. Everybody sees what is happening in long-term care homes and sees the state of care for our seniors.”
Meagan Gillmore is a freelance writer in Ottawa.