At the core of long term care: Leadership and Culture
Every Canadian citizen has been affected by the COVID-19 pandemic in profound, life-altering and, in the case of seniors and vulnerable populations, life-ending ways.
The fact that 11% of COVID-19 cases and 73% of total deaths in Canada occurred in Long-Term Care (LTC), nursing and seniors’ homes (HillNotes, 2020) is the true unspeakable tragedy of the pandemic. An alarming finding contained in a June 2020 report by the Canadian Institute for Health information was that the proportion of COVID-19 deaths in Canadian LTC facilities exceeded that of other OECD countries:
“Canadian LTCs from COVID-19 were at 81% of the total, while OECD countries reported LTC COVID-19 deaths of 10-66% (average of 38%) of their totals.” (CIHI Snapshot June 2020)
Most healthcare leaders and provincial and federal political leaders knew that our ability to comfortably house and safely care for our seniors and vulnerable populations was in a shambolic state prior to the pandemic. The pandemic simply and ruthlessly exposed the weaknesses, and we as a society appeared impotent to do anything about it. The image of bringing in the military to shore up a failing LTC system is a shameful reminder that there was no foreign enemy to fight, no natural disaster to overcome, but rather our failed attempt to prevent unnecessary casualties and profound suffering due to a virus. The root causes of this disaster were well known before the pandemic, and indeed, at least two provincial governments campaigned in their most recent elections on repairing the LTC system. Yet, the evidence is clear that we all fell horribly short on the stated repair objective.
In this position paper, we review the known root causes of this disaster, including: governance, structural relationships within the broad health care system, funding (public and private), and human resources, all necessary but not sufficient to repair the deficiencies. We will emphasize what we believe are the most challenging but fundamental requirements for change: leadership and culture.
Scope of the problem
In March 2020, Public Health Canada declared Canada was officially in a pandemic caused by COVID-19. At that early point in the pandemic, it was not recognized that the bulk of deaths were going to happen in congregant settings for the elderly, namely LTC facilities, Nursing Homes and Seniors Homes. One of the challenges we would discover is the inconsistent nomenclature referring to these settings across the country (Picard 2020).
Armstrong et al. (2020) put the situation into context by providing global benchmarking statistics:
“Numbers are changing rapidly, but to date, Canada has the highest reported proportion of COVID-19 deaths nationally for nursing home residents. Canada reports that 81% of total COVID-19 deaths are of nursing home residents. Other comparable countries report 27% (England and Wales), 28% (Australia), 31% (US), 34% (Denmark), 34% (Germany), 47% (Scotland), 49% (Sweden), and 66% (Spain). The Royal Society of Canada Working Group on Long-Term Care fatality rate for people who have COVID-19 is estimated at 3.4%,40 but that rate varies strikingly from country to country—from as low as 0.1% (Qatar) to as high as 26.3% (Yemen). In Canada, the fatality rate is estimated at 8.2%, but the Canadian fatality rate of nursing home residents is estimated at 25% (range 11%-35%). The global fatality rate for all persons over age 85, regardless of location, is 10%-27%.”
Armstrong et al. (2020) further implores relevant stakeholders to acknowledge their share of responsibility and face the dire reality of current care gaps amongst vulnerable older adults. The document highlights harnessing learning opportunities as an antidote for “short-sighted and siloed solutions” that fail to address root causes.
The analyses of why this tragedy has occurred in seniors’ congregant housing are not yet complete, but the themes emerging include the following.
- Multiple models of relationships to regional health authorities, acute care sector and government. No coherent theme across the provinces.
- Multiple models in the private sector with little to no accountability to governments.
Although there has been a political attack on the private sector management, it is not clear jurisdiction by jurisdiction that public sector facilities were/are faring any better. The argument is rendered moot when both private and public sector homes are accountable to provincial authority for standards of care. The financing and management systems differ, but accountability is the same.
Howlett (2021) provides insight into some of the realities facing some LTC facilities in Ontario:
“Ontario hospitals are currently managing 18 long-term care homes with outbreaks of COVID-19. But in many instances, the province is not sending in-hospital teams to take over management until COVID-19 has spread throughout the home and staffing has become critically low, leaving residents unable to get basic care.”
A scathing rebuke from Armstrong et al. (2020) highlights that a lack of integration across the community, continuing care, and acute care sectors in Canada may be partly to blame for many LTC facilities’ current state.
Goldfinger (2020) draws attention to the gap between policy intentions and their practical outworking, stating:
“The province’s “iron ring” around long-term care facilities has been criticized by advocates who’ve argued the policy didn’t work in controlling COVID-19 outbreaks and also contributed to adverse mental health effects among seniors who were in isolation.”
HillNotes (2020) points out the importance of co-ordinated leadership in the LTC sector, stating:
“A June 2020 report on LTC home staffing by the Royal Society of Canada stated that “the pandemic just exposed long-standing, wide-spread and pervasive deficiencies in the sector” and made nine recommendations to address “the workforce crisis in nursing homes,” urging “coordinated leadership” between the federal and provincial/territorial governments.”
Nuttall (2021) highlights potential focus areas stating that “Former Ontario Minister George Smitherman said a “cultural shift” in attitudes toward the elderly and those who care for them is needed to bring about changes to the troubled sector, which has plagued successive provincial governments.”
Armstrong et al. (2020) further assert that“The LTC sector requires strong, decisive leadership that is willing to move past incrementalism and tinkering at the margins to true transformative change. Leadership must also be willing to devote the resources needed to achieve this. We will need the ability and courage to not only implement promising practices, but also to cease practices that are not useful or effective.”
B. Physical Structures
For many years, the acute care sector has known that shared bathrooms and multiple bedded rooms were the single biggest physical plant barrier to reducing nosocomial infection spread. The standard for new hospital construction or renovation is a mixture of single bedded with some allowance for semiprivate rooms, with complete elimination of multi-bedded rooms.
The national standard in LTC facilities is not so clear; however, the Nova Scotian code, as presented in LONG TERM CARE FACILITY REQUIREMENTS – Requirements for Nursing Home Design in Nova Scotia, (2020), provides a helpful benchmark. The physical plant changes, including the more expensive, one patient per room option, must and will be addressed.
C. Human Resources
Howlett (2021) observes that a lack of transparency regarding staffing in LTC facilities is equally as concerning as the prevalence of cases and deaths.
A further noteworthy observation, raised by HillNotes (2020), is that the number of healthcare workers for 100 in Canadian LTC facilities is significantly lower than the OECD average.
The CIHI Snapshot June 2020 report notes that care aides often:
- receive low wages;
- receive minimal and variable education across the country;
- work part-time without benefits;
- are contracted through agencies and are unfamiliar with the LTC facility where they work; and
- are not included in decision-making and family conferences, despite spending the most time with residents.
There were few differences between publicly and privately managed institutions. In each setting, we were unable to determine because of a lack of data how many privately engaged personal care workers were paid for by patients’ families. Still, it is widely believed to be significant and related specifically to the unacceptable level of service budgeted for by the institutions. Sinha et al. (2019) provide some insight into spending on LTC:
Table 1: Visualization of Canadian Long-Term Care Spending Estimates for 2018,
based on Grignon & Spencer (2018) methods. (Cited in Sinha et al., 2019 pg 35)
Figure 1: Long-Term Care Expenditure (health and social components) by Government and Compulsory Insurance Schemes, as a Share of GPD, 2015 (or nearest year) Across OECD Nations (Cited in Sinha et al., 2019 pg 39)
D. Leadership and Culture
While addressing the physical structure and staffing volume needs of LTC facilities can be achieved with relative ease, bringing about the required leadership and cultural transformation to sustain an excellent care level is a more complex matter.
Leadership mindset has an undeniable impact on an organization’s culture, whether positively or negatively. Any improvements generated in the system as a healthcare leader, or a leader in any industry, always involve behavioural change.
Marrocco, Coke and Kitts (2020) emphasize the importance of leadership in LTC, stating;
“We learned from wave 1 that on-site leadership matters. We heard that homes where leaders were visible and provided clarity around staff roles and responsibilities fared better than those where leadership was less engaged. Homes with effective leaders were better prepared, had less outbreaks, and better-contained outbreaks when they occurred.”
PulvermacherKennedy and Associates (2021) observe that “time and again that when executives or leaders are very focused on self and what they want to do, rather than considering the greater good, the organization suffers as a result. Conversely, when leaders exhibit more inclusive mindsets, traits and behaviours, they feel a sense of purpose and personal satisfaction, which positively influences organizational culture.”
Effective leadership in times of intense stress and crises requires making tough choices (Picard, 2020). There is a natural inclination to think in an either-or fashion. For example, “do I set the bar high and risk losing more staff or do I avoid doing so and retain my complement of necessary employees.” The more effective leadership question uses an “and” rather than an “or.” The leader’s dilemma is, “how do I set the bar high and retain my scarce staff?”.
In affecting behavioural change, the process of coaching senior leaders can illuminate blind spots and boost performance by providing an outside perspective (Kennedy, 2017). However, the notion of the “heroic leader” riding in on his or her steed to save the day is an archaic one. Effective leadership implies building a strong and cohesive leadership team that pulls together in a crisis, challenges one another to design innovative solutions to challenging problems, and works to ensure the successful implementation of the solutions (Pulvermacher, 2020).
Finally, effective leadership requires asking staff how they can help identify or solve problems before they get out-of-hand. Effective leaders aren’t afraid to challenge people through penetrating questions and, above all, allow staff to ask them questions. Only in this manner can the leader nip issues in the bud instead of allowing issues to simmer and subsequently get out of hand.
- Physical plant solutions are well known and have been described extensively.
LONG TERM CARE FACILITY REQUIREMENTS – Requirements for Nursing Home Design in Nova Scotia (2020) provides a helpful example of best practice, stating that “Semi-private rooms or adjoining rooms must be provided at a maximum 1:48 resident ratio. Written justification must be provided for the inclusion of semi-private rooms (e.g. accommodating spouses, decreasing social isolation, etc.) as part of the functional program.” This essentially establishes single bedded rooms as the standard with a few
double-bedded rooms on special application
- HR solutions are also well documented and include better training, higher salaries, and better staffing ratios for
Sinha et al.(2019) provides a wealth of insight into the topic, contextualizes current challenges, and concludes by highlighting enabling factors and support opportunities for Long Term Care’s future provision. GPA consider this document essential reading for leaders in the field.
As noted by Picard: “The only way to rein in the on-the-verge-of-getting-out-of-control pandemic is with a united front – with leaders willing to make hard decisions.” Picard (2020)
This national shame is effectively a statement of Canadian values. We have failed to protect our senior and vulnerable citizens from an existential threat. The pandemic has been framed as a failure of planning, preparation, local vaccine production capacity, political will and competence.
The most distressing debate to observe is pitting the easing of public health restrictions and taking a risk with Canadian lives vs the financial survival of Canadian businesses. These are all crucial issues that Canada must address. However, in the final analysis, it is abundantly clear that establishing the appropriate care, compassion, valuing, and housing of seniors and vulnerable populations will significantly impact business and the economy. This approach is joyfully and entirely consistent with what we believe to be real Canadian values.
We should be singing our national anthem not at every sports event celebrating our young athletes but rather at the reopening of every senior’s facility in the country: “Oh Canada, we stand on guard for thee.”
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Marrocco, F., Coke, A. and Kitts, D., 2020. [online] Ltccommission-commissionsld.ca. Available at: <http://www.ltccommission-commissionsld.ca/ir/pdf/20201203_2nd_Interim_Letter-E.pdf> [Accessed 11 January 2021].
Nuttall, J., 2021. ‘I’m Not Sure We Care Enough:’ Cultural Shift Needed To Stop Tragedy In Care Homes, Experts Say. [online] thestar.com. Available at: <https://www.thestar.com/news/canada/2021/01/04/im-not-sure-we-care-enough-cultural-shift-needed-to-stop-tragedy-in-care-homes-say-experts.html> [Accessed 26 January 2021].
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Picard, A., 2020. With The Pandemic Surging, We Need More Leadership And Less Urging. [online] The Globe and Mail. Available at: <https://www.theglobeandmail.com/canada/article-with-the-pandemic-surging-we-need-more-leadership-and-less-urging/> [Accessed 26 January 2021].
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