Investigating the relationship between staffing structures, working conditions, and quality of care in Ontario Long-Term Care Homes

Abstract

Background: Chronic underfunding and increased privatization of the Canada’s long-term care (LTC) sector, coupled with an older population and increased complexity of care, has deteriorated working conditions. These conditions have created a reliance on contract work, intensified and stressful work, and decreased job satisfaction and created environments where workers are less inclined to stay at their jobs. Additionally, Ontario mandated an increase in direct care hours required for residents and intends to build more beds for older adults in need of care. These changes require additional staff to meet regulated care requirements. There is a clear need for strategies to recruit and retain a strong LTC workforce and to address retention by improving working conditions. Methods: This thesis sought to explore the relationships between quality of care, working conditions, and staffing practices in LTC through a narrative scoping review, an analysis of staffing data and resident care outcomes, and a qualitative analysis exploring the work experiences of staff and how staffing practices affect care and work. Results: The narrative scoping review (Chapter 2) investigated the contextual factors affecting staffing decisions and the impacts of staffing structures on direct care workers' quality of work-life and work-related outcomes. Contextual factors included market-based ideologies, increased care complexity, regulatory requirements, the impact of COVID-19 and organizational fiscal austerity. Generally, these factors reduced the number and skill mix of staff prior to the COVID-19 pandemic and negatively impacted the quality of work-life and work outcomes, such as reducing job satisfaction and increasing burnout. When homes relied on lean staffing models to save on costs, staff compensated by absorbing the negative impacts of fewer staff by working unpaid overtime and finding workarounds. Chapter 3 examined how PSW staffing patterns were associated with resident care quality outcomes in LTC. The regression analysis of the relationship between PSW staffing and resident quality of care composite score did not find any statistically significant relationships. The lack of relationships in Chapter 3 may be further explained, in part, by the qualitative exploration of staffing in LTC (Chapter 4). This study explored the LTC work environment and staff perceptions of how staffing is organized insofar as it affects their ability to provide care and have a healthy working environment. The qualitative analysis found that the addition of PSWs, as per mandated hours of care regulation, improved workloads for PSWs. However, quality of employees was as important as the quantity of employees. Disruption in team dynamics and distressed care markets may have resulted in a lower quality workforce. In addition, those in supervisory positions in LTC have a workload that has quietly changed and increased in scope but remained unmonitored, resulting in those with the most responsibility in LTC homes struggling with their workloads. Staffing in the LTC organization were not allocated based on care acuity, which impacted whether appropriate care personnel were available for different care requirements and created inequitable workloads between care units in the homes. Conclusions: With the growing demand for LTC globally, there will be a need to train, hire, and employ more care workers. To ensure that the care received by residents is of high quality, sustainable systems will need to be upheld and established that address the conditions of care, including work organization and staffing allocation appropriate to the care needs, education standards that promote well trained hiring pools, appropriate recognition of the time allocated for additional roles and responsibilities, and regulation that addresses skill mix disparities.