A multi-methods investigation of a long-term care staffing policy in Ontario

Abstract

Introduction: Long-term care is an important sector in the care continuum of older adults in Ontario. The challenges facing long-term care include, but are not limited to, lack of funding, complicated funding structures, limited workforce availability, and growing resident acuity (Long-Term Care Staffing Study Advisory Group, 2020). In 2021, the Ontario government introduced and funded a series of programs to increase the hours of care and the number of beds available in long-term care (Office of the Premier, 2020). The policy response came at a time of growing public concerns on the state of long-term care in Ontario, and excess resident mortality during the pandemic (Office of the Premier, 2020). Through this policy initiative, the Ontario government aimed to achieve an average of four hours of direct care per resident per day, and an average of 36 minutes per resident per day of allied health care, by March 31, 2025 (Office of the Premier, 2020). In addition to the average care hour policy, the Government of Ontario (2022) announced a goal of creating 30,000 new beds by 2028. Given the complex nature of the challenges facing the long-term care sector, there is a need to understand the potential impacts of the policy initiative on Ontario’s long-term care sector and workers.

Study Aims and Methods: To understand the potential impacts of the increase in hours of care policy, and its associated programs, a multi-methods investigation was conducted. Study 1 aimed to understand the impact of the staffing policy on the Government of Ontario budget. To do this, a budget impact analysis model was developed (Mauskopf et al., 2017), quantifying ministry programs and announcements. Study 2 aimed to understand the impact of the staffing policy on the long-term care sector and identify any potential effects on other parts of Ontario’s health system. Study 2 explored the grey literature published on long-term care (Godin et al., 2015); selected documents were examined using the document analysis method (Bowen, 2009) and analyzed thematically (Braun et al., 2019). The thematic analysis informed the subsequent health policy analysis using Walt and Gilson’s (1994) policy framework. In addition to the policy analysis, a theory of change (Knowlton & Philips, 2009) was developed to map the ministry’s strategies to implement the staffing policy. Study 3 aimed to understand the perspectives of long-term care staff on the introduction of the policy, identify potential barriers and facilitators to the policy’s implementation across long-term care homes and suggest additional policy initiatives that could support or enhance the policy’s implementation. For study 3, a qualitative descriptive study, as described in Sandelowski (2000) was done using semi-structured interviews. Fourteen participants were interviewed to understand their perspectives on the policy’s effects and implementation. Interview data were analyzed using qualitative content analysis (Sandelowski, 2000).

Results: After creating a budget impact model for the government policies, Study 1 provided cost estimates for the ministry programs and a bed funding database based on announced ministry projects, from 2021-2022 to 2029-2030. Study 1 provided estimates for the number of direct care workers required under the new policy until 2029-2030. In a no intervention scenario, ministry spending is estimated at $7.4 billion in 2029-2030. Compared to a baseline scenario where no policy or programs are introduced, the staffing policy would increase ministry spending to $13.32 billion in 2029-2030. The policy analysis provided insight into the staffing policy’s implementation and sustainability. Competing efforts and laws from the Ontario Government were identified as a potential factor that could limit the effects of the policy. A dynamic labour market, where competition is found between operators, health sectors, and direct care workers was identified as a challenge to ensure an increased number of hours and workers across long-term care homes. In Study 3, participants provided insight on their experiences in long-term care and their opinions on the staffing policy. Participants discussed limited staff availability, limited wage compensation, the demanding nature of long-term care work and competition across health sectors as some of the challenges in recruiting and retaining long-term care workers. Facilitators of this policy’s implementation included educational programs for personal support workers, and training workers for their roles. Participants identified potential efforts for the government to consider such as regulations and initiatives that could create a better work environment for workers and improved care for residents.

Conclusion: It is evident that addressing the current staffing challenges in long-term care requires efforts beyond adding more long-term care workers. The complex relation among factors including funding, work environment and rules and regulations has a direct impact on the recruitment and retention of long-term care workers. On a larger scale, better coordination between government agencies and ministries should be considered to enhance the effect of policies on the health care labour force. The introduced policy efforts coupled with supplementary policies targeting the health sector labour force and working conditions are some of the ways to ensure that the policy can influence change in long-term care. The increase in care hour policy, and the increase in beds in long-term care are important steps to start resolving the issues in long-term care. Ensuring that the policy achieves its aims has proved to be much more challenging, requiring ministry consideration of potential consequences that might affect long-term care and the larger health sector in Ontario.