Long-term care facilities have emerged as the single most critical setting for the outbreak of the COVID-19 pandemic across Canada.
In Alberta, nearly three quarters of COVID-19 deaths have been attributed to long-term care facilities, with Calgary particularly hard hit.
Issues such as chronic understaffing, an insufficient supply of personal protective equipment, and high levels of stress on patient families have justifiably received extensive media coverage.
However, far less attention has been paid to the health care aides (also often called personal support workers) within these institutions, whose jobs are socially and economically devalued and who perform work can be considered “3D” : “dirty”, difficult, and particularly during times of pandemic, highly dangerous.
Across Canada, at least 27 health care aides have died of COVID-19, the majority of whom were Black.
Within Calgary’s long-term care workforce, immigrant and racialized women, in particular, are overrepresented. These workers are especially vulnerable due to the front-line nature of their employment, as well as their gender, citizenship status, race, and/or class.
My recently published Parkland Institute report More than "Just a Health Care Aide": Immigrant women speak about the COVID19 crisis in long-term care summarizes the findings of interviews with 25 immigrant women health care aides working in long-term care in Calgary that were conducted virtually between January 1, 2021 and March 30, 2021 in collaboration with the Calgary Immigrant Women’s Association.
Four key areas of concern were highlighted by the immigrant women health care aides: (1) The harsh financial costs of the pandemic, (2) Exacerbated physical and mental health challenges in health care aide work, (3) Institutional (mis)management in long-term care, and (4) The need to centre the voices of health care aides in government decision-making.
The harsh financial costs of the pandemic
In explaining the severe financial challenges that they are currently experiencing, the immigrant women health care aides uniformly pointed to the single site work policy instituted by the Alberta provincial government in April 2020 as a protective measure to limit cross-contamination of the virus across multiple long-term care locations.
While the women did not question the wisdom of this policy, the majority of them had been working at more than one job site as a health care aide prior to the pandemic in order to pay their bills.
Many were currently making 40-70% as much income as they had previously. The women noted that current government measures (e.g. the Critical Worker Benefit and $2/hour wage top-up in private continuing care facilities) are inadequate to make up this difference in pay.
They voiced concerns about the rhetoric of gratitude towards essential workers —suggesting that it is empty without concrete changes to their wages.
In addition, they detailed difficulties in navigating the government and employer benefits available to them when they had to take time off work due to testing COVID-positive or having to isolate due to potential COVID-19 exposure.
You know, five years we didn't get [a wage] increase. It's too bad. Five years and no increase. Look at how everything is more expensive. It's too hard. You know, when they say ‘You are my hero! You are doing essential work, blah blah blah’, you know guys, what about money? We didn't get enough to be secure, you know. That is not nice…. Like we get a $2 increase, but that is temporary. We never know. Every paycheck is just $150 more [because of the wage top up]. It's nothing. (Alma, a refugee from Nigeria who arrived in Calgary in 2018 and has since been working full-time as an HCA in LTC)
Exacerbated physical and mental health challenges in health care aides work
The women stressed that the physical and mental health demands of being a health care aide in long-term care in Calgary have increased during the pandemic due to a variety of factors.
They detailed increased demands on the job due to additional COVID-19 protective measures (e.g. repeatedly donning and doffing PPE).
They talked about their heightened level of stress tied to fear of becoming personally infected with COVID-19, and/or, their fear of infecting their family members and particularly their children.
They discussed their overwhelming and ongoing feelings of loss and helplessness as a result of watching long-term care residents die of COVID-19 in large numbers.
At the same time, the women noted that they were, in some cases, also dealing with anger, blame, and racism from long-term care residents, some of whom lashed out with accusations that health care aides “brought the virus” into the long-term care site or who treat health care aides “like servants.”
Work was so mentally stressful when we had the outbreak because it was more of a workload on us. And then, even going home, when you think about your family, you don't know what you're going to be bringing in. I have little kids who are six and nine right? They're totally dependent on me…Every day when you come back home you don't know... what you're bringing to your family from work. No matter how hard you try with PPE and everything, still you are always rushing. (Ruchi, an immigrant from India who has been working as a part-time, temporary HCA in LTC for 8 years)
Institutional (mis)management in long-term care
The women repeatedly critiqued what they perceived as the prioritization of profits over quality of care by long-term care management.
In particular, those women who were working in private and non-unionized long-term care institutions in Calgary expressed greater dissatisfaction.
They detailed how institutional mismanagement had resulted in a lack of PPE during the first wave of outbreaks and in consistently inadequate staffing ratios.
They also noted a continued reluctance to provide full-time permanent employment to health care aides, which only exacerbated staffing deficits and increased worker precariousness.
They critiqued the growing reliance on health care aide staff from temp agencies, often without proper training or coordination, as their employers’ preferred strategy to fill any staffing gaps.
Finally, the women spoke about the movement of workers across floors/units within long-term care institutions without regard to limiting cross-contamination as a management decision, which contributed to devastating COVID-19 outcomes for both workers and residents.
It hurts me that I do everything for them [her employers]. I give everything for them. All my knowledge, all my skills… If they want me to do overtime, or if they want me to do seven days working straight, I do it for them. I really give everything to them, but then they can't give me a line [a permanent job] ….So I don't want to risk my life, or I don't want to risk my mom or my child getting sick to be a superhero if I don't have a line. They’re just using me if someone needs to have vacation… If they give me a line – a permanent line - after I've worked hard here for three years, maybe I would choose to stay. But nope, they do not. (Chesa, an immigrant from the Philippines who has worked at a private LTC facility as an HCA on a temporary basis for 4 years)
Need to centre the voices of health care aides in government decision-making
The women identified the need for an increased role for all levels of government in both regulating and investing in public forms of long-term care going forward. They stressed the need for a greater voice for health care aides in all aspects of long-term care decision-making.
This, in concrete terms, means a need to invest in both physical and human infrastructure in long-term care workplaces to ensure accessibility for residents so that health care aides have the supports that they need at work—including unions, child care, paid sick leave, and physical and mental health benefits.
In addition, the women noted the importance of regular and random inspections of long-term care facilities by Alberta Health Services, done on a surprise basis without prior notification to management. They pointed to the need to amplify, rather than dismiss, the voices of immigrant, racialized women who are health care aides. And they seek increased recognition of the essential work that lower-wage health care workers, such as health care aides, are providing during the pandemic, to move beyond suggestions that they are “just health care aides.”
HCAs are… the ones dealing one on one with them [infected residents]. Getting all the fluid that comes out. We are the ones taking all the care. ADLs [Activities of Daily Living], activities, we are the ones exposed to them. I don't think there is fair pay for all health care aides. I would say it's not. Because we're putting all the work in, more than anyone else!...HCA’s should be recognized and appreciated more. Or, I will not say more, like, fairly. (Ligaya, a Filipina immigrant who has been working at a public LTC institution as a part-time HCA for 5 years).
The twelve recommendations provided below are based on the information provided by the interview participants. These recommendations, in combination, provide guidance (rather than a detailed roadmap) on how to move forward and improve workplace standards for Health Care Aides in Long Term Care in Alberta, as well as more broadly across Canada.
Increase compensation & protections for health care aides in long-term care:
Raise hourly wages for health care aides and ensure ensure privately operated LTC institutions do not pay less than public institutions
2. Implement guaranteed paid sick days for all health care aides in long-term care;
3. Legislate higher staff-to-resident ratios within long-term care;
4. Promote unionization for health care aides in all long-term care settings;
5. Reduce or eliminate the use of temp agencies to staff health care aides in long-term care ;
6. Increase supplementary health and mental health benefits and supports for health care aides and their families;
Improve oversight, transparency, and equity within Alberta’s long-term care sector:
7. Reverse current trends toward investing further in private for-profit long-term care;
8. Increase unannounced government inspections of long-term care and implement more severe operator repercussions when standards are not followed;
9. Ensure that all health care aides in long-term care are prioritized for PPE, vaccination, and any and all other protections against current and future pandemic outbreaks;
10. Provide adequate social supports for safe and secure working conditions for health care aides in long-term care;
11. Increase diversity in leadership positions within long-term care, and implement mandatory Equity, Diversity and Inclusion training for all levels of long-term care management;
12. Ensure that the voices of health care aides are included in all decision-making processes within long-term care going forward.
These recommendations are necessary steps if we are going to get serious about addressing our LTC crisis and protecting and supporting health care aides and the vulnerable residents they serve. They come from interviews with workers in Calgary, but their experiences and recommendations are applicable across the long-term care system in all of Canada.