Care Aides Working Multiple Jobs: Considerations for Staffing Policies in Long-Term Care Homes During and After the COVID-19 Pandemic

Abstract

The ongoing COVID-19 pandemic has disproportionately affected older adults living in long-term care (LTC) homes, who have less functional immune systems, multiple comorbidities, and high levels of immobility and dementia. In Canada, 85% of COVID-19 deaths were LTC residents as of early May 2020—the highest among 14 countries.1Hsu A.T. Lane N. Sinha S.K. et al.Updated report: The COVID-19 Long-Term Care situation in Canada.2020Google Scholar In response, provincial health offices have issued numerous emergency orders and one focused on restricting health care aides to working at only 1 site.1Hsu A.T. Lane N. Sinha S.K. et al.Updated report: The COVID-19 Long-Term Care situation in Canada.2020Google Scholar, 2British Columbia Office of the Provincial Health OfficerFacility staff assignment order. British Columbia Office of the Provincial Health Officer, Vancouver, BC2020Google Scholar, 3National Institute on AgingThe NIA’s Recommended “Iron Ring” for Protecting Older Canadians in Long-Term Care and Congregate Living Settings.2020Google Scholar Health care aides represent up to 90% of the direct care workforce in LTC,4Hewko S.J. Cooper S.L. Huynh H. et al.Invisible no more: A scoping review of the health care aide workforce literature.BMC Nurs. 2015; 14: 38Crossref PubMed Scopus (118) Google Scholar and they are generally middle-aged women, with a high school diploma, and speak English as their second language.5Estabrooks C.A. Squires J.E. Carleton H.L. et al.Who is looking after mom and dad? Unregulated workers in Canadian long-term care homes.Can J Aging. 2015; 34: 47-59Crossref PubMed Scopus (79) Google Scholar The COVID-19 pandemic has placed significant demands on care aides because of increased complexity of care and adjustment to unprecedented changes in care practices and regulations as well as a significant risk for being infected. Here we comment on implications of the single-site order issued to control the COVID-19 spread. We used data from our Translating Research in Elder Care (TREC) program that surveyed 3765 care aides from 94 randomly selected and stratified LTC sites in western Canada between September 2019 and February 2020.6TRECTranslating Research in Elder Care. 2020.https://trecresearch.ca/Google Scholar Several questions specifically focus on work arrangements. Restricting care aides to a single work site may result in an abrupt decrease in care aide staffing. As shown in Table 1, nearly a quarter of care aides (24.3%, 915/3765) reported that they worked at more than 1 LTC site. On average, they worked for 16 hours a week at sites other than the primary LTC home where they held a regular position. The LTC sector was challenged by care aide shortages before the pandemic,4Hewko S.J. Cooper S.L. Huynh H. et al.Invisible no more: A scoping review of the health care aide workforce literature.BMC Nurs. 2015; 14: 38Crossref PubMed Scopus (118) Google Scholar and the current single-site order poses additional challenges to staff assignment at both the LTC home level and the provincial or regional health care system level. The British Columbia Ministry of Health has initiated a centralized staffing approach that manages staff resources at the provincial level based on the weekly updated data of worksite preference reported by employees.7British Columbia Office of the Provincial Health OfficerSingle-Site Staffing Initiative. 2020.https://bchealthstaffing.caGoogle Scholar Although the single-site order and the resultant staff assignment initiatives are implemented at the provincial level, adaptability to the local context—given the variation in the rates of using part-time and casual care aides across regions and owner-operator models—needs to be addressed. For example, according to our data, public not-for-profit and private for-profit homes had significantly higher proportions of care aides working at multiple LTC homes compared with voluntary not-for-profit (eg, faith based) homes (30.6%, 26.8% vs 18.8%).Table 1Care Aides Working in Multiple LTC Homes and Additional Job(s) in Non-LTC Locations (N = 3765)VariableFrequencyPercentWorking in multiple LTC homes91524.30Working additional job(s) in non-LTC locations56014.87Reason for working additional job(s) in non-LTC locations∗This is a “check all that apply” question. (n = 560) Financial41073.21 Cannot get a full-time position9617.14 Lighter workload407.14 Transition to a new role366.43 Other reasons12221.79Hours working in the LTC home(s) other than the primary home in the past 2 wk (n = 915), mean ± SD31.3417.75Hours working additional job(s) in non-LTC locations in the past 2 wk (n = 560), mean ± SD35.2423.81∗ This is a “check all that apply” question. Open table in a new tab The single-site order does not restrict care aides from employment outside their care aide vocation.2British Columbia Office of the Provincial Health OfficerFacility staff assignment order. British Columbia Office of the Provincial Health Officer, Vancouver, BC2020Google Scholar Our data show that approximately 15% of the care aides (560/3765) reported working the second or third jobs in locations other than LTC homes for an average of 18 hours a week (Table 1). Examples of the non-LTC locations/jobs included home care, hospital/acute care, assisted living/group homes, cleaning services, and grocery shops. The single-site order may deplete staffing availability to some degree in some non-LTC sites (eg, home care, assisted living). It may also increase the chance of being exposed to the virus and result in unknowing spread of the virus. However, tracking care aides’ work arrangement at non-LTC sites may be limited and might also raise jurisdictional and oversight issues. Clearly, in such circumstances ongoing training in infection control is even more critical, as is regular testing and sufficient personal protective equipment. Of the 560 care aides working additional job(s) in locations other than LTC homes, 73% (410/560) reported that the primary reason was financial; 17% (96/560) reported “cannot get a full-time position” as another reason (Table 1). In the short term, many provinces have increased wages and provided full-time employment with more appropriate compensation and benefits to stabilize the wrokforce.8Staff of the Canadian PressIncreasing pay for long-term care home workers high on agenda for Trudeau, premiers. Global News, 2020Google Scholar These strategies are necessary not only during the pandemic but also in the longer run, because stable staffing and continuity in care is important for residents, particularly for those with dementia.9Armstrong P. Armstrong H. Choiniere J. et al.Re-imagining Long-Term Residential Care in the COVID-19 Crisis. Canadian Centre for Policy Alternatives, Ottawa, ON2020Google Scholar Financial incentives and full-time employment together with a supportive organizational environment and favorable working conditions encourage essential workers to stay on their higher-risk jobs during these challenging times, and will also be critical to develop a long-term workforce that has sufficient resilience to confront future crises.10OECD. OECD Employment Outlook 2019: The Future of Work, Paris: OECD Publishing; 2019.Google Scholar Although limiting care aides from working in multiple LTC homes may be helpful to prevent the spread of the virus among care settings, the single-site order alone, of course, cannot provide adequate protection for residents and care providers. Several actions should be concurrent with the single-site order. In the long run, a supportive and favorable work environment will equip care aides with the resources, structures, and capacity to provide high-quality care and to themselves experience good quality of work life.9Armstrong P. Armstrong H. Choiniere J. et al.Re-imagining Long-Term Residential Care in the COVID-19 Crisis. Canadian Centre for Policy Alternatives, Ottawa, ON2020Google Scholar The authors acknowledge the Translating Research in Elder Care (TREC) team for its contributions to this study.