With Canadians now living longer than ever, the question of who will care for them — and under what conditions — when they can no longer care for themselves has become one of the country’s most pressing issues.
According to 2021 census data, the population aged 85 and over and 100 and over are growing at rates much faster than other population cohorts.
And the reality is that the longer we live, the more likely we are to experience chronic, multiple and complex health conditions like hypertension, osteoarthritis, heart disease, osteoporosis, chronic pulmonary disease, diabetes, cancer and dementia.
While most older people will continue to “age in place” in their own homes and in relatively good health, about eight per cent, or roughly 528,000, will require the specialized care provided in long-term care (LTC) or assisted living facilities.
This is especially true if they are experiencing progressive and intense illness or disease, disabilities or injuries, and if home care and family supports are limited.
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The LTC workforce under pressure
As the demand for long-term care grows, Canada is simultaneously witnessing an exodus of LTC workers through retirement or by seeking employment elsewhere due to chronic and sustained sector challenges, including lack of funding and the lingering impacts of the COVID-19 pandemic.
Roughly 14 per cent of the Canadian health-care workforce, or just over 50,000 people, are engaged in LTC. This number does not include every member of the care team but does include those who spend the most time providing care at residents’ bedsides.
These practitioners include personal support workers, licensed practical nurses (LPNs), registered nurses (RNs), nurse practitioners and occupational and physiotherapists — most of whom are racially diverse and female. Many feel overwhelmed and unheard.
Caring for the care providers
It is a well-worn but still valid cliché to say the pandemic shone a spotlight on longstanding challenges within LTC, including rising privatization trends and rigid hierarchical organizational structures.
During and after the pandemic, workers said they felt pulled in all directions. Overtime hours, absenteeism, mental-health issues and sick time escalated as staff performed dual roles as both workers and acting family members due to restrictive distancing protocols.
The Canadian Institute for Health Information reported that in 2023, the number of LPNs, RNs and occupational therapists declined by 6.1 per cent, 2.1 per cent and 9.1 per cent respectively. Despite of these conditions, the LTC workforce is known to go above and beyond the call of duty in providing care.
In the same year, a government consultation aimed at developing national standards for quality of care and safety in LTC reported that LPNs, aides and allied health professionals were calling for action on working conditions, emphasizing the importance of job stability, equitable wages, training, advancement opportunities, reasonable workloads and limits on mandatory overtime in support of their health, well-being and job satisfaction.
Sociologist Pat Armstrong, a leading Canadian expert in transforming care for older adults, has said that “the conditions of work are the conditions of care.” This is a poignant reminder of the critical relationship between workers and each LTC environment in the care of residents.
Her words underline a hard truth — without attending to this relationship adequately, the level of care for residents becomes compromised.
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A new model for aging well with dignity
The costs of providing LTC in large-facility settings bear further scrutiny.
The Conference Board of Canada suggested that 199,000 additional LTC beds will be needed between 2018 and 2035, an investment of $64 billion in capital spending and $130 billion in operating expenditures.
A 2021 survey of about 2,000 Canadians conducted by Ipsos and reported by the Canadian Medical Association noted that 97 per cent of those aged 65 and over are concerned about the state of Canada’s LTC system. Over 95 per cent of those same seniors said they will do everything they can to avoid moving into a LTC home.
Older people want to remain at home for as long as possible. But when they cannot, a growing global movement advocates for the development of smaller, less institutional, more home-like environments, including dementia-friendly communities, to care for older people, especially those living with dementia.
These new models are expanding across Canada, based on the De Hogeweyk Care Concept developed in the Netherlands in the 1990s, with the first village established in 2009. These villages offer settings that support social interaction and engagement in everyday life, provide access to outdoor spaces and gardens and help people retain dignity and autonomy for as long as possible.
For people living with dementia and older adults who desire to remain at home as long as they can, this is a silver lining.
Evidence is growing that these inclusive, age-friendly, home-like settings not only give residents a greater sense of comfort, control and autonomy; they also also provide an environment for direct-care workers to thrive and do meaningful work that makes a difference in their lives and in the daily lives of those they care for.
Creating environments that better support the conditions of care — quality of life for residents and workers, and having care labour recognized, respected and adequately remunerated across all sectors, with opportunities for training and career advancement — will encourage long-time workers to remain in the sector and help ensure that new health-care graduates continue to see LTC as a viable and rewarding career path.
If Canada wants to ensure dignity in aging, it must treat care work as essential infrastructure.
