Setting the Context
While there are many personal and environmental factors which impact healthy ageing, it is essential to have available and appropriate health, social, and community care providers, with the knowledge and expertise needed to care for older Canadians. Unfortunately, there are still no mandatory training requirements around providing care for older adults for most future health and social care professions in Canada. As a result, many of the current core and postgraduate training programs for health and social care professionals provide insufficient exposure towards understanding and managing the specific issues in caring for an ageing population.
Care providers represent a variety of professional backgrounds, beyond doctors and nurses, such as occupational therapists, physiotherapists, pharmacists, social workers, recreational therapists, personal support workers or care aides and others. In an assessment conducted on behalf of the Council of Ontario Universities of the core training curricula of 76 training programs for health and social care professionals, only half indicated having, “a required seniors care, gerontology, or geriatrics course”.[1] The survey also demonstrated that only half of the programs reported offering, “a required clinical or practicum experience with a focus on seniors care, gerontology or geriatrics”.[2] This Ontario report, however, reflects the variability and general lack of standardized training requirements related to the care of older adults that exists across Canada.
Furthermore, these findings illustrate that training in the care of older adults in Canada is lacking across the spectrum of care professionals, and not merely limited to physicians and nurses. There is a fundamental mismatch between the current training provisions and the fact that older Canadians are the greatest users of the health care system. Therefore, ensuring that Canada has a health human resources strategy that educates and trains professionals in care of older people will be essential.
What Is the Issue?
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Canada Does Not Have a National Health and Social Care Human Resources Strategy to Meet the Needs of the Ageing Population.
Current Canadian demographic trends estimate that the numbers of Canadians 65 and over and 85 and over will respectively double and quadruple over the next two decades. Compared to other developed countries around the world, Canada noticeably falls behind in both recognizing and preparing its health and social care professionals to meet the growing need for geriatrics expertise. When looking at the supply of physicians with training in geriatrics for example, both larger and smaller countries such as the United Kingdom and Iceland, have prioritized the training and hiring of geriatricians (see Box 5 for an Iceland vs Canada Comparison[3],[4],[5]). In 2018, the Canadian Medical Association reported that there are 304 geriatricians in Canada.[6] While Canada has 1 certified geriatrician for every 14,689 older Canadians[7], the disparity becomes even more pronounced at the provincial and territorial level – with four provinces and territories having either none or only one geriatrician to serve their entire population.[8] Another way of illustrating the existing health human resources mismatch can be understood by looking at the ratio pediatricians to geriatricians. For example, in 2018, there were approximately 304 geriatricians serving 6.6 million older adults in Canada, while at the same time, 2,887 pediatricians served 8.1 million children and adolescents under the age of 20.[9],[10],[11]
Box 5. International Case Example – Access to Geriatricians in Iceland and Canada
Iceland
Population: 330,000
Individuals >65: Approximately 44,000
Number of Practicing Geriatricians: 24
Geriatrician to > 65 Population Ratio: 1:1,833
Canada
Population: 37 million
Individuals >65: Approximately 6.6 million
Number of Practicing Geriatricians: 304
Geriatrician to >65 Population Ratio: 1:21,686
As the number of older adults already exceeds children under 15, planning for this shift is essential. Geriatricians play an essential role in supporting older adults to remain healthy and independent for as long as possible. Geriatricians often provide more appropriate cost-effective care when supporting people with more complex and inter-related health and social care needs. For example, evidence suggests that geriatric assessments in hospital have the ability to, “reduce short-term mortality, increase the chances of living at home at one year and improve an older person’s physical and cognitive function”.[12] Each of these outcomes can save costs within the health system, which is an important factor in determining whether geriatric training and resources should be prioritized.
The reasons behind the shortage of geriatric specialists are multifactorial. Geriatricians were traditionally some of the lowest paid specialists, until recently. In addition, the lack of focus on geriatric medicine in medical school curricula as well as the insufficient number of residency training programs are also barriers. Only 11 of the 17 Canadian medical schools offer an accredited geriatrics residency program.[13] No Ontario medical school, for example, currently offers core training in geriatrics, but every school offers core training in pediatrics despite that the majority of patients in the health system are likely to be older people.[14]
A lack of geriatricians, however, is only part of the larger health human resources and training challenge related to meeting the future care needs of older Canadians. Across the health care system and within the communities, other health and social care professionals interact with older Canadians with a much higher frequency than specialized physicians such as geriatricians or family physicians with additional training in care of the elderly. However, many professional training programs have no stated mandatory training requirements in care of older adults. Table 10 illustrates this finding for occupational therapy, pharmacy, nursing, and paramedicine as examples. In addition, health and social care trainees are provided with limited exposure to geriatrics, and to care settings such as nursing homes, rehabilitation and home and community care settings, where older adults are often the main recipients of care.
Table 10. Summary of Professional Accreditation Bodies, Competency Statements Sources and Requirements for Training around the Care for Older Canadians
Profession & Accrediting Body |
Competency Statements |
Geriatric Training as a Requirement? |
| Occupational Therapists;
Association of Canadian Occupational Therapy Regulatory Organizations |
|
|
| Pharmacists; National Association of Pharmacy Regulatory Authorities |
|
|
| Registered Nurses; Canadian Nurses Association | Framework for the Practice of Registered Nurses in Canada[15] |
|
| Paramedics; Canadian Medical Association (CMA) |
|
|
Adapted from McCleary, Boscart, Donahue & Harvey (2014)[16]
As Table 10 illustrates, national accreditation standards do not adequately emphasize training in the care of older adults. Given this lack of emphasis in national accreditation standards, many of the publicly funded training programs have not prioritized this training in their curricula. An adequately trained workforce that has the knowledge and skills needed to care for an ageing population needs to become a national priority. Encouraging and supporting the development of continuing educational opportunities for the existing workforce that focus on care for older people needs to occur as well.
Compounding the lack of appropriately trained health care professionals is an overall lack of care workers to adequately meet the needs of the older population. The health and social care sectors face serious human resource shortages. Therefore, in addition to curricula changes, sufficient numbers of professionals will be required – in particular geriatricians, geriatric psychiatrists, family physicians, nurse practitioners, nurses, physician assistants, social workers, pharmacists, therapists, paramedics, and personal support workers. Continuing to support the development of team-based care environments will also be integral to promoting the inter-professional care that older adults particularly benefit from. And with an ageing workforce,[17] ensuring that barriers to training are removed and that compensation for specialists trained in the care of the elderly is adequate will be just as important as ensuring that nurses and personal support workers, upon who much of the care for this population will depend, are valued and supported.[18]
The COVID-19 pandemic has revealed how vulnerable the staffing of Canadian LTC – or nursing homes – are to pandemics. As of September 2020, COVID-19 has killed 9,238 people, with 76.4% of them residing in 1,280 Canadian nursing or retirement homes. The case-fatality rate of residents who contracted COVID-19 in these settings has been a stunning 37.45% compared to an overall rate of 6.5%.[19] Furthermore, NIA researchers determined that during Canada’s first wave of COVID-19, older Canadians had a 73.7 fold greater chance of dying from it if they lived in a nursing or retirement home versus their own private dwelling.[20]
The reasons stem from the demographic features of the close to 500,000 Canadians who live in residential care homes that make them highly vulnerable to dying from COVID-19.[21] While the average age of a Canadian nursing home resident is 82 years of age, the majority live with dementia and multiple comorbidities requiring them to take more than 10 medications on average.[22],[23] Furthermore, 86% of Canadian nursing home residents require support with their basic activities of daily living such as dressing, toileting and feeding.[24] The high prevalence of dementia makes it further challenging for them to recognize and report symptoms their own of COVID-19.
The frail nature of those Canadians living in LTC settings is not aided when the majority of these settings report chronic staffing recruitment and retention challenges.[25] In Quebec, the provincial objective of having one staff member per eight residents in both hospitals and LTC homes was not met, especially during the pandemic, which witnessed ratios as low as 1 staff to 16 residents.[26] Overall in Canada, the Canadian Institute for Health Information reported the total direct care hours per resident day was 3.30.[27] As of 2018, the Ontario nursing homes report an average of 3.73 direct hours of care per resident, per day, short of the recommended minimum daily average of 4.1 hours of direct care per resident[28] The Canadian Centre for Policy Alternatives estimates that It would cost around $1.6 billion to meet this gap in care hours.[29] While demand for LTC has increased, shortages exist in the workforce for nurses and personal support workers, as a result, staff do not have enough time to provide high-quality care to residents.
Those who staff LTC settings also consist of a higher percentage of immigrant and visible minority women compared to other professions.[30] Furthermore, the share of Canadian immigrants that characterize this workforce has grown more quickly than other occupations, from 22% in 1996 to 36% in 2016. In larger metropolitan areas such as Toronto and Vancouver, over 70% of these workers are immigrants.[31] Despite this, these workers are more likely to have post-secondary education compared to their non-immigrant colleagues and tend to be paid less than their counterparts working in a hospital for similar work.[32] In addition, they are more often employed on a part-time basis without benefits or paid sick leave, and prior to the pandemic they would often work across multiple care settings.[33] Historically, provincial legislation such as Bills 29 and 94 introduced in 2001 and 2003 in British Columbia violated the collective bargaining rights of non-hospital health care workers. Over the last decade in British Columbia, more than 10,000 health care workers were laid off and then subsequently rehired at lower wages.[34],[35],[36] Finally, the high staff turnover that exists in LTC settings made pandemic preparedness difficult to implement and maintain, such as ensuring all staff were properly educated around infection prevention and control methods.[37]
Evidence-Informed Policy Option
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Develop a National Health Human Resources and Education Strategy to Meet the Needs of an Ageing Population
The planning and delivery of health and social care services is largely a provincial and territorial responsibility, while the training curricula for the regulated professionals are largely guided by national accreditation standards developed by professional colleges and societies. There is a clear disconnect between health human resource training and employment strategies at both the regional and national levels. There is an opportunity for the provinces and territories to partner with the federal government to understand and collectively address current and future health human resources issues. While the federal government is not in a position to create mandatory training requirements, they can nonetheless emphasize the importance of appropriate geriatrics knowledge and skills acquisition in entry-to-practice and continuing professional development programs – especially when the training and employment of Canada’s health and social workforce is largely funded by the taxpayers.
-
Stabilize the Workforce in LTC Homes through the Implementation of Better Employment Policies
The health care provider staff in Canadian LTC settings make up the backbone of this system and are responsible for the overall health and wellbeing and in supporting the daily activities of living for residents, whose care needs have only been intensifying over the past decade.[38] Prior to the pandemic, provinces and territories struggled with chronic staffing issues as a result of employment policies that have supported the provision of lower wages, and more part-time work with fewer to no benefits for LTC providers compared to their acute care colleagues.
Over the pandemic, all provinces/territories have implemented policies to limit staff from working in more than one care setting. Provinces like British Columbia went the furthest in announcing their strategy early in the pandemic to offer every LTC worker full-time pay with a standardized wage rate during the pandemic.[39]
Beyond the pandemic, greater consideration should be given to the offering of mostly full-time employment with wage parity and benefits, such as pensions and sick leave in LTC settings at the same level that may be done in local publicly-funded hospitals. This can help reduce the significant recruitment and retention problems that exist in this sector. According to the Canadian Foundation for Healthcare Improvement (CFHI) and the Canadian Patient Safety Institute (CPSI), nurses are not at wage parity with their hospital counterparts, with the exception of jurisdictions like Saskatchewan. Other jurisdictions like Alberta, Ontario and Quebec have either made across the board increases in salaries or offered hazard pay bonuses during the pandemic.[40] In addition to wage parity, single-site staffing should be continuously enabled to help minimize the possibility of transmitting infections between multiple care settings. Indeed, home care workers in Ontario, B.C., and Nova Scotia have also noted that being offered a work schedule that could minimize travel between clients and gaps in their workdays would help them provide better care.[41]
References
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[2] McCleary, L., Boscart, V., Donahue, P., Harvey, K. (2014). Core curricula for entry-to-practice health and social care worker education in Ontario. Council of Ontario Universities. Available at: http://cou.on.ca/policy-advocacy/health-education/pdfs/core-curricula-for-entry-to-practice-health-and-so.
[3] European Union Geriatric Medicine Society. (2016). Icealand. Available at: http://www.eugms.org/our-members/national-societies/iceland.html.
[4] Statistics Canada. (2020). Population estimates on July 1st, by age and sex. Available at: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710000501
[5] The Canadian Medical Association (2018). Geriatric Medicine Profile. Available at: https://www.cma.ca/sites/default/files/2019-01/geriatric-e.pdf
[6] The Canadian Medical Association (2018). Geriatric Medicine Profile. Available at: https://www.cma.ca/sites/default/files/2019-01/geriatric-e.pdf
[7] Statistics Canada. (2020). Population estimates on July 1st, by age and sex. Available at: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710000501
[8] The Canadian Medical Association (2018). Geriatric Medicine Profile. Available at: https://www.cma.ca/sites/default/files/2019-01/geriatric-e.pdf
[9] The Canadian Medical Association (2018). Geriatric Medicine Profile. Available at: https://www.cma.ca/sites/default/files/2019-01/geriatric-e.pdf
[10] The Canadian Medical Association (2018). Pediatrics Profile. Available at: https://www.cma.ca/sites/default/files/2019-01/pediatrics-e.pdf
[11] Statistics Canada. (2020). Population estimates on July 1st, by age and sex. Available at: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710000501
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[13] Royal College of Physicians and Surgeons of Canada. (2019). CanERA – Canadian Excellence in Residency Accreditation. Available at: http://www.royalcollege.ca/rcsite/accreditation-pgme-programs/accreditation-residency-programs-e
[14] Monette, M. (2012). Arm-twisting Medical Schools for Core Geriatric Training. Canadian Medical Association Journal. 184(10), pp. 515-516.
[15] Canadian Nurses Association. (2007). Framework for the practice of registered nurses in Canada. Available at: https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/framework-for-the-pracice-of-registered-nurses-in-canada.pdf?la=en
[16] McCleary, L., Boscart, V., Donahue, P., Harvey, K. (2014). Core curricula for entry-to-practice health and social care worker education in Ontario. Council of Ontario Universities. Available at: http://cou.on.ca/policy-advocacy/health-education/pdfs/core-curricula-for-entry-to-practice-health-and-so.
[17] Government of Canada, Special Senate Committee on Aging. (2009). Canada’s aging population: Seizing the opportunity. Ottawa, Ontario. Available at: http://www.parl.gc.ca/Content/SEN/Committee/402/agei/rep/AgingFinalReport-e.pdf
[18] Government of Ontario. (2011). Ministry of Health and Long-Term Care. Ontario Creating Registry for Personal Support Workers, McGuinty Government Working With PSWs to Deliver Quality Health Care. Toronto, Ontario.
[19] National Institute on Ageing. (2020). NIA Long-Term Care COVID-19 Tracker. Available at: https://ltc-covid19-tracker.ca/. Updated September 17, 2020. Accessed September, 2020.
[20] Sepulveda, E.R., Stall, N.M., Sinha, S.K. (2020). A Comparison of COVID-19 Mortality Rates among Long-Term Care Residents in 12 OECD Countries, Journal of the American Medical Directors Association, doi: https://doi.org/10.1016/j.jamda.2020.08.039
[21] Statistics Canada. (2016). Type of Collective Dwelling (16), Age (20) and Sex (3) for the Population in Collective Dwellings of Canada, Provinces and Territories, 2016 Census – 100% Data. Available at: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/dt-td/Rp-eng.cfm
[22] Canadian Institute for Health Information. (2013). When a Nursing Home is Home: How do Canadian Nursing Homes Measure Up on Quality? Available at: https://secure.cihi.ca/free_products/CCRS_QualityinLongTermCare_EN.pdf
[23] Ontario Long-Term Care Association (2019). About long-term care in Ontario: facts and figures. Available at: https://www.oltca.com/oltca/OLTCA/Public/LongTermCare/FactsFigures.aspx#Ontario’s%20long-term%20care%20residents%20(2015-2016)
[24] Ontario Long-Term Care Association (2019). About long-term care in Ontario: facts and figures. Available at: https://www.oltca.com/oltca/OLTCA/Public/LongTermCare/FactsFigures.aspx#Ontario’s%20long-term%20care%20residents%20(2015-2016)
[25] Choiniere, J., & Lowndes, R. (2018). Tensions for Registered Nurses in Long-Term Residential Care. In P. Armstrong & R. Lowndes (Eds.), Negotiating Tensions in Long-Term Residential Care: Ideas Worth Sharing (p. 75 – 82). Montreal, Quebec: RR Donnelley. Available at: https://www.policyalternatives.ca/sites/default/files/upl oads/publications/National%20Office/2018/05/Negotiat ing%20Tensions.pdf
[26] Levesque, L. (2020) The attendants’ turn to cry out for exhaustion. Available at: https://www.lapresse.ca/actualites/sante/201802/02/01-5152464-au-tour-des-preposes-aux-beneficiaires-de-crier-a-lepuisement.php
[27] Canadian Institute for Health Information. (2013). Residential Long-Term Care Financial Data Tables. Available at: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC2740
[28] Government of Ontario. (2020). Long-term care staffing study. Available at: https://www.ontario.ca/page/long-term-care-staffing-study.
[29] Canadian Centre for Policy Alternatives. (2020). What does it cost to care? Available at: https://www.policyalternatives.ca/publications/reports/what-does-it-cost-to-care
[30] Statistics Canada. (2020). The contribution of immigrants and population groups designated as visible minorities to nurse aide, orderly and patient service associate occupations. Available at: https://www150.statcan.gc.ca/n1/pub/45-28-0001/2020001/article/00036-eng.htm
[31] Statistics Canada. (2020). The contribution of immigrants and population groups designated as visible minorities to nurse aide, orderly and patient service associate occupations. Available at: https://www150.statcan.gc.ca/n1/pub/45-28-0001/2020001/article/00036-eng.htm
[32] Statistics Canada. (2020). The contribution of immigrants and population groups designated as visible minorities to nurse aide, orderly and patient service associate occupations. Available at: https://www150.statcan.gc.ca/n1/pub/45-28-0001/2020001/article/00036-eng.htm
[33] McMichael, T. M., Currie, D. W., Clark, S., Pogosjans, S., Kay, M., Schwartz, N. G., … & Ferro, J. (2020). Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine, 382(21), 2005-2011. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa2005412
[34] The Queen’s Printer – British Columbia. (2001). Bill 29 – 2002 health and social services delivery improvement act. Available at: https://www.bclaws.ca/civix/document/id/lc/billsprevious/2nd37th:gov29-1
[35] The Queen’s Printer – British Columbia. (2003). Bill 94 – 2003 health sector partnerships agreement act. Available at: https://www.bclaws.ca/civix/document/id/lc/billsprevious/4th37th:gov94-1
[36] Harnett, C. (2018). NDP to repeal Liberal-era health-sector labour laws. Available at: https://www.vancourier.com/sports/ndp-to-repeal-liberal-era-health-sector-labour-laws-1.23491940
[37] The Centers for Disease Control and Prevention. (2020). Preparing for COVID-19 in Nursing Homes. Available at:
[38] The Vector Poll. (2017). The Vector Poll – Canadian Federation of Nurses Unions Membership Poll on Long-Term Care and Home Care Conditions. Retrieved from: https://nursesunions.ca/wp-content/ uploads/2017/10/Vector-Poll_2017_HomeCareLongTerm Care_Summary.pdf
[39] Hanger, M. & Woo, A. (2020). B.C. health officer takes over nursing-home staffing as coronavirus spreads. Available at: https://www.theglobeandmail.com/canada/british-columbia/article-bc-health-officer-takes-over-nursing-home-staffing-as-coronavirus/
[40] Canadian Foundation for Health Care Improvement, & Canadian Patient Safety Institute. (2020). Reimagining Care for Older Adults: Next Steps in COVID-19 Response in Long-Term Care and Retirement Homes (Rep.). Retrieved August, 2020, from CFHI, website: https://www.cfhi-fcass.ca/docs/default-source/itr/tools-and-resources/reimagining-care-for-older-adults-covid-19-e.pdf
[41] Panagiotoglou, D., Fancey, P., Keefe, J., & Martin-Matthews, A. (2017). Job Satisfaction: Insights from Home Support Care Workers in Three Canadian Jurisdictions. Canadian Journal on Aging, 36(1), 1-14. Doi: 10.1017/S0714980816000726