Towards equitable representation in long-term residential care: widening the circle to ensure "essential voices" in research teams.

The COVID-19 pandemic exposed long-standing inequities in Canada's long-term residential care (LTRC) sector with life-threatening consequences. People from marginalized groups are overrepresented among those who live in, and work in LTRC facilities, yet their voices are generally silenced in LTRC research. Concerns about these silenced voices have sparked debate around ways to change LTRC policy to better address long-standing inequities and enhance the conditions that foster dignity for those who live and work in LTRC. Weaving an analysis of historical and cultural attitudes about LTRC, and promising strategies for engaging people with lived experience, we argue that the voices of people with lived experience of life and work (paid and unpaid) in LTRC are essential for ethically and effectively shifting long-standing inequities. Lessons from a 4-year, national, multi-disciplinary research study, known as the Seniors Adding Life to Years (SALTY) project, suggest that resident-determined quality of life can be prioritized by centring the perspectives of residents, their family/friends, direct care workers, volunteers, and people living with dementia in the research process. Accordingly, we highlight strategies to include these voices so that meaningful and impactful system change can be realized.

This article argues that long-term residential care facilities in Canada have a long history of perpetuating social inequalities, beginning with seventeenth century poor houses and almshouses, from which long-term residential care facilities evolved in North America. We highlight that those who currently reside in long-term residential care are more likely to be people with less social power­for example women, people living with dementia, and people with low-income. These residents are rarely included in research projects as co-designers of research, co-producers of knowledge, or experts on the realities of long-term residential care. We explore strategies for addressing these underrepresented voices and inequalities in research by highlighting promising examples of resident, family, and worker-engagement emerging from a pre-pandemic to early pandemic pan-Canadian research project on quality of life in long-term residential care. We argue that long-term residential care residents, their family/friend caregivers, people living with dementia, and direct care workers have voices that are essential in residential care design and research engagement strategies. By prioritizing these voices in research, we can better amplify their critical perspectives in broader policy and decision-making processes that guide meaningful and impactful system change.

With COVID Comes Complexity: Assessing the Implementation of Family Visitation Programs in Long-Term Care.

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) pandemic visitor restrictions to long-term care facilities have demonstrated that eliminating opportunities for family-resident contact has devastating consequences for residents' quality of life. Our study aimed to understand how public health directives to support family visitations during the pandemic were navigated, managed, and implemented by staff. RESEARCH DESIGN AND METHODS: Guided by the Consolidated Framework for Implementation Research, we conducted video/telephone interviews with 54 direct care and implementation staff in six long-term care homes in two Canadian provinces to assess implementation barriers and facilitators of visitation programs. Equity and inclusion issues were examined in the program's implementation. RESULTS: Despite similar public health directives, implementation varied by facility, largely influenced by the existing culture and processes of the facility and the staff understanding of the program; differences resulted in how designated family members were chosen and restrictions around visitations (e.g., scheduling and location). Facilitators of implementation were good communication networks, leadership, and intentional planning to develop the visitor designation processes. However, the lack of consultation with direct care staff led to logistical challenges around visitation and ignited conflict around visitation rules and procedures. DISCUSSION AND IMPLICATIONS: Insights into the complexities of implementing family visitation programs during a pandemic are discussed, and opportunities for improvement are identified. Our results reveal the importance of proactively including direct care staff and family in planning for future outbreaks.

Do Residential Long-Term Care Policies Support Family Involvement in Residents' Quality of Life in Four Canadian Provinces?

Family members are essential contributors to the quality of life (QoL) of persons living in residential long-term care (RLTC). This paper analyzes how the system enables or inhibits family involvement with residents in RLTC. Our analysis of 21 policies that regulate long-term care in four Canadian Provinces reveal differences in their portrayal of residents' families. Family roles are characterized procedurally (task-oriented) or relationally (interactive). Operational standards linked to licensing of RLTC homes employ more formal terminology, while RLTC program guidelines, use facilitative language to engage families and build relationships. Examples of orientation procedures, care protocols, living at risk, and end-of-life care reveal inter-provincial variations. We argue that there are opportunities to further engage families within the current regulatory framework and improve their continued contributions in the post-pandemic era.

The Role of Volunteers in Enhancing Resident Quality of Life in Long-Term Care: Analyzing Policies that May Enable or Limit this Role.

Research has shown that long-term care (LTC) volunteers play important roles in enhancing the quality of life (QoL) of older LTC residents, often through providing unique forms of relational care. Guided by Kane's QoL domains, we used a modified objective hermeneutics method to analyze how unique volunteer roles are represented and supported in provincial policies in Alberta, British Columbia, Ontario, and Nova Scotia. We found that policies define volunteer roles narrowly, which may limit residents' QoL. This happens through (1) omitting volunteers from most regulatory policy, (2) likening volunteers to supplementary staff rather than to caregivers with unique roles, and (3) overemphasizing residents' safety, security, and order. We offer insights into promising provincial policy directions for LTC volunteers, yet we argue that further regulating volunteers may be an inadequate or ill-suited approach to addressing the cultural, social, and structural changes required for volunteers to enhance LTC residents' QoL effectively.

Long-Term Residential Care Policy Guidance for Staff to Support Resident Quality of Life.

BACKGROUND AND OBJECTIVES: Amidst a complex policy landscape, long-term residential care (LTRC) staff must navigate directives to provide safe care while also considering resident-preferred quality of life (QoL) supports, which are sometimes at odds with policy expectations. These tensions are often examined using a deficit-based approach to policy analysis, which highlights policy gaps or demonstrates how what is written creates problems in practice. RESEARCH DESIGN AND METHODS: This study used an asset-based approach by scanning existing LTRC regulations in 4 Canadian jurisdictions for promising staff-related policy guidance for enhancing resident QoL. A modified objective hermeneutics method was used to determine how 63 existing policy documents might be interpreted to support Kane's 11 QoL domains. RESULTS: Analysis revealed regulations that covered all 11 resident QoL domains, albeit with an overemphasis on safety, security, and order. Texts that mentioned other QoL domains often outlined passive or vague roles for staff. However, policy texts were found in all 4 jurisdictions that provided clear language to support staff discretion and flexibility to navigate regulatory tensions and enhance resident QoL. DISCUSSION AND IMPLICATIONS: The existing policy landscape includes promising staff-related LTRC regulation in every jurisdiction under investigation. Newer policies tend to reflect more interpretive approaches to staff flexibility and broader QoL concepts. If interpreted through a resident QoL lens and with the right structural supports, these promising texts offer important counters to the rigidity of LTRC policy landscape and can be leveraged to broaden and enhance QoL effectively for residents in LTRC.

Team-Based Integrated Knowledge Translation for Enhancing Quality of Life in Long-term Care Settings: A Multi-method, Multi-sectoral Research Design.

Multi-sectoral, interdisciplinary health research is increasingly recognizing integrated knowledge translation (iKT) as essential. It is characterized by diverse research partnerships, and iterative knowledge engagement, translation processes and democratized knowledge production. This paper reviews the methodological complexity and decision-making of a large iKT project called Seniors - Adding Life to Years (SALTY), designed to generate evidence to improve late life in long-term care (LTC) settings across Canada. We discuss our approach to iKT by reviewing iterative processes of team development and knowledge engagement within the LTC sector. We conclude with a brief discussion of the important opportunities, challenges, and implications these processes have for LTC research, and the sector more broadly.

Complaints-Based Entrepreneurialism: Worker Experiences of the Employment Standards Complaints Process in Ontario, Canada.

In Ontario, workers who face unfair working conditions have the option of filing an official complaint with the Ministry of Labour. Complaints making is characterized as a widely available, easily accessible, and free-of-cost avenue for workers who may have experienced a violation of the law. However, interviews with Ontario workers who have filed complaints tell a different story. This paper is based on a community-university project on the enforcement of the Employment Standards Act in Ontario. We draw on 36 interviews with workers employed in precarious jobs in Sudbury, Toronto, and Windsor, who filed complaints to the Ministry. Workers characterize the complaints process as rife with bureaucratic complexity, risk, and unsuccessful payouts. Their experiences shed light on the efficacy of complaint-based approaches that are often promoted as a form of "bottom-up" enforcement of employment standards (ES). We demonstrate that the current ES complaints system requires workers to enact neoliberal entrepreneurialism (rather than agentic or collective entrepreneurialism) creating a highly stressful, enormously time-consuming, and demoralizing experience. We document the increasingly individualized and contradictory avenues through which workers must act as entrepreneurs to navigate and self-advocate when their rights have been violated. We argue that the current complaint processes limit the potentially empowering impact of this strategy.

En Ontario, les travailleurs confrontés à des conditions de travail injustes ont la possibilité de déposer une plainte officielle auprès du ministère du Travail. Le dépôt d'une plainte est caractérisé comme une avenue largement disponible, facilement accessible et gratuite pour les travailleurs qui pourraient avoir été victimes d'une violation de la loi. Cependant, les entrevues avec des travailleurs ontariens qui ont porté plainte racontent une histoire différente. Cet article est basé sur un projet université-communauté sur l'application de la Loi sur les normes d'emploi en Ontario. Nous avons utilisé 36 entretiens avec des travailleurs occupant des emplois précaires à Sudbury, à Toronto et à Windsor, qui ont porté plainte au ministère. Les travailleurs décrivent le processus de traitement des plaintes comme étant bureaucratique, complexe, risqué et infructueux. Leurs expériences ont mis en lumière l'efficacité des approches fondées sur les plaintes, qui sont souvent présentées comme une forme d'application "ascendante" des normes d'emploi. Nous démontrons que le système actuel de traitement des plaintes relatives aux normes d'emploi exige des travailleurs qu'ils adoptent un esprit d'entreprise néolibéral (plutôt qu'un esprit d'entreprise agent ou collectif), créant ainsi une expérience stressante, longue et démoralisante. Nous documentons les manières de plus en plus individualisées et contradictoires selon lesquelles les travailleurs doivent agir en tant qu'entrepreneurs et plaider pour eux-mêmes afin de défendre leurs droits. Nous soutenons que les processus actuels de traitement des plaintes limitent la capacité des travailleurs à bénéficier de telles stratégies.