The Changing Face of Long-Term Care

Long-term care (LTC) provides care and services for adults with significant health challenges and/or dementia, who require 24/7 access to nursing care and supervision. Over the past several years, the LTC sector has undergone profound change. In Ontario today, adults are entering into LTC more frail and in need of more medical and personal care than ever before (Ontario Long-Term Care Association, 2018). Today, over 90% of residents in LTC have two or more chronic conditions and two-thirds have dementia. In the last five (5) years, there has been a sharp rise in the complexity and frailty of LTC residents. For example, between 2012 and 2017 LTC has seen the number of residents who need extensive or complete help with activities of daily living increase from 77% to 85% (Ontario Long-Term Care Association, 2018).

In Ontario, the median wait time for LTC in 2016/17 was 149 days for residents waiting at home, and 92 days for residents waiting in a hospital (Health Quality Ontario, 2018). These wait times will only increase as adults continue to age and be in further need of LTC services. As the care needs of today’s new residents in LTC increase, so will the workloads of LTC teams, especially Personal Support Workers (PSWs), who are also called Resident Care Attendants or Health Care Aides.

What is a Personal Support Worker (PSW)?

Personal Support Workers provide supportive care to individuals across the lifespan including clients experiencing cognitive impairment, physical disability and mental health challenges, by assisting them with their activities of daily living.

For more information, see Personal Support Worker Program Standard (Ministry of Training, Colleges and Universities, 2014).

PSWs comprise 72.3% of the nursing and support staff in LTC (Ontario Long-Term Care Association, 2014). PSWs are integral members of the LTC team because they help residents with their activities of daily living, they provide comfort and social engagement, they report changes in resident needs, and they liaise with their friends and families. The number and role of PSWs is growing and changing within this changing face of LTC.

“They (PSWs) contribute to the quality of life of individuals who live in facilities and at home by promoting their independence; dignity; social, emotional and physical well-being; mobility; personal appearance; comfort and safety.” — Ontario Community Support Association, 2009, p. 2

Recruitment and Retention of Personal Support Workers in Long-Term Care

In spite of the critical roles PSWs play in LTC, there are not enough PSWs available and interested in working in LTC. A number of factors contribute to the growing worries about the future workforce and the ability to have sufficient PSWs to meet care needs:

  • Size of workforce in relation to increasing size of older adult population. The number of working age adults to support older adults is shrinking. In 1971, there were 6.6 working adults per older adult. In 2012, that number dropped to 4.2, and in 2036 it will drop further to 2.2 (Statistics Canada). As a result of this overall workforce shortage, LTC homes will increasingly compete to be seen as the employer of choice within the health care sector to recruit sufficient and competent staff.
  • Career appeal. LTC is not always perceived as an attractive work setting, nor as a preferred career path for graduates in health care. There are several reasons for this negative stigma, including ageism, stereotyping of LTC homes, limited understanding and exposure to LTC homes (Happell, 1999), low compensations (as compared to other care settings), and few role models and leaders promoting LTC as an attractive career choice (Levett-Jones, Lathlean, McMillan and Higgins, 2007). It is important to have new graduates who fully understand the LTC context as this LTC exposure can greatly improve and change the perception of graduates entering into LTC.
  • Competition for PSWs across health care sectors. Recent increases in government funding for community care, and new hiring practices of PSWs in acute care settings means increased competition and a shrinking pool of PSWs to work in LTC.
  • Retention of PSWs in the workplace. In Ontario, it is estimated that there are 90,000 PSWs working in health care. From this number, 57,000 PSWs work in LTC homes, 26,000 work in home care, and 7,000 work in hospitals (Personal Support Network of Ontario, 2011). Moreover, Ontario trains roughly 7,000 PSW students a year and yet, approximately 9,000 PSWs are lost to attrition every year (Personal Support Network of Ontario, 2009).

The above statements indicate that there are significant challenges in educating, recruiting and retaining PSWs to meet future workforce needs in LTC. Therefore, there is a case for action.

“Changing the way we educate health care providers is key to achieving system change and to ensuring that health care providers have the necessary knowledge and skills to work effectively in interprofessional teams within the evolving health care system.” — Carstairs and Keon, 2009, p. 148

Challenges for Post-Secondary Education for Personal Support Worker Education

Community colleges, continuing education programs and private career colleges all offer PSW programs. There are three challenges in relation to having sufficient PSWs with the capabilities needed to meet system requirements:

  • PSE enrollment challenges: Demographic shifts in the school system are resulting in fewer high school graduates. Hence, fewer prospective applicants are enrolling in PSE. At the same time, increasing numbers of mature individuals, including those working as PSWs, are returning to school to upgrade. Both situations place new challenges on PSEs to be able to reach out to potential applicants and attract them to careers such as PSW. Without increasing the number of students, it will not be possible to increase the number of PSW graduates.
  • Provincial standards: Historically, there have been different lengths of programs across the different providers and perceived differences in the quality of the graduates. As of September 2015, all providers of PSW education in Ontario are required to offer programs that meet the new provincial standard for PSW programs.
  • Quality of graduates: Notwithstanding the fact that all programs as of September 2015 must adhere to provincial standards and their related outcomes, there are still varying approaches to delivery and varying experiences with the quality of placement opportunities with LTC homes.

These concerns support the need for system-wide innovation in educating individuals who will contribute to continual improvement in LTC and the need to build collaborative relationships between LTC homes and PSEs.

Aligning Personal Support Worker Preparation and Long-Term Care Realities

Aligning what students learn in PSW preparation programs and how PSWs actually practice in the LTC environment is a challenge. Disconnects can be the result of PSEs not being sufficiently up-to-date on the current approaches and care practices in LTC homes (Pollard, 2008). Sometimes it is because LTC homes do not follow best practices in the way PSWs should be enacting their roles. In an ideal world, the learning environment mirrors the practice environment and vice versa. However, in reality, this is rarely the case in today’s LTC and PSE environment.

Most PSEs make considerable effort to expose PSW students to workplace environments through clinical placements, however, the opportunities available are limited and variable. High quality and effective clinical experiences require a commitment from the placement site (whether LTC, acute care or community care) to provide mentorship and guided preceptorship. However, unfortunately, this commitment does not always occur. As a result, students are not exposed to experienced practice leaders in these settings (Robinson, Abbey, Abbey, Toye and Barnes, 2009).

In today’s reality, LTC homes struggle with recruiting and retaining confident and competent PSWs to meet the various health care needs of residents in LTC. Living Classrooms (LCs), where PSE programs and LTC can co-exist on the same site, offer an innovative solution to these challenges.

Opportunities for New Value and Mutual Gain with the Living Classroom

An alliance between a LTC home and a PSE can address some of the challenges that each organization faces in regards to education of students and recruitment and retention of PSWs. From our experience, we demonstrated that such a relationship is both viable and impactful to meeting the workforce challenges in LTC. Our two organizations have united to create and implement a LC. Since 2008, we have learned much about how to integrate education into a LTC home operation.

Table 1: System Challenges Addressed by the Living Classroom

ChallengesLiving Classroom Contributions
LTC Workforce Challenges
Not enough PSWs available to hire. LTC is perceived as an unattractive work setting due to ageism, limited exposure, low compensations, low training, etc.
The LC creates an opportunity for students to be integrated in an experiential learning environment. Concepts taught in the classroom are immediately translated into practical experience.
PSW Enrollment Challenges
Inability to increase enrollment in PSW programs to meet workforce needs.
The LC offers a distributed program delivery and direct links to LTC home to recruit, which may increase the ability to attract students.
LTC Education Challenge
Lack of applied and integrated education by experienced role models in LTC homes and lack of faculty with expertise.
Students work alongside PSE faculty, LTC teams, and residents and families to enhance this view of LTC. The LC can develop and share new approaches for preceptors across the system, enhancing education capacity. The LC also provides a source of information regarding new practices in LTC to on-campus education programs and an environment conducive to shared learning between educators and practitioners.
Misunderstandings between PSE and LTC
PSE faculty and the LTC team are not consistently informed of one another’s roles, schedules and understandings due to limited interfacing.
PSE faculty and LTC teams are always in contact with one another because they remain in the same infrastructure. PSE faculty and LTC teams are able to exchange information easier. LTC teams can share current practices with PSE faculty.


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