key: cord-0841410-11z9qbza
authors: Kirkham, Julia; Shorey, Carrie L.; Iaboni, Andrea; Quirt, Hannah; Grigorovich, Alisa; Astell, Arlene; Lin, Esther; Maxwell, Colleen J.
title: Staff perceptions of the consequences of COVID‐19 on quality of dementia care for residents in Ontario long‐term care homes
date: 2022-05-05
journal: Int J Geriatr Psychiatry
DOI: 10.1002/gps.5725
sha: 7866992a5c498a6dda78a1fcd5ec41033f13680d
doc_id: 841410
cord_uid: 11z9qbza

OBJECTIVES: The first wave of the COVID‐19 pandemic necessitated extensive infection control measures in long‐term care (LTC) and had a significant impact on staffing and services. Anecdotal reports indicate that this negatively affected LTC residents' quality of care and wellbeing, but there is scarce evidence on the effects of COVID‐19 on quality of dementia care in LTC. METHODS: From December 2020 to March 2021, we conducted a cross‐sectional online survey among staff who worked in LTC homes in Ontario, Canada. Survey questions examined staffs' perceptions of the impact of COVID‐19 on dementia quality of care during the initial wave of the COVID‐19 pandemic (beginning 1 March 2020). RESULTS: There were a total of 227 survey respondents; more than half reported both worsened overall quality of care (51.3%) and worsening of a majority of specific quality of care measures (55.5%). Measures of cognitive functioning, mobility and behavioural symptoms were most frequently described as worsened. Medical and allied/support staff had the highest odds of reporting overall worsened quality of care, while specialized behavioural care staff and those with more experience in LTC were less likely to. LTC home factors including rural location and smaller size, staffing challenges, higher number of outbreaks and less COVID‐19 preparedness were associated with increased odds of perceived worsening of quality of dementia care outcomes. CONCLUSIONS: These findings suggest that COVID‐19 pandemic restrictions and related effects such as inadequate staffing may have contributed to poor quality of care and outcomes for those with dementia in LTC.

Globally, residential care homes were disproportionately affected by the initial wave of the COVID-19 pandemic. In Canada, 70% of longterm care (LTC) residents have dementia and a majority are of advanced age (mean 83 years) and frail, 1,2 making them particularly vulnerable to the effects of COVID-19. Over 6000 LTC residents died during the first wave of the pandemic, accounting for 66% of total COVID-19 related deaths in Canada. 3 The rapid spread and serious adverse health effects of COVID-19 in LTC necessitated sustained infection control measures and exposed or magnified longstanding problems, such as chronic understaffing. 4, 5 Visitor restrictions prevented the support from family and friend caregivers and limited access to healthcare and social services. These measures and associated consequences have undoubtedly affected LTC residents' quality of care and wellbeing.

Quality of care in Canadian LTC is closely monitored via publicly reported quality indicators, including measures of key outcomes reflecting resident functioning, safety, and quality of life. [6] [7] [8] At present, we have little understanding of how these quality indices may have changed and how their measurement was impacted by the pandemic. Past studies evaluating COVID-19 and quality of care in LTC have focused on whether pre-pandemic quality is associated with COVID-19 outbreaks and deaths, on which evidence is mixed. 9 Thus, there is an important opportunity to examine effects related to COVID-19 on quality of dementia care in LTC. Specific concerns include that the isolation of residents and the loss of support and advocacy from families may have resulted in a worsening of markers of quality in LTC, such as increases in the use of physical restraints or psychotropic medications such as antipsychotics, 10, 11 which have both been widely reported among persons with dementia in other settings. [12] [13] [14] To address the dearth of empirical data in this area, we conducted a survey among staff who worked in LTC homes in Ontario, Canada during the initial waves of the pandemic. This reflects a period when Ontario LTC homes implemented strict measures including masking, visitor and activity restrictions, and resident isolation and testing protocols to limit the introduction and spread of the virus. 5 Our objectives were to (i) examine staff perceptions of the impact of the COVID-19 pandemic and related restrictions on overall quality of care and specific quality of care measures for residents with dementia; and (ii) examine the associations between staff and home characteristics and perceived worsening of dementia quality of care during the initial wave of the pandemic.

A cross-sectional online survey of staff working in Ontario LTC homes was conducted during a 12-week period from December 16, 2020 to March 12, 2021 

Staff, home, and quality of care survey items were derived based on previous LTC research team and with input from stakeholder 2partners and organizations. [17] [18] [19] 

Respondents' role in the LTC was categorized as administrator (including director of care, manager); medical (including registered, practical or licensed practical nurse, physician); BSO team member (specialized staff who support the management of residents with dementia and behavioural symptoms); or allied healthcare or support services staff (including personal support work, physical therapy, social work, recreation, dietary and environmental services). They were asked about their age, gender, ethnic/cultural identity role in the LTC home, years of LTC experience, and average days/week providing or supporting care in the LTC home (since 1 March 2020). Responses for gender were collapsed as female versus non-female (male, non-binary or gender diverse, and prefer not to answer) given small cells.

Home items captured the size (number of beds), location population size (categorized as rural/small if less than 30,000 population and urban if 30,000 or more), ownership status (government owned, notfor-profit, for profit) and COVID-19 related challenges including staffing challenges since the start of the pandemic, perceived preparedness of the LTC home for COVID-19, and reported COVID-19 outbreaks in the home (number and size of the largest outbreak for both residents and staff). For size of COVID-19 outbreaks, those who reported I don't know were coded as missing. 

There were 228 completed web surveys with an average survey length of 23 min. We excluded one respondent who identified themselves (in open text field) as a family/friend caregiver, resulting in a final analytical sample size of n = 227.

Survey respondents had a variety of professional backgrounds, representing almost all facets of LTC staffing. A majority were either BSO (30.1%) or allied healthcare or support staff (32.7%); the remainder were administrative (19.0%) or medical staff (18.1%; 

At least half of staff respondents reported that residents' status had worsened in relation to their behaviours, cognition, daily functioning, mobility, and food/fluid intake following the onset of the pandemic ( Figure 1 ; Supplementary Table S2 ).

Worsening of a majority (≥5) of individual quality of care measures was reported by 55.5% of respondents ( Figure 2 Table 3 ). 30 In an Italian study, higher rates of physical restraint use alongside more frequent psychotropic medication use were reported. 31 We found some important respondent-and home-related factors associated with staff respondent perceptions of poorer quality of care for LTC residents with dementia during the initial wave of the shown that those with better training in dementia care have higher job satisfaction, motivation, and self-efficacy in their roles. 32-34 While we did not examine these factors, they may influence staff perceptions of quality of care provided (e.g. a sense of competence in providing high quality care despite the pandemic). A more skilled staff mix is associated with higher care quality and better resident outcomes in LTC, and more training and experience may also affect the ability to provide high quality care regardless of the circumstances. 35 The medical staff category in our survey included both physicians and nurses, whose experience and involvement in day to day, direct care are varied, which may have affected their perception of the care provided.

At the home level, the association between home factors such as challenges ensuring adequate staffing, smaller size and less COVID- Note: Table 2 shows the association between LTC staff respondent characteristics and perceived worsening of overall quality of dementia care. Medical and allied healthcare/support staff type years of experience in LTC, rural/small home region, significantly more challenging perceived adequacy of staffing levels, and lesser level of COVID-19 preparedness were significantly associated with a perceived worsening of overall quality of dementia care following the onset of the pandemic in adjusted models.

Abbreviations: CI, Confidence Intervals, LTC, long-term care.

a Final logistic regression model adjusted for staff role in LTC, years of experience in LTC, region of LTC home, adequacy of staffing levels, and level of COVID preparedness.

Ontario, more crowded homes were more likely to experience more severe outbreaks. 39 The impact of COVID-19 preparedness on outcomes has not been examined in other studies, though adequate staffing has been identified as a key aspect of pandemic preparedness in LTC. 40 Our study was not designed to identify why quality of care may 

Our survey of LTC staff found that COVID-19 was associated with worsened perceived overall quality of dementia care and worsening on a majority of specific quality measures. Although the impact of the COVID-19 pandemic beyond mortality in LTC is yet to be well described, this study suggests that poorer quality of care may be one Table 3 shows perceived worsening on a majority (≥5) of individual quality measures after adjusting for relevant covariates (see Supplementary Table 1 for the bivariate distribution of characteristics for this outcome). In adjusted models, staff respondents with fewer years of experience working in LTC, from smaller LTC homes, reporting greater challenges in ensuring adequate staffing since the pandemic onset, from LTC homes with a higher number of COVID-19 outbreaks, or a relatively low level of COVID-19 preparedness in the LTC homes were all significantly more likely to report perceived worsening of a majority of quality measures.

Abbreviations: CI, Confidence Intervals, LTC, long-term care.

a Final logistic regression model adjusted for years of experience in LTC, LTC home size, adequacy of staffing levels, number of outbreaks and level of COVID preparedness.

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The authors thank Ontario long-term care stakeholder partners for their involvement in developing and disseminating the survey, study participants for their engagement and time responding to the survey,

The authors have no relevant conflicts of interest to disclose.

This study was reviewed and received ethics clearance by the University Health Network Research Ethics Board (REB#20-5866) andUniversity of Waterloo Research Ethics Committee (ORE#42803).

The data that support the findings of this study are available from the corresponding author upon reasonable request.

https://orcid.org/0000-0002-9963-7073Hannah Quirt https://orcid.org/0000-0002-5326-6609