Voices from the field: Nurse practitioners speak about LTC during the COVID-19 Pandemic


We would like to thank RNAO’s NP Long-term Care (LTC) Council for contributing the following article. It builds on the collective experience of nurse practitioners (NP) participating in RNAO’s NPs in LTC Council webinars. For information about the council please contact Ann-Marie Morris amorris@rnao.ca or Council Co-Chair Kaitlan Laviolette, NP kaitlan.laviolette@hch.ca.

As nurse practitioners working in long-term care (LTC), we bring a unique perspective on the reality of working in Ontario’s LTC homes.

It is no secret that the COVID-19 virus has disproportionately affected the older population, especially those living in congregate care settings. We were saddened to hear – throughout the course of the COVID-19 pandemic – nothing but negative and horrific reporting about LTC. It is now well documented that the sector is broken, and the COVID-19 pandemic has shattered the deep crack that has existed for many years.

What has not been reported are the extreme sacrifices, enthusiasm, and passion that LTC staff bring to their work everyday to care for our complex frail seniors. With changing government regulations restricting visitors into facilities, staff has often stepped in for family, providing comfort and socialization, while at the same time remotely supporting families. We are often the only ones there to hold the hand of a resident as they take their last breath, when their family cannot be with them. Interprofessional teams in LTC continue to work tirelessly to prevent the spread of COVID-19, while striving to improve the quality of life for our residents and their families. We believe that the foundation of our work is about honoring the residents as individuals, providing compassionate care, as well as minimizing social isolation for our residents and their families.

The impact that the pandemic has had on LTC over the past year and more, has proven to be a platform for many powerful voices; however, the voices reflecting the day-to-day realities of those who work in LTC go unheard. LTC is probably the highest regulated health-care sector in Ontario. The strict Long-Term Care Homes Act and its accompanying regulations provide little room to think outside of the box. Ministry of LTC inspectors can walk in the door at any moment, day or night and inspect the home and document their findings in a report. Rather than beginning a collaborative process with the homes, these reports provide various levels of punitive orders with no mention of areas of achievement in the home. In the current COVID-19 context, additional inspections from public health and the ministry of labour have added to the stress and strain on the limited staff in an already underfunded sector. As a result, the inspection reports leave staff with a deflated feeling of failure and destroy their morale. This ultimately drives away staff who have worked so hard within the current system, especially now during the COVID-19 pandemic.

Instead of a fear-driven system, LTC facilities need positive feedback and a collaborative approach from the ministry, public health and other system partners. This collaborative effort will ultimately lead to changing the narrative about LTC among all stakeholders, including members of the media, which generally report only the negative aspects of this sector.

The pandemic has put a spotlight on the long-standing systemic issues that have plagued LTC care for decades. Unfortunately, we are seeing evidence from all levels of government that we are not on a path to positive reform. The administrative burden that we face because of the pandemic is crushing. It has taken away the purpose for which we are all working in LTC, which is to provide excellent quality of care to our complex older population. The voice of front-line LTC staff is missing from the table when it comes to policy and legislative change. Examples of this can be seen frequently, such as the government’s decision in wave one of the COVID-19 pandemic to limit health-care workers to only one LTC home. While the decision was necessary to prevent transmission of the virus, inadequate staffing even before the pandemic, little advance notice of the change, and no salary supports to enable the staff to earn a living wage while restricted to one setting, meant that many facilities were left scrambling to fill shifts to care for our residents. In the same way, the decision to mandate security guards as third-party oversight demonstrates the lack of insight and understanding of the sector and the fact that these facilities are people’s homes. Rash decisions seem to be made followed by back peddling after implementation. Thoughtful feedback and discussion are often lacking.

We believe the system can be fixed, and as a start, consideration should be given to once again merging the Ministry of Health and Ministry of Long-term Care. If that is not feasible, then establish a new position of chief medical officer of LTC. This position could be a nurse practitioner. Increased funding for staffing and an appropriate skill-mix must be a top priority, including PSWs, RPNs, RNs and NPs, as called for by RNAO’s Nursing Home Basic Care Guarantee (NHBCG). This call has now been echoed by Associate Chief Justice Frank Marrocco in his Ontario Long-Term Care COVID-19 Commission report. This is a must to meet the increasing complexity of individuals now living in LTC.

Nurse practitioners demonstrate robust expertise and deep knowledge of nursing and medical practice, and throughout this pandemic, contributed their expertise, enhancing the health of residents in the 60 nursing homes where we work. We also developed urgently needed new processes, policies and procedures in LTC facilities. NPs are highly regarded by the frontline staff and leadership team. Again, reflecting RNAO’s NHBCG, and based on our lived experience, our LTC NP Council is recommending one (1) an NP position for every 120 residents with no less that one (1) NP in every LTC facility. This is foundational to improve the quality of care to our LTC residents and to ensure residents receive the right care, at the right time, in the right place. The LTC Commission report recognized that NPs are underutilized in LTC and adopted this recommendation (see Recommendation 46).

As nurse practitioners working in LTC, we are passionate, knowledgeable, and committed to our work and a better future for the residents, families and staff colleagues. We are eager to shed light on the current reality of LTC. It has been too long that we and our colleagues have been silent.