What is LTC??

Long-term care goes by many names: nursing home, care facility, extended care, complex care, and many more derivatives depending on geography and historical period. When I am talking about long-term care or LTC I am referring to a non-acute care environment that offers 24 hour additional care and support to those individuals who are not able to remain in their own homes due to increased needs related to activities of daily living or independent activities of daily living. LTC has a very dark history and while the similarities to the almshouses of the past are mostly dismantled many still think of LTC simply as warehouses for vulnerable older adults.

I began my career in LTC as an employed student nurse, and when I graduated with my Bachelor of Science in Nursing, I continued in this complex, often overlooked environment. As a new graduate I was often questioned as to why I would ever want to work in the LTC environment, instead of somewhere more exciting, more glamorous, more stimulating like acute care. Often this questioning came from colleagues that I worked side by side with, and it saddens me still that these nurses could not see how interesting, complex, and necessary LTC is.

I continued my education by earning my Canadian Nurse Association Gerontology Certification and a Master of Science in Aging and Health from Queens University which lead to my current role as a Clinical Nurse Educator in LTC. My role as an educator and a leader in my organization allows me to advocate for better, more person-centred care, through a lens of cultural safety, trauma-informed practice, harm reduction, and inclusivity.

Since COVID 19 LTC has been thrust to the forefront in media and public discourse. Despite this, LTC remains often misunderstood, chronically under-served, under-resourced, and under-staffed, and under-acknowledged as an essential specialty.

Who lives in LTC?

The population in LTC often consists of older adults who have declined physically or cognitively and may have one or more chronic health issues that affect their ability to function. We often hear them referred to as ‘residents’ – although this terminology is frequently under debate due to the colonial implications of the term. With acknowledgment of that debate, for the purpose of this blog I will refer to those who live in LTC as persons receiving care or PRC/PRCs.

The population in LTC is further complicated by a growing demographic of PRCs needing support with significant mental health or substance use issues, and many of these individuals are younger and more physically robust than the typical PRC in this area. This added complexity is even more challenging in older style facilities which still use 4 bed wards (as opposed to the more modern single rooms) which inter-mingle PRCs with a variety of cognitive, physical, mental health, and substance use issues resulting in interpersonal conflict both between PRCs and staff.

The term Long-term care in itself is a misnomer as the length of stay in LTC has decreased significantly. Historically a PRC would live in LTC for years, but additional supports at home, fear of the environment itself, and lack of spaces has resulted in average lengths of stay dropping from 18 months to about 4 months.

Who works in LTC?

LTC in BC is generally staffed by an interdisciplinary team consisting of:

• Health Care Assistants (HCAs): unregulated caregivers who provide the majority of the direct personal care. Ratios of HCAs to PRCs vary anywhere from 6:1 to 25:1 depending on the shift

• Licensed Practical Nurses (LPNs), Registered Nurses (RNs), or Registered Psychiatric Nurses (RPNs): regulated nursing staff who are responsible for directing the individualized plan of care, medication delivery, nursing assessment and monitoring of PRCs condition/decline/response to interventions etc. Ratios of Nurses to PRCs vary from 1:25 to 1:100 depending on the shift and discipline.

• Allied Health: consisting of some combination of Occupational Therapists (OTs), Physiotherapists (PTs) Registered Dietician (RDs), Recreation Therapists (RTs), Social Worker (SW), rehab assistants, recreation assistants. Typically, facilities are covered by these disciplines on a part time basis, usually depending on the size of the unit. Some facilitates also have a clinical pharmacist, but many are supported by a central hospital or community pharmacy instead.

• Leadership: Typically consisting of a Manager, Clinical Nurse Leader, or Director of Care, some facilities have a Clinical Nurse Educator (this is my role!)

• Physician coverage varies. Some facilities have a small core group of physicians who manage all the care of PRCs lead by a medical coordinator, yet some others are covered by community GPs and could have upwards of 50 different physicians at any time. A few facilities have Nurse Practitioners as the first point of contact – the majority of PRC care can be managed by an NP, and that which can’t is referred to the NP’s Physician partner. As a nurse, I acknowledge my bias, but this is by far the most effective way to maintain continuity of care in this environment.

Many of the staff listed above will have additional education and experience working specifically with the kind of PRCs typically housed in LTC. However, it is an entry level environment which often attracts caregivers directly out of school, or those nearing retirement who perceive (often incorrectly!) that LTC will offer a slower, more relaxed pace to end their careers. My role as an educator in LTC is to provide learning opportunities and guide these staff to resources and education opportunities that will bolster their previous clinical learning and experience and better care for the PRCs.

Join me as I work through the PIDP program to gain more formal adult education experience and apply it to my role as a clinical educator in LTC!