00;00;01;03 - 00;00;35;15
Erica Machulak
Welcome back to the Hikma Collective podcast. I'm Erica Machulak and in this mini season we’re sharing collaborations with amazing public scholars. In this episode, you will hear Dr. Farinaz Havaei talk about her work with many partners and collaborators across the long term care sector to develop pandemic resilience strategies. Hope you enjoy.
00;00;40;11 - 00;01;28;16
Erica Machulak
Hi there. I'm Erica Machulak and you are listening to a conversation with Dr. Farinaz Havaei of the University of British Columbia School of Nursing. In this conversation, Naz talks about her work in the long-term care sector during the COVID-19 pandemic with partners, collaborators and actors across British Columbia. She talks about how some unintended consequences of pandemic policies have revealed systemic issues in long-term care, and she offers recommendations for addressing these issues. Naz also talks about why this work will remain important long after the pandemic for building resilience in the health care sector and improving quality of life and conditions for long term care residents, families and health care workers. Thanks for listening.
Hey, Naz. It's great to have you here. Would you please introduce yourself for our listeners?
00;01;29;06 - 00;02;05;05
Farinaz Havaei
Sure. My name is Farinaz Havaei. I am an assistant professor at UBC School of Nursing and a health services researcher. My work focuses on studying healthy work environments and studying workplace factors that enable nurses and health, health, human resources, health care providers to deliver quality and safe patient care across the health care health care spectrum. long-term care. Acute care. Community care sector.
00;02;05;27 - 00;02;11;04
Erica Machulak
Yeah. So will you tell us a little bit more about how you became interested in this work?
00;02;11;23 - 00;04;09;11
Farinaz Havaei
Absolutely. So when COVID-19 happened, the long-term care sector, as you know very well, became the epicenter of COVID-19. And we know that over 80% of COVID related mortalities in Canada essentially happened in the long-term care sector. So to mitigate the risk of spreading COVID-19, a series of policies and procedures were introduced in the sector to essentially ensure the health and safety of residents, staff, and family members. And so in 2020, after the pandemic, our team at UBC School of Nursing was fortunate enough to receive a research grant from Michael Smith Health Research B.C., to essentially evaluate whether or not these pandemic management policies and procedures had any unintended consequences for long-term care homes, their staff, residents and also their families. And so this was a study that was conducted in one long-term care home in Vancouver. It was a case study. And so the case study resulted in very many interesting findings. But the gap that we had was that we really did not know if our findings from the case study would be applicable to other care homes in the province. And so what we did was that we successfully received another grant from MSHR BC to work with long-term care home stakeholders, and that those include leaders, operators, residents, staff, families to essentially work together and collaboratively develop recommendations in relation to best pandemic management policies and practices for long-term care homes in the province.
00;04;11;17 - 00;04;21;02
Erica Machulak
And so just to get a really zoomed out lens of the context. Naz, why was the mortality rate so much higher in long-term care during the COVID-19 pandemic?
00;04;21;22 - 00;05;13;08
Farinaz Havaei
Absolutely, I personally think it was higher due to a variety of reasons. One of them being that, you know, we are dealing with a vulnerable population, the older adult population, you know, they have a greater risk of not being able to fight the virus and survive the virus. On top of that, I personally think that there are some more longstanding systemic challenges in the sector that may have played a role in how COVID-19 essentially impacted residents’ health and safety, the rate of mortality and also the same notion for staff members, in terms of contracting COVID and at times even mortality from COVID-19.
00;05;14;08 - 00;05;27;21
Erica Machulak
Interesting, very interesting. So, in terms of your personal work and what drew you to this project, have you always been interested in long-term care? Has that always been an area of focus for you?
00;05;28;16 - 00;06;14;03
Farinaz Havaei
This is a really good question, Erica. I actually started my work in terms of, you know, studying healthy work environments and studying those factors that enable healthcare providers, particularly nurses, to deliver quality and safe patient care in the acute care sector. But when the COVID-19 pandemic happened, and because of what, you know, happened to residents in terms of mortality, in terms of, you know, contracting COVID-19. In this sector, I just felt like there was a need to shift my focus from acute care to the long-term care sector. And that is when we actually started bringing in some of our understanding and expertise from the acute care sector, to the long-term care sector.
00;06;15;01 - 00;06;28;09
Erica Machulak
And for you, in terms of making that shift, given your own perspective as a researcher and the network that you had: what were some of the most significant adjustments that you had to make to your work to change focus?
00;06;29;05 - 00;07;08;05
Farinaz Havaei
So it really meant that I needed to listen, I really needed to listen to the perspectives and experiences of those in long-term care, I needed to have really open ears and an open heart to see what their unique experiences are, their unique perspectives, their unique challenges. And so, I've really been trying to invite a variety of representatives and groups from the long-term care sector to engage in my program of research.
00;07;09;10 - 00;07;19;07
Erica Machulak
Very interesting. And so can you walk us through sort of the journey of this project from the beginning of the pandemic to now May 2022?
00;07;20;12 - 00;08;47;12
Farinaz Havaei
So back in 2020, we started a study in one long-term care home to essentially evaluate the impact of pandemic management policies and procedures on residents, their families, as well as staff just because we were interested to see if these pandemic management policies and practices had any unintended consequences for providers and users of long-term care homes. And so, we did have very many interesting findings in terms of how some of these pandemic management policies and practices sort of had some unintended consequences, just because of either their nature or because of how they were implemented in the sector. They had some unintended consequences for residents, staff and families. And so we wanted to work with our stakeholders, long-term care experts, families, residents, operators, staff to determine how those pandemic management policies and practices could be improved to more effectively manage and deal with the pandemic. You know, the current pandemic, and also future pandemics and crisis in long-term care homes in the province.
00;08;48;10 - 00;08;57;16
Erica Machulak
So how did you go about studying this? How did how did you go about moving this project forward? What was the first step?
00;08;58;16 - 00;11;41;19
Farinaz Havaei
Very good question. So one of the first things that we did in this project was essentially establishing an advisory group of long-term-care experts, including representatives from the BC Ministry of Health, including representatives from other long-term care organizations, like BC Care Providers Association, as well as LTC, or long-term-care leaders, managers, providers, residents, and even their families. We also had researchers whose expertise was long-term care, and seniors here sort of involved and included in our advisory group. So we had a relatively large advisory group, I would say probably about 10 or 15 individuals working very closely and meeting regularly to essentially inform the direction of this research. And so in addition to this advisory group, the project also had three components. We started with a survey of long-term-care operators to essentially get a sense of, you know, to what extent pandemic management policies and practices were implemented – so how frequently – and also what might have been their impact on the health and safety of staff, residents, and their families. And so we essentially use the results of the survey then to have discussion and dialogue with long-term-care stakeholders through a series of five discussion forums – five virtual discussion forums with each of the five regional health authorities in BC. So we did have a discussion forum with Vancouver Coastal Health, we did have a discussion forum with Fraser health, and so on and so forth. And then finally, we used those discussions to develop a series of recommendations for best pandemic management, and then brought together all of these long-term-care experts from all of the health authorities, as well as our advisory group to reach consensus around these recommendations that, you know, we're going to put forth. So the team essentially worked together to sort of review those recommendations and at times also to make revisions and make suggestions in terms of, you know, how certain recommendations should be worded.
00;11;43;02 - 00;11;49;24
Erica Machulak
Hmm. And what what were the conversations like? What were some of the things that you learned through these dialogues?
00;11;50;12 - 00;13;41;29
Farinaz Havaei
Absolutely. So we essentially how we started, the conversation was, you know, we introduced the project and sort of shared some of our key findings from an earlier component of the project, which was our operator survey, which essentially spoke to, you know: this is how frequently pandemic management policies and practices were implemented, and this is their impact on residents on the health and safety of residents, families, as well as staff. And so it was really interesting to essentially see that our forum participants essentially also echoed a lot of the same and similar experiences as to our, you know, long-term-care operators, based on the survey. And then, when we actually shared the results of the survey, then we opened it up for discussion and conversation and dialogue with the participants in terms of what might be some of the changes that we would like to see in some of these pandemic management policies and practices or, how do we go – if there are any issues in certain pandemic management policies and practices – how do we go about resolving them? If we had a chance to start responding to this pandemic all over again? How would we do it? What do things look like in terms of pandemic management policies and practices? And what are some of the changes that you would like to see as long-term-care stakeholders? And so we used some of those conversations and discussions then to actually turn them into recommendations for better management in long-term care?
00;13;42;13 - 00;13;46;15
Erica Machulak
And what are some of the recommendations that you think are the most critical?
00;13;47;13 - 00;15;34;20
Farinaz Havaei
So, I mean, we have a series of recommendations. They are a relatively long list of recommendations, but I could probably just give you an example. So, as you might know, the strict visitation policy is one of the pandemic management policies or strategies that was actually a really significant source of concern and frustration for long-term care, particularly long-term-care residents and families. And so the families and residents were particularly concerned about the fact that the policy was developed, without or with limited engagement with, you know, families and residents and as a result, made a recommendation for more active involvement of residents and families through their respective councils in the policy development, policy implementation, and evaluation in their perspective, if they were, or if they had their voice represented at the policymaking table, some of the issues that happened as a result of the policy would not have happened to the same extent. So the recommendation that we have put forth as a result of some of these discussions, again, is to provide opportunities for engaging families and residents in policymaking through working with their respective councils.
00;15;35;29 - 00;15;45;27
Erica Machulak
Interesting. So is there a sense in which the stressors of the pandemic have opened up these opportunities to build better human infrastructure moving forward?
00;15;46;18 - 00;16;25;01
Farinaz Havaei
Absolutely. I think it it certainly took a pandemic for us as a country, and also provincially, in British Columbia, to be paying attention to some of those shortcomings, long standing shortcomings in the long-term care sector, some of the issues and challenges that we've been dealing with in this sector for a very long time. I think the pandemic, certainly the silver lining was that it revealed some of these issues, and it sort of created a sense of urgency, in terms of responding to some of these challenges and shortcomings.
00;16;25;20 - 00;16;34;11
Erica Machulak
Urgency in what sense? I mean, of course, the sense of immediate risk, but do you think that this issue has gotten more attention because of the pandemic?
00;16;34;25 - 00;17;06;00
Farinaz Havaei
I certainly think so. I mean, we've all heard of the stories that came out of long-term care homes in Ontario. So some of the issues in terms of some of the wrongdoings in terms of resident care delivery, and you know, the government sort of calling for investigations – so on and so forth. I don't think that without the pandemic we would have taken accountability for this sector, at least to the same extent.
00;17;08;06 - 00;17;38;27
Erica Machulak
So long-term care is itself, it sounds like, quite a complicated ecosystem embedded within the broader healthcare sector, which is also very, very complicated. When you think, in the way that you have been trying to map out the pandemic strategies that were put in place across all of these different facilities: how have you broken those strategies down? Do you have categories? Do you have themes? How have you organized the information?
00;17;39;20 - 00;18;50;08
Farinaz Havaei
Really, really good question. So we actually put our pandemic management policies and procedures into seven themes and categories. And those include screening, visitation, staffing, infection prevention and control, communication, physical layout, leadership and organizational support. And how we got to these seven themes is: we use a couple of approaches. The first one being that we actually created a list of pandemic management policies and procedures, based on the findings of our earlier case study. And also then we had our advisory group, particularly our stakeholders from BC Ministry of Health and BC Care Providers Association, who have that really deep understanding of pandemic management policies and practices review, and modify that list based on their expertise and experience. So that is essentially how we arrived to the seven themes of pandemic management policies.
00;18;52;03 - 00;18;59;05
Erica Machulak
And within those seven themes, were there ones that were particularly hot button themes in these dialogues?
00;18;59;26 - 00;19;45;16
Farinaz Havaei
Oh, absolutely. And I would say those were probably the ones that were really, really – they essentially triggered really hot conversation, visitation, and staffing visitation for the visitation policy for residents and families, the staffing policy certainly for operators, providers, and also for residents and families, because they are the ones at the receiving end of care and services from staff members who are really overburdened and exhausted and working under really, really sub-optimal working conditions.
00;19;46;27 - 00;19;51;22
Erica Machulak
And so tell us more about the single-site order, what was the single-site order?
00;19;52;16 - 00;20;16;16
Farinaz Havaei
So the single-site employment policy was a policy that was introduced into the long-term care sector – again, to mitigate the risk of spreading COVID-19. And the policy essentially prevented long-term care workers, particularly nurses and care aids from working in more than one long-term care home during the COVID-19 pandemic.
00;20;16;29 - 00;20;19;02
Erica Machulak
And why was that implemented exactly?
00;20;19;22 - 00;20;52;12
Farinaz Havaei
The reasoning makes a lot of sense. It was implemented, because it was a way to essentially, again, prevent the spread of COVID-19 through staff members, you know, going from one care home to another care home, you know. The risk of spreading it and taking the virus to multiple sites is essentially increased. So the solution was essentially to implement this policy that would then say: care home workers would have to stay and work in one care home during the pandemic and, in that way, slow the spread.
00;20;53;13 - 00;20;59;15
Erica Machulak
And was the single site order implemented across all healthcare facilities or only in certain ones?
00;21;00;09 - 00;22;09;10
Farinaz Havaei
So the single-site policy essentially was limited to long-term care homes. And what was actually really interesting – and something that we learned through our discussion forum dialogues – was that (or actually, it was a limitation that came out of limitation within the policy that came out from our conversations) and that was that the policy applied only to long-term care homes, and not to other other healthcare organizations like acute care settings, like hospitals. Let me give you an example. So, as a long-term care worker, I would not be able to concurrently work at more than one care home. But I could concurrently work in my long place of employment in long-term care, as well as an acute care setting, even a COVID-positive unit. Right? So this was essentially a limitation of the policy that was identified by our forum participants.
00;22;10;04 - 00;22;15;01
Erica Machulak
Hmm. And why was it implemented that way? Do we know?
00;22;15;20 - 00;22;37;22
Farinaz Havaei
I honestly don't know what the reasoning behind that was. But I suspect, highly suspect, that some of the systemic challenges that we're dealing with – and that we've been actually dealing with for decades in the sector – probably influenced how the policy was designed.
00;22;38;22 - 00;22;39;08
Erica Machulak
What do you mean?
00;22;39;28 - 00;23;28;11
Farinaz Havaei
So by systemic challenges, I essentially mean staffing shortages. The long-term care sector has been dealing with this whole issue of staffing shortages, particularly nursing shortages. And as a result of that, I personally think if the policy were to be inclusive of acute care sites, that long-term care homes would actually lose a lot of their staff to the extent that they could essentially not afford continuing to deliver resident care. And so the decision was then made to just limit the policy to long-term care homes and not other healthcare organizations or sectors I guess.
00;23;29;18 - 00;23;37;09
Erica Machulak
Interesting, huh. And could you say more about that? What are some of the specific staffing challenges in long-term care?
00;23;38;07 - 00;24;50;02
Farinaz Havaei
So I mean, some of the challenges that I could essentially speak to, I mean, just very simply in terms of ratios in long-term care. Typically, the ratios that you see in terms of registered nurse-resident ratios – it's sometimes one-to-twenty, one-to-thirty, one-to-forty. So this is nothing strange for the long-term care sector, as opposed to the acute care sector where you see ratios like one-to-four, one-to-five RNs per patient. So in addition to that, I think what one of the other issues or challenges might be is that a lot of nursing – new nurses, newly graduated nurses actually do not select long-term care homes as their place of employment. And the reason being is that one of their goals is to be developing and building their clinical competencies and skills, and they believe that long-term care homes may not provide some of the same opportunities in terms of skill building as acute care settings.
00;24;50;23 - 00;24;53;24
Erica Machulak
Hmm. What kinds of skills are you referring to?
00;24;54;18 - 00;25;41;17
Farinaz Havaei
So some of those perhaps a bit more hardcore, clinical nursing skills that you see in acute care settings: blood transfusion, caring for a patient with tracheotomy, maintaining an IV, so things like that. In long-term care homes, because some of these residents this is essentially their home, this is where they live, most of the nursing care is essentially focused on activities of daily living, medication administration – so on and so forth. So you don't really see some of those more hardcore clinical nursing skills.
00;25;42;28 - 00;25;51;03
Erica Machulak
And so, what were some of the – to bring all of this back to the dialogues – what were some of the recommendations around staffing that came out of them?
00;25;51;21 - 00;27;59;15
Farinaz Havaei
So one of the recommendations that we made around the staffing was essentially care homes, developing a contingency staffing plan that ensures quality and safe resident care delivery during potential crises, such as outbreaks, because we essentially found that the COVID-19 pandemic created a lot of issues in terms of staffing, and it actually exacerbated some of the staffing shortages, you know, staff, because of the single site policy, for example, a lot of care homes, lost some of their staff. And on top of that families and visitors were prohibited from coming to care homes. And as a result of that staff were sort of faced with increasing demands and responsibilities. They were now the ones that had to also care for the psychosocial aspects of resident needs, spending time with them, comforting them, talking with them, just just making sure that they're not isolated and lonely. On top of that, you know, there are the increasing infection prevention and control practices, staff having to don on and off PPE. And so all of that together, you know, increasing needs, but also staffing, shortages, staff leaving because of the single site or staff leaving, because, you know, they need to be taking time away from work because they’re sick with COVID or they have been exposed to the virus. And so, all of these factors essentially show that care homes must have a contingency staffing plan, that essentially tells them how to staff, how to ensure adequate levels and appropriate types of staff are available to continue to deliver resident centered care during potential crises and outbreaks.
00;28;00;10 - 00;28;19;15
Erica Machulak
All right. So, in terms of all of those staffing recommendations, how do you see the pandemic changing the profession of nursing moving forward? Do you think the pandemic has surfaced any new trends or changed the direction of the profession in different ways?
00;28;19;25 - 00;29;42;23
Farinaz Havaei
Really good question. I personally think that, honestly, again, the silver lining in the pandemic for the nursing profession was that it just simply showed the public the power of nursing. So when the pandemic happened, all of us were really scared. We were fearful of contracting the virus, most of us stayed home, we protected our family members, we really limited our social circle, we did not go to work, most of us, you know, continued our work virtually. But the nursing professionals did not have some of the same opportunities. They were actually the ones at the forefront of this fight. And so, I think, as we all saw during some of the earlier waves of the pandemic, we call them our heroes, nurses are heroes. And I think essentially the pandemic really helped speak to some of the, I guess, significance and importance of the profession. And I personally think that it provided the profession with a greater level of symbolic power.
00;29;43;20 - 00;29;48;19
Erica Machulak
And what do you hope that symbolic power has the power to do?
00;29;49;25 - 00;30;49;22
Farinaz Havaei
I certainly hope that healthcare leaders and decision makers actively seek the input and the expertise of nurses in terms of policymaking and decision making. Again, a lot of these policies that were implemented in the long-term care sector had to be enacted by nursing providers on the front line. So I think it will be really important to have their expertise included and reflected in the policies that are coming out during crisis. Because again, these nurses are going to be the ones at the forefront of the fight. So we need to be drawing upon their expertise to develop policies that are going to be reasonable, and that are going to make sense to nurses, because, again, they are the ones that are going to be enacting some of these policies.
00;30;50;22 - 00;31;01;23
Erica Machulak
Mm-hmm. And the pandemic was a chaotic time for everyone, and it sounds like, particularly in long-term care. What were some of the decisions that nurses were making on a daily basis?
00;31;02;20 - 00;33;00;29
Farinaz Havaei
So. The decisions that nurses were making on a daily basis. This is an interesting question. I think the decisions that they were making, just, I guess, in terms of the pandemic management policies, how to implement them, how to how the implementation of certain policies would negatively impact residents, their families, and also the nurses themselves. And how would they resolve some of those, you know, negative impacts and outcomes? So I can give you an example. When the strict visitation policy was implemented in long-term care, as I said earlier, again, a lot of family members and visitors could not really come in to spend time with their loved one, to see them, to comfort them, to talk with them, to socialize with them. And so it's sort of a negative outcome of that. And one unintentional impact of that was that we were seeing an increasing level of resident isolation and loneliness. So, stories were coming out of the pandemic from nurses in the long-term care sector that were saying essentially nurses were coming to the facility on their own time without any compensation to spend time with these residents, to socialize with them, to read them a book, to paint their nails. So just any little thing they could do to just make them feel better because they were not able to see their families or have a connection with them, especially during those earlier days. So, I mean, I think that is very valuable and speaks to just how quickly nurses are able to adapt and respond to crises and pandemics and outbreaks onward.
00;33;03;01 - 00;33;11;25
Erica Machulak
If we're talking about a shortage of nurses in long-term care, what would motivate more nurses to choose that as their career path?
00;33;13;02 - 00;34;55;13
Farinaz Havaei
That's a really good question. And I think there are certain things that we could do, like as researchers, policymakers, decision makers, to essentially encourage more nurses to choose long-term care as their place of employment. So one of those things I think would be improving working conditions in the long-term care sector, ensuring that there are adequate numbers of staff and appropriate types of staff to effectively meet the day-to-day care needs of long-term care residents. Because if I as a registered nurse, as a newly graduated registered nurse, if I know that if I go for a, you know, just in terms of my place of employment, if my first place of employment is long-term care, and if I'm expected to provide care and lead care activities for 40 or more residents, I think that is a pretty intimidating responsibility, particularly for a new group. So I would say, you know, just providing mentorship opportunities, supporting newly graduated nurses maybe for a few months or even a year so that they essentially get settled into their positions, creating body shift opportunities. These are some of the examples of some of the things that could be done to essentially promote nurses and particularly registered nurses to choose long-term care as their place of employment.
00;34;56;20 - 00;35;28;14
Erica Machulak
Those are great insights, Naz. So, I want to get to the heart of one thing that I think many of your listeners may be wondering. A lot of the people listening to this podcast may be thinking or at least hoping that the pandemic is over, or this version of the pandemic where we're all in crisis has passed. So from that perspective, why is this work still relevant?
00;35;29;11 - 00;38;34;24
Farinaz Havaei
That's a really good question. I think one of the important reasons as to why this work is important is because it essentially provides some direction and guidance for the potential redesign of pandemic management policies and practices during the current pandemic, but also direction and guidance in relation to how future pandemics or crises could be effectively handled in the sector. Another really important reason about these recommendations and this work is that they essentially point to the importance of addressing some of those systemic issues in the sector. So if we are essentially speaking to like challenges, particular challenges specific to the pandemic, the recommendations essentially realize that these recommendations are not going to be effective unless they are effectively implemented. And their effective implementation is going to require addressing challenges and systemic issues in the sector. Let me give you an example. So, for example, in relation to the single site employment order, yes, this policy was developed and maybe it would have been. It's certainly effective in relation to slowing down the spread of COVID, but there wasn't any consideration given to how it would impact care homes in relation to adequate levels and appropriate types of staff. Because as you would imagine, and because of the policy definition prohibiting staff to one site, it essentially resulted in care homes losing some of their staff. And these care homes are already struggling with staffing shortages pre-pandemic. So the implementation of the policy certainly exacerbated some of those staffing shortages. So we have made within our recommendations, we have sort of made a broader recommendation that speaks to care homes, having to have a contingency staffing plan and maybe to address staffing shortages in long-term care homes and also to ensure equity and fairness. Maybe this policy needs to be modified such that staff with the required relevant vaccines are actually allowed to work in more than one outbreak free long-term care home and also non long-term care home sites like acute care and hospital settings. So we have in our recommendations, we have done our best to essentially consider the unique context of long-term care homes and some of the challenges that they have been dealing with for a very long time.
00;38;35;26 - 00;38;42;28
Erica Machulak
Hmm. Naz, what were some of the findings and recommendations around infection prevention and control?
00;38;44;02 - 00;40;29;27
Farinaz Havaei
So one of the most important issues or I guess findings in relation to infection prevention and control was the fact that operators and staff were really concerned about the frequency, and at times even the inconsistency, of recommendations communicated to them from different organizations. So for example, communication coming out from the Ministry of Health, from BCCDC saying something and then another communication coming out, I don't know, maybe within a couple of hours with slightly conflicting information in relation to a policy or a procedure. And so based on that finding, our forum participants essentially felt like an appropriate recommendation would be that infection prevention and control recommendations must be clear, must be concise and consistent. And that means that recommendations actually must be communicated to care homes from a single organization in the province. Because that really caused a lot of challenges for care homes, you know, especially during earlier waves of the pandemic, not knowing which is the most appropriate information, what is the policy? And then them having these uncertainties, then creating challenges in relation to how do they respond to staff questions, families questions and also residents questions. So really they felt like having one organization sending out communication in relation to pandemic management policies would really help streamline that information.
00;40;30;18 - 00;40;40;11
Erica Machulak
Mm-hmm. And it seems like that recommendation is really tied into some of the others that we've been talking about in terms of human resources and communication needs.
00;40;40;20 - 00;40;41;15
Farinaz Havaei
Absolutely.
00;40;42;04 - 00;41;06;14
Erica Machulak
So, we've talked about how the context of long-term care is different from many other contexts in the healthcare ecosystem. But even within long-term care, you have these different homes that I imagine create very different experiences for residents. Could you talk about some of the key differences from home to home that might affect the way that residents in long-term care experienced pandemic?
00;41;07;23 - 00;43;51;26
Farinaz Havaei
There are certainly differences across care homes in relation to how their building is designed, how old they are, where they are located, how big or how small they are, how many beds they have. So that certainly creates some differences across physical layout. But what was perhaps a bit common across our participants from a variety of care homes was the fact that they recognized that there were certainly challenges and limitations related to physical layout associated with older buildings, things like poor ventilation, poor HVAC systems, having shared rooms because a lot of the care homes actually have buildings that are on the older side. And so that creates challenges in relation to having suboptimal ventilation systems or like rooms that are shared by two or three or four residents. And you know, this is not a very resident centered environment because again, these long-term care homes are supposed to be home to these residents. And can you imagine living in a room with three or four people in the same room and just living there for years after years and after years? And so it really has an impact on residents' quality of life. So we are essentially just realizing that we have to be making a recommendation that is feasible just because of, you know, worker sort of in the context of having finite resources. We have essentially made a recommendation asking the B.C. Ministry of Health to work with the health authorities to develop a plan for updating the infrastructure of long-term care homes, doing an assessment of their ventilation on fact systems just to make sure if they're working okay, if they're functional. And for those homes that have some of those older suboptimal systems to essentially get them replaced. And also in relation to shared rooms, we have essentially sort of put forth a recommendation for the B.C. Ministry of Health to start outlining strategy for minimizing and eventually eliminating the use of shared rooms in long-term care homes. Just because, again, from the perspective of resident quality of life, I think it would be important. I think it would be an important step.
00;43;52;18 - 00;43;56;27
Erica Machulak
And who are the recommendations for? Who are you calling on?
00;43;57;29 - 00;44;39;09
Farinaz Havaei
So, I would say that these recommendations are mainly directed to policy makers and decision makers in long-term care because essentially they are the ones that make important decisions in relation to how resident care delivery is organized in the sector and also in relation to how some of these policies were developed and the implementation process, all of these sort of pandemic management strategies, policies, procedures were sent to care homes, were developed and sent to care homes, from policy makers and decision makers.
00;44;40;01 - 00;44;53;24
Erica Machulak
And what are the next steps for the project, do you think? You have developed this report and facilitated these dialogs. What do you think is the next step for you and your partners?
00;44;54;09 - 00;45;30;10
Farinaz Havaei
So, the next step for us is to essentially distribute very widely the results of the project. So our recommendations with our key stakeholders, the B.C. Ministry of Health, the health authorities that participated in the project, long-term care organizations like B.C. Care Provider Association and even Safe Care B.C., and with even families and residents through their respective councils . So we're going to be sort of distributing these recommendations to as as many stakeholders as possible.
00;45;30;13 - 00;45;40;04
Erica Machulak
So, in terms of the recommendations that you think are ready for immediate implementation, what are some of the ones that you think are the most important right now?
00;45;41;07 - 00;46;57;29
Farinaz Havaei
So, I think in terms of our staffing recommendations, we certainly have some recommendations that are more long-term. There are things that cannot be implemented overnight. They require more long-term, long-term planning and more coordinated efforts. But we also have more concrete recommendations that could be implemented right away immediately. One of those recommendations is essentially implementing a comprehensive and systematic approach to understanding and measuring long-term care resident needs. And there are evidence based tools and approaches out there that do exactly that. And our research team has essentially been very fortunate to receive a signature grant to implement this tool that exactly does that. It operationalizes its resident needs in relation to five acuity characteristics and three dependency characteristics. And then, from there on, uses those numbers and scores to inform staffing decisions. Just as a way to help staff with their workload management.
00;46;58;14 - 00;47;04;09
Erica Machulak
Hmm, interesting. And do you have a sense so far of how well that's going?
00;47;05;20 - 00;48;03;06
Farinaz Havaei
So, not a lot, because we just started the project. But this is a very promising intervention. And the reason being is that we have used it in several acute care settings in the past and we have seen really positive outcomes and positive results. We have used it in B.C. Women's and Children's Hospital, Kelowna Cancer Agency. And right now, we're actually using it in Royal Columbian Hospital in three of their surgical, neuro, and ortho units. And we have also used this tool outside of the province. A few of my colleagues have actually used it in emergency departments, so on and so forth. So it is an evidence based tool. It works. There’s research that backs it up, but it's the first time that it's actually been extended to long-term care.
00;48;03;24 - 00;48;09;10
Erica Machulak
And what are some of the considerations that you have to make to apply it in long-term care instead of acute care?
00;48;09;24 - 00;49;07;21
Farinaz Havaei
So, one of the great things about the tool is that it is adaptable to different contexts and to different patient populations because as you can imagine, the needs of a particular patient population is going to be different and across different specialties. So if you're in labor delivery versus a surgical patient versus an ortho patient versus a cardiac patient versus a long-term care resident, your needs are going to be different. And so the tool essentially provides the opportunity where it actually encourages the care team to adapt it for their patient population, in this case, long-term care residents . So we're going to be working very closely with the long-term care providers to essentially adapt a tool for their unique context and based on the needs of the resident population.
00;49;10;25 - 00;49;17;02
Erica Machulak
That's really exciting. What is your hope for the tool? What possible impact could it have?
00;49;18;00 - 00;50;13;21
Farinaz Havaei
I certainly think that – I certainly hope – that it will provide some, it alleviates some of the issues in terms of workload that the staff have been dealing with in long-term care, that it alleviates some of their stress, that it provides them with opportunities or it supports them to provide a more effective resident care that they have the time and the ability to better meet the needs of the resident population. And there is certainly, I'm very optimistic in that. I mean, there are systematic reviews and systematic reviews on a very high level of evidence are very rigorously done that essentially support that the use of the tool is associated with more positive patient staff and organizational outcomes.
00;50;14;09 - 00;50;37;15
Erica Machulak
Mm hmm. So, in the way that you talk about all of your work, from the dialogs to the implementation of this tool, you talk a lot about all of the different kinds of people that the work could benefit and also all of the different kinds of people from decision makers to residents and families that you work with to move this work forward. Would you tell us a bit about your approach to knowledge translation?
00;50;37;27 - 00;51;51;00
Farinaz Havaei
Absolutely. So, I have a very collaborative approach. The particular approach that I use is integrated knowledge translation in which you work very closely with stakeholders, with partners, with those individuals who are going to be impacted as a result of your work and as a result of the issue at hand. And you work very closely with them, they are really equal partners. Throughout the research process, you bring in their expertise, you invite their input and actually incorporate it into your decisions throughout the research, you know, from formulating a research questions to data collection, recruitment, and believe it or not, even in terms of interpreting the results of what does a particular finding mean in relation to those in the frontline leaders, staff members? How do they go about interpreting a certain finding? So you really have them involved throughout the project as equal partners, as researchers.
00;51;51;24 - 00;51;58;00
Erica Machulak
So tell us how your approach to knowledge translation played out in these virtual dialogs?
00;51;58;14 - 00;54;31;08
Farinaz Havaei
Absolutely. So we started the project by establishing an advisory group of long-term care experts with representatives from the resident group, family member group, operators, leaders, managers, providers, having partners from the Ministry of Health Care, Provider Association, and researcher groups. So we did have a relatively large advisory group whom we worked with very closely throughout the project to inform the direction of the project and in every step of the process sort of consulting with them and obtaining their input. But on top of that we had the discussion forums and the discussion forums again were open to all long-term care members. So anybody affiliated with long- term care, whether they were leaders, nurses, residents, family members, staff members, they were essentially invited to participate in discussion forums with the four health authorities Interior Health, Vancouver Island Health, Fraser Health, and Vancouver Coastal Health Authorities. And so what we did was after we presented the findings of our operators survey, we essentially invited participants to comment and share their experiences and share their perspectives. And they could you know, we've sort of adopted a very flexible approach. They could just unmute themselves and speak to us. They could write their comments in the chat box. And we even stayed, after discussion forums were ended, we actually stayed on for a few minutes extra just in case there were any participants that just wanted to have a private conversation with us. And we also, on top of all of that, we invited participants to reach out if there were any other comments and sort of input that they wanted to share with us, to feel free to do that. And believe it or not, Erika, we actually did have quite a number of our forum participants personally reach out to me to share additional comments and input that they did not recall during the forum. And so they took the time to essentially share that with us through email.
00;54;32;00 - 00;54;37;28
Erica Machulak
And how did you take all of that input and turn it into these recommendations?
00;54;38;12 - 00;56;22;10
Farinaz Havaei
So, this was a very complex process because as you can imagine, we had lots of input from many people from the health authorities. We also had the input of our advisory group. We had the results of the survey. And so we had to bring all of that together to create our recommendations. And so what we did was that during our final discussion forum, we then took the recommendations that we had created based on what we heard during these these discussion forums and the survey and advisory group consultations, we took our recommendations to this final virtual debrief and provided opportunities for long-term care members, our diverse, diverse group of participants. To have a say in terms of these war dead right? Is this how we want to approach this issue? Is this really the recommendation that we want to be making in relation to this policy? So really providing opportunities for people to share their comments. It's a safe environment, a free environment, ensuring to invite them to, you know, provide input, participate and provide alternative modes of participation. If anybody's not comfortable with, you know, just verbally communicate, communicating their feedback to provide opportunities. You know, just in terms of like putting the comments in the chat box or even reaching out, reaching out to us via email.
00;56;22;28 - 00;56;38;18
Erica Machulak
Mm hmm. I would imagine that one of the things that makes accessibility especially challenging during a pandemic is working with long-term care residents on signing into a Zoom call. Were there any special measures that you took to make sure that everyone who wanted to participate could?
00;56;39;07 - 00;57;17;20
Farinaz Havaei
Absolutely. So we actually asked, when we invited residents, we essentially reached out to them for those that had registered to participate in our discussion forums. They actually personally reached out to them and asked them if they needed support with connection and if in a few instances they essentially said, yes, that they would require support in terms of connecting to Zoom, so on and so forth. And then we actually contacted their care home and found a staff member who could then support them with technology related issues.
00;57;18;11 - 00;57;24;21
Erica Machulak
Nice. And so how many residents do you know offhand how many residents came to these dialogs?
00;57;25;03 - 00;57;34;28
Farinaz Havaei
We had about five residents participate in all of the health authority, as well as the final virtual debrief.
00;57;34;28 - 00;57;37;15
Erica Machulak
And how many people total came to these dialogs?
00;57;38;00 - 00;57;59;01
Farinaz Havaei
So the total, I would say it's probably around 60 or 70 people altogether. But, I mean, there were some people who were participating in the Health Authority Discussion Forum as well as the final virtual debrief. But overall, I think there were probably about 60 or 70 people.
00;57;59;17 - 00;58;04;20
Erica Machulak
Mm hmm. And that's in addition to all of the people who would have provided input through your operator survey.
00;58;05;01 - 00;58;09;23
Farinaz Havaei
Exactly. And we had about 20 people that respond to our operator survey.
00;58;10;05 - 00;58;18;15
Erica Machulak
Mm hmm. And the operator survey, just to have a sense of the context, how what did that look like? How was that administered? What kinds of questions did it ask?
00;58;19;12 - 00;59;44;26
Farinaz Havaei
So the operator survey essentially asked about pandemic management policies and practices in relation to seven domains, COVID-19 screening, the strict visitation policy, staffing, infection prevention and control procedures, communication, physical layout, leadership, and organizational support, particularly in relation to how frequently were you able to or how effectively were you able to implement these pandemic management policies and practices, and what were their impact on the health and safety of residents, family members and staff members? And what was their impact on mitigating the risk of spreading COVID-19? And so we essentially had this survey sent out to a purposefully selected sample of care homes. I believe there were about 100 hundred care homes that were purposefully selected by our advisory group members. And so we sent our survey to those individuals obtaining their email addresses and contacts through the B.C. Ministry of Health and Care Provider Association and essentially inviting their operators to complete our survey.
00;59;45;17 - 00;59;55;01
Erica Machulak
And between the survey and the dialogs, was there anything that really surprised you?
00;59;56;10 - 01;00;39;09
Farinaz Havaei
I have to say that the one thing that really surprised me was just the resilience, the resilience of everybody within long-term care staff, providers, leaders, residents, family members, dealing with the challenges, the pandemic, the challenges within the long-term care sector, and also challenges of the pandemic management policies and practices. It was honestly, really, really inspiring to see how everybody adapted very quickly and worked together to to survive the pandemic and survive it well.
01;00;41;13 - 01;00;50;00
Erica Machulak
What were some of the creative strategies that people at long term care developed to make it through some of the challenges of the pandemic?
01;00;50;12 - 01;01;53;22
Farinaz Havaei
Yeah. So one example, Erica, could be the fact that care homes adopted various ways of communicating with residents, family members as well as staff members. So not just sending emails but also phoning people if they had to – sending letters, posting on social media, making in-person visits to just make sure that everybody received those important updates in relation to pandemic management policies. As an example, another example I could give you in relation to the visitation policy, for example, when families could not come in to the facility as a result of the policy, essentially using technology, staff members, using technology, iPads, iPhones, smart devices to make sure that residents and families have a way to stay continue to stay in touch and connected.
01;01;54;05 - 01;02;19;22
Erica Machulak
Mm hmm. When we think about all of the different evolutions that all of us had to make in the way that we communicated during the pandemic, it sounds like this would be particularly challenging in the context of long-term care. I'm wondering in the conversations that you had through these dialogs and through other means, are there recommendations that have come out specifically related to communication?
01;02;19;28 - 01;03;56;16
Farinaz Havaei
Absolutely. One of the really important challenges in relation to communication for long-term care operators on staff was that they had received communication in relation to some of the policies and practices at the same time as other members of the public or without really advance notice, they were told to implement some policies and practices and so they were not because of that they did not really have the necessary resources to effectively implement, and it just created lots of challenges for them. So one of the recommendations that we've made is around the communication process, that it should be streamlined to ensure that essentially care homes are given enough time to appropriately implement new or modified policies, particularly with respect to policies that require proactive planning and resource allocation. As an example, the single site employment policy required a lot of work for care homes in terms of determining, you know, which which staff members were working at multi-site multi care homes, doing a lot of, you know, just, I guess, surveys and interviews with the staff to find that information out because care homes prior to the pandemic did not have at least a clear list of their staff members place of employment.
01;03;57;13 - 01;04;02;20
Erica Machulak
What are some of the recommendations that you think are most important to highlight coming out of this report?
01;04;03;11 - 01;06;11;29
Farinaz Havaei
So I think we already talked a bit about the visitation policy, the staffing situation, the communication issue, the other important pandemic management strategies, leadership and organizational support. We certainly know that the pandemic and pandemic related stressors created lots of mental health related challenges for staff as well as leadership. So one of the other recommendations that we're essentially making is, is for long-term care homes, to establish workplace mental health supports and interventions for their workers, and special attention must be given to certain groups of workers, including newly graduated health care workers, nurses, as well as those who might be a bit more novice in managerial and leadership positions. Because I think the leader and manager groups are certainly an overlooked population in the context of the pandemic, in that they were the ones that really orchestrated it and how the sector and how care homes responded to the pandemic, how policies were implemented, and they were really being pulled from different directions. You know, they had to respond to the concerns of staff members, to the concerns of family members, residents. So they had all of these demands and added demands and responsibilities placed on them and also having to deal with policies that were coming from the ministry dealing with health authority, sort of requirements, instructions sought and so forth. So they are really in need of mental health support. And so we need to be thinking of ways and strategies that could essentially be implemented in the sector to protect the mental health of our long-term care leaders, because we certainly don't want to lose them as a result of the pandemic.
01;06;13;13 - 01;06;50;21
Erica Machulak
Yeah, absolutely. One of my senses from all of the recommendations that you've been talking about, is that, in a sense these recommendations are, you know, thematically-oriented to consider something like staffing, consider improving a particular policy, but it's not on the level of “do this, this, and that.” It's on the level of: take this component of our context seriously and talk to the people who have been there to really develop policies that will build resilience across the healthcare ecosystem moving forward. Is that fair to say?
01;06;51;06 - 01;07;33;02
Farinaz Havaei
Absolutely. I think one of the most important overarching themes that we see across the recommendations is that we need to be responding to challenges to pandemic management policies and practices in collaboration with key stakeholders, whether they are in the staff group, leadership group, family group, resident group. We need to be inclusive of their perspective. And we need to make sure that strategies that and interventions that we introduced to the sector essentially reflect their needs.
01;07;35;13 - 01;07;48;03
Erica Machulak
And when people talk about that kind of inclusion in decision making, they often use this metaphor of creating a seat at the table. But in this context now, what are the tables that we're talking about?
01;07;49;04 - 01;08;40;04
Farinaz Havaei
So, I would say, like really these recommendations, Erica, are for policy makers and decision makers. And those would be within the Ministry of Health, within the health authorities in the province, and also with the leadership of long-term care homes, because they are the ones that are really in close contact with the B.C. Ministry of Health , with some of the other long-term care organizations, with the health authorities, and sort of everybody working together to ensure that the policies and the procedures that are developed for the sector during the pandemic and also beyond that are reflective of the needs of the users and the providers of the long-term care.
01;08;41;21 - 01;09;01;26
Erica Machulak
Naz, these dialogs and this whole initiative has covered such a richness of information in such a complicated space, as listeners are processing everything that you're sharing here and reading over your recommendations, once people take out their headphones, finish listening to this episode, what's the next step?
01;09;03;07 - 01;09;41;22
Farinaz Havaei
So the next step for our team is essentially to share the results as widely as possible with key stakeholders. The B.C. Ministry of Health, the participating health authorities, long-term care organizations like the B.C. Care Provider Association, Safe Care BC, long-term care homes. And also with families and residents through their respective councils. I think, by way of raising awareness about these recommendations, we're going to sort of keep each other accountable in terms of implementing these recommendations, hopefully in the near future.
01;09;42;13 - 01;09;49;10
Erica Machulak
Mm hmm. And a year from now, if all of this work has been successful, what do you expect to see?
01;09;49;14 - 01;10;34;12
Farinaz Havaei
I hope that, you know that at least some of these recommendations are effectively implemented and that we actually see an improvement in residents’ quality of life in staffs’ mental health and well-being, in working conditions of long-term care homes, in how families are sort of at the end of, or at the receiving end of the care, and essentially just having improved outcomes for various stakeholder groups and also for long-term care homes as a whole.
01;10;35;17 - 01;10;42;13
Erica Machulak
Mm-hmm. And if decision makers want to connect with you to get more involved in the work that you're doing, what's the best way for them to reach out?
01;10;42;24 - 01;10;58;15
Farinaz Havaei
I would say they can essentially either search my name online or send me and just, I guess, send me an email. My contact information would be available both on the recommendation booklet and also through UBC School of Nursing.
01;10;59;04 - 01;11;01;21
Erica Machulak
Hmm. Great, Naz. Thank you very much.
01;11;02;29 - 01;11;03;24
Farinaz Havaei
Thanks, Erica.
01;11;04;29 - 01;11;46;18
Erica Machulak
Thank you so much for listening to this conversation with Dr. Farinaz Havaei of the University of British Columbia School of Nursing. Naz's work has been advanced in collaboration with partners, collaborators. and actors across British Columbia and has been supported by the Michael Smith Foundation for Health Research. This podcast was produced by Hikma Strategies. I'm Erica Machulak, Hikma's founder. Production oversight by Sophia van Hees, our creative director, and the original music you're listening to now was composed by our artist in residence, Matthew Tomkinson. Thanks for listening.
