Applied Science, Faculty of
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International Journal of Environmental Research and Public Health 22 (4): 520 (2025)
Boamah, Sheila A.
Akter, Farzana
Karimi, Bahar
Havaei, Farinaz
(1) Background: The enduring impact of COVID-19 on the long-term care (LTC) sector remains uncertain, necessitating targeted efforts to address current and emerging challenges. This study aims to identify the key stressors faced by healthcare workers (HCWs) in LTC and to co-develop innovative, actionable strategies that mitigate these stressors, foster resilience, and promote workforce retention. (2) Methods: This study utilized a qualitative co-design methodology within a mixed-methods, multi-phase framework conducted between July 2023 and October 2024. This article focuses on Phase 1, which involved 11 semi-structured focus groups and steering group discussions with 24 HCWs, including personal support workers (PSWs), nurses, and LTC administrators across Ontario to explore workplace-related distress and foster a shared understanding of challenges in the LTC sector. Data were audio-recorded, transcribed verbatim, and analyzed using thematic analysis to derive key themes and actionable insights. (3) Results: Key themes emerging from co-design sessions included the need for (i) effective workload management tools, (ii) the prioritization of psychological safety and mental health services, (iii) reducing regulatory and bureaucratic burdens, (iv) strengthening management practices, and (v) fostering recognition and a positive sector image. Co-design sessions with HCWs and leaders facilitated the identification of priority issues and high-level solutions, including addressing workload issues, implementing mental health and support programs, enhancing work–life integration, improving management training, and promoting psychological safety in LTC settings. (4) Conclusions: This study deepens our understanding of workplace challenges in the LTC sector and the factors contributing to HCWs’ mental distress. Leveraging a co-design approach offers valuable insights into the lived experiences of HCWs and leaders. The findings provide actionable guidance for LTC leaders and policymakers to create effective, tailored interventions that actively engage HCWs in addressing workplace stressors and mitigating recurrent challenges.
Academic Editor: Paul B. TchounwouReceived: 1 February 2025Revised: 15 March 2025Accepted: 25 March 2025Published: 28 March 2025Citation: Boamah, S.A.; Akter, F.;Karimi, B.; Havaei, F. NavigatingWorkforce Challenges in Long-TermCare: A Co-Design Approach toSolutions. Int. J. Environ. Res. PublicHealth 2025, 22, 520. https://doi.org/10.3390/ijerph22040520Copyright: © 2025 by the authors.Licensee MDPI, Basel, Switzerland.This article is an open access articledistributed under the terms andconditions of the Creative CommonsAttribution (CC BY) license(https://creativecommons.org/licenses/by/4.0/).ArticleNavigating Workforce Challenges in Long-Term Care:A Co-Design Approach to SolutionsSheila A. Boamah 1,* , Farzana Akter 1, Bahar Karimi 2 and Farinaz Havaei 31 Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, ON L8S 4K1, Canada;akterf1@mcmaster.ca2 Thrive Group Centre of Excellence in Healthcare Innovation, Hamilton, ON L9C 7N4, Canada;bkarimi@thrivegroup.ca3 Faculty of Health, School of Nursing, University of British Columbia, Vancouver, BC V6T 2B5, Canada;farinaz.havaei@ubc.ca* Correspondence: boamahs@mcmaster.caAbstract: (1) Background: The enduring impact of COVID-19 on the long-term care (LTC)sector remains uncertain, necessitating targeted efforts to address current and emergingchallenges. This study aims to identify the key stressors faced by healthcare workers(HCWs) in LTC and to co-develop innovative, actionable strategies that mitigate these stres-sors, foster resilience, and promote workforce retention. (2) Methods: This study utilizeda qualitative co-design methodology within a mixed-methods, multi-phase frameworkconducted between July 2023 and October 2024. This article focuses on Phase 1, whichinvolved 11 semi-structured focus groups and steering group discussions with 24 HCWs,including personal support workers (PSWs), nurses, and LTC administrators across On-tario to explore workplace-related distress and foster a shared understanding of challengesin the LTC sector. Data were audio-recorded, transcribed verbatim, and analyzed usingthematic analysis to derive key themes and actionable insights. (3) Results: Key themesemerging from co-design sessions included the need for (i) effective workload managementtools, (ii) the prioritization of psychological safety and mental health services, (iii) reducingregulatory and bureaucratic burdens, (iv) strengthening management practices, and (v) fos-tering recognition and a positive sector image. Co-design sessions with HCWs and leadersfacilitated the identification of priority issues and high-level solutions, including addressingworkload issues, implementing mental health and support programs, enhancing work–lifeintegration, improving management training, and promoting psychological safety in LTCsettings. (4) Conclusions: This study deepens our understanding of workplace challengesin the LTC sector and the factors contributing to HCWs’ mental distress. Leveraging aco-design approach offers valuable insights into the lived experiences of HCWs and leaders.The findings provide actionable guidance for LTC leaders and policymakers to create effec-tive, tailored interventions that actively engage HCWs in addressing workplace stressorsand mitigating recurrent challenges.Keywords: co-design; mental health; healthcare workers; long-term care; workforce well-being;retention1. IntroductionLong-term care (LTC) homes in Canada serve a vital role in supporting vulnerablepopulations, providing essential care to individuals who require assistance with dailyactivities and medical needs [1]. Despite their importance, the sector is grappling withInt. J. Environ. Res. Public Health 2025, 22, 520 https://doi.org/10.3390/ijerph22040520Int. J. Environ. Res. Public Health 2025, 22, 520 2 of 19persistent challenges, including inadequate funding and resource limitations, which notonly compromise the quality of care but also undermine the well-being of healthcareworkers (HCWs) who serve in these homes/facilities [1].The LTC sector in Canada comprises 2076 facilities, including nursing homes, con-tinuing care facilities, and residential care homes, overseen by provincial and territorialgovernments responsible for their planning, funding, and regulation [2]. Governancewithin this sector is divided between public (46%) and private (54%) ownership, with thelatter further categorized into for-profit (29%) and not-for-profit (23%) entities [2]. Whilethis structure offers diverse care models, it also introduces significant challenges, includingsystem fragmentation, regulatory complexity, chronic understaffing, high resident-to-staffratios, and an increasingly medically complex resident population [3]. Additionally, dispar-ities in funding and limited public engagement in policy development exacerbate theseissues [3]. The structural deficiencies contribute to excessive workloads and difficultiesin maintaining consistent, high-quality care, further emphasizing the urgent need forcomprehensive systemic reform to better support both HCWs and residents.As one of the most highly regulated sectors in Canadian healthcare, LTC has facedincreasing scrutiny over persistent concerns regarding care quality [4]. However, regulatoryoversight, often introduced reactively in response to public scandals and crises, has notnecessarily translated into improved accessibility or care standards. This was particularlyevident during the COVID-19 pandemic, where LTC homes/facilities bore a dispropor-tionate burden, accounting for over 80% of first-wave deaths—twice the average of otherOrganisation for Economic Co-operation and Development (OECD) countries [2].Although concerns about care standards in LTC have been raised for decades [5], thepandemic brought these systemic issues into sharp focus and exposed substantial gaps inthe Canadian LTC system, particularly its lack of readiness for public health emergencies.Deficiencies in infection control protocols, restricted access to personal protective equip-ment (PPE), and inadequate training in infection prevention and control (IPAC) furtherexacerbated the sector’s vulnerabilities [6]. These shortcomings contributed to significantstress, anxiety, compassion fatigue, and moral distress among HCWs, impairing theirmental health and ability to provide high-quality care [7–9].Workplace distress, particularly burnout, is prevalent among HCWs working inhigh-stress, high-risk environments and is strongly associated with poor mental healthoutcomes [10,11], reduce attentiveness to residents, increased medical errors, and lowerresident and patient satisfaction, all of which impose significant costs [12]. Chronic un-derstaffing further exacerbates these challenges, with 50% of Ontario’s personal supportworkers (PSWs) leaving the sector within five years, and 43% citing short-staffing as a keyreason [13]. Supporting HCWs’ mental health and well-being is vital for their resilience butalso essential for improving care quality and achieving better outcomes for LTC residents,reinforcing its importance as a priority for systemic improvement.While several studies have explored the workplace factors contributing to increasedstress and mental health concerns among HCWs broadly [14,15], relatively little re-search [10,11] has focused on the unique challenges encountered by HCWs in LTC, in-cluding PSWs, nurses, and leaders/administrators, both during the pandemic and duringits aftermath; and how these issues impact their ability to provide effective resident care.This oversight is acutely critical given the profound impact of COVID-19 on LTC environ-ments, where workers were disproportionately exposed to health risks, emotional strain,and systemic vulnerabilities. The LTC workforce, particularly those in unregulated rolessuch as PSWs, confronts stark inequities. These workers, who are predominantly women,new immigrants, and individuals from BIPOC communities, remain underpaid, under-valued, and inadequately supported, reflecting systemic disparities within the sector [16].Int. J. Environ. Res. Public Health 2025, 22, 520 3 of 19Compounding this issue is the lack of granular data on the LTC work environment and itseffects on worker health and well-being, particularly at the level of individual LTC homesand within specific provincial contexts, further perpetuating these inequities and hinderingtargeted interventions.This study seeks to address this critical gap by focusing on HCWs in Ontario’s LTCsector, the most populous province in Canada. By using a co-design approach, it not onlydelves into the unique needs and challenges faced by these workers—such as factors con-tributing to distress and burnout—but also actively involves them in developing pragmaticand actionable strategies to improve their well-being and resilience. This approach ensuresthe study is grounded in the lived experiences of those most affected, paving the way forsolutions that are both contextually relevant and impactful.2. Materials and Methods2.1. Study DesignThis study utilized a qualitative co-design approach, guided by the Experience-BasedCo-Design (EBCD) framework [17], within a mixed-methods, multi-phase design to explorethe experiences of HCWs working in LTC homes in Ontario, Canada. This paper focusesexclusively on Phase 1 of the study, as subsequent phases are still in progress.2.2. Co-Design and Its Methodological BenefitsCo-design leverages human-centered design principles to understand experiences andimprove services through collaborative, participatory approaches, integrating the creativityof design thinking with systems thinking’s analytical rigor [18]. In healthcare, it effectivelyengages clinicians and service users to develop interventions that are both feasible andacceptable, particularly in promoting physical activity among older adults [18,19]. Whileco-design methods vary, they consistently emphasize shared decision-making, ensuringthat individuals with lived experience and expertise contribute meaningfully throughoutthe design process [20,21].A defining strength of co-design is its commitment to inclusivity, prioritizing marginal-ized voices and addressing epistemic injustices in traditional decision-making [22]. Bycritically examining power dynamics, co-design fosters equitable contributions from allstakeholders, leading to more contextually relevant solutions. One specific co-designmethod, EBCD, exemplifies this approach, integrating narrative-driven engagement withcollaborative service improvements [23]. EBCD identifies key “touchpoints” in the patientjourney—moments where experiences are most profoundly shaped—to drive meaningfulhealthcare transformations. Unlike conventional service redesign, which prioritizes processoptimization, EBCD focuses on enhancing patient experiences, recognizing their criticalrole in health outcomes and quality of life.The increasing adoption of EBCD aligns with the broader shift toward person-centeredcare and the Institute for Healthcare Improvement’s Triple Aim framework—enhancingpatient experience, improving population health, and reducing costs—later expanded to theQuadruple Aim to include provider well-being [24]. Its effectiveness has been demonstratedacross diverse healthcare settings, including mental health [25] and elderly care [26], withtangible benefits such as improvements in mental health services and the optimizationof medication discontinuation processes for older adults [26]. By embedding patientexperiences at the core of service innovation, EBCD cultivates meaningful collaborationbetween healthcare professionals and service users, ensuring responsive, sustainable, andpatient-centered care.Building on the EBCD framework, this study adopted an adapted approach tailored tothe perspectives of HCWs and leaders in LTC, recognizing the potential for transformativeInt. J. Environ. Res. Public Health 2025, 22, 520 4 of 19impacts on health and well-being. The selection of research methods for exploring HCWs’and leaders’ experiences was guided by four core EBCD principles [27], as outlined in TextBox 1. In this study, co-design served as a dynamic and promising approach for developinginterventions aligned with human-centered principles.Box 1. Adapted source: Bate and Robert [27].The initial four stages of EBCD are:1. Observation: A researcher or non-participant examines the clinical environment to understanduser-provider interactions.2. Provider interviews: Interviews with healthcare providers contextualize service delivery andidentify key pressure points.3. User interviews: Service users share their experiences, highlighting critical moments in theircare journey.4. Data analysis: Emerging shared narratives of defining moments, or touchpoints, capture theessence of both care experiences and workplace dynamics (or work environment).2.3. Sampling, Participants, and Sample SizeThis study employed a combination of purposive and convenience sampling strategiesto recruit participants from diverse roles within the LTC sector, including PSWs (or careaides), nurses, social workers, managers, and administrators or leaders. To capture a broadspectrum of perspectives and experiences, efforts were made to ensure representationby inviting participants from varied training and professional backgrounds, levels ofexperience, and geographic locations, including rural and urban settings across Ontario.Emails were sent to various LTC homes and organizations across the province to informand encourage participation. To promote participation, several webinars and workshopswere held. Flyers were distributed across LTC networks, allowing existing contacts toinform others about the opportunity. Social media platforms such as X (formally known asTwitter), LinkedIn, and Facebook were utilized to expand reach and spread recruitmentinformation. All recruitment materials were developed in plain English, employing gender-neutral language and considering sensitivities around ethnicity, race, and intersectionalfactors to ensure inclusivity. Guided by previous co-design studies [17], the target samplesize was 20–25 participants.Interested participants were required to complete a screening process to verify theirwork experience in Ontario-based LTC homes and confirm their HCW or leader roles. Eli-gible participants included HCWs in direct care or leadership roles with at least six monthsof experience in their current organization and familiarity with the National Standard ofCanada for Psychological Health and Safety in the Workplace (“the Standard”) [28]. TheStandard provides voluntary guidelines, tools, and resources to support organizations inpromoting mental health and preventing psychological harm in the workplace. Potentialparticipants were invited to access the project link to read the letter of information andcontact the research team if they were interested in participating in the study. The projectteam then obtained both written and verbal consent, and participants were informed thatparticipation was voluntary. Participants received an honorarium in the form of a CAD100 gift card for this phase of the project.2.4. Data CollectionBetween July 2023 and October 2024, eleven co-design focus group discussions (FGDs)were conducted over a 10-month period, involving 24 participants. These sessions, heldboth virtually via Zoom and in person, were organized into two distinct phases. The initialsix sessions, with groups of 4–5 participants, explored the work-related experiences ofLTC workers, focusing on challenges such as distress and burnout. The subsequent fiveInt. J. Environ. Res. Public Health 2025, 22, 520 5 of 19sessions aimed to collaboratively refine and develop actionable strategies, engaging thesame participants throughout. To minimize bias, encourage open and honest dialogue, andmitigate power dynamics, two additional sub-group sessions were organized specifically forcertain HCW groups, such as PSWs, to gain insight into their unique needs and challengesin greater depth. Two discussion guides, developed by the research team, facilitated FGDs,which focused on LTC experiences during and after COVID-19. Key themes includedworkplace conditions, drivers of stress and burnout, and broader social influences on workand personal life. Discussions also covered psychological health, workplace safety, and theevaluation of standard measurement tools, such as the World Health Organization-FiveWell-Being Index for assessing mental well-being and identifying distress. Designed asstructured consensus-building exercises, the FGDs prioritized outcomes driven by HCWs,aligning with their identified needs and priorities.Participants were engaged as equal partners in identifying strategies and solutionsthrough a co-design approach that prioritized authentic collaboration. This approachacknowledged and valued the expertise and lived experiences of diverse LTC stakeholders,ensuring their contributions were both integral and central to the process. By fosteringinclusivity and shared ownership of outcomes, the approach ensured that the solutionswere deeply informed by and authentically reflected the lived realities of those most di-rectly impacted. All FGDs were moderated by a principal investigator—an expert inqualitative interviewing—and supported by a trained facilitator. Open-ended questionsencouraged participants to share personal experiences, challenges, strategies, and percep-tions of organizational support. Data saturation was achieved when the influx of pertinentnew information dwindled or ceased, and any subsequent data only reiterated existingknowledge without enhancing the understanding or contributing additional insights to theestablished themes [29]. Each session, lasting approximately two hours, was both audioand video recorded for transcription and analysis, with participants’ informed consent.Comprehensive notes, taken by a research team member, supplemented the recordings toensure accuracy and depth in capturing the discussions.2.5. Data AnalysisThe audio from the FGDs was transcribed using Otter.ai, with the research teamreviewing and verifying transcriptions for accuracy, noting any inaudible sections. Identify-ing details were removed to ensure participant anonymity. Transcripts were cross-checkedagainst the audio recordings to resolve discrepancies, ensuring completeness and reliability.Thematic analysis, guided by Braun and Clarke [30], was conducted using Microsoft Excel.The investigator team immersed themselves in the data through repeated listening andreading, with inter-coder reliability checks performed during coding.The analysis reflected the iterative nature of the co-design method. Initial codingframeworks were informed by research questions and emergent concepts. Two researchassistants independently coded each transcript, with discrepancies resolved collaborativelyunder the guidance of the principal investigator. Preliminary themes were development,capturing challenges, impacts on LTC workers, and potential strategies. Regular teamdiscussions refined these themes, ensuring coherence and responsiveness to the data. Asummary of the themes was shared with participants for feedback, which was incorporatedto refine the final themes and subthemes. Participants were also given an additional twoweeks to provide further verbal or written input. Following principles outlined by Williamsand Moser [31], the process emphasized flexibility and depth. Collaborative resolution ofambiguities ensured a rigorous and reflective approach to the analysis.Int. J. Environ. Res. Public Health 2025, 22, 520 6 of 192.6. Ethics Approval and ConsiderationsApproval for this study was granted by the Institutional Research Ethics Board(blinded for review). In reporting this study, we followed the Consolidated Criteria forReporting Qualitative Research (COREQ) guidelines [32].In this research, we critically engaged with the ethical dimensions (ethics of care)of both digital platforms such as Zoom and in-person focus groups by addressing pro-cedural ethics, situational ethics, ethical relationships, and broader ethical concerns [33].Procedural ethics involved strict adherence to institutional guidelines, including obtaininginformed consent, protecting participant confidentiality, and securing institutional ethicalapproval. Situational ethics required navigating context-specific challenges such as privacybreaches, technical failures, and participant discomfort. Given the heightened privacyrisks of digital platforms, the focus groups were conducted in isolated spaces/officesusing headphones to minimize unintended exposure—controls more easily managed inface-to-face sessions. Ethical relationships focused on building trust and rapport throughintentional engagement, including nonverbal cues like nodding and validating participants’experiences. Broader ethical concerns encompassed data security, unauthorized access, anddigital accessibility. To mitigate cybersecurity risks, we adhered to institutional guidelines,restricting data access to designated team members. Additionally, technical support wasprovided before and during sessions to address potential digital literacy barriers and en-sure equitable participation. While digital platforms introduce unique challenges, ethicalconsiderations—such as obtaining informed consent, maintaining participant confiden-tiality, and fostering trust—was equally vital in face-to-face interactions. By upholdingrigorous ethical standards across both modalities, we ensured a secure, respectful, andequitable research environment.3. ResultsA total of 24 HCWs participated in this study, comprising 10 personal support workers(PSWs), 5 registered nurse/registered practical nurses (RN/RPN), 2 social workers (SW),1 horticultural therapist, 1 behavioral therapist, and 5 administrators/managers (Table 1).Table 1. Participant characteristics (n = 24).Profile n (%)SexFemale 21 (87.5)Male 3 (12.5)RaceWhite 16 (66.7)Other 8 (33.3)Role/job titlePersonal support worker (PSW) 10 (41.7)Nurse (RN/RPN) 5 (20.8)Leader (director/manager/administrator) 5 (20.8)Allied health (social worker, behavioral and horticultural therapist) 4 (16.7)Age range 27–71 yearsMean 50 yearsYears of experience 1–30 yearsRN = registered nurse, RPN = registered practical nurse.The findings were organized into five major themes: (i) the need for effective workloadmanagement tools, (ii) the prioritization of psychological safety and mental health services,Int. J. Environ. Res. Public Health 2025, 22, 520 7 of 19(iii) reducing regulatory and bureaucratic burdens, (iv) strengthening management prac-tices, and (v) fostering recognition and a positive sector image. Each theme reflects theprofound impact of the pandemic and its aftermath on workers’ mental, emotional, andprofessional well-being. The co-design process identified actionable strategies to addressthese challenges, including sustainable workforce planning, establishing mental healthprograms, promoting self-care and reducing its stigma, enforcing work–life boundaries,and fostering psychological safety in LTC settings. The findings, organized by theme, withillustrative quotes from participants, provide deeper insight into the lived experiences ofLTC workers and are presented in the subsequent sections. Figure 1 illustrates a thematicmap of the identified challenges and corresponding solutions.Int. J. Environ. Res. Public Health 2025, 22, 520 7 of 20services, (iii) reducing regulatory and bureaucratic burdens, (iv) strengthening manage-ment practices, and (v) fostering r cognition an a positive sector ima e. Each theme re-flects the profound impact of the pandemic and its aftermath on workers’ ntal, emo-tional, a professi nal well-being. The co-design process identified actionable strategies to address these challe es, inclu ing sustainable workforce pla ning, establishing men-tal healt programs, promoting self-care and reducing its stigma, enforcing work–life boundaries, and fostering psychological safety in LTC settings. The findings, organized by theme, with illustrative quotes from participants, provide deeper insight into the lived experiences of LTC workers and are presented in the subsequent sections. Figure 1 illus-trates a thematic map of the identified challenges and corresponding solutions.Figure 1. Thematic map of the identified challenges and corresponding solutions.3.1. Identified Needs and Challenges3.1.1. The Need for Effective Workload Management ToolsThe chronic staff shortages during the pandemic increased workloads for HCWs, leading to widespread burnout and exhaustion. Many staff worked extended hours, often exceeding full-time schedules, to cover for absent colleagues. One RN shared the experi-ence, stating,“To make up for missed coworkers, many employees put in extra hours, even going above and beyond their full-time schedules. I personally had worked part-time during the pandemic but was working over full-time hours because there just were not enough nurses… The nurses we have were burning out.” (Assistant Director of Nursing01)The heavy workloads were compounded by burnout among PSWs, many of whom took stress leave, time off, or exited the field entirely. One participant noted,Figure 1. Thematic map of the identified challenges and corresponding solutions.3.1. Identified Needs and Challenges3.1.1. The Need for Effective Workload Management ToolsThe chronic staff shortages during the pandemic increased workloads for HCWs,leading to widespread burnout and exhaustion. Many staff worked extended hours,often exceeding full-time schedules, to cover for absent colleagues. One RN shared theexperience, stating,“To make up for missed coworkers, many employees put in extra hours, even going aboveand beyond their full-time schedules. I personally had worked part-time during thepandemic but was working over full-time hours because there just were not enoughnurses. . . The nurses we have were burning out.” (Assistant Director of Nursing01)The heavy workloads were compounded by burnout among PSWs, many of whomtook stress leave, time off, or exited the field entirely. One participant noted,Int. J. Environ. Res. Public Health 2025, 22, 520 8 of 19“Now I find in the PSW staff that they are taking stress leaves, and they are taking, youknow, time off and or quitting the field entirely.” (Assistant Director of Nursing02)The mental and emotional toll of these staffing shortages is substantial, with manyparticipants expressing a feeling of helplessness as they attempted to maintain high stan-dards of care under untenable conditions. Participants identified staffing shortages andsubsequent heavy workloads and described them as persistent, affecting all levels of staff,from frontline workers to management.3.1.2. The Prioritization of Psychological Safety and Mental Health ServicesThe psychological toll on HCWs during the pandemic was immense. Many staffdescribed the experience as emotionally and physically draining, with one participantlikening it to “drowning”, stating,“It is very much like you’re drowning and I know the frontline felt like that, too.” (SW01)Another added,“The staff, I feel, are burnt out and looking to management for some support, but manage-ment themselves are burnt out.” (Assistant Director of Nursing01)The quotes vividly depict the overwhelming strain experienced by HCWs duringcrises. The first highlights the feeling of being overwhelmed and unsupported, likenedto drowning, a sentiment shared across frontline workers. The second emphasizes thecascading nature of burnout, where staff seek support from management, only to find thatmanagement is equally exhausted, revealing a systemic cycle of stress and exhaustion thathampers effective support and care delivery. The emotional strain was compounded by theneed for additional mental health support, as many staff turned to medication for anxietyand depression, as one participant explained:“I will tell you; we have had more people than I have ever known before, disclose that theystarted an anti-anxiety or an anti-depression medication during the course of COVID.”(Horticulture Therapist)Symptoms of post-traumatic stress disorder (PTSD) were also prevalent, as healthcareworkers faced high-stakes, high-stress conditions. As one administrator explained,“There’s a lot of, there’s a lot of PTSD among a lot of different team members that I’ve seenand experienced, and even personal experience, where, you know, you feel for everythingyou’ve gone through, and, you know, and if you’re not in long term care, you don’tfully know.” (Administrator 01)Isolation from friends and family further contributed to their distress, with many feel-ing lonely and disconnected due to the necessary precautions against spreading COVID-19.One participant shared,“You start to get isolated from your friends and your family. It’s very sad, actu-ally,” (SW02)Adding to this burden was the stigma around self-care in caregiving roles. Many feltguilty for prioritizing their own well-being, as reflected in the following statement:“You’re not allowed to be selfish if you’re a caregiver, but it’s not really selfish. It’s abouttaking care of yourself.” (SW02)The quote highlights the paradox faced by HCWs in caregiving roles: the culturaland professional expectation that caregivers must prioritize others’ needs above their ownoften leads to the perception that self-care is “selfish.” However, the participant challengesthis notion, emphasizing that self-care is not an act of selfishness but a necessary practiceInt. J. Environ. Res. Public Health 2025, 22, 520 9 of 19to maintain their well-being and sustain their ability to provide quality care for others.This perspective underscores a critical truth: caregivers cannot effectively support othersif they neglect their own physical, mental, and emotional health. It reframes self-care asan essential, rather than indulgent, component of caregiving—a mindset shift crucial toreducing burnout and fostering resilience among HCWs.3.1.3. Reducing Regulatory and Bureaucratic BurdensThe regulatory and bureaucratic demands placed on HCWs during the pandemicfurther strained their capacity to provide care. Constant changes in directives from multiplehealth authorities created confusion and disrupted workflows, leaving staff feeling over-whelmed. One participant described the experience as “being in the vortex” (SW02) dueto conflicting requirements from the authorities. The frequent changes in directives alsodisrupted the efficiency of care delivery. Staff were forced to pivot repeatedly, spendingvaluable time deciphering and implementing new protocols rather than attending directlyto residents’ needs. These constant adjustments created a sense of chaos and left workersfeeling disoriented and unsupported:“We have both Ministry of Health and Public Health at the same time. . . it was soinsulting and so degrading to have outside people coming in to teach us what to do likewe had never been in the sector before.” (SW02)This quote captures the frustration and perceived disrespect felt by LTC staff whenexternal authorities, such as the Ministry of Health and Public Health, intervened duringthe pandemic with directives and training. It highlights how these actions were perceivedas dismissive of their expertise and experience in the sector, undermining their autonomyand competence. This perceived lack of trust in their capabilities added to their emotionalburden, leaving many feeling undervalued and unsupported.3.1.4. Strengthening Management PracticesManagement practices during the pandemic often left HCWs feeling unsupportedand undervalued. Many participants expressed dissatisfaction with how they were treated,referring to a lack of empathy and prioritization of bureaucratic demands over staff well-being. One participant shared their sense of betrayal, stating,“My employer ended up finding a way to push me out of a job I had for 16 years. . . thenew management treats people horribly.” (Manager02)Additionally, the focus on regulatory compliance over employee support furtherdemoralized staff, with one participant noting,“I think that we just become numbers. . . making sure we are compliant with the ministryand all of that. . . there is some aspect of micromanaging for certain areas of our work,which makes it difficult.” (SW02)This strained the relationships between employees and management, leaving workersfeeling unrecognized and overworked.3.1.5. Fostering Recognition and a Positive Sector ImageLack of acknowledgment and appreciation for HCWs’ efforts during the pandemicleft many feeling demotivated. Despite their sacrifices, participants shared their frustrationwith the absence of gratitude from management. One participant shared,“We were never acknowledged for our knowledge for our work. And it was very,very upsetting.” (SW02)The long-term effects of this lack of recognition were profound, with another stating,Int. J. Environ. Res. Public Health 2025, 22, 520 10 of 19“There has never, to my knowledge, been any acknowledgement of anything that happenedduring COVID. . . none.” (SW01)Another added,“You do not have any more time left, and then you are still not appreciated.” (Manager02)This failure to express appreciation or respect for their contributions during a crisisadded to the emotional toll and left HCWs feeling abandoned.On the other hand, the gap between how LTC workers are publicly perceived andthe reality of their experiences on the frontlines further intensifies the problem. Partic-ipants pointed out that media narratives rarely highlight their successes or the deeplycompassionate care they provide. One participant remarked,“It’s frustrating that no one talks about how we heal, how we bring people back to life butthey just focus on the failures.” (Manager01)The negative perception perpetuated by the media and the lack of internal recog-nition undermines efforts to foster pride within the sector. It also impacts recruitmentand retention, as potential workers see a profession that is underappreciated and poorlysupported. Participants suggested a need for consistent and meaningful recognition, bothat the organizational and the societal levels. One participant emphasized,“The senior leadership needs to acknowledge us more—our efforts, our sacrifices, ourhumanity. That would make a huge difference. We need more than pizza parties. We needrespect, acknowledgment, and appreciation for what we do.” (Manager01)Beyond recognition, participants called for a cultural shift that celebrates LTC as avital and compassionate field of healthcare. They believe that by amplifying positive storiesand recognizing the dedication of its workers, the sector can rebuild trust and pride amongboth staff and the public.3.2. Proposed Strategies3.2.1. Workforce PlanningParticipants highlighted the urgent need for effective workforce planning to addresspersistent staffing shortages and workload challenges in LTC. They advocated for proactivemeasures, including accurate forecasting of staffing needs, targeted recruitment campaigns,and retention strategies centered on competitive wages, comprehensive benefits, andopportunities for professional development. As one participant stated,“I think having permanent staff would be a much better solution. Somehow, finding a wayto retain staff and new graduates, making long-term care a more attractive option, wouldhelp. Right now, a lot of young nurses don’t even want to work here because hospitalspay more.” (RPN01)These initiatives, participants noted, are essential not only to attract new talent butalso to retain experienced workers. Furthermore, they highlighted the importance of collab-oration among government bodies, regulatory agencies, and LTC stakeholders to establishsustainable funding models that support hiring and retention efforts. By addressing thesesystemic workforce challenges, participants emphasized, these measures would improveworking conditions and the quality of life for HCWs while improving care outcomesfor residents.3.2.2. Mental Health ProgramsStructured mental health programs in LTC homes are essential for addressing thepsychological challenges, as many participants highlighted the need for concrete mentalInt. J. Environ. Res. Public Health 2025, 22, 520 11 of 19health measures, such as regular check-ins, access to counselors, and resilience-buildingworkshops. These programs need to normalize discussions around mental health andcreate an environment where employees feel safe seeking help. As one participant stated,“Health and safety might help with the psychological health and safety as amandated component.” (SW01)Participants also noted that systemic reforms, such as mandating mental health ini-tiatives in workplace policies and incorporating psychological health into national andprovincial laws, could ensure emotional and physical support for workers.3.2.3. Self-Care PromotionPromoting self-care is a professional need rather than a luxury. Participants acknowl-edged the critical need for rest and recovery, sharing their strategies for incorporatingself-care into their routines. One participant explained,“We are really of no use to anybody when we’re not rested, and when we’re not in a goodspace ourselves.” (Behavioral Therapist)Practices like meditation during lunch breaks or stepping outside for fresh air werehighlighted as small but impactful ways to recharge. Managers in LTC homes can activelyencourage self-care by training staff to recognize signs of burnout and creating a no-blameculture where workers feel comfortable prioritizing their health. Participants called forstructured policies that mandate regular breaks and provide designated quiet spacesfor relaxation, which are important to reducing stress and enabling workers to deliverquality care.3.2.4. Enforcing Work–Life BoundariesHCWs often struggle with boundaries between work and personal life, ultimatelyleading to burnout. Participants stressed the need for strict policies to protect personal timeand prevent interruptions during vacations or off-hours. Participants also emphasized theimportance of setting clear boundaries. Discussion highlighted the importance of effectivepolicies to ensure uninterrupted personal time and organizational efforts to make LTC amore attractive and balanced career option. One participant shared,“People like me are not allowed to not be called on vacation or at one in the morning. . .you have to have a safe space in your personal life to be able to come back.” (SW01)This quote reflects the strain and lack of boundaries faced by some HCWs, highlightingthe expectation of constant availability even during personal time. Participants emphasizedthe need to establish a safe space to recharge, as it is essential for maintaining resilience,well-being, and effectiveness in demanding roles, enabling workers to return with renewedfocus and energy.3.2.5. Fostering Psychological Safety in LTC SettingsParticipants highlighted the importance of fostering psychological safety through opencommunication, collaboration, and mutual trust among team members. Concerns wereraised about workplace violence, especially in instances involving cognitively impairedresidents who may exhibit behavioral issues. While many expressed empathy toward theseresidents and their conditions, participants emphasized the need for proactive measures toprioritize safety and well-being for all within LTC environments. One participant remarked,“Management needs to understand the mental toll that abuse from residents takes on us.There should be regular check-ins, counseling options, or just an acknowledgment thatwe need support.” (PSW01)Int. J. Environ. Res. Public Health 2025, 22, 520 12 of 19This quote spoke to the need for leadership to recognize the emotional impact ofresident-related abuse on HCWs. Participants emphasized the importance of proactivemeasures, including regular check-ins, access to counseling, and recognition of workers’challenges, to support their mental well-being. Cultivating an environment where indi-viduals feel safe to voice concerns, share ideas, and learn from mistakes fosters a cultureof support, resilience, and continuous improvement in LTC settings. Table 2 presents asummary of the identified challenges and the proposed strategies and solutions.Table 2. Identified challenges and proposed strategies.Identified Challenges Proposed Strategies and SolutionsWorkload Management• Chronic staff shortages leading to burnout and exhaustion• Extended working hours• Stress leave, time off, and attrition among PSWs• Recruitment challenges due to non-competitive wagesand benefitsWorkload Planning and Management• Workload management tools to distribute tasks equitably,monitor trends, and identify overburdened staff fortimely interventions.Mental Health and Psychological Safety• Psychological toll, including PTSD, anxiety,and depression• Isolation from friends and family• Stigma around self-care in caregiving roles• Emotional abuse from residentsMental Health Program and Promoting Psychological Safety• Access to mental health counselors andresilience-building workshops.• Normalizing discussions on mental health and promotingopen communication.• Promoting self-care as a necessity, with structured policiesfor breaks and relaxation spaces.• Encouraging a no-blame culture and designating quietspaces for relaxation.• Introducing regular check-ins and acknowledgment ofmental health challenges by management.Regulatory and Bureaucratic Burdens• Conflicting directives from multiple health authorities• Perception of external oversight as dismissiveand unnecessaryStreamlined Communication and Policy Coordination• Streamlining communication and collaboration andconsolidating directives to minimize confusion.• Fostering trust by involving LTC staff in policy discussionsand valuing their expertise.Management Practices• Lack of empathy and prioritization of bureaucracyover well-being• Perception of being treated as numbers rather thanvalued contributors• Micromanagement creating a demoralizingwork environmentFostering a Supportive and Empathetic Management Culture• Comprehensive training program for management onempathetic leadership and prioritizing staff supportalongside compliance.• Encouraging managers to actively listen to staff concernsand provide timely, meaningful solutions that prioritizeemployee well-being.• Creating accountability measures to ensure managementpractices are consistently supportive and aligned withorganizational values.• Encouraging healthy work–life boundaries be modeled.Recognition and Sector Image• Lack of acknowledgment of and appreciation forHCWs’ sacrifices• Negative media portrayal undermining sector pride• Recruitment and retention challenges due tonegative perceptionsEncouraging Recognition and Elevating the LTCSector’s Image• Establishing meaningful recognition programs at both theorganizational and societal levels.• Sharing positive stories and achievements of LTC workerspublicly to improve the sector’s image.• Highlighting the importance and compassion of LTC rolesthrough media campaigns and professionalgrowth opportunities.Int. J. Environ. Res. Public Health 2025, 22, 520 13 of 194. DiscussionThis study demonstrates the value of employing co-design and active engagementprinciples to identify challenges faced by HCWs in the LTC sector and to explore practicalsolutions. By incorporating stakeholder input, this approach enhances the real-worldimpact of the research. The findings highlight the compounded and persistent challengesconfronting HCWs in Canada’s LTC sector, particularly in the aftermath of the COVID-19pandemic. Consistent with existing literature, these challenges include chronic staffingshortages, psychological and moral distress, and deeply entrenched systemic barriers thatimpede the delivery of effective care [34,35]. While HCWs and leaders reflected on theircurrent experiences, their narratives were heavily influenced by the enduring impacts ofthe pandemic, highlighting its profound and lasting repercussions on the sector. Despitethe lifting of lockdown measures nearly three years ago, participants emphasized that thesechallenges remain unresolved, illustrating the ongoing strain on the workforce. This isespecially critical in the LTC context, where residents, many of whom belong to vulnerablepopulations, continue to face heightened risks associated with COVID-19 and its aftermath.Unsurprisingly, and consistent with other studies [36,37], our findings supported a linkbetween heavy workloads and unmet resident care needs, as well as the significant physicaland emotional toll on workers. These challenges were magnified during the pandemic,leading to widespread exhaustion and diminished care quality, further illustrating thecritical need for targeted, stakeholder-informed interventions in the sector.A prominent theme emerging from the co-design discussions was the psychologicaland moral distress that care workers experienced, an acute issue driven by ethical conflicts,systemic constraints, and the emotional toll of high-stress work environments. Moraldistress, which occurs when HCWs are unable to act in accordance with their ethical beliefsdue to external constraints, has been linked to long-term psychological impacts such asmoral injury, emotional exhaustion, and burnout [38,39]. Similar to the work of Boamah andcolleagues [10], LTC workers reported increased workloads, inadequate time for residentcare, and limited personal recovery time, further intensifying their moral distress andcompounded emotional fatigue.Our study highlighted systemic barriers—notably, regulatory and bureaucraticburdens—as key contributors to stress among LTC HCWs. Frequent changes in direc-tives from health authorities disrupted workflows and created confusion, echoing broaderchallenges in the field, where unclear or excessive regulations are linked to heightenedstress and inefficiency [40–42]. While these demands are crucial for ensuring quality careand accountability, they often impose significant administrative workloads that detractfrom direct patient care. Combined with chronic understaffing, these burdens intensifyworkloads, extend shifts, and exacerbate stress, leading to burnout.Consistent with Ontario’s LTC COVID-19 Commission report [43], participants in thisstudy reported that bureaucratic tasks hinder their ability to provide personalized care,frequently causing moral distress as they balance regulatory compliance with holistic care-giving. Workers described a culture overly focused on rule adherence and over-reporting,often at odds with residents’ health, safety, and well-being. Regulatory frameworks wereperceived as overly complex, inflexible, and misaligned with the diverse realities of LTCsettings (e.g., urban vs. rural), leaving workers unsupported in adapting to these demands.A prevailing perception of regulatory bodies as adversarial, prioritizing error detectionover collaboration, further fueled feelings of scrutiny, fear, and psychological distress. Thisculture undermines morale, reduces job satisfaction, and underscores the pressing need forregulatory approaches that are more supportive, adaptable, and aligned with both workerand resident needs.Int. J. Environ. Res. Public Health 2025, 22, 520 14 of 19Our findings align with Elstad and Vabø [44], who argued that undervaluation bymanagement and inadequate recognition both at the local and societal levels—along with alack of appreciation from the media and the public—are factors contributing to job dissatis-faction and turnover intention, particularly in eldercare settings. The demoralizing impactof rigid hierarchies and micromanagement, as highlighted in this study, are consistent withthe work by Marcella et al. [45], which underscored the detrimental impact of inflexible or-ganizational structures on staff morale and interprofessional collaboration. These findingsilluminate the multifaceted challenges within Canada’s LTC sector, reinforcing the need fortargeted interventions to address structural, organizational, and emotional dimensions ofHCW well-being.During the co-design process, HCWs and leaders collaboratively identified severalstrategies to address the challenges within the LTC sector. Workforce planning emergesas a critical intervention to mitigate chronic staff shortages. Forecasting models project asignificant shortfall in PSWs and nurses by 2035, necessitating the urgent need for strategicplanning to align workforce supply with future demands [46]. Innovative approaches,such as the program logic model implemented at the Ottawa Hospital, provide actionablesolutions for addressing staffing gaps. Recruitment strategies should include attractingunemployed individuals, re-engaging emigrated workers, and recruiting foreign workers(“Ensuring the availability of sufficiently trained carers”) [47]. Furthermore, retentionefforts must prioritize improving training programs, developing clear career pathways, andcultivating a positive work culture, as these factors are pivotal to improving job satisfactionand reducing turnover (“Ensuring the availability of sufficiently trained carers”) [47].Mental health programs and interventions are equally vital. Resilience-buildingworkshops and mindfulness-based interventions were identified as effective measures formitigating short-term effects of burnout and improving psychological well-being [48,49].Participants emphasized the need to foster supportive workplace culture that encouragesself-care and enforces clear work–life boundaries, thereby protecting staff from furtherexhaustion and burnout [50–52]. Complementary interventions and strategies, such astraining HCWs in self-leadership and emotional intelligence, can empower them withthe tools needed to manage stress more effectively [53]. As per the study participants,addressing mental health and other systemic issues in LTC necessitates comprehensivestructural reforms that go beyond mitigating immediate crises to tackling entrenched issueswithin the sector.As highlighted in this study, fostering psychological safety within LTC settings ispivotal for establishing a supportive and collaborative work environment. Lai and Jamalet al. [54,55] emphasize the vital role of leadership in cultivating spaces where staff feelvalued and empowered to voice concerns without fear of judgment or reprisal, therebyenhancing both team dynamics and care quality. Interventions such as participatory changemanagement and targeted staff training have been shown to strengthen safety culture andbuild organizational resilience [56].HCWs and leaders stressed the need for systemic reforms to improve regulatory prac-tices, streamline administrative processes, and align policies with the practical realities offrontline care. Such measures would better equip and support staff in meeting the complexneeds of residents. These findings emphasize the urgent need for collaborative effortsamong policymakers, healthcare organizations, and senior LTC leaders/administratorsto address systemic challenges. Implementing sustainable reforms is critical not onlyto enhancing worker well-being but also to improving the overall quality of life withinLTC settings.Int. J. Environ. Res. Public Health 2025, 22, 520 15 of 194.1. ImplicationsThe findings suggest that both tangible aspects of care work, such as working condi-tions, roles, and workplace social relations, and intangible factors, such as perceptions ofsocietal recognition and value, significantly influence staff retention. These results empha-size the need for systemic and organizational reforms within the LTC sector to address thepersistent workforce challenges. Priority measures include strategic workforce planning toensure adequate staffing and prevent burnout, implementing mental health programs orinitiatives to support HCWs’ psychological well-being, and fostering a workplace culturethat normalizes and promotes self-care. The insights from this study extend beyond the LTCsector, offering valuable guidance for healthcare settings at large and informing policiesand practices across diverse jurisdictions.To achieve meaningful change, policymakers, healthcare organizations, and LTC ad-ministrators must prioritize collaborative efforts to allocate resources effectively, streamlineregulatory and documentation processes, and implement inclusive workforce strategies.Reducing these regulatory and administrative burdens on non-priority issues aligns withthe goals proposed in the Government of Canada’s [57] nursing retention toolkit, focusingon freeing up HCWs to focus on the tasks and care that they are uniquely skilled to provide.Empowering LTC workers through training and flexible guidelines, and involving them inpolicy-making decisions, can reduce the emotional toll and enhance their ability to deliverquality care.The findings present actionable strategies to address identified challenges, offering afoundation for future research to implement and evaluate the impact of these interventionson HCWs. By integrating HCWs’ lived experiences into policy and practice, this studyadvocates for sustainable solutions designed to improve worker satisfaction, retention, andresilience in the LTC sector. Moreover, the co-design approach employed in this studyserves as a replicable framework for engaging stakeholders in developing practical andcontext-sensitive solutions that can be adapted to other high-stress healthcare settings. Byactively engaging LTC workers as equal partners in the research process, this approachfostered a collaborative space where participants could candidly share their experiencesand priorities, enabling a deeper and more nuanced understanding of the challenges theyface compared to traditional qualitative methods [17]. The co-design framework not onlyhighlighted the systemic nature of regulatory burdens but also facilitated the creation ofactionable, tailored solutions that reflect the lived realities of those most impacted. Thisapproach effectively bridges the gap between theoretical insights and practical applications,ensuring that proposed interventions are both meaningful and implementable withincomplex healthcare settings.4.2. Strengths and LimitationsThis study’s strengths lie in its innovative use of a co-design approach to actively en-gage HCWs and leaders in Ontario’s LTC sector. By focusing on identifying challenges andco-developing strategies informed by their lived experiences, the study ensures relevanceand applicability to real-world conditions. To our knowledge, no prior workplace inter-ventions in LTC have utilized a co-design methodology to specifically address the needsof HCWs during and after the pandemic, highlighting the novelty of this research. Addi-tionally, the integration of a virtual co-design process, complemented by live discussions,provided significant advantages: it was cost-effective, accessible, and facilitated the inclu-sion of diverse perspectives. This approach enabled robust collaboration among HCWsand stakeholders, overcoming barriers related to geography and scheduling constraints.Limitations of this study included participants’ time constraints during the co-designprocess. Data collection took place during and after the pandemic lockdown (2023–2024), aInt. J. Environ. Res. Public Health 2025, 22, 520 16 of 19period when HCWs and leaders were overburdened, making it challenging to secure theirparticipation. To address this, focus group sessions were limited to two hours with sched-uled breaks, and asynchronous options, such as email feedback and collaboration tools,were provided for flexibility. However, time constraints may have impacted participationrates, and the range of distress sources identified. Additionally, technological challengesposed risks to engagement, particularly in virtual sessions. To mitigate these issues, aco-host moderator swiftly managed technical difficulties, while staggered participationallowed for flexible involvement at different stages of the design process, accommodatingdiverse schedules. Future research should expand to include participants from other Cana-dian provinces and linguistic groups, including Francophones, to enhance representationand applicability.5. ConclusionsThe study findings highlighted the profound workforce challenges in Canada’s LTCsector, which has been made worse by the COVID-19 pandemic. The findings reveal thesignificant impact of short-staffing, moral and psychological suffering, regulatory con-straints, ineffective leadership and management practices, and lack of acknowledgmentand recognition on the mental health and well-being of HCWs and the quality of care theyprovide. The study emphasizes that achieving high-quality resident care and fostering aresilient LTC workforce requires prioritizing HCWs’ mental health and improving work-place conditions. Moving forward, a collaborative, multi-stakeholder approach is essentialto building a sustainable and supportive LTC environment that benefits both residents andthe dedicated individuals who care for them.Author Contributions: Conceptualization, S.A.B.; methodology, S.A.B.; data curation, S.A.B.; soft-ware, S.A.B.; validation, F.A.; formal analysis, F.A.; investigation, S.A.B.; writing—original draftpreparation, S.A.B. and F.A.; writing—review and editing, S.A.B., F.H., B.K. and F.A. supervision,S.A.B.; project administration, S.A.B.; funding acquisition, S.A.B. All authors have read and agreed tothe published version of the manuscript.Funding: This research was supported by grant funding from the Canadian Institutes of HealthResearch (grant #478306) on 30 June 2022.Institutional Review Board Statement: Ethics approval for this study was obtained from the Hamil-ton Integrated Research Ethics Board (14837, date: 30 June 2022). Participants provided writteninformed consent to participate, and consent was also obtained for the publication of any potentiallyidentifiable images or data included in this article.Informed Consent Statement: Informed consent was obtained from all participants involved inthe study.Data Availability Statement: The study data are not publicly available due to restrictions, such asparticipant privacy, in line with the ethics agreement. 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Article
eng
Reviewed
Vancouver : University of British Columbia Library
Multidisciplinary Digital Publishing Institute
CC BY 4.0
Faculty
Researcher
co-design
mental health
healthcare workers
long-term care
workforce well-being
retention
Navigating Workforce Challenges in Long-Term Care : A Co-Design Approach to Solutions
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