Developing National Standards for Long-term Care: Tensions and Opportunities
Written by Jiale Xie, TMED MSc'25 (Candidate)
On October 5th, 2023, the Department of Medicine welcomed health and social services research expert Dr. Pat Armstrong to share her insights on the process of developing the Health Standards Organization (HSO) standards for Canadian Long-Term Care (LTC),1 as well as her research that provided the foundation for these standards, entitled “Reimagining Long-term Residential Care: An International Study of Promising Practices”.2
In her research, Dr. Armstrong, along with a team of 32 interdisciplinary and international academics and graduate students, observed and conversed with residents and workers at LTC facilities across six developed countries including Canada.2 From their study, they democratically identified key principles that define quality in LTC.
First, she shared that context, population, and gender matter, as do racialization and social class.3–5 This perspective, she noted, sharply contrasts with the traditional positivist scientific and medical standpoint, as it rejects the notion of a singular "right way" to approach LTC.5 She highlighted the need for customized approaches based on individual resident needs considering the diversity of the populations in LTC.3 Institutionally, best practices vary based on location and planning, such as in uncertain times like a pandemic.3 Thus, she advocated for evidence-informed standards over strict standardization. Recognizing the value of standardization in reinforcing practices,4 she nevertheless prompted the audience to reflect on the dilemma of setting standards that accommodate different contexts while maintaining accountability.
Next, she highlighted the core understanding that, LTC homes are both homes and workplaces, where the conditions of work are the conditions of care.1,6–8 A healthy and competent workforce is more likely to provide relationship-centered, personalized, and home-like care.6–8 Therefore, her team thought to reframe the discussion on residents' rights and staff rights as essentially synergistic, rather than separate and opposing, as was assumed by participants in her study.
The third principle she discussed was that high-quality resident-centred care is team-based, and enables equity, diversity, inclusion, and cultural safety.1,9 Notably, she underscored that the concept of team extends beyond just the healthcare workforce and incorporates residents themselves, essential care partners (e.g., family, friends, other residents), and the entire workforce.9 This workforce encompasses both clinical and non-clinical staff, including those in roles like clothing, food/dietary, and laundry, which are often overlooked in discussions about quality of care.9
Fourthly, she emphasized the importance of respecting LTC residents' autonomy, allowing them to choose to live with certain risks, all while ensuring that they are well-informed. This stands in contrast to the prevailing historical emphasis on enforcing safety measures such as limited mobility and dietary restrictions, which have often prioritized safety at the expense of residents' ability to feel truly at home and live life to the fullest in LTC settings.10(p1)
Lastly, she discussed that the HSO standards do not address jurisdictional requirements, bargaining agreements, professional requirements, and ownership.1 The absence of commentary on these elements may be unsatisfactory, considering their significant impacts on LTC conditions.11 Nevertheless, the existing standards, as outlined, offer a valuable starting point for organizations and caregivers seeking guidance on how to initiate improvements in resident care.
In Dr. Armstrong’s post-lecture discussion with the TMED graduate students, we explored the positive impact of HSO standards on specific populations in LTC, such as young patients.12 The discussion then shifted to sociocultural factors affecting translational research and patient care, including unpaid volunteer work, gender and immigrant wage disparities, and LTC waitlists.13 In our discussion, Dr. Armstrong restated the importance of personalized care at the resident-staff interaction level, backed by system conditions like adequate staffing, training, pay regulations, and public ownership. Lastly, she advised young trainees to become community activists early, celebrate small victories, and surround themselves with supportive colleagues for ongoing learning, motivation, and opportunities.
Dr. Armstrong’s talk provides many directions on how to conduct research with a translational bench-to-bedside and back model. This includes including interdisciplinary, holistic perspectives in the core research team and participant groups, which will allow for a fuller understanding of the research phenomenon with more nuances and context. Another direction is researching with humility and learning, as Dr. Armstrong implied that every new lesson she shared came with the prerequisite of an open mind. On the class’s behalf, I would like to thank Dr. Armstrong for the opportunity to learn from the process of re-imagining LTC to embrace new perspectives to our research from patients to field professionals, and critically consider the boundary of applicability of our research at an individual and system level. With little doubt, these lessons will motivate meaningful translation and innovation in our respective fields.
(749 words before references)
1. Health Standards Organization (HSO). CAN/HSO 21001:2023 (E) Long-Term Care Services. Standards. Published 2023. Accessed October 6, 2023. https://healthstandards.org/standard/long-term-care-services-can-hso210…
2. Armstrong P, Adams A. Re-imagining Long-term Residential Care – An international study of promising practices. Accessed October 6, 2023. https://reltc.apps01.yorku.ca/
3. Armstrong P, Cohen M. A Higher Standard: Setting Federal Standards in Long-Term Care and Continuing Care. Canadian Centre for Policy Alternatives; 2020:4. Accessed October 6, 2023. https://policyalternatives.ca/publications/reports/higher-standard-0
4. Choiniere JA. Accounting for care: exploring tensions and contradictions. ANS Adv Nurs Sci. 2011;34(4):330-344. doi:10.1097/ANS.0b013e3182356c31
5. Armstrong P, Daly T. Introduction. In: Exercising Choice in Long-Term Residential Care. Seniors issues and pensions. Canadian Centre for Policy Alternatives; 2017. Accessed October 6, 2023. https://policyalternatives.ca/publications/reports/exercising-choice-lo…
6. Armstrong P, Armstrong H. Is there a future for nursing homes in Canada? Healthc Manage Forum. 2022;35(1):17-20. doi:10.1177/08404704211037788
7. Armstrong P, Armstrong H, Choiniere J, Lowndes R, Struthers J. Re-Imagining Long-Term Residential Care in the COVID-19 Crisis. Canadian Centre for Policy Alternatives; 2020:7-11. Accessed October 6, 2023. https://policyalternatives.ca/publications/reports/re-imagining-long-te…
8. Canadian Health Coalition. Coalition urges HSO to improve working conditions in its new standards. Published July 29, 2021. Accessed October 6, 2023. https://www.healthcoalition.ca/coalition-urges-hso-to-improve-working-c…
9. Armstrong P, Armstrong H, Bourgeault IL. Teaming up for long-term care: Recognizing all long-term care staff contribute to quality care. Healthc Manage Forum. 2023;36(1):26-29. doi:10.1177/08404704221115811
10. Armstrong H. Chapter 1: Tension Between Risk and Safety. In: Armstrong P, Lowndes R, eds. Negotiating Tensions in Long-Term Residential Care. Health, health care system, pharmacare; Seniors issues and pensions. Canadian Centre for Policy Alternatives; 2018. Accessed October 6, 2023. https://policyalternatives.ca/publications/reports/negotiating-tensions…
11. Armstrong P, Armstrong H, Buchanan D, et al. Investing in Care, Not Profit: Recommendations to Transform Long-Term Care in Ontario. Canadian Centre for Policy Alternatives; 2021. Accessed October 6, 2023. https://policyalternatives.ca/publications/reports/investing-care-not-p…
12. Grandview Lodge Haldimand County, Ontario Centre for Learning, Research and Innovation in Long-Term Care. A Home for All: Younger Residents Living in Long-Term Care.; 2018. https://clri-ltc.ca/files/2019/01/Younger-Residents-in-LTC-Handout.pdf
13. Armstrong P. Unpaid Work in Nursing Homes: Flexible Boundaries. Policy Press; 2023. Accessed October 6, 2023. https://yfile.news.yorku.ca/2023/07/14/professors-book-details-care-hom…