Long-term care (LTC) is an increasingly crucial part of Canada’s healthcare system, particularly in Atlantic Canada, which has some of the highest current proportions and future projections of adults over the age of 65 nationwide. Most of the direct care within LTC homes is provided by care aides, yet little is known about this critical workforce. In this study, we explore cross-sectional data from 1,338 care aides from the four Atlantic provinces, which were collected through the Atlantic Research Collaboration on Long-term Care (ARC LTC). Overall, we find that these workers are primarily middle-aged women with almost a decade of experience in the sector. While care aides in the region appear to like their work, their commitment is undermined by significant personal and professional strain, with over half at high risk of burnout, nearly a third reporting below-average mental health scores, and one-in-three considering quitting their job.

Care homes are vulnerable to respiratory syncytial virus (RSV) outbreaks, with residents at risk of severe disease outcomes, though surveillance studies are lacking. In September 2024, RSV vaccination was introduced for adults in England aged 75–79 years, excluding most residents (median age 86 years). Between October 2024 and March 2025, we prospectively extracted information on RSV outbreaks in English care homes reported to UK Health Security Agency (UKHSA). Enhanced surveillance questionnaires (ESQs) were completed for a sample of outbreaks, including information on symptomatic residents, testing, and outcomes. Acute respiratory infection (ARI) cases were defined symptomatically, RSV cases based on test-positive RSV (≤5 residents tested per home), and RSV outbreaks as ARI outbreaks including ≥1 RSV case. We described outbreak trends, attack rates, hospitalizations, and deaths. Of 2419 ARI outbreaks in care homes, 222 (9%) were RSV outbreaks, with additional respiratory viruses identified in 69 (31%). Among 48 (22%) RSV outbreaks completing ESQs, the median ARI attack rate was 15% (IQR 10%–24%). Of 350 ARI cases, 32% (112) were confirmed RSV cases on routine testing, 20% (71) were hospitalized, and 6% (20) died. These findings demonstrate the vulnerability of care home residents to RSV infection, hospitalization, and death, which are potentially preventable through vaccination.

Nonprofit, public, and for-profit welfare institutions have different operational logics. The distinctiveness of a nonprofit institution is more prominent in some circumstances than in others. This paper is based on case studies conducted in Norwegian municipalities to understand when and why nonprofits operate with distinctive steering mechanisms. Based on the framework of hybrid organizations, I analyze the interaction among institutions in the public sector that have democratic legitimacy through a hierarchical organization, the for-profit sector that seeks efficiency to compete in the market, and the nonprofit sector that has civil society logic. The study revealed how more detached demand-driven regulation of nonprofit schools gives them more room to pursue goals different from those of the public sector institutions, which can be contrasted with the supply-driven regulation of nursing homes that have far less room for steering independent of the municipalities. Surprisingly, the results also suggested that small close-knit communities influence institutions in ways that diverge from the hierarchical steering, and that this happens across the sector split. Moreover, regulation and alternative sources of income contribute to making the organization more hybrid, in the sense that the hierarchical steering is challenged.

People with dementia have complex needs and priorities that change along the condition’s trajectory. Attending to these needs requires person-centred long-term care and support to be sensitized to the experiences and subjective realities of people with dementia. Regulators assessing the quality of care and support are important change agents in the health system. Research on regulatory assessments of care and support at home is, however, scarce. This qualitative research aimed to gain insight into the experiences of people with dementia receiving person-centred care and support at home, and to explore how regulators assess the quality of care and support provided in clients’ homes. Using the emotional touchpoint method, we found that people with dementia often experience a tension between wanting to maintain a sense of agency and having to accept increasing dependence on others. Using interviews and document analysis, we identified that regulators found it difficult to include the knowledge gained from clients’ experiences of care and support in their assessments. In regulatory assessments, objective risks are prioritized and assessment criteria are based on a largely positivistic epistemology, favouring measurable criteria. This results in regulators assessing observable or documentable aspects of care that do not acknowledge the necessary nuances and emotional aspects that are most important to people with dementia. We conclude that alternative approaches to regulatory assessments are necessary to evaluate person-centred long-term care and support in a way that reflects the experiences and needs of people with dementia and promotes person-centred practices.

Approximately 25% of older adult residents who experience an acute change in health status are transferred from Long-Term Care (LTC) to Emergency Departments (ED). We explored the use of an intervention (i.e., LTC to ED) care and referral pathway, INTERACT® Change in Condition cards, and STOP AND WATCH tool, in informing decision making regarding resident transfers. We conducted 22 semi-structured interviews with Health care Providers (HCPs) involved in the LTC to ED care pathway in Western Canada. Thematic analysis of the qualitative interviews was used to evaluate the use of the pathway and tools. We identified six themes influencing decision making around resident transfers including interprofessional practice and conflict, ambiguous and clear medical cases, ageism, health care providers’ goals, family involvement in resident care, and intervention tools. The intervention may be useful in streamlining, documenting, and increasing transparency in complicated LTC resident care and transfer decisions.

The devastating impacts of the COVID-19 pandemic highlighted the missing voices of families and residents in long-term care (LTC) decision-making and policy processes. Family and resident councils constitute one method of raising these voices, but there is currently a gap in evidence of how to promote the effectiveness of these councils. We conducted five focus groups and two interviews with LTC home leaders, residents, family members, and advocates in British Columbia using a participatory approach integrating knowledge-users throughout the research process. Using a framework analysis, we found modifiable (communication, structure, recruitment/engagement, council leadership, culture/attitudes, and resources/supports) and non-modifiable factors (medical complexity of residents and short lengths of stay) affecting council effectiveness. We discuss strategies implemented by knowledge-users to address modifiable effectiveness factors and construct a preliminary tool (a 35-question survey) that operationalizes and identifies areas that can increase council effectiveness in practice to ensure that their voices are heard in LTC decision making.

Pandemic-related restrictions in nursing homes have undermined the critical role that family and friend caregivers play in enhancing resident quality of life. We examined how family caregiver access restrictions in nursing homes were implemented and how they impacted the mutual well-being of and relationships between residents and their caregivers over time. Between March 2021 and March 2022, 24 ‘designated caregivers’ in Atlantic Canada were interviewed three times. We identified changes in family relationships and activities over time, constricted support networks, the increasing need for advocacy and monitoring, and the generally negative cumulative impacts of restrictions, especially during residents’ end-of-life. Subsequent adaptations to access restrictions allowed caregivers to contribute to essential monitoring, care relationships, and advocacy roles. We argue that the role of designated caregivers in nursing homes must be maintained during public health emergencies to ensure resident’s supportive family relationships and general well-being.

Scabies outbreaks cause significant morbidity and disruption in aged care facilities and other institutional settings. Failure to manage scabies outbreaks may be attributable to low awareness amongst healthcare workers. A survey was distributed to healthcare workers across aged care facilities in South-East Queensland, Australia. The survey captured demographics, prior scabies experience, knowledge-based questions, and attitudes. Scabies was common in aged care facilities, with 41% of 128 respondents encountering the disease while working in aged care. Participants demonstrated sound theoretical knowledge regarding scabies (median knowledge score 82%). Scabies knowledge was not associated with years of experience in the sector or educational level but was associated with respondent age (p = 0.017). Knowledge gaps were evident regarding diagnosis, incubation periods, and treatment. Respondents demonstrated an inconsistent ability to identify atypical clinical presentations of scabies, showing discordance between theoretical knowledge and its practical application. The ability to identify crusted scabies was low, reflecting the high frequency of misdiagnosis of index cases in scabies outbreaks. Respondents considered scabies to be a problem and were supportive of improved management guidelines. These study outcomes will inform the design of accessible, targeted educational resources for scabies to help prevent and reduce the impact of outbreaks.

This article proposes ethical — and legal — accountability for lawyers representing clients such as private equity (PE) firms who create ownership structures for nursing home systems. Using PE ownership as a case study, I will show that nursing home residents are often harmed and Medicaid costs inflated. I propose private law provides tools to compel such accountability, through (1) aiding and abetting doctrines and (2) fiduciary doctrines that require that the fiduciary be responsible for its vulnerable beneficiaries, not just ethically but for damages and equitable relief. I further propose that the teaching of Professional Responsibility needs to be changed to force law students to consider the effect of legal practice on third parties in situations like health care financing.

This paper contributes to the legal and socio-legal literature on long-term care (LTC) facilities (also known as nursing homes) by drawing from the responsive regulation literature and empirical research conducted in 2021 and 2022. Enforcement is an under-explored aspect in the legal and socio-legal literature on LTC. This research asks how the regulator’s enforcement activities shape compliance of LTC homes in Ontario. This paper reports the results from eleven semi-structured key informant interviews with associations that represent LTC facilities, advocacy organizations, unions, and professionals, such as lawyers. The current enforcement activities do not appear to evoke responsiveness in at least some of the LTC homes because the regulator’s approach is not dynamic: the regulator does not change its mix of “persuasion” and “coercion” in order to respond to the motivations and behaviours of homes. Inspection and enforcement activities have had little impact on how homes respond to rules.