CARE AIDES’ JOB SATISFACTION AFFECTED BY COVID-19 PANDEMIC IN
LONG-TERM CARE SETTINGS IN NORTHERN BRITISH COLUMBIA

by

Maryam Sarfjoo Kasmaei
B.Sc., Deylaman University, 2016
M.Sc., University of Environment, 2019

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN
HEALTH SCIENCES

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
August 2024

©Maryam Sarfjoo Kasmaei, 2024

Abstract
The COVID-19 pandemic impacted healthcare settings, particularly long-term care
facilities (LTCFs) that serve vulnerable older adults. Measures implemented to enhance LTCF
resident’s safety also had profound effects on staff, especially care aides who provide direct care,
yet little is known about their specific experiences during the pandemic. This study aims to shed
light on the experiences of care aides working in LTCFs in northern British Columbia during the
COVID-19 pandemic, focusing on their job satisfaction. A systematic review using Arksey and
O'Malley's (2005) scoping study framework examined four databases: PubMed MEDLINE,
CINAHL, Social Work Abstracts, and APA PsycINFO. Secondary qualitative data from eight
care aides, collected through one-hour semi-structured interviews, was analyzed using Braun and
Clarke's (2006) thematic analysis method. The findings reveal that the COVID-19 pandemic
increased workloads and stress levels among care aides, negatively impacting their job
satisfaction due to inadequate support systems, disrupted communication, and new safety
policies. The study underscores the need for increased staffing, better psychological and financial
support, and enhanced communication channels, recommending crisis management training and
ongoing education. Further research is needed to evaluate the long-term effects of the COVID-19
pandemic on care aides' job satisfaction and mental health, particularly in rural areas.
Keywords: Personal support worker, Nursing home, Quality of work-life, COVID-19 outbreak,
Rural BC

ii

Table of Contents

Abstract ............................................................................................................................... ii
Table of Contents ............................................................................................................... iii
List of Tables ................................................................................................................... viii
List of Figures ..................................................................................................................... 1
Glossary .............................................................................................................................. 2
List of Abbreviations .......................................................................................................... 1
Acknowledgements ............................................................................................................. 1
Chapter 1: Introduction ....................................................................................................... 1
Background ..................................................................................................................... 1
Long-Term Care .............................................................................................................. 2
Long-Term Care in Canada ............................................................................................. 2
Long-Term Care in British Columbia ......................................................................... 3
Long-Term Care in Northern British Columbia .......................................................... 4
Role of Care Aides in Long-Term Care Settings ............................................................ 6
Job Status and Job Satisfaction of Care Aides ................................................................ 6
Impact of COVID-19 on Care Aides Work-life .............................................................. 7
My Personal Experience During the COVID-19 Pandemic............................................ 8
Purpose of the Study ..................................................................................................... 10
Objectives and Study Question.................................................................................. 10
Chapter 2: Literature Review ............................................................................................ 12
Search Methodology ..................................................................................................... 12
Scoping Review Approach ........................................................................................ 12
Step 1: The Identification of the Research Question ................................................. 13
iii

Step 2: Identifying Inclusive and Exclusive Criteria ................................................. 14
Step 3: Identification of Relevant Studies ................................................................. 15
Step 4: Study Selection .............................................................................................. 16
Step 5: Collecting, Summarizing and Reporting the Results .................................... 16
Findings ......................................................................................................................... 18
Care Aides ................................................................................................................. 18
Care Aides in Long-Term Care ................................................................................. 20
Factors Impacting Care Aides' Job Satisfaction in Long-Term Care During the
COVID-19 Pandemic ................................................................................................................ 20
Job Satisfaction .......................................................................................................... 21
Exhaustion ................................................................................................................. 22
Fears........................................................................................................................... 24
Anxiety ...................................................................................................................... 25
Quality of Work-life .................................................................................................. 27
Workload ................................................................................................................... 28
Discussion ..................................................................................................................... 31
Impact on Care Aides ................................................................................................ 31
Gendered Impacts ...................................................................................................... 32
Long-Term Care Facility Resident Care Implications .............................................. 32
Limitations .................................................................................................................... 33
Future Directions ........................................................................................................... 34
Chapter 3: Methodology ................................................................................................... 35
Research Design ............................................................................................................ 36
Qualitative Design ......................................................................................................... 36
Sample and Recruitment ............................................................................................... 37

iv

Data Collection .............................................................................................................. 39
Data Analysis ................................................................................................................ 40
Thematic Analysis and Qualitative Methodology Framework .................................. 40
Thematic Analysis Using Braun and Clarke's Six-Step Approach ........................... 40
Precision and Reliability ............................................................................................... 42
Trustworthiness of the Research................................................................................ 44
Ethical Consideration .................................................................................................... 45
Chapter 4: Results ............................................................................................................. 47
Dataset Overview .......................................................................................................... 47
Overview of Themes ..................................................................................................... 48
Theme 1: Work Environment and Conditions Affected Care Aides Job Satisfaction .. 49
Work Experience ....................................................................................................... 50
Changes in Work Environment ................................................................................. 52
Availability and Use of Personal Protective Equipment ........................................... 55
Workload Changes .................................................................................................... 57
Short Staffing and New Staffing Issues ..................................................................... 60
Theme 2: Emotional and Psychological Impact on Care Aides .................................... 61
Feeling Supported During COVID-19 ...................................................................... 61
Emotional Responses to Resident Deaths and Grief ................................................. 63
Perceived Value and Recognition of Care Aides ...................................................... 65
Theme 3: Impact of COVID-19 on Communication and Team Dynamics .................. 67
Team Communication ............................................................................................... 67
Changes in Team Interactions ................................................................................... 69
Impacts of Social Distancing on Team Dynamics ..................................................... 70

v

Theme 4: Impacts of Resident Care and Safety During the COVID-19 Pandemic on
Care Aides Job Satisfaction....................................................................................................... 71
Impact on the Quality of Resident Care .................................................................... 71
Challenges in Maintaining Resident Safety and Well-being ..................................... 73
Theme 5: Impact of Policies on Care Aides Role at Long-Term Cares ........................ 74
Effects of Vaccination Policy on Care Aides ............................................................ 74
Effects of Visitor Policies on Care Aides .................................................................. 76
Effects on Work Environment and Team Dynamics ................................................. 79
Chapter 5: Discussion ....................................................................................................... 81
Impact of Care Aide's Background and the Facility Characteristics on Job Satisfaction
................................................................................................................................................... 81
Impact of PPE Availability and Usage on the Work Life of Care Aides During the
COVID-19 Pandemic ................................................................................................................ 85
Reflection on Increased Workload for Care Aides During the COVID-19 Pandemic . 87
Impact of Short Staffing and New Staff Issues During the COVID-19 Pandemic ....... 90
Management, Financial, and Psychological Support During the COVID-19 Pandemic
................................................................................................................................................... 91
Emotional and Psychological Toll of Resident Deaths on Care Aides ......................... 93
Perceived Value and Recognition of Care Aides' Work During the COVID-19
Pandemic ................................................................................................................................... 94
Impact of Social Distancing due to COVID-19 on Care Aides' Team Communication 96
Impact of COVID-19 Policies on Care Aides in Long-Term Care Facilities ............... 97
Strengths and Limitations of the Study ....................................................................... 101
Strengths of the Study.............................................................................................. 101
Limitations of the Study .......................................................................................... 102
Summary and Recommendations ................................................................................ 103
vi

Conclusion ................................................................................................................... 105
References ....................................................................................................................... 107
Appendix A ..................................................................................................................... 118
Appendix A-1: Narrative Description of PubMed Search....................................... 118
Appendix A-2: Narrative Description of CINAHL Search ..................................... 119
Appendix A-3: Narrative Description of Social Work Abstracts Search ................ 120
Appendix A-4: Narrative Description of APA PsycINFO Search .......................... 121
Appendix B ..................................................................................................................... 122
Appendix B-1: PubMed search strategy screenshot: July 2023 .............................. 122
Appendix B-2: CINAHL Search Strategy Screenshot: July 2023 ........................... 123
Appendix B-3: Social Work Abstracts Search Strategy Screenshot: July 2023...... 127
Appendix B-4: APA PsycINFO Search Strategy Screenshot: July 2023 ................ 131
Appendix C ..................................................................................................................... 137
Demographic Information from Literature Review ................................................. 137

vii

List of Tables
Table 1. Population, Intervention and Effect Keywords................................................... 13
Table 2. Terms for Documentation Search ....................................................................... 14
Table 3. Inclusion and Exclusion Criteria......................................................................... 15
Table 4. Trustworthiness Framework Criteria of Lincoln and Guba (1985) .................... 43
Table 5. Recommendations for Improving Care Aides' Work Conditions ..................... 104

viii

List of Figures
Figure 1. Map Depicting Northern Health Communities .................................................. 5
Figure 2. PRISMA Flowchart .......................................................................................... 17
Figure 3. Themes Identified in the Study on the Impact of the COVID-19 Pandemic on
Care Aides' Job Satisfaction in LTCFs ......................................................................................... 49

1

Glossary
Burnout: A state of physical, emotional, and mental exhaustion caused by prolonged stress and
overwork, particularly prevalent in caregiving professions.
Care Aides: Healthcare workers who assist patients with daily activities and provide basic care
in LTCFs.
COVID-19: An infectious disease caused by the novel coronavirus SARS-CoV-2, characterized
by a range of symptoms from mild respiratory issues to severe illness leading to acute respiratory
distress syndrome and fatalities.
Employment Status: Refers to the type of employment arrangement, such as full-time, parttime, or casual, which impacts job satisfaction and financial stability.
Ethics Approval: Official permission granted by an ethics review board to conduct research
involving human participants, ensuring ethical standards are met.
Job Satisfaction: A measure of how content an individual is with their job, including factors
such as work environment, responsibilities, and management support.
Long-Term Care Facilities (LTCFs): Healthcare facilities that provide long-term support and
services to individuals with chronic illnesses, disabilities, or age-related conditions.
Mental Health: A state of well-being in which individuals can cope with normal stresses, work
productively, and contribute to their community.
NVivo: A qualitative data analysis software used to organize and analyze non-numerical or
unstructured data.
Ontology: The study of being and existence, including the nature and structure of reality.
2

Participant Confidentiality: Ensuring that personal information about research participants is
not disclosed without their consent.
Personal Protective Equipment (PPE): Protective clothing and equipment, such as masks,
gloves, and gowns, used to prevent the spread of infectious diseases.
Person-Centered Care (PCC): A healthcare approach that respects and responds to the
preferences, needs, and values of patients, ensuring that patient values guide all clinical
decisions.
Public Health Emergency of International Concern: A formal declaration by the World
Health Organization (WHO) that indicates a public health crisis of international importance.
Qualitative Research: A research method focusing on understanding individuals' experiences
and perspectives through methods like interviews and observations.
Resilience: The capacity to recover quickly from difficulties; toughness, particularly in the
context of managing stress and emotional challenges.
Saturation: In qualitative research, the point at which no new information or themes are
observed in the data.
Secondary Analysis: The re-examination of existing data collected for a previous study, using
new methods or perspectives to gain additional insights.
Semi-Structured Interviews: A qualitative data collection method that uses a mix of
predetermined questions and open-ended prompts to gather in-depth responses from participants.
Sense of Coherence (SOC): A concept that reflects a person’s capacity to perceive life as
comprehensible, manageable, and meaningful, often used to measure well-being and resilience.
3

Short Staffing: A situation where there are not enough staff members to adequately cover the
workload, leading to increased stress and potential burnout.
Thematic Analysis: A method for identifying, analyzing, and reporting patterns (themes) within
qualitative data.
Trustworthiness: Criteria for evaluating the quality and reliability of qualitative research,
including credibility, dependability, confirmability, and transferability.
Turnover Intention: The likelihood that an employee will leave their current job within a
certain period.
Visitor Policies: Regulations that control the visitation of family members and friends to
residents in healthcare facilities, which were particularly strict during the COVID-19 pandemic

4

List of Abbreviations
BC: British Columbia
CDC: Centers for Disease Control and Prevention
CINAHL: Cumulative Index to Nursing and Allied Health Literature
HSDAs: Health Service Delivery Areas
LPN: Licensed Practical Nurses
LTC: Long-Term Care
LTCFs: Long-Term Care Facilities
NASW: National Association of Social Workers
NCBI: National Center for Biotechnology Information
NHA: Northern Health Author
NLM: the U.S. National Library of Medicine
PCC: Person-Centered Care
PHAC: Public Health Agency of Canada
PPE: Personal Protective Equipment
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
PSW: Personal Support Workers
RN: Registered Nurse

1

SOC: Sense of Coherence
UNBC: University of Northern British Columbia
WHO: World Health Organization

2

Acknowledgements
I deeply thank everyone who supported and guided me in completing this thesis.
First and foremost, I extend my heartfelt thanks to my supervisor, Dr. Shannon Freeman.
Your unwavering support, insightful guidance, and continuous encouragement have been
invaluable to me. Your expertise and dedication have greatly contributed to the success of this
research, and I am profoundly thankful for your mentorship. I also express my sincere appreciation
to my committee members, Dr. Davina Banner-Lukaris and Dr. Tammy Klassen-Ross. Your
constructive feedback, thoughtful suggestions, and generous support have been instrumental in
shaping this thesis. I am thankful for your time, effort, and commitment to this project. I am
thankful to Dr. Taru Manyanga, Dr. Richard McAloney, and others at UNBC for their guidance.
Your assistance and camaraderie have been greatly appreciated. Additionally, I acknowledge the
care aides who participated in this study. Your willingness to share your experiences during such
a challenging time has been vital to this research.
Special thanks to Dr. Marius Leon Terblanche, Yvonne Terblanche, and Justin for their
kindness and making me feel at home. Your motivation has been a great source of inspiration.
To my family, words cannot fully express my gratitude. To my husband, Mahmoud, your
unhesitating support and encouragement have been my bedrock. Your patience, understanding,
and faith in me have been a constant source of strength.
To my parents, Farahnaz and Farzad, who are my first teachers and instilled in me a
curiosity for science and research, and to my sister, Hanna, your unconditional love and
encouragement have been invaluable. Thank you for always believing in me.
Thank you all. This thesis would not have been possible without you.
1

Chapter 1: Introduction
Background
COVID-19
The emergence of COVID-19, stemming from the novel coronavirus SARS-CoV-2,
stands as a watershed moment in contemporary global health. Initially characterized as cases of
pneumonia with an unknown origin towards the close of 2019, the gravity of the situation swiftly
caught the attention of the WHO, prompting the declaration of COVID-19 as a public health
emergency of international concern on January 30, 2020 (WHO, 2024). Subsequently, on March
11, 2020, the WHO updated the status to a pandemic, marking a pivotal juncture in the trajectory
of the crisis (Beeching et al., 2021). This infectious respiratory illness exhibits a broad spectrum
of symptoms, ranging from mild respiratory discomfort akin to the common cold to severe
manifestations culminating in viral pneumonia, often leading to acute respiratory distress
syndrome and, regrettably, fatalities (Beeching et al., 2021). In response to the escalating threat
posed by COVID-19, Canadian provincial authorities implemented a series of rigorous measures
aimed at curbing viral transmission and safeguarding public health. These measures
encompassed the declaration of states of emergency, the imposition of social distancing
protocols including Stay-At-Home directives, restrictions on indoor and outdoor gatherings,
closure mandates for public amenities such as dine-in establishments, and widespread adoption
of mask-wearing mandates (Public Health Agency of Canada [PHAC], 2021). Individuals were
encouraged to leverage technological innovations for remote communication and essential
activities, reflecting the innovative adaptability necessitated by the exigencies of the COVID-19
pandemic context (PHAC, 2021). The advent of COVID-19 has precipitated profound
repercussions across global health, societal dynamics, and healthcare infrastructure (WHO,
1

2020) With its rapid dissemination worldwide, the virus ushered in an era of unparalleled
challenges and disruptions, extending beyond the realm of public health to permeate social,
economic, and healthcare domains (Centers for Disease Control and Prevention [CDC], 2024;
Fisman et al., 2020).
As of March 2024, the global death toll from COVID-19 surpassed 3.4 million, with over
410 million confirmed cases reported worldwide (WHO, 2024). In Canada, the COVID-19
pandemic has claimed the lives of over 220,000 individuals, with more than 8.5 million
confirmed cases reported across the country (PHAC, 2024).
Long-Term Care
Long-term care facilities are an integral component of Canada's healthcare system,
providing essential support to individuals with chronic illnesses, disabilities, or age-related
conditions requiring ongoing assistance with daily tasks (Jones et al., 2022). These facilities offer
a comprehensive range of services, encompassing medical care, personal assistance, and
therapeutic activities, all aimed at promoting independence, dignity, and quality of life for
residents. Interdisciplinary teams within LTCFs, comprising healthcare professionals such as
nurses, therapists, social workers, and care aides, collaborate to deliver comprehensive and
holistic care to residents (Boscart et al., 2020). Care plans are tailored to meet the unique needs
and preferences of each resident, focusing on enhancing physical and mental well-being.
Additionally, LTCFs organize recreational programs, social activities, and community
engagement opportunities to enrich residents' overall quality of life.
Long-Term Care in Canada
LTCFs in Canada serve a great number of the aging population, with over 425,000
individuals aged 65 and older residing in LTCFs (Statistics Canada, 2016). As the demand for
2

LTCF services continues to grow due to demographic shifts, there is increasing pressure on
LTCFs to expand capacity, enhance care quality, and improve accessibility (Breton & Marier,
2023). Provincial and territorial governments regulate LTCFs in Canada, setting standards for
care delivery, staffing ratios, facility design, and infection control (Government of Canada,
Legislation Services, 2017).
Long-Term Care in British Columbia
In British Columbia (BC), the provision of health services falls under the portfolio of the
Ministry of Health, which collaborates with a provincial health authority and five regional health
authorities, alongside a First Nations Health Authority (see Figure 1). The regional health
authorities -Fraser Health Authority, Interior Health Authority, Northern Health Authority
(NHA), Vancouver Island Health Authority, and Vancouver Coastal Health Authority- govern,
plan, and deliver healthcare services within their respective geographic areas. Within LTCFs in
BC, a comprehensive range of services is provided to residents (BC Ministry of Health, 2023).
These services encompass standard accommodations, the development and maintenance of
individualized care plans identifying clinical support services such as rehabilitation and social
work services, social and recreational activities, nutritional support including meals and
therapeutic diet needs, routine laundry services, provision of general hygiene and medical
supplies, incontinence management, and basic wheelchairs, as well as specialized care such as
dementia or palliative care (BC Ministry of Health, 2023). The staffing within LTCFs in BC is
diverse and includes both healthcare and non-healthcare professionals. Direct care staff comprise
registered nurses (RN), licensed practical nurses (LPN), and care aides, who play significant
roles in providing day-to-day care and medical assistance to residents (Plecas, 2017).
Additionally, allied healthcare staff members such as occupational therapists, physiotherapists,
3

social workers, dietitians, recreational therapists, and activity workers contribute to the holistic
well-being of LTCF residents (Plecas, 2017). Furthermore, non-healthcare staff members are
integral in providing essential support services within LTCFs. These roles encompass food
services, laundry and housekeeping services, and building maintenance services, all of which
contribute to the overall comfort, cleanliness, and safety of LTCF environments (Plecas, 2017).
The collaboration among these diverse professionals and support staff ensures comprehensive
care and support for residents in LTCFs across BC. The first COVID-19-related death in Canada
was reported at a LTCF in BC in March 2020, leading to the implementation of stringent
measures to prevent further outbreaks (Government of Canada, Statistics Canada, 2020).
Provincial health orders restricted LTCF staff movement and imposed vaccination mandates to
protect residents (BC Office of the Provincial Health Officer, 2021).
Long-Term Care in Northern British Columbia
Northern BC is a region that comprises more than half the province geographically-at
approximately 500,000 km sq., it is larger than California or Japan and twice the size of the
United Kingdom (Reschny et al., 2014). The NHA, the northernmost regional health authority in
BC, provides healthcare services to a total population of 285,300 residents (Parker et al., 2021).
There are three distinct Health Service Delivery Areas (HSDAs), which are the geographic
operating divisions that make up the region, including: Northern Interior, Northwest, and
Northeast as seen in Figure 1. The population of each area is estimated of: 141,700 in the
Northern Interior, 73,103 in the Northwest, and 68,102 in the Northeast (Government of Canada,
Statistics Canada, 2020).

4

Figure 1
Map Depicting Northern Health Communities (Northern British Columbia, 2024).

Northern BC presents unique challenges and opportunities for LTCFs due to its remote
geography and diverse demographics (Berger et al., 2020). LTCFs in Northern BC serve
communities with distinct cultural, linguistic, and socioeconomic characteristics, requiring
culturally competent care approaches. Additionally, logistical challenges in healthcare delivery
are exacerbated by the region's rugged terrain and harsh weather conditions (Parker et al., 2021).
The region's remote location and sparse population density pose logistical challenges for
healthcare delivery, particularly during public health emergencies such as the COVID-19
pandemic (Bryant et al., 2023). Despite challenges, LTCFs in Northern BC play a vital role in
5

supporting the health and well-being of older adults and other vulnerable populations in the
region. These facilities offer a range of services, including skilled nursing care, rehabilitative
therapies, and specialized dementia care, tailored to meet residents' unique needs.
Interdisciplinary care teams collaborate closely to optimize resident outcomes and promote
quality of life (Berger et al., 2020). Understanding the context of LTCFs in Northern BC requires
an examination of the impacts of the COVID-19 pandemic, healthcare policies, and the unique
characteristics of LTCFs in this region.
Role of Care Aides in Long-Term Care Settings
Care aides play an essential role in providing personal support and assistance to
individuals residing in LTCFs. As frontline healthcare workers, care aides are responsible to
deliver direct care to residents, spanning a spectrum of activities crucial for their well-being
(Boscart et al., 2020). These activities include but are not limited to assisting with activities of
daily living, such as bathing, dressing, and grooming, administering medications as prescribed,
and providing emotional support and companionship to residents (Boscart et al., 2020). The
contributions of care aides are integral to maintaining the overall well-being, dignity, and quality
of life for residents within LTCFs.
Job Status and Job Satisfaction of Care Aides
Despite the fundamental importance of their role, care aides often encounter a myriad of
challenges within the healthcare landscape that can impact their job satisfaction and overall wellbeing. Job satisfaction among care aides is influenced by various factors, including
organizational support, workload, and the quality of the work environment (Bryant et al., 2023).
Organizational support encompasses aspects such as adequate staffing levels, access to training
and resources, and effective communication channels, all of which contribute to the overall
6

satisfaction and engagement of care aides in their roles (Bryant et al., 2023). Furthermore, the
workload experienced by care aides, including the number of residents under their care and the
complexity of their needs, considerably influences their job satisfaction and ability to provide
quality care (Navarro Prados et al., 2022). High job satisfaction among care aides has been
associated with several positive outcomes, including improved morale, higher retention rates,
and enhanced quality of care provided to residents (Navarro Prados et al., 2022). Care aides who
experience job satisfaction are more likely to exhibit greater dedication and commitment to their
roles, resulting in increased resident satisfaction and improved overall quality of life within
LTCFs (Bryant et al., 2023). Conversely, low job satisfaction among care aides can lead to
decreased motivation, increased turnover rates, and compromised quality of care, ultimately
impacting the well-being of residents and the effectiveness of healthcare delivery within LTCFs
(Navarro Prados et al., 2022).
Impact of COVID-19 on Care Aides Work-life
The COVID-19 pandemic has made care aides' already difficult jobs even more difficult
by increasing their workload and raising burnout rates. Care aides have faced increasing
demands as LTCFs deal with outbreaks and infection control measures. These pressures include
the installation of strict safety regulations, additional administrative duties, and psychological
stress related to the COVID-19 pandemic (White et al., 2021). Care aides' mental health and job
satisfaction were at risk due to the raised stress and burnout levels that resulted from these causes
(Morgan et al., 2023; Zhao et al., 2021). Understanding the unique challenges faced by care aides
in LTCFs during the COVID-19 pandemic is for implementing targeted interventions and
support systems. By addressing factors contributing to workload and burnout, such as staffing
levels, access to personal protective equipment (PPE), and psychosocial support, healthcare
7

organizations can lessen the adverse effects of the COVID-19 pandemic on care aides and
optimize the quality of care delivered to residents (Morgan et al., 2023).
My Personal Experience During the COVID-19 Pandemic
Prior to the COVID-19 pandemic, I held a position as an Environmental Engineer at a
LTCF in my hometown. The facility's small and friendly environment allowed me to form close
bonds with both the staff and residents. In addition to my primary duties, I often found myself
assisting with various tasks. I provided companionship to LTCF residents, listened to their
stories, and helped organize events to lift their spirits. These interactions gave me a deeper
understanding of the daily challenges faced by both the LTCF residents and the staff, making my
role there very fulfilling. As my studies began in another city, I started to work remotely while
continuing my role at the LTCF. However, this remote work did not keep me away from the
LTCF staff and residents for long periods, as I usually returned every weekend. When the
COVID-19 pandemic began to spread globally in early 2020, the government imposed a
lockdown in Rasht, where my LTCF was located, due to a major outbreak of COVID-19 cases
found there. This sudden lockdown isolated me from my colleagues and friends at the facility.
Rasht, being one of the earliest cities to experience a severe outbreak, faced extreme shortages of
PPE and medical supplies. The situation was exacerbated by widespread misinformation, leading
to public fear and non-compliance with health measures. Maintaining a virtual connection with
the LTCF staff and residents became pivotal during this period. I provided emotional support,
helped source essential supplies, and offered assistance from afar. The care aides and nurses
were overwhelmed with increased workloads and the psychological stress of managing the crisis.
Their exhaustion and fear were understandable, and the sense of helplessness I felt from being
unable to provide physical assistance was deeply distressing. The impact of the COVID-19
8

pandemic on the all individuals working and living in the LTCF environment was obvious.
LTCF residents, who were already vulnerable, became increasingly scared and isolated, unable
to engage in their usual social activities. The care aides faced heightened levels of burnout and
emotional distress due to the cruel demands of their roles. The loss of healthcare workers to the
virus, including a young nurse my age as the first healthcare worker lost in the country,
underscored the severity of the crisis. This experience of remote connection, coupled with the
helplessness of being unable to assist physically, emphasized the urgent need for adequate
support and resources for frontline workers.
When my supervisor, Dr. Freeman, suggested that I study how the COVID-19 pandemic
affected care aides for my thesis, it felt very personal and important to me. The idea immediately
resonated because I had seen firsthand the challenges these workers faced during the COVID-19
pandemic. Working closely with care aides and residents in the LTCF, I knew how hard their
jobs were even before the COVID-19 pandemic, only made things more difficult. My own
experiences gave me a clear view of the struggles LTCF care aides and residents went through.
As the COVID-19 pandemic started, I stayed connected with the staff and residents, tried to
provide support and help however I could. This connection allowed me to understand their fears,
exhaustion, and the increased workload they had to manage. I realized that this thesis could be a
way to highlight their voices and bring attention to the difficulties they faced daily. Doing this
research is a chance to shine a light on the essential workers and show the world what they went
through. My time at the LTCF and my continued interactions with the staff and residents
provided me with a unique insight into their lives, especially during the crisis. This
understanding makes me passionate about finding ways to better support LTCF care aides.

9

By focusing on the experiences of care aides in northern BC, I hoped to describe the
specific problems they faced as care aides in rural areas, and the factors that affected their job
satisfaction and well-being. My goal was to suggest practical solutions that can help these
workers feel more supported and valued. Improving their job satisfaction and well-being not only
helps them but also leads to better care for the LTCF residents. This research is not just about
collecting data; it is about making a real difference. I believe that by amplifying the voices of
LTCF care aides and showing what they went through, we can help create a better future for
them. This research aims to make their lives easier and improve the quality of care they provide
to LTCF residents, benefiting everyone involved.
Purpose of the Study
There is a strong need to investigate the complex effects of the COVID-19 pandemic on
burnout and job satisfaction among care aides in LTCFs across Canada, considering these
unusual obstacles and organizational shortcomings. The concept of job satisfaction is complex
and includes factors like emotional health, task management, and organizational support. It has a
notable impact on the resilience, performance, and retention of healthcare professionals,
including care aides (Rostami et al., 2021). To improve employee well-being and the quality of
care provided in LTCFs, policy reforms, organizational strategies, and targeted interventions
must take into account the factors influencing job satisfaction and burnout among care aides
during the COVID-19 pandemic (Hewko et al., 2015).
Objectives and Study Question
This research seeks to address the following main objectives:
•

To examine the impact of the COVID-19 pandemic on the job satisfaction and burnout of
care aides working in LTCFs.
10

•

To identify and analyze the multifaceted determinants of job satisfaction and burnout among
care aides, including organizational support, workload management, and pandemic-related
stressors.

•

To explore potential strategies and interventions for mitigating burnout, enhancing job
satisfaction, and promoting the overall well-being of care aides in LTCF environments
amidst the ongoing COVID-19 crisis.
The research question guiding this study is:
1. How has the COVID-19 pandemic affected care aides’ job satisfaction in LTCFs?

11

Chapter 2: Literature Review
By consolidating existing literature, this review establishes a foundation for future
research and interventions aimed at improving working conditions and outcomes for care aides
across various hospital environments. Through a comprehensive analysis of the literature, this
review contributes to the advancement of knowledge and practice in the field of healthcare
assistance.
Search Methodology
Scoping Review Approach
The framework proposed by Arksey and O'Malley (2005) was utilized as a guide to aid
the process of conducting the literature review. The research involved a methodical exploration
of four databases, namely PubMed (MEDLINE), CINAHL, Social Work, and PsycINFO,
utilizing appropriate keywords related to "job satisfaction," "care aides," and "LTC". Arksey and
O'Malley (2005) argue that there are four major justifications for conducting a scoping study.
These include examining the scope, breadth, and characteristics of research activity, determining
the feasibility of conducting a comprehensive systematic review, synthesizing and disseminating
research findings, and identifying gaps in the existing literature (Arksey & O’Malley, 2005). The
Arksey and O'Malley approach was chosen due to its notable efficacy in conducting
comprehensive investigations into the intricate aspects associated with the research inquiries and
goals. This approach is highly suitable for analyzing the multiple dimensions that directly impact
the job satisfaction of care aides amidst the COVID-19 pandemic. This enables a thorough
analysis to be conducted of several elements, such as satisfaction, exhaustion, fears and
pressures, anxiety and stress, quality of work-life, and workload changes. These criteria are
important for comprehending the complex dynamics of job satisfaction in the LTCF sector in
12

tough circumstances. Hence, this methodology fits with the research objectives to facilitate an
investigation into the various factors that contribute to the overall job satisfaction of care aides.
The framework developed by Arksey and O'Malley (2005) consists of five separate stages, as
outlined by Arksey and O'Malley (2005). The steps in the research process include:
1.

Identification of the research question.

2.

Identifying relevant studies.

3.

Identifying pertinent research articles.

4.

Charting and organizing the acquired data.

5.

Compiling, analyzing, and summing up the research results.

Step 1: The Identification of the Research Question
The PIE table (Table 1) titled Population, Intervention, and Effect was constructed to
facilitate the formulation of the research question.
Table 1
Population, Intervention and Effect Keywords
Population/problem/patient

Care Aides

Intervention/issue

Working in Long-Term Care (during COVID-19)

Effect/evaluation

Job Satisfaction

Similar words were determined by conceptualizing the concepts in the PIE table (Table 2).

13

Table 2
Terms for Documentation Search
Theme

Care Aides

Long-Term Care

Job Satisfaction

COVID-19
Pandemic

Subsidiary

Nursing Assistants

Nursing Homes

Burnout

Search

Personal Support

Homes for the Aged

Distress

Terms

Workers (PSW)

Residential Home

Retention

Health Care Assistant

2019-2023

Burden
Quality of Life
Fatigue

Step 2: Identifying Inclusive and Exclusive Criteria
The fundamental components of the research inquiry, including the group being studied
(care aides in LTCF and related terms), the intervention, and the outcome (COVID-19 pandemic
and job satisfaction), were integrated into the criteria for inclusion. Non-English publications
were omitted. In addition, the literature evaluation focused on research published in the past 5
years of data collection (2019-2023). Care aides, sometimes referred to as nursing assistants,
personal support workers or healthcare assistants, are essential in providing direct care to patients
in LTCFs. Their responsibilities include providing aid in daily tasks, overseeing the well-being
of patients, and upholding a secure and nurturing atmosphere (Aloisio et al., 2021). The precise
meaning of LTCF may differ on a worldwide scale. In this literature review, LTC, also known as
residential care or care homes, is considered to be the most advanced level of nursing home care.
This level of care includes continuous on-site supervision, provision of professional health
services, aid with everyday activities, and administration of home tasks for individuals
experiencing cognitive or physical impairments round the clock (Nürnberger, 2023). A
comprehensive overview of the inclusion and exclusion criteria are shown in Table 3.
14

Table 3
Inclusion and Exclusion Criteria
Inclusion
•
•
•
•

Care Aides
Long-Term Care
COVID-19 Pandemic
Burnout/Retention/Distress/Burden
Job satisfaction/ Quality of life

Exclusion
•
•
•
•

Non-English
Hospitals or Community-based
Settings
Non-Care Aide Healthcare Workers
Not related to COVID-19 Pandemic

Step 3: Identification of Relevant Studies
The databases PubMed (MEDLINE), CINAHL, Social Work Abstracts, and APA
PsycINFO were chosen to curate pertinent articles for the study. PubMed (MEDLINE), a freely
accessible resource developed by the National Center for Biotechnology Information (NCBI) and
overseen by the U.S. National Library of Medicine (NLM), was selected for its comprehensive
biomedical literature, offering an expansive view of the biomedical facets linked to the COVID19 pandemic and its repercussions on healthcare workers (U.S. National Library of Medicine
(NLM), 2023). CINAHL (Cumulative Index to Nursing and Allied Health Literature) was
specifically chosen for its extensive compilation of literature in the nursing and allied health
disciplines. This selection directly aligns with the study's focus on staff in LTCFs (EBSCO,
2023). The National Association of Social Workers (NASW) Social Work Abstracts database
was chosen for its wide coverage of social work and human services periodicals from 1965. This
resource is useful for researching mental health themes like anxiety, stress, exhaustion, and
discomfort due to its thorough indexing and abstracts. Its inclusivity matches the study's focus on
healthcare workers' mental health, particularly LTCF care aides (EBSCO, 2023). APA
PsycINFO, a database maintained by the American Psychological Association, was preferred for

15

its substantial collection of literature in the field of psychology and related disciplines. This
database is critical for gaining insights into the psychological resilience of staff working in
LTCFs (American Psychological Association, 2023).
Step 4: Study Selection
A detailed explanation of how various search techniques were customized and used for
specific databases may be found in Appendix A. This required using keywords and subject
headings based on the unique characteristics of each database. The chosen headings were
constructed to cover the primary topics listed in Table 1, providing a targeted and allencompassing approach to data collection. This approach ensured that the data gathered was
comprehensive and pertinent by expanding the search area. A screenshot of each database's
search technique is included in Appendix B.
Step 5: Collecting, Summarizing and Reporting the Results
The evaluation process involved a comprehensive analysis of all article titles and
abstracts. Irrelevant content was eliminated based on specific inclusion and exclusion criteria. 83
papers were excluded using a comprehensive full-text screening process that identified and
discarded any articles that did not match the inclusion criteria. The outcomes of this
methodology are visually presented in Figure 2 through a Preferred Reporting Items for
Systematic reviews and Meta-Analyses (PRISMA) diagram (PRISMA, 2023), which effectively
demonstrates the comprehensive search and elimination techniques.

16

PRISMA Flowchart

Figure 2

17

Findings
After conducting the final literature search, a total of 18 publications met the criteria
for inclusion, as depicted in Figure 2. The publications were published from 2020 to 2023.
Three studies were conducted in Canada (Hapsari et al., 2022; Titley et al., 2023; Voth et al.,
2022), the United States (Bryant et al., 2023; Franzosa et al., 2022; White et al., 2021), and
Spain (Blanco-Donoso et al., 2021; Blanco‐Donoso et al., 2022; Navarro Prados et al., 2022),
Two studies were conducted in Ireland (Doyle et al., 2023; Nestor et al., 2021). Additionally,
one study each was undertaken in Austria (Hoedl et al., 2021), Australia (Muduzu et al.,
2023), Italy (Mangialavori et al., 2022), France (Altintas et al., 2022), Georgia (Morgan et
al., 2023), China (Zhao et al., 2021), and South Korea (Chang et al., 2020) as shown in
appendix C. A variety of research approaches was noticed among the 18 papers reviewed.
One article employed a mixed-methods design, integrating qualitative and quantitative
methodologies. Quantitative approaches were dominant, with 11 papers applying a
quantitative framework, specifically utilizing a cross-sectional design or survey
methodology. The variety of research methods enhances the breadth and depth of viewpoints
in the literature.
Care Aides
Care aides, sometimes referred to as healthcare assistants or nursing assistants, play a
crucial role in ensuring the smooth operation of different healthcare settings in contemporary
healthcare systems (Doyle et al., 2023; Efird-Green et al., 2023). Their importance spans
several settings such as hospitals, LTCFs, and community health organizations, where they
carry out vital responsibilities beyond fundamental caregiving duties, including LTCF
resident surveillance and support with everyday tasks (Titley et al., 2023). Care aides who
18

are also referred to as nursing assistants (NAs) and personal care aides (PCAs) play vital
roles in the caregiving sector of nursing homes and assisted living facilities (Efird-Green et
al., 2023; Hapsari et al., 2022).
Care aides provide up to 90% of the direct care for LTCFs (Chamberlain et al., 2019).
Most of them are over 40 years old and female (90%-95%) (Chamberlain et al., 2019;
Hewko et al., 2015): Most care aides have limited post-secondary education or formal
training (Armstrong, 2020). Many of them are immigrants and speak English as their second
language (Chamberlain et al., 2017, 2019). Before the COVID-19 pandemic, it was noted
that care aides were under high pressure, and at high risk of burnout, job dissatisfaction and
poorer mental and physical health (Hoben et al., 2017).
The distinctive demographic characteristics of care aides highlight their essential role
in delivering essential care to a varied and susceptible population. Care aides are assigned
challenging and complex tasks to do, as evidenced by the numerous studies (Altintas et al.,
2022; Mangialavori et al., 2022; Muduzu et al., 2023; Navarro Prados et al., 2022; Titley et
al., 2023; Voth et al., 2022). The challenges may encompass tasks such as simultaneous
management of multiple patients with diverse needs (Muduzu et al., 2023), overcoming
communication barriers arising from language differences (Navarro Prados et al., 2022),
addressing cultural sensitivities and preferences in the provision of care (Altintas et al.,
2022), adapting to rapidly changing environments and protocols (Mangialavori et al., 2022),
managing emotional and psychological stressors associated with LTCF resident care (Voth et
al., 2022) and coping with physical demands and occupational hazards (Titley et al., 2023).

19

Care Aides in Long-Term Care
The importance of care aides is particularly evident in LTCF settings, where they
navigate complex healthcare environments and meet the unique needs of LTCF residents
(Altintas et al., 2022; Doyle et al., 2023; Efird-Green et al., 2023). To develop effective
solutions that improve the well-being and job satisfaction of care aides, it is important to
understand their experiences and concerns due to the complex nature of their roles (Doyle et
al., 2023; Efird-Green et al., 2023) and to enhance the standard of LTCF resident care.
Factors Impacting Care Aides' Job Satisfaction in Long-Term Care During the
COVID-19 Pandemic
Care aides can experience burnout, a phenomenon that has been increased by the
challenges presented by the COVID-19 pandemic (Altintas et al., 2022). This burnout is
more than just being tired; it also includes bodily responses to ongoing work related stress,
such as emotional and mental tiredness, a strong sense of detachment from their duties, and a
reduction in self-confidence in their accomplishments or professional skills.(Mangialavori et
al., 2022; Voth et al., 2022). These signs highlight how much care aides' wellbeing can be
negatively impacted by the duties of caregiving, especially when added stresses like those
encountered during the COVID-19 pandemic. (Hapsari et al., 2022; White et al., 2021). A
comprehensive investigation revealed an association between burnout among healthcare
staff, especially care aides, and diverse negative outcomes (Perez et al., 2022).
Research demonstrated a notable correlation between burnout and diminished job
satisfaction, heightened likelihood of leaving the profession, elevated rates of employee
turnover, and detrimental effects on the physical and mental well-being of care aides (Perez
et al., 2022). Moreover, burnout not only impacts care aides but also has detrimental effects
20

on LTCF residents care (Hapsari et al., 2022; White et al., 2021). Research highlighted the
relationship between burnout and safety culture, reduced sense of service quality, and
decreased LTCF residents’ safety in healthcare environments. Burnt-out healthcare workers
are more likely to disregard important caregiving responsibilities, which causes problems for
both patients and caregivers. (Blanco-Donoso et al., 2021).
Job Satisfaction
Care aides' job satisfaction is a complicated concept that extends beyond simple
emotional well-being to include positive attitudes, feelings, and perspectives on their job
responsibilities and workplace (Bryant et al., 2023; Titley et al., 2023). Organizational
support and staffing levels play a decisive role in assessing job satisfaction through their
ability to deliver person-centered care (PCC), which provides insightful information for
solutions focused on improving the well-being of care aides (Blanco‐Donoso et al., 2022;
Bryant et al., 2023; Morgan et al., 2023). The relationship between job satisfaction and
overall well-being is important, as it has a substantial impact on the motivation, dedication,
and standard of care delivered by care aides (Navarro Prados et al., 2022). It is important to
prioritize the elements that contribute to job satisfaction to provide a supportive work
environment and eventually improve LTCF resident care in the healthcare sector (Chang et
al., 2020; White et al., 2021). Sense of Coherence (SOC) can be protective in mitigating
burnout among care aides. A positive evaluation of life experiences, which is illustrative of
subjective well-being, lowers emotional exhaustion and detachment, and encourages a sense
of personal fulfillment. Additionally, Navarro Prados et al. (2022) underscore the direct
correlation between SOC and perceived social support, availability of resources, and welldefined professional responsibilities, underscoring their significance in enhancing job
21

satisfaction (Altintas et al., 2022). Emphasizing the impact of work-life quality on turnover
rates, stress levels, organizational cohesion, and overall care quality, researchers highlight
the challenges faced by care aides in LTCF institutions. These challenges may include high
patient-to-staff ratios, complex care needs requiring extensive time and attention, limited
resources for training and development, and emotional demands associated with providing
end-of-life care (Chang et al., 2020). Research on the increased workload caused by staff
shortages, higher LTCF resident acuity levels, stricter infection control protocols, and
increased stress and anxiety among care aides is noteworthy as it advances our understanding
of workload issues, especially in light of the COVID-19 pandemic (Nestor et al., 2021; Titley
et al., 2023; White et al., 2021; Zhao et al., 2021). Furthermore, the positive effects of PCC
on various aspects, including job satisfaction, self-esteem, satisfaction related to care,
professionalism, and stress reduction among care aides, are emphasized (Chang et al., 2020).
Exhaustion
The emotional stress of witnessing the suffering and loss experienced by LTCF
residents and their families, along with the continuous fear of receiving and distributing the
virus at work, added to the care aides' already heavy daily workload. An analysis of
caregivers' fatigue, particularly in the context of the COVID-19 epidemic, revealed a
multifaceted interaction between physical, psychological, and emotional exhaustion (Nestor
et al., 2021; White et al., 2021; Zhao et al., 2021). The heightened caregiving demands,
intensified by the COVID-19 pandemic, contributed to mental fatigue, as care aides manage
a variety of tasks and encounter cognitive strain (Altintas et al., 2022). The burden on care
aides was exacerbated by organizational deficiencies, including insufficient personnel and
support, resulting in psychosocial and cognitive exhaustion due to increased caregiving
22

requirements (Bryant et al., 2023; Morgan et al., 2023). The lack of a supportive work
environment and necessary resources posed an additional risk to the mental well-being of
care professionals amidst the uncertainties of the global health crisis (Blanco-Donoso et al.,
2021; Voth et al., 2022; White et al., 2021). The long-term health effects of COVID-19, such
as chronic fatigue and respiratory problems in those who have recovered, are quite
concerning, especially when considering the extended duration of the COVID-19 pandemic.
The COVID-19 virus, distinguished by extended symptoms following the initial phase of the
virus, was exacerbated by emotional strain and heightened job obligations throughout the
COVID-19 pandemic, resulting in physical and mental fatigue (Doyle et al., 2023). Care
aides working in LTCFs encountered numerous difficulties, including increased work
requirements, lack of staff, and financial struggles, which worsened their susceptibility to the
lasting consequences of COVID-19 (Bryant et al., 2023; Franzosa et al., 2022; Titley et al.,
2023).
It is essential to acknowledge and address these difficulties to uphold the well-being
of care aides and minimize the effects of extended COVID-19 on healthcare professionals
and the healthcare system in its entirety. Personnel employed in LTCFs, amidst heightened
psychological distress due to the COVID-19 pandemic, exhibited similar levels of
discomfort, regardless of their roles (Styra et al., 2022). As a key factor in reducing distress,
resilience was found to be essential. This suggests that interventions aimed at improving
resilience could effectively improve negative mental health results (Mangialavori et al.,
2022). The combination of increasing workloads, inadequate staffing levels, and the
emotional stress of tending to worried residents within the COVID-19 pandemic
substantially contributes to burnout among nursing care providers (White et al., 2021). The
23

long-lasting health disaster made things harder for healthcare workers, which shows how
important it is to keep an eye on both distress and resilience over time (Nestor et al., 2021).
Creating a conducive work environment in LTCFs, with an emphasis on achieving work-life
balance through activities such as physical exercise, is essential for reducing physical fatigue
and job-related stress among healthcare workers (Chang et al., 2020). To effectively address
the distinct stressors encountered by care aides, it is necessary to have a detailed awareness
of the multifaceted issues they face. This understanding should inform tailored interventions
(Altintas et al., 2022; Titley et al., 2023).
Fears
In the midst of the COVID-19 pandemic, care aides experienced a multitude of
challenges and external pressures extending beyond typical healthcare concerns (Voth et al.,
2022). Understanding the complex nature of these issues is vital for obtaining a
comprehensive grasp of care aides' experiences (Altintas et al., 2022). Regarding the inherent
risks of providing direct care in the presence of a highly contagious virus, one major worry is
personal safety (Bryant et al., 2023; Zhao et al., 2021). The heightened anxiety not only
impacted the psychological well-being of care aides but also influenced the quality of care
they are capable of providing, requiring a delicate balance between work commitment and
self-care (Muduzu et al., 2023). The ongoing global health crisis, exacerbated by the
COVID-19 pandemic, intensified these challenges, underscoring the need for tailored
interventions that address specific concerns related to personal safety, fear of infection, and
heightened stress amid the global health emergency (Muduzu et al., 2023; Voth et al., 2022).
During the COVID-19 pandemic, care aides who experienced extreme Emotional Exhaustion
(EE) showed increased levels of anxiety (Blanco-Donoso et al., 2021; Pappa et al., 2020).
24

This is evident through the use of the fear of COVID-19 scale (Altintas et al., 2022). This
study showed the notable influence of anxiety on the psychological welfare and occupational
performance of care aides, specifically in healthcare environments (Altintas et al., 2022). It
also highlighted how important it is for care aides to get personalized therapies right away to
deal with stress and emotional exhaustion, which would improve their overall mental health
and job satisfaction (Blanco‐Donoso et al., 2022). The findings showed that these problems
are complicated and varied. In order to assist, interventions need to be developed that are
appropriate to the different worries and stresses that care aides experience in their daily
duties (Blanco‐Donoso et al., 2022). Healthcare professionals, particularly care aides,
experienced a great deal of anxiety and stress during the COVID-19 pandemic, thus specific
treatments are needed to enhance their overall welfare (Voth et al., 2022). Moreover, the
differences in concerns across various healthcare settings highlighted the distinct issues
encountered by professionals in LTCFs (Voth et al., 2022).
Anxiety
The multifaceted and demanding nature of care aide responsibilities within LTCFs
made anxiety highly prevalent. This showed how important it is to have a complete plan to
deal with all the problems that care aides face in their job (White et al., 2021). Care aides
have many duties, such as assisting residents with activities of daily living (ADLs) including
bathing, dressing, and grooming, providing medications, monitoring vital signs, and
providing emotional support (Boscart et al., 2020). These duties require a high level of
attention to detail, compassion, and patience, as care aides must navigate complex care plans
tailored to each LTCF resident's unique needs and preferences. Furthermore, care aides are
responsible for mobility assistance, fall prevention strategies, and ensuring a safe
25

environment for LTCF residents. They play a major role in communicating residents' needs
and concerns to the interdisciplinary care team, participating in care planning meetings, and
providing input on LTCF resident care plans. Additionally, care aides may assist with
therapeutic activities, recreational programs, and social engagement initiatives aimed at
enhancing LTCF residents' quality of life (Aloisio et al., 2021; Hewko et al., 2015).
Providing care to individuals increased the mental stress on care aides, as they often develop
close relationships with residents and witness their mental and physical disabilities over time.
This emotional burden can lead to feelings of helplessness, depression, and compassion
fatigue, which increased anxiety and stress levels among care aides (Nestor et al., 2021).
Moreover, the COVID-19 pandemic has introduced additional challenges, including fears of
contracting the virus, implementing infection control measures, and managing increased
workloads due to staff shortages (Zhao et al., 2021).
The uncertainties related to the health crisis during COVID-19 pandemic, which
included a great amount of hospitalized residents and the lack of healthcare personnel led to
increased challenges for care aides, further emphasizing the need for tailored support (White
et al., 2021). It is critical to address anxiety and stress for care aides because of the emotional
stress that comes with facing uncertainties (Zhao et al., 2021). Understanding the challenging
landscape of anxiety and stress is essential for enhancing the emotional well-being and
adaptability of care aides (Nestor et al., 2021). Healthcare organizations can enhance care
aide resilience by implementing focused interventions to address stressors during a
pandemic. This will ultimately create a supportive environment that allows care aides to
manage their responsibilities with emotional resilience and adaptability (Blanco-Donoso et
al., 2021).
26

Quality of Work-life
A supportive work environment greatly affects the quality of work life for care aides,
emphasizing the vital need for a friendly and supportive atmosphere (Hapsari et al., 2022).
Positive social contacts among coworkers in the caregiving environment are essential for
maintaining a high quality of work-life, impacting job satisfaction and performance
considerably (Altintas et al., 2022; Mangialavori et al., 2022). To create a positive work
environment and create a balance between job and personal life, organizational rules and
procedures are momentous (Doyle et al., 2023; Titley et al., 2023). Prioritizing the
improvement of work-life quality is essential for enhancing the work environment for care
aides, as it is not only a goal but also an essential requirement for developing a sustainable
and supportive workplace (Doyle et al., 2023). Although the presence of teamwork and
commitment positively influences collaboration, the caregiving experience is also
characterized by challenges such as extended working hours and the absence of breaks
(Doyle et al., 2023).
The care aides' quality of work life is dependent on their interaction with supervisors,
which includes aspects such as the frequency of feedback, the amount of guidance provided,
the availability of supervisors, and the success of resolving complaints (Bryant et al., 2023).
The previously mentioned issue influence the quality of care provided to individuals residing
in LTCFs, highlighting the importance of creating supportive work cultures (Titley et al.,
2023). Inadequate compensation and assistance for frontline personnel presented risks to the
welfare of susceptible individuals, hence requiring the establishment of strong support
structures (Titley et al., 2023). The high rates of employee absenteeism among care aides in
LTCFs can be explained by the demanding nature of the profession and unfavorable working
27

conditions (Franzosa et al., 2022). Participating in quality improvement projects can improve
job satisfaction and retention among care aides (Franzosa et al., 2022). The researchers
examined the influence of the care quality experience on the well-being of workers,
especially during the COVID-19 pandemic, using the Care Quality Perception Scale (Altintas
et al., 2022). Care aides faced substantial job insecurity as a result of decreased working
hours and heightened unemployment rates (Hapsari et al., 2022). Consequence of both the
client’s illness and their refusal to accept assistance. In contrast, LTCF care aides
experienced job layoffs and financial insecurity (Hapsari et al., 2022). The mentioned
problems highlight the need for comprehensive support measures to reduce job instability
and protect the well-being of frontline healthcare professionals in evolving situations
(Hapsari et al., 2022).
Workload
The workload in the care aide profession includes a number of different
responsibilities and tasks (Voth et al., 2022). The study examined the complex nature of
workload increase in care aides daily work-life, highlighting its substantial influence on care
professionals and the level of burnout and job satisfaction they experienced (Voth et al.,
2022). The COVID-19 pandemic worsened the level of job satisfaction in care aides and the
rate of healthcare workers’ burnout, highlighting the importance of workload in the
caregiving field (Titley et al., 2023). An in-depth examination of the challenging nature of
caring duties, especially in the midst of the COVID-19 pandemic, revealed a complex
connection between workload, burnout, and job satisfaction (Chang et al., 2020) and
emphasized the need for a sophisticated comprehension of these variables (Blanco-Donoso et
al., 2021). Effectively managing workload is determinig for enhancing the overall well-being
28

and effectiveness of care aides working in LTCFs. The delicate balance between the variety
and complexity of assigned tasks greatly influences on general experiences of care aides
(Mangialavori et al., 2022). By utilizing the knowledge obtained from these research
endeavors, organizations and policymakers may strategically design interventions to enhance
performance. This allows care professionals to effectively carry out their duties while also
protecting their personal well-being (Blanco‐Donoso et al., 2022).
Recognizing and addressing difficulties linked to workload is not only a practical
necessity but also a crucial step in creating a supportive and sustainable environment for care
aides. By putting priority to the complexity of workload management, stakeholders can
develop a resilient and skilled care workforce that is well-prepared to handle the dynamic
challenges of caregiving (Navarro Prados et al., 2022). The increasing infection rates, use of
PPE, and strict isolation procedures during the COVID-19 pandemic amplified the workload,
stress, and fatigue for healthcare personnel (Doyle et al., 2023). Care aides highlighted the
increased workload they faced due to the increased number of meal deliveries and time
limitations (Doyle et al., 2023). The study conducted by Bryant et al. (2023) revealed a
strong correlation between pandemic-induced stresses, such as insufficient protocols,
excessive workload, heightened transmission risks, and understaffing, and decreased job
satisfaction among care aides. Care staff concerns about time limitations and understaffing
related to COVID-19 safety procedures were recorded in a study (Morgan et al., 2023). The
study highlighted the substantial influence of isolation measures on the workload of care
aides, which is exacerbated by staffing shortages (Titley et al., 2023). A further study
revealed that resident’s behavior had changed during the isolation, requiring greater effort for
care aides, particularly in the area of managing difficult behaviors (Muduzu et al., 2023). The
29

implementation of collaborating procedures and open-door policies was stressed as a means
of efficiently addressing heavy workloads, and this resulted to increased appreciation and
recognition for care aides (Franzosa et al., 2022).
The COVID-19 pandemic resulted in healthcare personnel experiencing great
workloads and psychological distress, which has led to a notable rise in workload, physical
and mental strain, and staff turnover (Mangialavori et al., 2022). It is momentous to
understand and address the various dimensions of workload in order to establish a resilient
and well-supported staff even when issues persist. During the COVID-19 pandemic, care
aides experienced increased duty pressure, dealing with illnesses and fatalities, and a
shortage of resources, according the study (Blanco‐Donoso et al., 2022). The study
emphasized the unequal influence on women in comparison to men, stressing the genderspecific consequences of the heightened workload (Blanco‐Donoso et al., 2022). Long work
hours have been shown to have a negative effect on care aides making it more difficult for
them to handle stressful situations. Specific challenges were identified through using the
Workload component of the Secondary Traumatic Stress Questionnaire. The challenges
included having to make decisions based on unclear criteria, working under tension, and
suffering from the physical and psychological effects of working long shifts in emergency
situations (Navarro Prados et al., 2022). The COVID-19 pandemic led to a notable rise in the
workload in LTCFs. This revealed issues such as increased workload, social expectations,
exposure to mortality and distress, shortage of staff and PPE, and the high rate of secondary
traumatic stress in care aides (Blanco-Donoso et al., 2021). Diverse evaluations and
perspectives of qualitative workloads were noted among nursing home employees; the

30

majority of care aides noticed interventions as physically and psychologically burdening
(Hoedl et al., 2021).
Discussion
The COVID-19 pandemic had a profound impact on care aides' job satisfaction in
LTCF settings, exacerbating existing challenges and introducing new stressors. The literature
review revealed that care aides experienced heightened levels of anxiety, stress, and burnout
during the COVID-19 pandemic, resulting from increased workload, fears of infection, and
uncertainty about the future. These factors affected care aides' job satisfaction and overall
well-being, raising concerns about the sustainability of the LTCF workforce in the face of
long-lasting crisis.
Impact on Care Aides
The challenges faced by care aides in LTCF settings, particularly worsened by the
COVID-19 pandemic, emphasize how important it is for organizational support to reduce the
pressure on their mental health and overall well-being (Hapsari et al., 2022). Staffing
shortages have been a longstanding issue in LTCFs, and the COVID-19 pandemic made it
worse that has increased workload pressures on care aides (Zhao et al., 2021). They have
been required to adapt rapidly to new protocols, manage increased responsibilities, and cope
with the emotional toll of the COVID-19 pandemic, leading to heightened levels of stress
and anxiety (Nestor et al., 2021; White et al., 2021). The psychological strain experienced by
care aides underscores the importance of implementing strategies to support their resilience
and well-being, including access to mental health resources, regular check-ins, and
opportunities for self-care (Hapsari et al., 2022). The highest priority of care aides' mental

31

health and well-being by organizations can lead to higher job satisfaction and retention rates,
which in consequence improves the quality of care provided to residents of LTCFs.
Gendered Impacts
Workload has different effects on individuals based on their gender (Blanco‐Donoso
et al., 2022). Therefore, it is necessary to adopt a workforce management approach that takes
into account gender-specific impacts. The unequal distribution of workload and its
consequences requires an update of existing policies and support strategies to ensure
reasonable treatment and outcomes for all care professionals (Blanco‐Donoso et al., 2022).
Tailored workload management strategies are essential to address the specific needs and
challenges encountered by women in caregiving roles (Mangialavori et al., 2022). By
considering gender dynamics and society’s expectations, organizations can develop
approaches that promote gender equity and support the well-being of care aides in the
healthcare sector.
Long-Term Care Facility Resident Care Implications
The results shed light on the gradual effect of workload difficulties on LTCF resident
care. The relationship between increased burnout and decreased job satisfaction among care
aides is associated with compromised LTCF resident safety, lower service quality, and a
weakened safety policies within healthcare settings (Bryant et al., 2023; Titley et al., 2023).
The unbreakable correlation between the general well-being of care aides and the quality of
care demonstrates the need for a multifaceted strategy that considers both aspects of the
caring equation.
Organizational support is necessary for implementing effective measures to manage
the workload. Open-door policies, collaborative methods, and PCC are essential factors in
32

reducing the negative impact on workload (Franzosa et al., 2022; Navarro Prados et al.,
2022). Establishing cultures that value and support care aides should be a top priority for
organizations. This means offering helpful assistance and creating a working atmosphere that
recognizes and appreciates their contributions (Blanco‐Donoso et al., 2022; Doyle et al.,
2023).
Limitations
Despite the valuable insights provided by the literature review, several limitations
should be noted. Firstly, the studies that were included had different methods, sample sizes,
and locations, which could make it harder to generalize the results to other contexts
(Franzosa et al., 2022; Blanco-Donoso et al., 2021). The majority of studies focused on the
experiences of care aides in specific healthcare settings, such as nursing homes or LTCFs,
limiting the applicability of the findings to other care settings (Hoedl et al., 2021; Muduzu et
al., 2023). Moreover, the dynamic nature of the healthcare industry, particularly in the
context of the COVID-19 pandemic, may result in changes to workload management
strategies and their impact over time, highlighting the need for ongoing research and
evaluation (Doyle et al., 2023; Navarro Prados et al., 2022). None of the articles examined
addressed issues specific to rural areas, such as those found in Northern BC, indicating a gap
in the literature regarding the experiences of care aides in these settings. Although an attempt
was made to incorporate a wide variety of studies, it is possible that relevant research
accidentally excluded from the analysis, which could have an impact on the accuracy of the
findings (Chang et al., 2020; Morgan et al., 2023).

33

Future Directions
This research project aims to contribute to addressing these gaps by conducting a
comprehensive analysis of workload management strategies in the framework of care aide
responsibilities. By combining existing literature and exploring possible solutions, this study
seeks to provide insights into effective approaches for reducing the negative effects of
COVID-19 pandemic on care aide job satisfaction, well-being, and workload. Through its
focus on understanding the specific challenges faced by care aides and evaluating the impact
of customized interventions, this research attempts to inform the development of evidencebased practices that can enhance the quality of care and support the well-being of care aides.

34

Chapter 3: Methodology
The purpose of this research study is to explore the impact that the COVID-19
pandemic has had on the level of job satisfaction of care aides working in LTCFs as part of a
larger primary study titled "Assessing the Health and Human Resource Impact of COVID-19
in the LTC Setting in Northern British Columbia" (Ethics Approval Number H21-01883).
This study aims to investigate the factors that influence the experiences of LTCF care aides
and their job satisfaction while they are dealing with the difficulties brought on by the
COVID-19 pandemic. The objective was to collect the personal experiences of care aides in
LTCFs during the COVID-19 pandemic, with a particular emphasis on the mental health,
quality of life, and overall well-being of the individuals involved. Furthermore, the purpose
of the interviews was to investigate the impact that COVID-19 pandemic has had on both
ongoing and newly implemented policies and procedures in LTCFs. This study provides
insights into the impact that job satisfaction has on care aides who are employed in LTCFs
during the COVID-19 pandemic. The initial pool of 53 interviews was conducted with a
variety of staff members and included eight care aides. Transcripts from these eight care
aides form the foundation for the current study. This methodological approach ensures that
research will be conducted with a focus on the complex personal experiences and
perspectives of the integration and consequences of the COVID-19 pandemic on care aides
working in LTCFs. By analyzing these features within the larger framework of care aides,
this study hopes to offer helpful insights into the challenges faced by LTCF care aides during
the COVID-19 pandemic.

35

Research Design
The methodology of this thesis project is a secondary analysis of qualitative data
from the broad data of the LTCF Staff Working During COVID-19 in Northern BC study.
This study comprised of a comprehensive analysis of qualitative data obtained from hourlong semi-structured interviews that were conducted by LTCF personnel as an integral
component of the primary research agreement. The secondary analysis consists of a thorough
examination and interpretation of uncoded transcripts, following along with the
recommendations of Ruggiano & Perry (2019). This approach enables an original and
unbiased examination of the data.
Qualitative Design
To better understand how care aides felt and what they thought during the COVID-19
pandemic crisis, qualitative research is a useful tool. Because it takes place in the real world,
qualitative research gives us a full picture of how people live their lives in their social
settings (Braun & Clarke, 2022; Peel, 2020). Philosophical ideas, such as epistemology and
ontology, form the basis of this approach. Epistemologically, qualitative research recognizes
that knowledge is socially constructed and subjective, emphasizing the importance of
understanding individuals' lived experiences within their social contexts. It recognizes that
there are different subjective realities that can be explored through qualitative inquiry to find
different meanings and points of view (Creswell & Poth, 2016; Kivunja & Kuyini, 2017).
For this study, a qualitative approach is essential because it enables a thorough investigation
of the intricate and multidimensional aspects of care aides' job satisfaction in the face of the
COVID-19 pandemic's challenges. It is possible to gain insight into the perspectives,
feelings, and coping mechanisms of care aides by using qualitative methods to record their
36

detailed accounts of their experiences. This method produces insights that might not be
obtained by using only quantitative measurements, and leads to a thorough comprehension of
the issue being studied (Creswell & Poth, 2016; Tracy, 2010).
Sample and Recruitment
The present study utilized data from a broader, multi-methods research project that
was conducted to evaluate the COVID-19 pandemic's effects on the health and human
resource management of people employed in LTCFs in northern BC. Teamwork between
academics and NHA leaders was needed for the project. Dr. Shannon Freeman, who is the
Academic Director of the Center for Technology Adoption in the North (CTAAN) and an
Associate Professor at the University of Northern British Columbia's (UNBC) School of
Nursing, and Dr. Piper Jackson, an Assistant Professor in Computing Science at Thompson
Rivers University, led the research team. 53 participants from all the 24 LTCFs in the NHA
region participated in semi-structured interviews from November 08, 2021, to January 20,
2022, as part of the data collection for the study. The COVID-19 social distancing guidelines
were followed by conducting interviews via phone or Zoom, depending on what worked best
for the participants. The interviews were recorded and then transcribed. Using NVivo 12, a
qualitative descriptive analysis was performed on the interview data. The age distribution of
the participants was 24 years old to 69 years old. Concerning gender, 44 of the participants
were women and nine were men. The participants' varied ethnic backgrounds offered a wide
range of cultural perspectives. Regarding the qualitative aspect, LTCF employees from all
specialties, including management and front-line direct care providers, who worked in the
NHA region of northern British Columbia were invited to participate in one-hour semistructured interviews as part of the COVID-19 in Northern BC study to share their
37

experiences. Participants had various types of positions related to health, which helped the
wide range of insights obtained from the study. Participants’ roles included: Care aide,
Leadership/Management, Recreation (Therapist/Assistant/Music Therapy), LPNs, RNs, food
service staff, social worker, and dietitian bringing up a sizable portion of the participant
population. Each unique role, like Physical Therapist/Occupational Therapist lying under
"Other" categorize. The current study examined the effects of COVID-19 pandemic on
LTCF care aides’ job satisfaction in northern BC, so the data extracted from eight individuals
from care aides’ role of the primary research were used.
In qualitative research, saturation means that the data no longer reveal any new
information or themes (Morse, 1995; Saunders et al., 2018). This means that the sample size
is appropriate for answering the research questions and aims. When saturation is reached, the
study is sure to have fully looked into the interesting phenomenon and that more data
collection is not likely to reveal any new information (Morse, 2015). The thematic analysis
approach, which is frequently used in qualitative research to find, examine, and report
patterns or themes within the data, has been utilized in this study to address saturation
(Morse, 2015). A systematic and comprehensive analysis of participant narratives is made
possible by thematic analysis, which also helps identify important themes and common
trends regarding the effect of the COVID-19 pandemic on care aides' job satisfaction in
LTCFs (Saunders et al., 2018). Throughout the analysis, I continually checked the data to see
if it is saturated by seeing if new themes or insights keep coming up with each new
transcripts of participant's interviews. It was concluded when there were no more themes to
be identified, which meant the sample size was appropriate for answering the research
questions.
38

Data Collection
Semi-structured interviews were the instrument utilized to collect data for the main
study. Semi-structured interviews facilitate open-ended questioning while guaranteeing that
all participants cover important subjects in a consistent approach. The research team worked
collaboratively to create the open-ended interview questions, which were designed to get
comprehensive responses from participants. The questions were written carefully to ensure
participants could understand and respond to them easily. Technical vocabulary were
avoided. Depending on the preferences and practical concerns of the participants, interviews
were done over the phone or via Zoom. In accordance with COVID-19 social distancing
guidelines, participation was facilitated through the use of technology-enabled remote
interviews. Each interview was planned to be in around one hour, which allowed for an indepth analysis of the experiences and perspectives of the participants. All interviews were
recorded with permission from the participants and then transcribed using the qualitative data
analysis program NVivo 12 for analysis. To accurately capture participant responses,
including non-verbal cues and language nuances, the transcription process required close
attention to detail. To maintain the confidentiality and privacy of the participants, transcripts
were made anonymous. After transcription, the information was arranged and coded to
identify themes, patterns, and connections throughout the dataset. The research team
members attended regular debriefing sessions to discuss emerging themes and ensure the
analysis process was rigorous and consistent.

39

Data Analysis
Thematic Analysis and Qualitative Methodology Framework
Braun & Clarke's (2006) thematic analysis was used as a flexible way to analyze
qualitative data. This method helps identify, examine, and report patterns or themes within
the data. It can be used with various theories and ethical views, making it suitable for
exploring the experiences and meanings of the participants. Thematic analysis is based on the
idea that language, meaning, and experience are connected. This allows us to understand
meaning, motivation, and experience from the transcripts. Themes found in the analysis were
organized into an Excel matrix, summarizing the data to create broader theories about their
importance.
To ensure accuracy, the collected transcripts were organized into a dataset and
checked against the original audio recordings. This step was essential to make sure that the
data was complete and precise. By carefully comparing the transcripts with the recordings,
any mistakes or omissions could be corrected. The qualitative analysis was then carried out
by categorizing the data into themes using Braun & Clarke 's six-step approach (Braun &
Clarke, 2006). This structured method allowed for a thorough examination of the data,
ensuring that the themes accurately reflected the participants' experiences and perspectives.
Thematic Analysis Using Braun and Clarke's Six-Step Approach
1. Familiarization with Data: The first step of thematic analysis involved repeatedly
reading transcripts and listening to audio recordings to become thoroughly familiar with the
data. Initially, I listened to the audio recordings without referring to the transcripts, which
allowed me to understand the emotions and overall tone of each interview. This active
listening helped capture the nuances and subtleties of the participants' stories, providing a
40

basic understanding of the context. This step was fateful for developing an empathetic
understanding of their experiences and for engaging deeply with the data, thus setting a
strong foundation for the analysis process.
2. Generating Initial Codes: The second step involved systematically coding
interesting features across the entire dataset. I reviewed the recordings while reading the
transcripts to ensure all words were correctly captured and important points were noted.
This dual review process was essential for verifying the accuracy of the transcripts and
provided deeper insight into the detailed accounts and emotions of the care aides. During
this phase, I identified and labeled relevant data segments, creating a comprehensive list of
initial codes that captured significant aspects of the participants' experiences. This step
ensured that no meaningful information was overlooked.
3. Searching for Themes: In the third step, the initial codes were collated into potential
themes. This involved organizing the coded data into meaningful groups and gathering all
relevant data for each theme. By systematically coding the data and extracting important
sentences from the interviews, I could identify recurring themes and patterns. This process
was essential for breaking down the data into manageable parts, making it easier to analyze
and interpret overarching patterns and relationships within the data.
4. Reviewing Themes: The fourth step involved checking if the identified themes
worked in relation to the coded extracts and the entire dataset. This step required refining
the themes to ensure they accurately represented the data and were coherent and distinct
from one another. By reviewing the themes in the context of the entire dataset, I ensured
that the themes were well-supported by the data and provided a comprehensive
understanding of the participants' experiences.

41

5. Defining and Naming Themes: The fifth step involved ongoing analysis to clearly
define and name each theme. This process provided specific names and clear definitions for
each theme, ensuring that they accurately reflected the underlying data. This step helped in
creating a structured and organized framework for the final analysis, facilitating a deeper
understanding of the themes.
6. Producing the Report: The final step was writing a detailed report of the analysis.
This report provided a compelling narrative that contextualized the data within the research
questions and objectives, highlighting the significance of the identified themes. The report
aimed to convey the depth and richness of the participants' experiences, making the
findings accessible and meaningful to the intended audience.
Precision and Reliability
The trustworthiness criteria developed by Guba & Lincoln (1994) are widely utilized
in qualitative research. These criteria include aspects such as credibility, dependability,
confirmability, transferability, and validity. These factors guarantee the strength and
dependability of qualitative research findings. Table 4 provides a clear description of the
meanings of these terms and the strategies used in this study to maintain the reliability and
credibility framework suggested by Lincoln & Guba (1985), as modified by Polit & Beck
(2008, p. 787-8). Validity, generalizability, and reliability, which are commonly used as
quality criteria in quantitative research, are not appropriate indicators of quality for
qualitative studies.

42

Table 4
Trustworthiness Framework Criteria of Lincoln and Guba (1985)
Criterion

Definition

Planned Strategies to Promote
Trustworthiness for this Study

Credibility

The “confidence in the truth
of the data and interpretations
of them” by “carrying out the
study in a way that enhances
the believability of the
findings” and “taking steps to
demonstrate credibility in
research reports”

- All steps taken for this study
documented and reported in the final
research report.
- Transcripts have been reread twice
with audio recordings to ensure
accuracy of the transcripts.
- Illustrative quotes used to support the
interpretation of findings.
- A peer review with the committee
was done as part of the analysis
procedure.

Dependability

The “stability (reliability) of
data over time and
conditions”.

- Immersion into data and use of
researchers’ notes of the interviews
themselves ensured attention was paid
to the context such that the codes truly
emerged from the data.
- Regular check-ins with the thesis
supervisor, who is the primary
investigator of the original study for
documentation and exploration of
relevant presuppositions and
reflections on the emerging data.

Confirmability

Refers “to objectivity, that is,
the potential for congruence
between two or more
independent people about the
data’s accuracy, relevance or
meaning” and “findings must
reflect the participants’ voices
and the conditions of the
inquiry, and not the
researcher’s biases or
perspectives”

- Regular analysis meetings with the
committee to document and analyze
relevant presumptions.
- Ensuring transparency and reflective
thinking in data interpretation.

43

Transferability Refers “to the potential for
extrapolation, that is, the
extent to which findings can
be transferred or have
applicability in other settings
or groups”, and “the
investigator’s responsibility is
to provide sufficient
descriptive data so that
consumers can evaluate the
applicability of the data to
other contexts”

- Descriptive data of the participants
reported, including sex, gender,
workplace size, and geographical
information about the NHA LTCF sites
included in the report.

Authenticity

- Quotes from participants will be used
during the reports to illustrate the
themes identified.

Refers “to the extent to which
researchers fairly and
faithfully show a range of
realities. Authenticity emerges
in a report when it conveys the
feeling tone of participants’
lives as they are lived.”

- The themes identified will be
triangulated with findings in the
literature regarding care aides’
experience in LTCF.

Trustworthiness of the Research
Several methods were used to ensure that this research is trustworthy. The first step
was to read the data very carefully and actively engaged with it. This required listening to the
audio recordings and reading the transcriptions aloud multiple times to guarantee accuracy
and encourage a complete comprehension of the data. This process considered the specific
characteristics of the participants and the situation they were in. This allowed an in-depth
investigation of the themes and patterns that were drawn up.
Throughout the analysis, illustrative quotes were used to support the interpretation of
findings. To illustrate important points and back up the findings from the data, these quotes
were carefully selected. Transparency and credibility were strengthened by including direct
quotes from participants that readers may utilize to evaluate the validity of the
44

interpretations. A peer review with the committee was done as part of the analysis procedure.
The analysis discussed and validated during regular meetings with Dr. Shannon Freeman,
who is both the thesis supervisor and the primary study investigator. Ensuring the integrity
and confirmability of the findings requires collaborative dialogue and critical reflection to
identify and address potential biases and assumptions. The nature of secondary data analysis
also made member checking with primary study participants impossible. However,
throughout the research process, active reflection on researcher bias was a top priority. To
ensure transparency and reflective thinking in data interpretation, regular analysis meetings
with the committee have been held. These meetings helped document and analyzed relevant
presumptions.
All things considered, these approaches strengthened the research's credibility,
criticality, and integrity, made it more trustworthy and guaranteeing reliable and credible
outcomes.
Ethical Consideration
In conducting this research, ethical considerations were important to ensure the
protection and confidentiality of participants. Ethics approval for the study was obtained
through a rigorous process as part of the original ethics application. Ethical approval from
both the UNBC Research Ethics Board and the NHA Ethics Board was unified (Ethics
Approval Number H21-01883). Prior to their involvement in the study, all participants
provided informed consent, acknowledging their voluntary participation, and understanding
of the research objectives. This ensured that participants were aware of their rights and the
potential risks and benefits associated with their involvement. Strict procedures were put in
place to protect participant data's security and confidentiality. All electronic data, including
45

audio recordings and transcriptions, were stored in a dedicated and secured passwordprotected folder on a server managed by the UNBC's Information Technology Services.
Additionally, a master participants list containing identifiable information was stored
separately from other study data to further enhance confidentiality. Physical documents and
interview notes were also handled with care and stored securely. Hard copies of documents
were stored in a locked cabinet within a locked office on the UNBC campus, ensuring
restricted access and protection against unauthorized disclosure. Throughout the research
process, these ethical considerations were vital in preserving the values of respect, integrity,
and confidentiality. This helped maintain ethical standards and guidelines while also keeping
participants' trust and confidence.

46

Chapter 4: Results
This chapter presents the findings of the study examining how the COVID-19
pandemic has affected care aides' job satisfaction in LTCFs in Northern BC. The analysis of
the study data revealed five main themes: 1) Work Environment and Conditions, 2)
Emotional and Psychological Impact, 3) Communication and Team Dynamics, 4) Resident
Care and Safety, and 5) Impact of Policies. Each theme encapsulates different aspects of the
care aides' experiences during the COVID-19 pandemic, highlighting how deeply the
COVID-19 pandemic has affected care aides' personal and professional lives. These themes
provide a comprehensive understanding of the varied experiences and challenges faced by
care aides in Northern BC. These findings offer valuable insights into the factors influencing
job satisfaction, suggesting potential areas for intervention and support. The chapter delves
into each theme in detail, illustrating the profound impact of the COVID-19 pandemic on
care aides' professional lives.
Dataset Overview
The data for this study was collected through interviews with care aides from 24
LTCFs in Northern British Columbia. To ensure confidentiality, care aides are identified by
gender, average age, and years of experience. LTCFs were categorized by size, rather than
the number of beds, and their names are not disclosed. This contextual measure categorizes
LTCFs based on the number of beds as follows: facilities with 100 beds or more are
classified as large LTCFs; those with 30 to 99 beds are classified as medium LTCFs; and
those with 1 to 29 beds are classified as small LTCFs (Canadian Institute for Health
Information, n.d.). The interviews were conducted with care aides from a diverse range of
facilities, including both small, medium, and large LTCFs, providing a broad cross-section of
47

the LTCF sector in the region. This diversity in facility size ensured that the study captured a
wide array of experiences and challenges faced by care aides during the COVID-19
pandemic.
Overview of Themes
This study identified five major themes through the detailed analysis of interviews
with eight care aides. These themes offer a comprehensive understanding of the impact of
how the COVID-19 pandemic has impacted their personal and professional lives. The
emergent themes encompass various aspects of their experiences, including the work
environment, emotional and psychological responses, communication and team dynamics,
resident care and safety, and the influence of policies implemented during the COVID-19
pandemic. Each theme highlights different dimensions of the challenges faced and
adaptations made by care aides, providing comprehensive insights into their job satisfaction,
mental health, and overall well-being during this unprecedented period. The following
sections will present these themes and their corresponding subthemes in detail, illustrating
the varied experiences of the care aides.

48

Figure 3
Themes Identified in the Study on the Impact of the COVID-19 Pandemic on Care Aides' Job
Satisfaction in LTCFs.
Theme 1: Work Environment and Conditions effecting Care Aides Work-life
• Work Experience (Size of the facility, position, employment status [full-time/parttime/Casual], duration in that position)
• Changes in Work Environment Due to COVID-19
• Availability and Use of Personal Protective Equipment
• Workload Changes
• Short Staffing and New Staffing Issues
Theme 2: Emotional and Psychological Impact on Care Aides
• Feeling Supported During COVID-19 (Management, financial, psychological support)
• Emotional Responses to Resident Deaths and Grief
• Perceived Value and Recognition of Their Work During COVID-19
Theme 3: Impact of COVID-19 on Communication and Team Dynamics
• Team Communication (Both Virtual and In-Person)
• Changes in Team Interactions
• Impacts of Social Distancing on Team Dynamics
Theme 4: Impacts of Resident Care and Safety During COVID-19 Pandemic on Care Aides
Job Satisfaction
• Impact on the Quality of Resident Care
• Challenges in Maintaining Resident Safety and Well-being
Theme 5: Impact of Policies on Care Aides Role at Long-Term Cares
• Effects of Vaccination Policy on Care Aides
• Effects of Visitor Policies on Care Aides
• Effects on Work Environment and Team Dynamics
Theme 1: Work Environment and Conditions Affected Care Aides Job Satisfaction
The COVID-19 pandemic altered the work environment and conditions for care aides
in LTCFs. These changes affected various aspects of their daily routines, from the increased
workload and use of PPE to staffing issues and the emotional toll of their roles. This theme
49

explores the major transformations in their work environment and how these changes
impacted their job satisfaction and overall well-being.
Work Experience
The work experience of care aides in LTCFs varied based on the size of the facility,
the position held, and employment status, whether full-time, part-time or casual. These
factors influence the day-to-day work environment and overall job satisfaction. A majority of
the participants (n=6/8) reported similar experiences regarding how the size of the facility,
the position they held, and their employment status (full-time, part-time or casual) influenced
their work environment and job satisfaction. They highlighted the challenges and variability
in their roles depending on these factors.
Multifaceted challenges were emphasized by many care aides, especially among
those with childcare and family care responsibilities. The demanding nature of the work and
the emotional difficulty of dealing with the increased numbers of dying LTCF residents
during the COVID-19 pandemic were notable. Care aides often juggled multiple shifts,
which can be physically and emotionally taxing. The constant shift work and physical
demands of the job can lead to burnout, especially for those with long tenures.
Resilience and dedication of care aides in balancing personal and professional
demands while providing compassionate care was highlighted by a participant with more
than 20 years of experience.
I have three children so long-term care is shift work, lots of juggling, not the best pay,
physically it’s very, it’s hard on the body. Ya, emotionally it can be hard, they’re
dying, but that’s okay, usually they’re ready to die and you know that and you’re
taking care of them… I’ve been working here for 20 years and I’ve seen a lot of
changes over time, particularly in the complexity of care we provide.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
50

The flexibility and variability in employment status for care aides in smaller LTCFs
played a decisive role in their job satisfaction and stability. Working in smaller facilities
often meant that care aides must be adaptable and flexible, taking on multiple roles as
needed. The need for flexible employment arrangements to accommodate personal
circumstances and career development was emphasized. For instance, some care aides
transition between full-time, part-time, and casual positions based on their life circumstances
and the facility’s needs. This variability can impact their financial stability and job
satisfaction. One participant explained:
I work as a care aide in a long-term care at our local hospital. Currently I’m in a
casual position there but I used to be in the past a part-time care aide and I’m also
training on the acute ward. Our hospital is small so I’m also training on the acute
ward as well… So I’ve been with the [name of the hospital] for 18 years but not
always, not all those years I have been working many hours. Some years I have been
working quite a bit less.
(P3 female aged 40-49, 15-20 years of experience, small-sized LTCF)
Additionally, the physical environment in larger and newer LTCFs was noted to
greatly impact job satisfaction. Care aides in these facilities often appreciated the modern,
homey, non-institutional feel of the environment, which contributed to a more pleasant and
stable work experience. Most participants commented on how the design and layout of the
facility affected both the staff and the LTCF residents' comfort and satisfaction. They noted
that well-designed spaces promoted better interactions between staff and LTCF residents,
fostering a more supportive atmosphere. The stability of the staff at these facilities also
indicated a supportive work environment that may contribute to lower turnover and higher
job satisfaction. A stable team environment helps build strong team dynamics and ensures
continuity of care for residents. One participant described:

51

[LTCF’s name] is a newer facility, it’s a much bigger space and the staff is stable
there it’s a nice looking environment.
(P5 male aged 50-59, 10-15 years of experience, large-sized LTCF)
The participant also emphasized the positive impact of well-designed spaces on both staff
and residents, enhancing comfort and satisfaction:
The building layout is very pleasing, it’s homey, sort of. It’s not quite so facilitated
looking, like a hospital and that. I’ve worked elsewhere and it’s much more, ya, home
environment focused so that makes it a little more comfortable at least. The people
seem to enjoy it more.
(P5 male aged 50-59, 10-15 years of experience, large-sized LTCF)
Changes in Work Environment
The work environment for care aides in LTCFs underwent lots of changes due to the
COVID-19 pandemic. Most participants reported increased difficulty in their jobs,
highlighting the physical discomfort of wearing masks and goggles, the additional tasks that
increased their workload, and the confusion and stress caused by constantly changing
policies. A participant indicated that:
COVID was really tough, not only because of the fear of bringing the virus into the
facility but also because of how much harder it made our jobs. We had to wear masks
and goggles all the time, which was suffocating. There were so many extra tasks we
had to do, like escorting family members to rooms, and that added to our already
heavy workload…. One day we’d be told to take our uniforms off before leaving, the
next day we’d hear through the grapevine that it wasn’t necessary anymore. It was
confusing and made everything more stressful because we never knew what the
correct procedure was.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
Another participant highlighted the ongoing uncertainty and constant changes in policies,
which made it difficult to feel settled or confident in her role: "…It still feels like at the
beginning where kind of everything is all up in the air and you never really know what’s kind
of going on because policies are always changing" (P7 male aged 30-39, 1-5 years of
experience, medium-sized LTCF).
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The emotional and psychological toll on both care aides and LTCF residents was
notable, with issues like loneliness and anxiety among LTCF residents being exacerbated by
the COVID-19 pandemic. Masking made it hard for LTCF residents to recognize staff,
leading to confusion and sometimes violent behavior. One participant shared:
COVID didn’t help for sure. I would say a lot of elderly are struggling, right, with
loneliness, anxiety, other issues…the masking it has been unreal. They don’t know
who is coming. It doesn’t matter we have a name tag, like they cannot read
sometimes, right. Like it’s hard, that’s definitely, you know, patients becoming
violent, right, because they have dementia already and they don’t know what the heck
is going on...
(P3 female aged 40-49, 15-20 years of experience, small-sized LTCF)
The other participant mentioned:
We had like probably close to three of them, I’m pretty sure died of a broken heart
cause they just couldn’t see their family. The isolation was too much for them to bear,
and it was heartbreaking to witness. It was devastating to see them deteriorate
because of loneliness, and it made our job feel even more overwhelming.
(P8 female aged 30-39, 1-5 years of experience, medium-sized LTCF)
Feelings of frustration and burnout from dealing with the ongoing impacts of COVID-19
were expressed. Despite getting vaccinated, care aides were still required to wear masks,
which added to their sense of fatigue and annoyance. One participant described the persistent
struggle with the COVID-19 pandemic, indicating that they had come to view COVID-19 as
an enduring challenge, comparable to the flu.
COVID nowadays we’re all very burned out by it, we’re annoyed by wearing the
masks, despite having to get the vaccinations we have to wear the masks and we’re
just sort of slogging along sort of regarding COVID as it’s going to be the new flu.
(P4 female aged 50-59, 15-20 years of experience, large-sized LTCF)
Initially, there was an assumption that the COVID-19 pandemic would end quickly, leading
to a ‘business as usual’ approach for the first year. However, as shortages and limitations

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persisted, the realization set in that adjustments and adaptations were necessary. A
participant shared:
It didn’t happen all at once, you know, we all assumed it was going to go away
quickly and we’d be right back to normal, you know, so for the first year or so it was
just business as usual for the most part we just dealt with the shortages and then the
supply shortages and all that kind of stuff, our limitations for what we could do
because we don’t have the products to do it as well.
(P5 male aged 50-59, 10-15 years of experience, large-sized LTCF)
In contrast, two participants did not report major changes in their work environment due to
COVID-19, indicating that their experiences were somewhat different from the majority. For
these participants, the emotional and operational aspects of their jobs remained mostly
unchanged despite the COVID-19 pandemic. They felt that the core nature of their work,
including the emotional demands and responsibilities, stayed the same. One participant
stated, "I don’t think that it’s any different emotionally; it’s the same" highlighting that the
emotional strain and tasks they handled before the COVID-19 pandemic continued similarly
during it (P5 male aged 50-59, 10-15 years of experience, large-sized LTCF).
The lack of family visits and group activities resulted in residents becoming
depressed and withdrawn, which added to the emotional burden on care aides. The use of
therapeutic tools, like toy dogs, was one way care aides tried to compensate for the absence
of real therapy animals due to visitation restrictions. Despite all efforts, the mental
exhaustion caused by LTCF residents' unhappiness due to the lack of activities, haircuts, and
foot care was profound. LTCF residents' dissatisfaction often resulted in them taking out
their frustrations on the care aides, adding to the already high levels of stress and fatigue
among the staff.
It’s mentally exhausting cause the residents are unhappy cause there’s activities not
being done, you know, like I said there’s no haircuts happening, the foot care isn’t
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being done. So then they’re not happy. Well, when they’re not happy they take it out
on us. Because we’re the ones that are there.
(P6 female aged 40-49, 10-15 years of experience, large-sized LTCF)
Availability and Use of Personal Protective Equipment
The availability and use of PPE were major challenges during the COVID-19
pandemic. Most care aides reported considerable physical discomfort from wearing masks,
especially N95 masks, and other PPE for long durations. This often led to skin problems like
rashes and acne. In addition to the physical discomfort, there were shortages in availability of
PPE, especially at the start of the COVID-19 pandemic. This made their already tough jobs
even more stressful. One participant described their experience:
Ya, so in the beginning I think there was a lot of anxiety, people were afraid. The
handwashing was like insane, which is probably by the guidelines to be honest. Every
time you enter a room, every time you leave a room. But my hand ended up getting
really infected actually by the sanitizer and I had to go on all these steroid creams and
stuff and that didn’t heal for probably nine months.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)
Another participant emphasized:
We had to wear PPE all the time, masks, N95 masks which were very hard. We
couldn’t even breathe properly and had to wear glasses and everything, which made
me more stressed. The continuous use of PPE was exhausting and often caused skin
issues like rashes and acne. It was very difficult to wear all the PPE kits for the whole
time, like wearing masks, because we were not used to that before. We had to use
gloves all the time and wash our hands a lot, which made our skin dry and bright, and
it also gave us skin rashes and over-the-mouth rashes. The physical discomfort of
wearing PPE for long periods was a big challenge.
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Many care aides had to ration PPE, especially masks and gowns, which added to their
anxiety because they were not sure if they would have enough PPE supplies for their shifts.
A participant indicated:
I can’t remember if there was ever a shortage of the cytotoxic gowns but I know the
yellow ones that were disposable we mainly use those in long-term care and at the
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hospital and we kind of just hang them up and reuse them. That’s what most staff did.
I don’t think that was like the recommendations or kind of the directions from
management but it was just like the reality of not having enough.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)
This rationing was common and reflected the uncertainty and increased pressure of managing
limited supplies. The initial shortage of PPE was a challenge, although the situation
improved over time. A participant indicated:
The gowns were tough for awhile and they’d be rationing those and gloves were
rationed… There were days when we were told we had to ration our PPE. Masks and
gowns were particularly tough to come by, especially on weekends. Gloves were also
rationed. It added an extra layer of stress because you never knew if you'd have
enough supplies to last through your shift… The PPE was a challenge. At first, we
didn’t always have what we needed, and we had to make do. Eventually, things
improved, but there were definitely times when it was touch and go.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
A care aide from a small-sized LTCF noted occasional shortages of specific PPE
items like booties and gloves. At times, gloves were even locked up to manage the supply.
This statement reflects the sporadic availability of PPE and the measures taken to control its
use during shortages.
Ya, there was a shortage a little bit, for example, booties I’m missing, like we had to
wear booties over our shoes. And all of a sudden there were no booties, right, some
time. I think gloves too like some gloves were put under lock actually.
(P3 female aged 40-49, 15-20 years of experience, small-sized LTCF)
Supply chain problems led to changes in safety protocols, which increased the risk of
spreading infections. For example, instead of having ample supplies of gloves in each room,
they were given limited boxes of gloves for the entire day, which increased the risk of crosscontamination as they moved from one area to another.
We had just like supply shortages for gloves and things like that, right. So we used to
have a large supply, we had gloves in every room, things like that, you know, so we
wouldn’t be cross-contaminating and such. So once this happened and the supply
chains were disrupted, they removed all the gloves and then we were basically given
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a box of gloves for the day, that sort of thing, you know, for our wing. And it just, it
changed the safety protocols because we had to carry our gloves with us so then we
have the chance of cross-contamination happening so we couldn’t, if there was
something going on over here, I mean we practice universal protocols and
precautions but when you’re bringing products from one place to another there’s a
possibility for something to be picked up, right.
(P5 male aged 50-59, 10-15 years of experience, large-sized LTCF)
Communication challenges posed by wearing masks caused residents to struggle to
see care aides’ faces and hear them clearly. This situation sometimes required care aides to
speak louder or lower their masks, which could compromise safety. A participant noted:
It’s been really hard and it seems to be just getting harder. The residents don’t get to
see our faces at all right now so I mean then they can’t hear us half the time. So we’re
either having to talk quite a bit louder than we normally we would or we have to pull
the mask down cause some of them they use your lips to also help.
(P6 female aged 40-49, 10-15 years of experience, large-sized LTCF)
The confusion and fear that PPE could cause among residents, particularly when care
aides approached them in full protective gear. A participant also noted the variation in glove
quality due to supply shortages, which affected their ability to provide care:
The masks we were wearing anyways but the face shield and the gown and the gloves
typically you don’t always, you know, like approach residents like that and I think it
was quite confusing and it was probably frightening for some of the people I would
imagine…There were times where we didn’t always have the PPE and so we
typically had, I wouldn’t be able to tell you the brand, but we typically had really nice
quality gloves and I think this was everywhere, and we got quite a, there was the
newer gloves that we got, there was a shortage, they were getting all these different
brands of gloves and they’re really bad quality.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)
Workload Changes
The workload for care aides in LTCFs increased during the COVID-19 pandemic.
The increase included additional responsibilities, irregular hours, and need for constant
sanitization and PPE changes which subsequently created a challenging work environment
that affected the physical and mental well-being of the care aides. Most participants reported
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having to work overtime frequently due to numerous sick calls from colleagues who were
afraid of getting infected. This led to the need to cover shifts and work extra hours, which
participants described as exhausting, especially in the context of working night shifts.
A participant explained that she had to work overtime frequently due to numerous
sick calls from colleagues who were afraid of getting infected. The constant need to cover
shifts and work extra hours was exhausting, especially when working night shifts. The
isolation and irregular hours compounded the stress, making it difficult to get adequate rest
and manage the workload.
We had to work overtime too over there sometimes because there were so many sick
calls at that time, cause people like don’t want to work at that time because they were
also worried if they can get infected they will get residents and their family members
too. The constant need to cover shifts and work extra hours was exhausting. I worked
the nightshifts too over there and at the nighttime, you know, when everybody was
sleeping and you were only one awake then it gave you all the, like negative vibes,
right. The isolation of night shifts compounded the stress, making it a lonely and
challenging experience… Like I said I worked nightshifts too and I also worked like
one night and the next day I had to come in the evening shift. So my hours were
changed at that time and I had to work overtime too. So that also gave me stress and I
couldn’t get enough sleep. The irregular hours and lack of rest were particularly hard
to manage.
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Another participant shared:
Sometimes it [the work shifts] has to do with family conflict and things of that nature
although that’s not something I actually probably experience that more as a health
care worker, that’s more of a dayshift thing. I mainly work nights now but ya.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)
Another Participant also mentioned:
My hours changed significantly during the pandemic. We had to work more shifts
because many staff were either sick or didn’t want to come in because they were
afraid of getting sick. I ended up working night shifts and overtime frequently, which
was exhausting…Workload increased dramatically. We had to sanitize everything
constantly, wear full PPE, and still perform all our regular duties. It felt like we were
always behind, always rushing. I found it really soul-sucking. Like I found the
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staffing was skeletal, like it was a skeletal crew. People that don’t do well with
change were going off very quickly and there were injuries happening so people were
off… The constant sanitizing and PPE changes were essential but time-consuming. It
added to our workload and made everything take longer.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
The extensive responsibilities that a care aide had to manage alone, including serving
dinner, feeding, toileting, and preparing residents for bed has been reported by a participant.
The workload for that number of residents was overwhelming for her, and the time
constraints made it impossible to complete all tasks thoroughly. The pressure to rush through
tasks and the inability to have meaningful interactions with residents contributed to job
dissatisfaction.
I had to serve dinner, I have to feed people. I have to get people ready for bed. I have
to toilet these people. There’s so much that you need to do and you’re by yourself and
they’re not all easy people to work with. You’ve got all different sizes, you know,
slings, non-slings, it’s a lot to try and do for [number of residents which is more than
15] people by yourself. And things aren’t going to get done 100%, it’s just not
possible, cause you just can’t do that…You don’t really get to have a nice
conversation. You’re rushing. So okay, wash your face, ya do this quickly and I don’t
like that. But how else do you get everything done before you go home? Like cause
you’re trying to, cause you’ve got all these people who like to go to bed early. They
don’t want to wait until 8, 9:00 at night. They want to go to bed early.
(P6 female aged 40-49, 10-15 years of experience, large-sized LTCF)
Additionally, another participant also shared their experience of the increased workload:
It was very stressful because policies kept changing. One day we would be told one
thing, and the next day it would be completely different. It was hard to keep up with
the new guidelines, and it felt like we were always behind. The inconsistency made it
challenging to feel confident in what we were doing. On top of that, we were dealing
with physical discomfort from wearing masks and goggles all the time. It was really
tough.
(P8 female aged 30-39, 1-5 years of experience, medium-sized LTCF)

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Short Staffing and New Staffing Issues
Staff shortages and the influx of new, often undertrained staff exacerbated the
workload and stress for care aides. The constant need to adapt to new team members and the
lack of adequate staffing made it challenging to maintain a high standard of care.
The stress of being short-staffed, with many colleagues calling in sick or not showing
up due to fear of infection reported by a participant. The arrival of new staff who were not
properly trained added to the workload, as experienced care aides had to train them while
managing their own duties. This situation highlighted the frustration and increased workload
caused by inadequate staffing and training.
There were many days when we were severely short-staffed. People would call in
sick or simply not show up because they were afraid of getting infected. It was
incredibly stressful because the residents still needed care, and there were fewer of us
to provide it...We had new staff coming in, but they were often not properly trained.
They didn't know the routines, and it added more work for us because we had to show
them what to do on top of our regular duties. It was frustrating…
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
The challenges of working with casual staff, whose abilities and commitment levels
varied, was also an important problem mentioned by a participant. The unpredictability of
casual staffs’ performance added frustration and made it difficult to plan and execute the
workload efficiently:
Every day that I work short and they fill the space with a casual employee I really
don’t know what to expect and it’s very frustrating to design your workload around
that and to work with a person you don’t know and some of them you get to know
whether or not they’re fast or slow or just there to put the time in, so you try to work
with it, but it just gets very tough that way because you can’t rely on it and you know
that they’re going to be gone.
(P5 male aged 50-59, 10-15 years of experience, large-sized LTCF)
A participant described a specific instance where she had to work alone for a
significant part of her shift due to staff shortages. The situation was further complicated by
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COVID-19 clusters in different areas of the facility, limiting staff movement and
exacerbating the staffing issues:
I can give you a perfect example, the other evening I had to work from 3:30 to 9:00
by myself or 3:30 to 8, sorry, and it was tough. We have also been in a cluster at our
facility up on one of the floors and on one of the other ones so that’s really affecting
us as well because they’re trying not to pull people from those areas to come and
work in other areas, so then the other areas get short…Staffing shortages have been
an ongoing issue but right now [during the COVID-19 pandemic] this last little while
it’s been really bad.
(P6 female aged 40-49, 10-15 years of experience, large-sized LTCF)
Theme 2: Emotional and Psychological Impact on Care Aides
The emotional and psychological impact of the COVID-19 pandemic on care aides in
LTCFs was profound. The level and type of support from management played a critical role
in their well-being. The experiences of care aides varied widely, with some feeling supported
by proactive and compassionate leadership, while others felt abandoned and stressed due to
inadequate management involvement. These differences in support influenced care aides’
morale, mental health, and ability to cope with the increased demands of their roles during
the COVID-19 pandemic.
Feeling Supported During COVID-19
The support from management, including financial and psychological support, was
indispensable in determining the emotional and psychological well-being of care aides
during the COVID-19 pandemic. The level of support varied widely across different LTCFs,
with low levels of support negatively influencing staff morale and mental health. Feeling
stressed and unsupported due to inadequate management involvement reported by most
participants. They noted that LTCF management did not provide adequate emotional support,
did not check in on staff during times of extreme short staffing, and did not offer recognition

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or appreciation for the increased workload and stress. Participants expressed a great lack of
support from management. For example, one participant reported, "Basically a lot of the
times we kind of feel that we’re just on our own in some ways" (P6 female aged 40-49, 1015 years of experience, large-sized LTCF). Another participant mentioned: "We lead
ourselves successfully without the help of management because our management really had
poor form." (P4 female aged 50-59, 15-20 years of experience, large-sized LTCF).
Additionally, one participant mentioned that they did not feel supported by their manager,
especially during times of extreme short staffing:
We didn’t feel supported by our manager. There were days when we were extremely
short-staffed, and she didn’t even come out of her office to check on us or see how
we were doing. It was really demoralizing… Like there’s no, we’re working, we’re
short-staffed…
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
Another participant expressed frustration with the lack of emotional and managerial support.
He noted that while management followed protocols, they did not provide the necessary
emotional support or appreciation for the staff's efforts.
Well, the leadership has protocol being put in place. they’ve kept up to that, so
they’ve done what they’ve been requested to do by the Provincial Health Authority or
the officer there... There hasn’t been much presence, like our manager doesn’t come
around or anything like that…Some kind of support would’ve been nice. Emotionally
supportive would’ve been nice. Would’ve been helpful. Ya, everybody is feeling the
crush and some of us are getting it a little more than others. And we haven’t had any
support, I believe. There should’ve been something done for the staff, some sign of
appreciation that we’re just killing ourselves here, but every time I turn around I’m
getting a slap in the face. I’m getting it from management, I’m getting that I’m not
doing my job, I’m not doing enough and we’re doing ten times more than we ever did
before and we’re getting ridiculed for it…Our manager literally told us to deal with it
ourselves, in our staff meeting. If we have any way that we want to work on our team,
there’s no direction, there’s no guidelines, we just do whatever we want to do. We’ve
been told that directly.
(P5 male aged 50-59, 10-15 years of experience, large-sized LTCF)
Another participant noted:
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Honestly, I mean it feels like sometimes we have no supports through management
and stuff, or a lot of the time it doesn’t make sense and then when you ask them about
it, they don’t necessarily have an answer for you and so that’s really frustrating.
(P6 female aged 40-49, 10-15 years of experience, large-sized LTCF)
Conversely, three participants reported experiencing strong leadership and support from their
managers. The care aides described how their managers provided flexibility with shifts,
resources for mental health, and made themselves available for support, which was
significant in helping the team cope with stress. Some participants mentioned receiving
financial incentives or recognition, which helped alleviate some of the stress and provided
motivation to continue working under difficult conditions.
My manager like really played a good role as a leader, right. So she also advised us
do this and this and she also like said if you want to like stay at home then please let
me know before, right, so she can exchange a shift with somebody so that I can feel
good and then I came to work. That was the good thing at that time. ...My manager
said if you feel stressed, you can call me anytime so she made a one paper and put in
on the table so that everybody can see and she like if you feel a mental stress then call
me anytime I can help you with that. And there was also one helpline number. She
also gave us and she said if you feel like more negative vibes some of them, …
Leadership was very important at that time because if there was nobody to lead the
team then the team was not going on. My manager like really played a good role as a
leader.
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Emotional Responses to Resident Deaths and Grief
The emotional and psychological impact of LTCF resident deaths during the COVID19 pandemic was notable for care aides. A profound emotional impact due to resident deaths,
with the added restrictions and isolation, making the experience even more distressing was
reported by most of the interviewees. Social distancing and lockdown measures which
prevented and/or limited the ability of family members to visit dying LTCFs residents added
emotional and morale distress, as care aides often had to witness and manage the grief of
both the LTCF residents and their families. The ongoing stress and trauma from witnessing
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these deaths affected their sleep and mental health, leading to nightmares and persistent
feelings of sadness and anxiety.
… I called my manager please come right now, that the one resident passed away and
their family members came on the same time and when I saw her daughter cry, like it
made me crying. I was crying more than her and you know that thing when I like
remind me of that person I was like oh no what happened that day, like literally make
my mind change I have to quit the nursing. So after that, you know, at the time the
manager said it is a like good thing that you see the person last breathing and there
was one word that she said, I don’t remember now. So like that word gave me, also
like made me cry. Like if I imagined that thing again my eyes like this again start
crying…that was the first time and that day changed my whole life…I was very sad
for the whole night. I couldn’t work properly at that time. I just said to the other girl
can you do this and she was like okay cause she didn’t see that person passed away so
she said are you okay. My manager said are you okay, can you make the shift? I said
okay I can make it and when I came to home, I took a bath and then I went to sleep
and in my sleep my dreams, dark things again like happening and it made me
scared….
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Some participants described the LTCF residents as being like family, and despite the lack of
COVID-related deaths in some facilities, the loss of any resident remained a deeply
emotional experience. A participant indicated:
It’s always sad when we lose somebody. I’m with these people all the time, they’re
like family to me and it’s hard when you lose somebody but I don’t think that it’s any
different emotionally it’s the same. I don’t know how to say anything different since
COVID has happened. (P5 male aged 50-59, 10-15 years of experience, large-sized
LTCF)
Another care aide shared:
It actually hurt quite emotionally… [I] checked on her at 5:30 in the morning, she
was fine and then I get back from my second nightshift and I find out she had passed
away between when I checked her and between the time the day nurse checked her.
And I knew she was, there was quite a few people that really, like family people, the
family was in every day… like for me watching that was just very emotional… It was
very emotional…, it was very emotional and I almost went down that little dark
path…
(P8 female aged 30-39, 1-5 years of experience, medium-sized LTCF)

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The bonds formed over time made each death particularly hard to withstand, as care
aides were not just losing patients, but people they had grown to care for deeply. In some
cases, the grief and stress were so intense that it made care aides consider quitting their jobs,
questioning their ability to continue in such a demanding and emotionally taxing role. As one
participant stated, "It was very emotional. Like during school, I ended up having to go back
on my anti-depressants" (P8 female aged 30-39, 1-5 years of experience, medium-sized
LTCF). The other participant mentioned:
… [some days] ago with me and the one girl were on the shift and there was one
resident who were just like their last breathing and he passed away in front of me.
Like that thing gave me very upset. On that day I made my mind like I had to quit the
nursing cause I couldn’t see that, like what happened.
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Another participant also added:
I’ve made a decision to leave healthcare basically … it just breaks my heart not to be
able to do things for people, you know, and I can’t do anything about it, you know,
… it’s just breaking my heart to see what happens, …. Ya, I’m looking at changing
positions to get out of the frontline, you know, interacting with the people cause it’s
just emotionally draining.
(P5 male aged 50-59, 10-15 years of experience, large-sized LTCF)
Perceived Value and Recognition of Care Aides
The perceived value and recognition of care aides' work during the COVID-19
pandemic varied. While some care aides felt motivated and appreciated, others experienced
underappreciation. Some care aides found a heightened sense of motivation and fulfillment
during the COVID-19 pandemic, feeling satisfaction in knowing their role was vital in
keeping LTCF residents safe and healthy. Witnessing the residents' happiness, especially
when they were able to see their children again, reinforced the value of their efforts and
made the challenging times feel rewarding. Simple gestures of appreciation from LTCF
residents, like smiles and hugs, provided a sense of value and recognition, even when
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physical touch and close interactions were limited. Conversely, other care aides felt
underappreciated and disciplined for actions they believed were unjust. Despite their efforts,
the lack of recognition and the disciplinary measures they faced were disheartening,
highlighting the negative impact of feeling undervalued on job satisfaction and morale. Some
care aides hoped that the COVID-19 pandemic shed light on the crucial role of healthcare
workers, especially those in LTC, believing that the increased visibility of their work could
help the public understand the realities of working in a nursing home, which might lead to
greater appreciation and recognition for their efforts.
Despite everything, I feel more motivated because I know how important my role is
in keeping the residents safe and healthy. It’s satisfying to see the residents happy and
well-cared for, especially during such a challenging time…Seeing the residents happy
when they could finally see their children again made me feel that all the effort was
worth it. It was a tough time, but knowing we made a difference was rewarding.
(Participant 01_ female care aide_ in her 20s_1-5 years of experience_ small-sized LTCF)
Another care aide mentioned the appreciation she received from residents through simple
gestures like smiles and hugs. These moments of connection provided a sense of value and
recognition for her work, even when physical touch and close interactions were limited:
I guess the appreciation, right, like some people would really appreciate the smile, the
hug because we as a worker still could kind of do that, you know, touch them a
certain way, right, when they were not able to see other people.
(P3 female aged 40-49, 15-20 years of experience, small-sized LTCF)
On the other hand, a participant who felt underappreciated described the impact of lack of
recognition and unjust disciplinary measures: "… So trying to do everything you can and
you’re still underappreciated and disciplined for something that you haven’t even done. You
know, well within my rights still and it was quite disheartening" (P5 male aged 50-59, 10-15
years of experience, large-sized LTCF).

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Another care aide hoped that the COVID-19 pandemic would shed light on the imperative
role of healthcare workers, especially those in LTC. He believed that the increased visibility
of their work could help the public understand the realities of working in a nursing home,
which might lead to greater appreciation and recognition for their efforts:
I think that at least I hope that it kind of put a little bit of spotlight on the people who
work in healthcare, especially long-term care, cause I’m sure for a lot of people it’s
hard to even think of what a nursing home is like.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)
Theme 3: Impact of COVID-19 on Communication and Team Dynamics
The COVID-19 pandemic brought about considerable changes in communication and
team dynamics among care aides in LTCFs. With restrictions on in-person interactions, care
aides had to adapt to new methods of communication, relying heavily on virtual platforms
and written notes. These changes, while necessary, posed several challenges, including
maintaining effective communication, ensuring continuity of care, and managing team
cohesion. The shift in communication methods highlighted the adaptability and resilience of
the care aides as they navigated these new dynamics.
Team Communication
Communication among care aides underwent changes during the COVID-19
pandemic, with reliance on virtual methods and written notes replacing some in-person
interactions. These changes posed challenges, but also highlighted the adaptability of the care
aides’ team. Communication shifted to phone calls, video meetings, and written notes due to
restrictions on gatherings. While challenging, these methods allowed the team to stay
informed and maintain continuity in care. The reliance on virtual communication and written
notes created confusion, especially with constantly changing policies. The lack of in-person

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meetings made it difficult to stay on the same page, leading to misunderstandings and missed
information. A participant mentioned:
… In the pandemic, it’s not a like team, we work in a team cause they were, we were
only communicating by a phone or video calls at that time, right, cause we couldn’t
get together and all can come and join the meeting at once because we were not
allowed to get together at that…
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Another participant noted that the reliance on virtual communication and written notes
created confusion, especially with constantly changing policies:
Communication during the pandemic was challenging. We had to rely more on phone
calls and video meetings because we couldn’t gather in person. It wasn’t the same,
and it made teamwork more difficult…There was a lot of confusion because of the
constantly changing policies. We’d get emails and updates, but not everyone checked
their email regularly, so sometimes people were out of the loop. It made it hard to
stay on the same page…We had to write notes and leave them for the next shift,
which wasn’t as effective as having a face-to-face handover. Important information
sometimes got missed or misunderstood.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
Despite these challenges, A participant reflected positively on teamwork during the COVID19 pandemic, emphasizing that a good team made the work manageable even when shortstaffed: "For me personally the teams that I’ve had have been really good. My normal team,
we worked really, really well together even when we’re short if we have a good team it’s
good" (P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF).
Over time, as morale increased, team dynamics improved, making the job easier and
more manageable. One participant explained that team communication shifted to phone calls,
video meetings, and written notes due to restrictions on gatherings:
… we like do the meetings on the video call and share the things and when the other I
mean the other care aide comes then we also shared that whole thing for the day like
this happening and this, just only that communication at that time…We had to

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communicate a lot through notes and messages because we couldn’t meet in person.
It was challenging but we managed to keep each other informed.
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Similarly, another care aide noted that higher morale post-pandemic made it easier to
perform their duties, reflecting the positive impact of improved team dynamics on job
satisfaction: "I think the team dynamics now because the morale is higher, it’s a little bit
easier to do the job but ya, I think most people are happy it’s passed and it feels normal again
to go to work" (P8 female aged 30-39, 1-5 years of experience, medium-sized LTCF).
Changes in Team Interactions
Team interactions changed due to social distancing and other pandemic-related
restrictions, impacting the sense of companionship among care aides. Social activities and
shared meals were no longer possible, affecting their ability to bond and enjoy each other's
company. The isolation from these restrictions led to a loss of normal social interactions,
making the work environment feel more isolating and less supportive. Social distancing
measures also forced care aides to eat separately during breaks, which further diminished the
sense of camaraderie. A participant shared:
… it was affected like we couldn’t share our lunch boxes with them and we couldn’t
eat all together so if anybody wants to eat their dinner, then they will said like I am
going, now you can go over. Like it was that thing happened and we couldn’t like go
for the parties or for our friends for their birthdays or anything so we couldn’t enjoy it
at that time.
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
The other participant also mentioned:
You don’t realize that when you’re in a staffroom and you’re having your lunch how
nice it is when you have other people to talk about. Just about mundane things but it’s
nice and then when there’s nobody there, you’re like oh, I’m by myself, well this is
kind of crappy.
(P6 female aged 40-49, 10-15 years of experience, large-sized LTCF)

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The inability to gather for social events, such as birthday celebrations and team
parties, removed opportunities for team bonding and morale-boosting activities. The lack of
regular meetings prevented communication and team cohesion, reflecting the broader impact
of the COVID-19 pandemic on routine team interactions. These changes disrupted the usual
support systems among care aides, making it challenging to maintain a sense of unity and
teamwork during a time of increased stress and workload. One participant described how
social distancing led to isolation during breaks, as they had to eat separately. This change
made the work environment feel more isolating and less supportive: "Our interactions
changed a lot. We used to be able to sit together during breaks and have a chat, but with
social distancing, we had to eat separately. It felt isolating" (P2 female aged 40-49, more
than 20 years of experience, medium-sized LTCF).
Impacts of Social Distancing on Team Dynamics
The physical separation and the inability to engage in normal social interactions
affected team cohesion and morale. Social distancing made it harder for care aides to feel
connected to their colleagues. Restrictions meant they could not celebrate birthdays or other
events together, which impacted team spirit. The necessity to keep their distance from each
other led to a sense of isolation and strained team dynamics, with increased stress and
arguments. Despite some moments of companionship, overall team morale suffered. This
loss of social interaction emphasized the importance of these moments for maintaining team
cohesion and morale. The absence of these informal interactions and the need to maintain
physical distance created a work environment that felt more clinical and less supportive,
further straining the mental health and job satisfaction of care aides. Additionally, the stress

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of adhering to strict social distancing guidelines added another layer of pressure, making it
difficult to foster a sense of teamwork and mutual support.
Social distancing was highlighted by one participant as a notable barrier to feeling
connected with colleagues:
Social distancing made it harder to feel connected to my colleagues. We were all
trying to stay apart, but it made it feel like we were each dealing with our own
struggles alone. The restrictions meant we couldn’t celebrate birthdays or other
events together. It might seem small, but those little moments of connection were
really important for our team spirit…Having to keep our distance from each other
made it feel less like a team. We were all just trying to get through our shifts without
getting too close to anyone, which was really sad… Team dynamics were strained
because everyone was so stressed and overworked. There were more arguments and
less patience with each other…We had some good moments and laughs together,
especially when dealing with the absurdities of the situation, but overall, it was a
tough time for team morale.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
Theme 4: Impacts of Resident Care and Safety During the COVID-19 Pandemic on
Care Aides Job Satisfaction
The COVID-19 pandemic greatly affected the care and safety of residents in LTCFs.
Care aides had to handle more work and stress and follow strict isolation rules. These
changes made it hard to provide high quality of care. The COVID-19 pandemic changed the
way care was given and care aides experienced challenges in keeping residents safe and well.
Impact on the Quality of Resident Care
The quality of resident care was impacted by the COVID-19 pandemic. The increased
workload, emotional stress, and isolation measures made it challenging for care aides to
provide the same level of attention and care to LTCF residents. The inability of LTCF
residents to see their families led to emotional distress, compounding the challenges faced by
care aides in ensuring resident well-being during the COVID-19 pandemic:
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The quality of care was impacted as residents couldn't see their families, leading to
emotional distress. Residents, like I said they had like to go to the dining room alone,
not all together so that’s the thing cause they do not wear the mask at that time…We
did our best to ensure residents received the care they needed, but the increased
workload and stress made it difficult at times.
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
The increased workload and stress made it difficult to maintain the quality of care,
despite best efforts. Staff shortages and increased tasks meant that care aides were often
rushing to complete duties, leaving them feeling like they were always behind. The need to
maintain a fast pace reduced the time available for meaningful interactions with residents,
impacting the overall quality of care. Balancing efficiency with the need for personal
connection became a challenge, as the emotional and practical difficulties of the COVID-19
pandemic took a toll on both LTCF residents and care aides. A participant noted:
The quality of care definitely suffered. With fewer staff and more tasks to do, it was
impossible to give residents the same level of attention and care they deserved…We
tried our best to keep the residents safe and happy, but there were definitely days
when we felt like we were just putting out fires and couldn’t give them the quality of
care we wanted to.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
Another participant also mentioned:
… we have to try to cheer them up as best we can and when we’re running our butts
off we don’t have the time to interact with them at all. That’s one of the things that
have really slowed down is our interaction with our residents because we’re so busy
trying to pick up the pace and we don’t have the time to interact with them.
(P5 male aged 50-59, 10-15 years of experience, large-sized LTCF)
The other participant also emphasized:
You’re rushing them, you know, and it just sucks… You don’t really get to have a
nice conversation. You’re rushing… You have to focus so much on the residents and
the safety you don’t even really get to even consider having much of a conversation
because not only are you thinking about that one resident you’re also in the back of
your mind going oh my God, I’ve still got blah, blah, blah, whatever, whoever still to
do.
(P6 female aged 40-49, 10-15 years of experience, large-sized LTCF)
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Challenges in Maintaining Resident Safety and Well-being
Maintaining resident safety and well-being during the COVID-19 pandemic
presented challenges for care aides in LTCFs. The need to balance physical safety with
emotional and social needs was particularly difficult, exacerbated by staff shortages and
restrictions on activities and visits. Ensuring LTCF residents' safety while also trying to meet
their emotional and social needs became a complex task. A participant noted: "Maintaining
resident safety was challenging because of the constant need for PPE and isolation measures,
but these measures were necessary to prevent the spread of the virus" (P1 female aged 20-29,
1-5 years of experience, small-sized LTCF).
The isolation caused by the COVID-19 pandemic led to residents feeling abandoned,
and there was not enough staff to provide the necessary attention. Another participant
reflected on the effectiveness of safety measures, noting that while they helped prevent
outbreaks, they made the job more difficult and increased the residents' sense of isolation:
We had to wear masks, goggles, and sometimes gowns. These measures were
necessary, but they made it harder to do our jobs and made the residents feel more
disconnected from us…I think the safety measures were effective in preventing
outbreaks, but they came at the cost of making us feel more stressed and the residents
more isolated.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
While it was necessary to keep potentially infected individuals isolated, it sometimes
involved coercing residents to stay in their rooms, which could be challenging. One
participant discussed the practice of isolating residents exhibiting COVID-19 symptoms:
Anybody exhibiting any signs that might be COVID we had to basically keep them in
their room but it wasn’t necessarily something that was like you can’t forcibly
confine somebody but, you know, you kind of did, it was kind of something people
would be coerced into staying in their room. Like you’re very sick, you can’t come
out, you know, there’s this virus.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)
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To compensate for the absence of real therapy animals due to visitation restrictions, the use
of therapeutic tools, like a toy dog, has been mentioned by one of the participants. These
small acts were important in trying to maintain residents' emotional well-being amidst the
limitations: "We have like a therapeutic, like a toy dog, so even handing that little toy dog to
someone because the real dog cannot come to visit" (P3 female aged 40-49, 15-20 years of
experience, small-sized LTCF).
Theme 5: Impact of Policies on Care Aides Role at Long-Term Cares
The implementation of various policies in response to the COVID-19 pandemic had
notable effects on the operations and morale within LTCFs. Policies such as vaccination
mandates, visitor restrictions, and changes to the work environment greatly influenced
staffing levels, workload, and overall stress among care aides. While these policies were
intended to protect the health of LTCF residents and staff, they also brought about
challenges, including staff resignations, increased workloads, and changes in team dynamics.
These policies impacted how care aides interacted with LTCF residents, their colleagues, and
their overall work environment. This theme examines the multifaceted effects of these
policies on care aides' daily experiences and their ability to provide quality care during the
COVID-19 pandemic.
Effects of Vaccination Policy on Care Aides
The vaccination policies in LTCFs had great effects on care aides, impacting staffing
levels, workload, and overall stress. These policies were essential to stopping the spread of
COVID-19, but they also brought many challenges. The vaccination policy was a point of
stress for many, with some staff leaving due to reluctance to get vaccinated. Although the

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process of getting the vaccine was relatively easy, there was a lot of misinformation and fear
surrounding it, contributing to anxiety among the staff. One of the participants noted:
The vaccination policy was a point of stress for many of us. Some staff didn’t want to
get vaccinated and ended up leaving, which made us even more shortstaffed…Getting the vaccine was made fairly easy for us, but there was a lot of
misinformation and fear about it. Some people were really anxious about getting
vaccinated…I got my vaccine as soon as it was available, but the process for the
second dose was less organized, and it took longer than it should have.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
One participant expressed strong disagreement with mandatory vaccination policies, feeling
that it infringed on personal choice:
I very much disagree when somebody tells you have to. To have this injected in you.
Right now the mandates from the provincial health officials is that health care
workers have to be injected with these vaccines, otherwise they’re not allowed to
work.
(P3 female aged 40-49, 15-20 years of experience, small-sized LTCF)
The impact of vaccination mandates on colleagues with religious objections to vaccination
was discussed by one of the participants. She found it sad to see coworkers terminated due to
their refusal to get vaccinated, losing their benefits and seniority as a result:
There’s a lot of religious reasons why people aren’t getting vaccinated so it’s very sad
to see these people being terminated, right. You know, they’re blaming the [name]
party, they’re not realizing that this is a government mandate, so it’s very sad to see
our co-workers be terminated from their positions and they lose a lot in terms of like
the benefits package and the seniority.
(P4 female aged 50-59, 15-20 years of experience, large-sized LTCF)
One participant shared his personal conflict regarding the vaccine, stating that he wouldn't
have gotten it if he weren't working in healthcare. He weighed the risks and ultimately
decided to get vaccinated, viewing the potential risk of contracting COVID-19 as greater
than the unknowns of the vaccine:

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For me I didn’t really, I personally didn’t really want the vaccine and I mean I still
don’t unless like other than working in healthcare, if I wasn’t working in healthcare I
probably wouldn’t get it. If I was in an area where I could reasonably isolate myself
and if this thing was going to be over in a few years that would maybe be something I
would think about not getting the vaccine but just due to I was weighing the risks of,
there’s a lot we know about COVID and there’s a little bit we know about the vaccine
but the unknowns like the greater risk was getting COVID to me so I decided to get
the vaccine just based on that.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)
Despite these issues, many care aides chose to get vaccinated to keep their jobs,
weighing the risks of COVID-19 against the uncertainties of the vaccine. Care aides’
decision to get vaccinated was driven by a strong commitment to their profession and the
well-being of the LTCF residents they cared for. The vaccination policies had a complex
impact, balancing the need for public health measures with the personal and professional
challenges faced by care aides. Some care aides were supportive and complied willingly,
understanding the importance of public health, while others were resistant due to personal
beliefs or concerns. This division led to professional challenges such as staff shortages and
workplace tensions. One participant noted:
The vaccination policy led to staffing shortages as some care aides chose not to get
vaccinated, which increased the workload for the remaining staff and added to their
stress levels…There were one or two of my friends who also resign from the work
cause they didn’t want to get that vaccine but I was like no, if I want to get in this
field then I have to get that vaccine, so I got it and I follow all the orders.
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Effects of Visitor Policies on Care Aides
Visitor policies implemented during the COVID-19 pandemic were essential to
prevent the spread of the virus, but they also increased the workload and emotional strain on
care aides. Limiting visitors meant care aides had to take on additional responsibilities, such
as helping LTCF residents connect with their families through video calls and ensuring
visitors followed strict safety protocols during essential visits. This added work was
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especially challenging when dealing with very sick residents, as the emotional toll of
facilitating virtual goodbyes was huge. One participant described the challenges of restricting
visitors:
Restricting visitors was necessary but difficult. It added to our responsibilities as we
tried to keep residents connected with their families through virtual means. There was
one person who was very sick and I think she was on the palliative and we tried to
call their children and they couldn’t come, like to see her…Like there were only
essential visitors allowed at the time. Like I mentioned there was one resident, like so
they got the consent from the doctor, like if they wanted to go see their parents so that
was the thing, like they have to get the consent from the doctor and they should be all
vaccinated…
(P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
The strict visitor policies were difficult for both LTCF residents and their families. Care
aides had to manage visits and ensure compliance with safety rules, which added stress and
made their jobs even more demanding. Another care aide noted:
The visitor policies were strict, and that was tough for both the residents and their
families. It also added more work for us because we had to manage the visits and
ensure everyone followed the rules. There were times when family members would
show up unannounced and get frustrated with us for not letting them in. It was hard to
deal with their anger and sadness…The restrictions meant we had to take on more
roles, like being the emotional support for residents who couldn’t see their families. It
was a heavy burden.
(P2 female aged 40-49, more than 20 years of experience, medium-sized LTCF)
The isolation caused by these restrictions led to residents feeling lonely and sad,
further increasing the emotional burden on care aides. The emotional work of reassuring
residents and their families, combined with the physical demands of the job, created a
challenging work environment. One participant shared that the lack of family visits required
her to spend extra time with residents to provide emotional support, leading to burnout:
…during the first year of COVID, I was spending just a little bit more extra time and
just, you know, kind of make sure that they’re feeling okay and that they’re happy
and try to bring up their spirits and I always ended up almost kind of burning myself
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out by the end of the day cause I was just spending a little extra time and then I’d end
up having to rush through and get all my other chores done.
(Participant 08- female care aide, in her 30s, 1-5 years of experience, medium-sized LTCF)
Additionally, without family visitors, care aides had to take on extra tasks, like
providing technical support for virtual visits, which added to their already busy schedules.
They also had to spend more time with residents to provide emotional support, which, while
necessary, contributed to burnout. The constant need to lift the spirits of LTCF residents who
missed their families was emotionally exhausting. A participant noted:
As time has progressed, you know, then you realize that how much the families
actually do help and you appreciate the families more because of the fact that, you
know, when their family member is needing something that with their TV and they
need a bunch of stuff reprogrammed or things like that, well that’s not something that
I really have time to do…
(P6 female aged 40-49, 10-15 years of experience, large-sized LTCF)
Despite efforts to decrease these effects through window visits and phone calls, the
lack of direct contact with family members made LTCF residents feel even more isolated and
depressed. This added to the care aides' stress and emotional load, as they had to spend extra
time providing emotional support to residents, leading to burnout. The need to maintain
LTCF residents' spirits, combined with their regular duties, was exhausting and contributed
to overall stress and fatigue among care aides.
It was really sad because the visitation stopped and it kind of made you question
whether the things that we were doing was actually better for people because it
seemed to cause a lot of cognitive decline in some people and they just became, their
disease process seemed to kind of progress as a result of maybe just not seeing family
and not having that interaction…People were able to see their family through the
window. You kind of set the resident up near the window and then you’d open it and
their family could be on the other side. And they’re supposed to maintain social
distancing but for some people this didn’t happen…Then they took the window visits
away and then people couldn’t have visitors anymore so then you’re sending them,
you know, sometimes I think like up by the window and we’d have people on the
phones talking to the people that were outside.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)
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Effects on Work Environment and Team Dynamics
The policies implemented during the COVID-19 pandemic impacted on the work
environment and team dynamics in LTCFs. These policies, though necessary, introduced
stress, altered communication methods, and affected team cohesion. The constant policy
changes required staff to continuously adapt to new guidelines, creating a challenging work
environment. Residents struggled with isolation and lack of social interaction, and care aides
had to maintain both safety and emotional support for residents while dealing with frequent
updates and new procedures. This added to the stress and made it difficult to establish a
stable work routine. A participant mentioned: "The constant policy changes were stressful.
We had to keep up with new guidelines and ensure everyone was following them. It was hard
to see residents isolated from their families and struggling with the lack of social
interaction." (P1 female aged 20-29, 1-5 years of experience, small-sized LTCF)
Despite the increased workload and stress, there was a strong sense of team support
among care aides. They focused on providing emotional support to colleagues, knowing that
everyone was facing the same challenges. This support system helped maintain a sense of
teamwork even during difficult times. Some participants observed that team dynamics
improved after the departure of staff who were opposed to vaccination. The removal of this
source of conflict and negativity led to higher staff morale, as remaining team members felt
more cohesive and supportive of each other.
It’s kind of weird but the dynamic has almost gotten better even though we’re more
worked, but the anti-vax group that like, you know, left or got let go or whatever,
they were getting to the point of bullying other care aides so it was almost like staff
morale went up because there weren’t these people talking in our ears and like oh
like, you know, so you went and did this, you went and got the jab, pulling out these
numbers of you’re going to die in two years or all this other stuff and you’re like
you’re going to be infertile, blah, blah.
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(Participant 08- female care aide, in her 30s, 1-5 years of experience, medium-sized LTCF)
Another participant emphasized:
It really felt like you were in a team then and you were also trying to support all the
other staff members that you work with as well… Just focusing I guess on the things I
do have power of. Ya, like I said, going in there and trying to be a source of support
to people knowing they don’t have that anymore.
(P7 male aged 30-39, 1-5 years of experience, medium-sized LTCF)

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Chapter 5: Discussion
The COVID-19 pandemic profoundly impacted the work environment and job
satisfaction of care aides in LTCFs. In this study, care aides shared many major challenges,
including increased workload, staff shortages, and the need to adapt to constantly changing
protocols and new, often untrained, staff members. These issues not only heightened stress
and burnout among care aides but also affected the quality of care provided to LTCF
residents. By analyzing these findings, this chapter highlights the critical need for improved
staffing strategies, comprehensive training programs, and strong support systems to enhance
the well-being of care aides and ensure the delivery of high-quality care in LTCFs.
Impact of Care Aide's Background and the Facility Characteristics on Job Satisfaction
The size and design of the facility impacted job satisfaction among care aides, with
larger, modern facilities that provide a homey, non-institutional atmosphere being perceived
to be more pleasant and conducive to a supportive work environment. This finding highlights
the importance of the physical environment in LTCF, as a well-designed space can greatly
reduce stress and create a more inviting and comfortable atmosphere for both staff and
residents. This finding reflects the findings of Choi et al. (2021), who conducted a
descriptive, correlational study involving 235 care staff from 13 LTCFs in Korea. The study
aimed to examine the relationship between person-centered care environments and staff
outcomes, including job satisfaction and turnover intention. They found that a supportive and
well-designed physical environment that promotes care setting is associated with higher job
satisfaction and lower turnover intention among staff.
Similarly, Lee et al. (2021) conducted an exploratory, descriptive qualitative study based on
focus groups with 24 staff members (nurses and care aides) from four LTCFs (two in Canada
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and two in Sweden). The study explored staff perspectives on the physical environment in
supporting their care practices for residents living with dementia. They identified that a welldesigned environment with a home-like ambiance, effective space arrangements, and
stimulating sensory stimuli positively impacts care practices and job satisfaction among staff.
Furthermore, the scoping review by Chaudhury and Xu (2022) examined the role of the built
environment on the quality of life for residents in LTCFs in the Asia-Pacific region. The
review synthesized empirical research and highlighted that the quality of built environmental
features, such as lighting, ventilation, and furniture configuration, greatly influences the
quality of life of older residents, particularly those with dementia. The review emphasized
that a well-designed built environment could contribute to better care quality and overall
well-being for residents, which indirectly supports higher job satisfaction among care staff.
A pleasant physical environment was found to foster better interactions between staff
and residents, contributing to a more positive and collaborative atmosphere. This indicates
that when care aides work in an environment that feels more like a home rather than a
hospital, they are more likely to feel appreciated and valued, which enhances their overall job
satisfaction and reduces turnover rates. The design and physical environment of LTCFs,
particularly larger and newer facilities, strongly affect job satisfaction. Care aides in these
facilities often appreciate the modern, home-like environment, which contributes to a more
pleasant and stable work experience. The inclusion of studies that directly address the impact
of the physical environment on job satisfaction strengthens the argument and provides a
comprehensive view of the factors influencing care aides' job satisfaction in LTCFs. A welldesigned physical environment can enhance the quality of interactions between LTCF staff
and residents, promoting a sense of community and belonging. This, in turn, can improve job
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satisfaction and reduce the likelihood of burnout. Providing a pleasant and supportive
physical environment can also attract and retain high-quality staff, contributing to a more
stable and effective workforce.
The employment status of care aides, whether full-time, part-time, or casual, played a
vital role in their job satisfaction and stability. Flexibility in employment arrangements is
often necessary to accommodate personal responsibilities, such as raising children, which
can influence their overall work experience. Many care aides transition between different
employment statuses based on their life circumstances and facility needs. This variability
highlights the need for flexible employment policies that support care aides' work-life
balance. This study’s findings indicate that the variability in employment status impacts
financial stability and job satisfaction among care aides. The lack of financial stability
associated with casual or part-time positions can negatively impact job satisfaction and
increase stress levels among care aides. These observations are supported by Titley et al.
(2023), who found that employment status variability greatly impacted financial stability and
job satisfaction among care aides. Moreover, the study by White et al. (2021) highlights how
organizational factors, including employment status, influence job satisfaction among care
aides during the COVID-19 pandemic. They emphasized the need for flexible work
arrangements and adequate support to ensure job satisfaction and stability for care aides.
White et al. (2021) also documented the experiences of front-line nursing home staff during
the COVID-19 pandemic, finding that the variability in employment status impacted
financial stability and job satisfaction. Additionally, McGilton et al. (2022) provided further
evidence, showing that care aides in Catalonia were more likely to be in full-time
employment compared to those in Ontario (81% vs. 61%). They identified part-time
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positions and underpayment as major stressors, leading many staff to work in multiple
nursing homes to earn a living income, contributing to job dissatisfaction and stress. (Bryant
et al., 2023) also discussed how care aides frequently transition between different
employment statuses based on various factors, such as changing personal responsibilities,
caregiving duties, and shifts in facility staffing requirements. These transitions can impact
their financial stability, access to benefits, job security, and overall job satisfaction. This
variability in employment status and the resulting instability underscore the need for flexible
employment policies that support care aides' work-life balance, ensuring they can maintain
job satisfaction and provide high-quality care without excessive stress or burnout.
Care aides faced challenges due to the demanding nature of their work, including the
physical and emotional toll of dealing with dying residents. During the COVID-19 pandemic,
these challenges were exacerbated by increased mortality rates among LTCF residents, social
distancing requirements, and severe staffing shortages. The need for social distancing meant
that care aides had to provide end-of-life care under extremely isolating conditions, often
without the usual familial support for the LTCF residents. Additionally, staffing shortages
meant that care aides had to take on increased workloads, further adding to their stress and
emotional burden. The constant shift work can lead to burnout, particularly for those with
long tenures. The resilience and dedication of care aides are critical in balancing these
demands while providing compassionate care. This finding is supported by research from
Chang et al. (2020), Franzosa et al. (2022), and Hoedl et al. (2021), who found that
supportive work environments are essential in reducing burnout and enhancing job
satisfaction among care aides. The emotional pressure of dealing with end-of-life care can be
overwhelming. In a qualitative study conducted by Franzosa et al. (2022), they interviewed
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care aides in six nursing homes in the New York metro area and discovered that care aides
experienced great emotional stress due to high mortality rates and the necessity of providing
care under socially distanced conditions, which often left LTCF residents isolated from their
families during their final moments. The study highlighted the critical importance of a
supportive work environment where care aides feel valued and supported, influenced their
job satisfaction. Franzosa et al. emphasized that providing emotional support and resources
for care aides can help them manage their job's challenges, thereby reducing the risk of
burnout and fostering a more positive work experience.
A supportive work environment is pivotal for the well-being and job satisfaction of
care aides. Stability in the workforce, facilitated by a supportive environment, can reduce
turnover rates and improve job satisfaction. This perspective is reinforced by studies such as
those by (Franzosa et al., 2022; Morgan et al., 2023; Muduzu et al., 2023; Titley et al., 2023),
which highlight the importance of supportive work environments in enhancing job
satisfaction and reducing stress among healthcare workers. Providing adequate resources,
training, and support can help care aides feel more confident and capable in their roles,
reducing stress and promoting job satisfaction. A supportive work environment can also
foster a sense of community and belonging, helping care aides feel valued and appreciated.
This, in turn, can improve the quality of care provided to residents and enhance overall job
satisfaction.
Impact of PPE Availability and Usage on the Work Life of Care Aides During the
COVID-19 Pandemic
The availability and use of PPE presented challenges for care aides during the
COVID-19 pandemic. Many care aides reported severe physical discomfort from wearing
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masks and other protective gear for extended periods, often leading to skin problems such as
rashes and acne. These findings are consistent with Titley et al. (2023), who noted that
prolonged use of PPE caused similar skin issues among healthcare workers. The physical toll
of wearing PPE was compounded by the stress and anxiety caused by PPE shortages,
especially at the beginning of the COVID-19 pandemic. Care aides had to ration masks,
gowns, and gloves, leading to uncertainty about whether they would have enough supplies to
safely complete their shifts. This mirrors the concerns highlighted by Hapsari et al. (2022),
Hoedl et al. (2021), Muduzu et al. (2023), Nestor et al. (2021), and White et al. (2021), who
documented the widespread anxiety and stress among healthcare workers due to insufficient
PPE supplies. PPE shortages also led to changes in safety protocols, sometimes increasing
the risk of infection. Limited supplies of gloves, for instance, meant that care aides had to use
the same gloves for multiple tasks, raising the risk of cross-contamination. White et al.
(2021) and Zhao et al. (2021) discussed similar challenges, noting how healthcare workers
struggled to maintain infection control with limited resources.
The constant need to manage limited PPE supplies added a layer of stress and
complexity to the care aides' already demanding roles. The discomfort caused by masks also
affected their ability to communicate with LTCF residents. Masks made it hard for LTCF
residents, especially those with dementia, to recognize staff, leading to confusion and
distress. This aligns with the findings of Hoedl et al. (2021), Muduzu et al. (2023), and Titley
et al. (2023), who reported similar communication difficulties due to mask-wearing in
healthcare settings. In some facilities, maintaining adequate PPE supplies ensured that care
aides could perform their duties without the additional stress of worrying about running out
of protective gear. A participant in this study noted that their facility was proactive in
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securing PPE, responding promptly to the need for gloves even during global shortages. This
experience is similar to the findings of a study by Doyle et al. (2023), where participants
viewed management as supportive in ensuring adequate PPE supplies and arranging ongoing
infection prevention control training to keep staff updated with ever-changing policies and
guidelines.
However, the inconsistency in PPE availability across different LTCFs meant that not
all care aides had the same experience. One participant highlighted the anxiety and stress
caused by PPE shortages, noting that rationing of masks, gowns, and gloves added an extra
layer of stress, especially on weekends. This sentiment was echoed in a study by Muduzu et
al. (2023), which indicated that there was a shortage of PPE at the beginning of the COVID19 pandemic, although the situation improved with more lockdowns. They emphasized that
adequate PPE supplies, such as gowns, gloves, masks, goggles, and hand sanitizer, along
with adequate training and specific practices to prevent contagion, were necessary.
This disparity highlights the uneven impact of the COVID-19 pandemic on care
aides' work environments and underscores the critical need for consistent and reliable PPE
supplies. This finding is reinforced by (Navarro Prados et al., 2022; Nestor et al., 2021;
White et al., 2021), who emphasized the importance of adequate PPE to reduce stress and
burnout among healthcare workers.
Reflection on Increased Workload for Care Aides During the COVID-19 Pandemic
The workload for care aides in LTCFs considerably increased during the COVID-19
pandemic, which had a harmful impact on their physical and mental well-being. With
additional responsibilities, irregular hours, and the constant need for sanitization and PPE
changes, the work environment became increasingly demanding. Care aides frequently
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reported working overtime due to lots of sick calls from colleagues who feared infection.
This need to cover extra shifts was particularly exhausting, especially during night shifts.
The irregular hours added to the stress, making it difficult for care aides to get adequate rest
and manage their increased workload. The constant sanitizing and full PPE usage further
complicated their duties, leaving them feeling perpetually behind and overwhelmed.
Additionally, some care aides had to handle extensive responsibilities alone, including tasks
like serving dinner, feeding, toileting, and preparing residents for bed. This overwhelming
workload led to job dissatisfaction, as no care aides reported any reduction in workload or
positive changes in their work environment during the COVID-19 pandemic. These
experiences are mirrored in existing literature. For instance, care aides faced increased
workloads and stress due to staff shortages and additional responsibilities, leading to long
hours and the physical and mental strain of constant sanitization and PPE usage, which
exacerbated feelings of burnout and exhaustion (Song et al., 2024). Similarly, the difficulties
care aides experienced with increased workloads, especially in terms of meeting the needs of
residents and managing rapid changes in pandemic guidelines, led to substantial stress and
frustration as they tried to balance their duties with the new safety protocols (Reynolds et al.,
2022). The challenges of working consecutive night shifts were also emphasized, with
frequent short-staffing due to colleagues' fears of getting sick placing additional burdens on
those present (Hoedl et al., 2021). Additionally, the ongoing psychological toll was
significant, as care aides faced constant stress from policy changes and frequent absences of
colleagues, leading to a persistent feeling of never being able to catch a break (Titley et al.,
2023).

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The increased workload and additional responsibilities experienced by care aides
during the COVID-19 pandemic align with findings in the existing literature. Studies noted
that healthcare workers, including care aides, faced heightened workloads due to staff
shortages and increased demands on their time and energy (Hoedl et al., 2021; Reynolds et
al., 2022; Song et al., 2024). Additionally, the increased physical and mental strain on
healthcare workers, exacerbated by the need for constant sanitization and PPE changes, was
highlighted by some studies (Blanco-Donoso et al., 2021; Hoedl et al., 2021; Muduzu et al.,
2023; Nestor et al., 2021). These findings are consistent with the experiences of care aides
who reported feeling overwhelmed and exhausted by their expanded duties. Moreover, the
irregular hours and the need to work overtime frequently due to sick calls from colleagues
further compounded the stress experienced by care aides. Irregular work hours and the
inability to get adequate rest impacted the mental well-being of healthcare workers, leading
to increased stress and burnout (Hoedl et al., 2021; Morgan et al., 2023; Titley et al., 2023;
Zhao et al., 2021). This mirrors the experiences of care aides who struggled to manage their
increased workload while also coping with irregular hours and insufficient rest. Additionally,
the lack of reported decreases in workload or positive changes in the work environment
during the COVID-19 pandemic reflects the broader challenges highlighted in the literature.
The COVID-19 pandemic exacerbated existing issues in healthcare settings, with little relief
or improvement in working conditions for staff (Franzosa et al., 2022; Hoedl et al., 2021;
Muduzu et al., 2023; Nestor et al., 2021; White et al., 2021). The continuous pressure and
lack of support led to a decline in job satisfaction and an increase in job dissatisfaction
among care aides. The compounded stress and burnout from increased workload and

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inadequate support affected healthcare workers' mental health (Blanco-Donoso et al., 2021;
Navarro Prados et al., 2022; White et al., 2021).
Impact of Short Staffing and New Staff Issues During the COVID-19 Pandemic
The findings show that the lack of care aides and arrival of new, often untrained
workers during the COVID-19 pandemic made things very hard for care aides in LTCFs.
They had to constantly adjust to new team members and deal with not having enough staff,
which made it tough to provide good care. Many care aides said they were very short-staffed
mostly because their colleagues often called in sick or didn't show up due to fear of infection
(Hoedl et al., 2021; Titley et al., 2023; White et al., 2021). This added stress and frustration
as care aides had to cover extra shifts and handle their own duties. Training new staff while
doing their own work made things even harder for experienced care aides, making them feel
overwhelmed and unable to give the quality care they wanted (Franzosa et al., 2022; Titley et
al., 2023; White et al., 2021). The different skill levels and commitment of casual staff made
planning and doing the work even more difficult (Franzosa et al., 2022; Muduzu et al., 2023,
2023; Titley et al., 2023; White et al., 2021). In some cases, care aides had to work alone for
long parts of their shifts because of staff shortages, which got worse with COVID-19 clusters
in different facility areas (Titley et al., 2023; White et al., 2021).
These findings echo other studies that not enough staff leads to burnout and lower job
satisfaction among care aides (Blanco‐Donoso et al., 2022; Bryant et al., 2023; Morgan et al.,
2023; Navarro Prados et al., 2022). Proper training and support for new staff are essential so
they can help the team and reduce the burden on experienced care aides (Doyle et al., 2023;
Franzosa et al., 2022; Hoedl et al., 2021; Muduzu et al., 2023; Titley et al., 2023). Research
also shows that staff shortages and high turnover rates lead to a lack of coherence in care,
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which affects residents' well-being (Franzosa et al., 2022; Navarro Prados et al., 2022).
Ensuring enough staff and good training programs can greatly reduce stress and workload for
care aides, improve job satisfaction, and reduce turnover rates, which is important for
keeping a stable workforce in LTCFs (Bryant et al., 2023; Franzosa et al., 2022; Navarro
Prados et al., 2022; White et al., 2021). The quality of care given to residents is closely
linked to the well-being and job satisfaction of care aides, so it's important to focus on
staffing and training to improve the overall work environment (Bryant et al., 2023; Chang et
al., 2020; Franzosa et al., 2022; Hoedl et al., 2021; Navarro Prados et al., 2022). By
addressing these issues, healthcare administrators can create a more supportive and stable
work environment for care aides, improving job satisfaction and the quality of care provided
to LTCF residents.
Management, Financial, and Psychological Support During the COVID-19 Pandemic
The COVID-19 pandemic had a profound emotional and psychological impact on
care aides in LTCFs, with the support provided by management playing a critical role in
determining their well-being. During the COVID-19 pandemic, care aides' experiences
varied widely; some felt supported by proactive and compassionate leadership, while others
felt abandoned and stressed due to inadequate management involvement. These differences
in support influenced their morale, mental health, and ability to cope with the increased
demands of their roles. Effective leadership, characterized by flexible scheduling, mental
health resources, and clear communication, was vital in helping care aides manage their
stress and feel valued despite the challenging circumstances (Franzosa et al., 2022; Muduzu
et al., 2023; Navarro Prados et al., 2022). Conversely, inadequate management involvement,
lack of regular check-ins, and unclear communication about changing policies led to
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confusion and frustration, adversely impacting their emotional well-being (Bryant et al.,
2023; Doyle et al., 2023).
Financial support, such as hazard pay or bonuses, also played a vital role in boosting
morale and providing a sense of appreciation for the additional risks and workload
undertaken during the COVID-19 pandemic. This finding is supported by Chang et al. (2020)
and Franzosa et al. (2022), who noted that financial motivations and recognition from
management were important motivators, enhancing care aides' resilience and ability to
provide high-quality care. The absence of sufficient psychological support and inadequate
financial compensation further exacerbated stress and reduced job satisfaction, underscoring
the need for comprehensive support systems in LTCFs (Blanco‐Donoso et al., 2022; EfirdGreen et al., 2023; Franzosa et al., 2022; Hapsari et al., 2022; Mangialavori et al., 2022;
Styra et al., 2022; Voth et al., 2022; White et al., 2021).
These findings align with the literature, highlighting the critical role of management
in maintaining care aides' well-being during crises. Studies have shown that effective
organizational support, including clear communication and mental health resources, greatly
impacts job satisfaction and reduces stress (Bryant et al., 2023; Doyle et al., 2023; Hapsari et
al., 2022; Nestor et al., 2021). The presence of strong leadership and access to mental health
resources were required in helping care aides cope with the heightened anxiety and
emotional strain caused by the COVID-19 pandemic (Bryant et al., 2023; Chang et al., 2020;
Franzosa et al., 2022; Mangialavori et al., 2022; Voth et al., 2022). By implementing
effective support strategies, healthcare facilities can better support their staff, fostering a
resilient workforce capable of delivering high-quality care even in challenging times (Bryant
et al., 2023; Chang et al., 2020; Doyle et al., 2023; Nestor et al., 2021; Voth et al., 2022). The
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importance of strong leadership, clear communication, and adequate financial and
psychological support in maintaining care aides' resilience and job satisfaction cannot be
overstated. These findings underscore the need for healthcare administrators to prioritize the
mental health and well-being of care aides, which in turn improves the quality of care
provided to residents in LTCFs. By addressing the challenges faced during the COVID-19
pandemic and implementing comprehensive support systems, healthcare facilities can create
a more inclusive and supportive work environment, ultimately enhancing care aides' job
satisfaction and professional growth (Blanco‐Donoso et al., 2022; Efird-Green et al., 2023;
Franzosa et al., 2022; Hapsari et al., 2022; Mangialavori et al., 2022).
Emotional and Psychological Toll of Resident Deaths on Care Aides
The emotional and psychological impact of resident deaths during the COVID-19
pandemic was profound for care aides in LTCFs. Most interviewees reported emotional
distress due to the deaths of residents, compounded by restrictions and isolation. These
restrictions prevented family members from visiting dying residents, leaving care aides to
manage the grief of both the LTCF residents and their families, adding to their emotional
burden. This experience is supported by Doyle et al. (2023), Titley et al. (2023), who found
that the inability of family members to be present during LTCF residents' final moments
placed additional emotional burdens on care aides, who often had to fill the role of
alternative family members. The ongoing stress and trauma from witnessing these deaths had
severe repercussions on their mental health, affecting their sleep and leading to nightmares,
persistent sadness, and anxiety (Navarro Prados et al., 2022; Titley et al., 2023; White et al.,
2021).

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Care aides often formed deep bonds with LTCF residents, viewing them as family
members, which made each death particularly hard to bear. Even in LTCFs without COVID19 related deaths, the loss of any LTCF resident was a deeply emotional experience, causing
some care aides to consider quitting due to the overwhelming grief and stress (Doyle et al.,
2023; Mangialavori et al., 2022; Titley et al., 2023). The mental health impact was so severe
that some care aides needed to resume medications like anti-depressants to cope with the
ongoing stress. The compounded effect of witnessing multiple deaths, coupled with isolation
from their own families and support networks, left many care aides feeling overwhelmed and
unsupported (Doyle et al., 2023; Hoedl et al., 2021; Titley et al., 2023). Research has shown
that the emotional burden of witnessing LTCF resident deaths, combined with the inability to
provide family support, exacerbates stress and grief among healthcare workers (Altintas et
al., 2022; Mangialavori et al., 2022; Muduzu et al., 2023; Nestor et al., 2021).
Perceived Value and Recognition of Care Aides' Work During the COVID-19
Pandemic
The perceived value and recognition of care aides' work during the COVID-19
pandemic varied greatly. While some LTCF care aides felt motivated and appreciated, others
experienced underappreciation and discipline, impacting their morale and job satisfaction.
Some LTCF care aides found a heightened sense of motivation and fulfillment during the
COVID-19 pandemic, feeling satisfaction in knowing their role was crucial in keeping LTCF
residents safe and healthy. This aligns with literature indicating that feeling appreciated and
valued considerably impacts job satisfaction and motivation (Rostami et al., 2021; Titley et
al., 2023). Witnessing the LTCF residents' happiness, especially when they were able to see
their children again, reinforced the value of their efforts and made the challenging times feel
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rewarding. This intrinsic reward, as highlighted by care aides, is supported by studies
showing that witnessing the positive impact of their work is indispensable for maintaining
morale during challenging times (Rostami et al., 2021; Titley et al., 2023). Simple gestures
of appreciation from LTCF residents, like smiles and hugs, provided a sense of value and
recognition, even when physical touch and close interactions were limited. This is supported
by the literature, which emphasizes the importance of intrinsic rewards for job satisfaction
and motivation (Rostami et al., 2021; Titley et al., 2023).
Conversely, other care aides felt underappreciated and disciplined for actions they
believed were unjust. Despite their efforts, the lack of recognition and the disciplinary
measures they faced were disheartening, highlighting the negative impact of feeling
undervalued on job satisfaction and morale. This reflects broader findings in the literature
that insufficient recognition and support for care aides in LTCFs can lead to job
dissatisfaction and high turnover rates (Franzosa et al., 2022; Rostami et al., 2021; Titley et
al., 2023; White et al., 2021).
Some care aides hoped that the COVID-19 pandemic would shed light on the critical
role of healthcare workers, especially those in LTC, believing that the increased visibility of
their work could help the public understand the realities of working in a nursing home, which
might lead to greater appreciation and recognition for their efforts. Addressing these issues is
critical for improving the work environment and ensuring the well-being of care aides.
Providing regular recognition, fair treatment, and support can enhance job satisfaction and
retention, ultimately leading to better care for residents (Bryant et al., 2023; Franzosa et al.,
2022; Rostami et al., 2021; White et al., 2021). By putting an emphasis on recognizing and

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appreciating the work of care aides, healthcare managers can create a more supportive and
inspiring workplace, encouraging resilience and dedication among staff.
Impact of Social Distancing due to COVID-19 on Care Aides' Team Communication
The COVID-19 pandemic fundamentally altered the way care aides in LTCFs
communicated and worked together, presenting both challenges and opportunities for
adaptation. Restrictions on in-person interactions necessitated a heavy reliance on phone
calls, video meetings, and written notes. This shift posed difficulties in maintaining effective
communication, ensuring continuous care, and preserving team cohesion. The new methods
sometimes led to misunderstandings and missed information, especially with the frequent
changes in policies. Despite these hurdles, care aides demonstrated resilience by keeping
each other informed and striving to uphold care standards. Over time, as they adjusted, team
dynamics improved, easing their job. These changes underscore how healthcare teams
adapted during the COVID-19 pandemic, with studies highlighting the importance of
communication and teamwork in crisis situations (Doyle et al., 2023; Franzosa et al., 2022;
White et al., 2021). Social distancing measures also greatly affected team dynamics, making
care aides feel isolated and reducing their sense of companionship. Not being able to have
regular social interactions, like shared meals and team celebrations, disrupted their usual
support systems and made the work environment feel more clinical and less supportive. This
loss of social interaction created a challenging work environment, further straining the
mental health and job satisfaction of care aides. The absence of informal interactions
highlighted the importance of these moments for maintaining team cohesion and morale.
Specific examples from the literature further illustrate these points. Care aides
reported feelings of isolation and loneliness due to the lack of social interaction from social
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distancing measures, significantly impacting their mental health and overall job satisfaction
(Hoedl et al., 2021). The absence of informal social interactions, such as shared meals and
casual conversations, disrupted the usual support systems within teams, making the work
environment feel more clinical and less supportive (Morgan et al., 2023). This lack of
camaraderie further strained care aides' mental health (Morgan et al., 2023). The critical role
of regular social interactions in maintaining team morale and cohesion was emphasized,
noting that social distancing measures hindered these interactions, leading to a more
challenging and less supportive work environment (Franzosa et al., 2022). The psychological
impact of reduced social interactions among care aides was highlighted, noting that the
inability to engage in informal social activities led to increased stress and reduced job
satisfaction (Rostami et al., 2021). Similarly, the loss of social interactions due to COVID-19
protocols affected team dynamics, leading to decreased morale and increased feelings of
isolation among care aides. White et al. (2021) also emphasized the importance of social
support for maintaining a positive work environment. The combined effects of social
distancing and changes in communication methods appeared to be needed for reviewing care
aides’ support strategies. Effective interventions, like regular team-building activities (even
virtual ones) and improved communication protocols, are necessary to reduce the negative
impacts on team dynamics. Providing ways for informal interactions and ensuring clear and
consistent communication can help maintain team cohesion and support the mental wellbeing of care aides.
Impact of COVID-19 Policies on Care Aides in Long-Term Care Facilities
The policies implemented in LTCFs during the COVID-19 pandemic impacted the
roles of care aides, introducing numerous challenges that altered their daily routines and
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ability to provide quality care. Vaccination mandates and visitor restrictions were necessary
to ensure the safety of residents and staff. However, these policies also resulted in increased
stress and workload for care aides. The constant changes in regulations required care aides to
adapt quickly, often leading to feelings of uncertainty and anxiety. These new policies not
only affected their professional responsibilities but also disrupted team dynamics, making it
harder to maintain a cohesive and supportive work environment.
Vaccination policies had a major impact on care aides, affecting staffing levels,
workload, and stress. These policies were necessary to prevent the spread of COVID-19 but
brought several challenges. Many care aides felt more stressed due to the mandatory
vaccination, and some quit their jobs because they didn't want to get vaccinated. This made
the staff shortages worse, increasing the workload and stress for those who stayed. Fear and
misinformation about the vaccine added to their anxiety. Some care aides felt that mandatory
vaccination took away their personal choice, causing disagreements and the termination of
colleagues with religious objections. This tension hurt team morale and cohesion. The
remaining staff had to work longer hours and take on more responsibilities. The constant
worry about catching COVID-19 added to their stress. Despite these issues, many care aides
chose to get vaccinated to keep their jobs, showing their commitment to their profession and
the residents' well-being. It was noted that the vaccination policy led to staffing shortages as
some care aides chose not to get vaccinated, which increased the workload for the remaining
staff and added to their stress levels. It was also mentioned by the participants that the
vaccination policy was a point of stress for many, with some staff leaving due to reluctance
to get vaccinated. Although the process of getting the vaccine was relatively easy, there was
a lot of misinformation and fear surrounding it, contributing to anxiety among the staff.
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Despite these issues, many care aides chose to get vaccinated to keep their jobs, weighing the
risks of COVID-19 against the uncertainties of the vaccine. Care aides’ decision to get
vaccinated was driven by a strong commitment to their profession and the well-being of the
LTCF residents they cared for.
Although the literature generally supports vaccination to prevent disease spread,
specific impacts on care aides during the COVID-19 pandemic were not documented,
highlighting the new perspective of this study. Studies like those by Titley et al. (2023) and
White et al. (2021) support the general efficacy of vaccination in preventing disease spread,
but the detailed impacts on care aides, such as increased workload and stress due to
vaccination policies, were not extensively covered. For example, Hoedl et al. (2021)
discussed the broader implications of vaccination policies in healthcare settings, noting that
mandatory vaccination can lead to stress and anxiety among staff, especially when coupled
with misinformation and fear. Similarly, Morgan et al. (2023) highlighted that mandatory
vaccination policies, while essential for public health, can lead to staffing shortages as some
employees may leave their jobs rather than comply with the mandates. This creates
additional stress and workload for the remaining staff, similar to the experiences of the care
aides in this thesis study. Additionally, Muduzu et al. (2023) emphasized the importance of
clear communication and support from management during the implementation of
vaccination policies to mitigate fear and misinformation among healthcare workers. This
aligns with the findings of this study, where care aides expressed anxiety and stress due to
the lack of clear information and the spread of misinformation about the vaccines.
Visitor policies during the COVID-19 pandemic also impacted care aides. These
policies were essential to stop the virus but added to the workload and emotional strain on
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care aides. Limiting visitors meant care aides had to help LTCF residents connect with their
families through video calls and make sure visitors followed strict safety rules during
essential visits. This added work was tough, especially with very sick residents (Hoedl et al.,
2021). The strict visitor policies were hard for both residents and their families. Care aides
had to manage visits and ensure compliance with safety rules, adding stress to their jobs
(Morgan et al., 2023). Family members often became frustrated and emotional due to the
restrictions, and care aides had to handle these interactions while staying professional and
compassionate. The isolation caused by these restrictions made residents feel lonely and sad,
further increasing the emotional burden on care aides (Muduzu et al., 2023). Despite efforts
to ease these effects through window visits and phone calls, the lack of direct contact made
residents feel even more isolated and depressed. This added to the care aides' stress as they
had to provide extra emotional support to residents, leading to burnout. The literature shows
that visitor policies impacted the emotional well-being of residents and increased care aides'
responsibilities and stress, highlighting the need for better support systems (White et al.,
2021). For example, Hoedl et al. (2021) noted that care aides faced challenges in helping
residents maintain contact with their families while ensuring compliance with visitor
restrictions, which added to their workload and emotional strain. The burden of managing
visitor policies fell on care aides, leading to increased stress as they navigated the emotional
reactions of family members and residents (Morgan et al., 2023). The psychological toll on
care aides who had to provide additional emotional support to isolated residents, which often
led to burnout was emphasized by (Muduzu et al., 2023). Similarly, White et al. (2021)
highlighted the compounded stress and responsibility placed on care aides due to strict visitor
policies, underscoring the need for better support systems to mitigate these effects.

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Strengths and Limitations of the Study
Strengths of the Study
The study has several strong points. First, it covers many aspects that affected care
aides during the COVID-19 pandemic, such as facility design, staffing levels,
communication, workload, emotional stress, and policies. This broad approach helps increase
understanding of the full range of challenges care aides faced, making the study
comprehensive. By looking at multiple factors, the study provides a comprehensive view of
the care aides' work environment and the COVID-19 pandemic's impact. This broad scope
ensures that various elements contributing to job satisfaction and stress are examined,
providing a thorough understanding of the multifaceted nature of care aides' experiences.
Second, the study uses real quotes and stories from care aides, which gives a clear
and detailed picture of their experiences. These first-hand reports add depth to the findings
and make the issues more relatable and understandable. The use of direct quotes ensures that
the voices of care aides are heard, providing a richer context to the data. By including these
narratives, the study captures the emotional and psychological variations that numbers alone
cannot convey, highlighting the human aspect of the challenges faced by care aides during
the COVID-19 pandemic.
Third, this study compares its findings with other research, showing that care aides’
experiences during the COVID-19 pandemic are part of a bigger picture. This comparison
with existing literature validates the study’s conclusions and puts the findings within a
broader research context. It shows that the issues faced by care aides are not isolated, but part
of a larger pattern observed in other studies. This connection with other research highlights
the reliability of the study's findings and demonstrates that the experiences of care aides
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during COVID-19 are consistent with global observations, which improves the credibility of
the results.
Finally, it brings new insights, especially about how COVID-19 policies affected care
aides, adding valuable information to what we already know. The study highlights areas that
may not have been fully explored before, such as the detailed impact of vaccination
mandates and visitor restrictions on care aides. These new perspectives enhance our
understanding and highlight the unique challenges faced during the COVID-19 pandemic. By
shedding light on these specific aspects, the study contributes to a more nuanced and
comprehensive understanding of the effects of pandemic policies on care aides, filling gaps
in the existing literature and providing a basis for further research.
Limitations of the Study
The study also has some limitations. First, the results are based on a specific group
and situation, so they might not apply to all LTCFs. The experiences of these care aides
might be different from those in other areas or countries, making it difficult to generalize the
findings universally. This geographic and background limitation reduces the applicability of
the results across diverse settings, as the specific challenges and conditions faced by care
aides in different regions or countries may vary considerably. For instance, LTCFs in urban
areas might face different issues compared to those in rural settings, such as differences in
access to resources, staff availability, and the prevalence of COVID-19. Moreover, cultural
differences can also play a role in how care is provided and received, which might influence
the experiences of care aides. Thus, while the findings provide valuable insights into the
challenges faced by care aides during the COVID-19 pandemic, they must be interpreted
with caution when applied to broader contexts.
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Lastly, the study talks about the emotional impact on care aides but doesn’t fully
explore the long-term mental health effects due to the study’s cross-sectional qualitative
design. This means that while findings from this study highlight immediate emotional stress
and burnout, they do not offer a comprehensive analysis of the long-term effects these
experiences may have on care aides. The study does not address whether the stress and
emotional toll experienced during the COVID-19 pandemic could lead to chronic mental
health issues like depression or anxiety. Without this long-term perspective, the full scope of
the COVID-19 pandemic's impact on care aides' mental health remains unclear.
Understanding these long-term effects will be helpful for developing comprehensive support
systems that address both immediate and lasting mental health needs.
Summary and Recommendations
This study explores the multifaceted impact of the COVID-19 pandemic on care aides
in LTCFs in northern British Columbia, examining factors such as facility design, staffing
levels, communication, workload, emotional stress, and policies. The use of real quotes and
stories from care aides adds depth and relatability to the findings, providing a comprehensive
understanding of their experiences during the COVID-19 pandemic. The study highlights
significant challenges faced by care aides, including increased workloads, emotional and
psychological stress, disrupted communication, and new safety policies, all of which
negatively affected their job satisfaction.
The findings emphasize the need for enhanced organizational support, including
increased staffing levels and comprehensive psychological and financial support. Improving
communication channels within teams and with management, especially during crises, is
crucial for better teamwork and support. The study also suggests the development of training
103

programs focused on crisis management, use of PPE, and stress coping mechanisms to better
prepare care aides for future challenges. Furthermore, the study underscores the importance
of continuing education opportunities to keep care aides updated on best practices and
protocols. Incorporating emotional resilience training will help care aides manage grief and
loss effectively, building their capacity to cope with emotional stress.
Based on the findings, several recommendations have been identified to address these
challenges. These recommendations are summarized in the table below, categorized by
practice, education, and research:
Table 5
Recommendations for Improving Care Aides' Work Conditions
Category
Practice

Recommendations
Increase staffing levels to reduce workload and prevent burnout.
Enhance support systems with comprehensive psychological and
financial support.
Improve communication channels within teams and with management,
especially during crises.

Education

Develop training programs focused on crisis management, use of PPE, and
stress coping mechanisms.
Offer continuing education opportunities to keep care aides updated on best
practices and protocols.
Incorporate emotional resilience training to help care aides manage grief
and loss effectively

Research

Conduct further studies on the long-term effects of the COVID-19
pandemic on care aides' job satisfaction and mental health.
Evaluate the effectiveness of various interventions aimed at improving job
satisfaction and reducing burnout.
Focus on the unique challenges faced by care aides in rural and remote
areas to develop tailored support strategies.

104

By implementing these recommendations, LTCFs can enhance the work environment
for care aides, thereby improving their job satisfaction and the quality of care provided to
residents. The study provides valuable insights into the unique challenges faced by care aides
during the COVID-19 pandemic and offers practical solutions to improve their working
conditions and overall well-being.
Conclusion
This study offers a comprehensive exploration of the experiences and challenges
faced by care aides in LTCFs during the COVID-19 pandemic. By conducting qualitative
interviews with eight care aides and reviewing relevant literature, the research delved into
various aspects that influenced their job satisfaction and work environment, such as facility
design, staffing levels, communication methods, emotional stress, and the impact of COVID19 policies like vaccination mandates and visitor restrictions. The data collection and
analysis provided a rich, first-hand thought of the care aides' experiences, highlighting the
increased workloads, constant need for modification, and the emotional and psychological
impact they experienced. The study's comparative analysis with existing literature validated
these findings, demonstrating that the challenges faced by care aides were part of a global
pattern. This comprehensive approach underscores the critical need for improved staffing
strategies, comprehensive training programs, consistent PPE supplies, and strong mental
health support to enhance care aides' well-being. While acknowledging some limitations,
such as geographic focus and the reflective nature of the interviews, the study emphasizes the
universal relevance of its findings. By highlighting the importance of strong management
support and effective support systems, this research contributes greatly to our understanding

105

of the COVID-19 pandemic's impact on care aides and provides actionable insights for
improving their work conditions and job satisfaction.

106

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Appendix A
Appendix A-1: Narrative Description of PubMed Search
Theme

Care aides

LTC

Job
satisfaction

AND

Title/Abstract Keywords

Number found

"Nursing Assistants"[MeSH Terms] OR "care
aides"[Title/Abstract] OR "personal support
workers"[Title/Abstract] OR "health care
assistant"[Title/Abstract] OR "health
workers"[Title/Abstract]
"Nursing Homes"[MeSH Terms] OR "Homes for the
Aged"[MeSH Terms] OR "Residential Facilities"[MeSH
Terms] OR "Assisted Living Facilities"[MeSH Terms] OR
"long term care"[Title/Abstract] OR "residential
homes"[Title/Abstract]

27,296

"Job Satisfaction"[MeSH Terms] OR "Caregiver
Burden"[MeSH Terms] OR "Quality of Life"[MeSH
Terms] OR "Compassion Fatigue"[MeSH Terms] OR
"alert fatigue, health personnel"[MeSH Terms] OR
"Fatigue"[MeSH Terms] OR "Mental Fatigue"[MeSH
Terms] OR "distress"[Title/Abstract] OR
"retention"[Title/Abstract] OR "burden"[Title/Abstract]
("Nursing Assistants"[MeSH Terms] OR ("care
aides"[Title/Abstract] OR "personal support
workers"[Title/Abstract] OR "health care
assistant"[Title/Abstract] OR "health
workers"[Title/Abstract])) AND ("Nursing Homes"[MeSH
Terms] OR "Homes for the Aged"[MeSH Terms] OR
"Residential Facilities"[MeSH Terms] OR "Assisted
Living Facilities"[MeSH Terms] OR ("long term
care"[Title/Abstract] OR "residential
homes"[Title/Abstract])) AND ("Job Satisfaction"[MeSH
Terms] OR "Caregiver Burden"[MeSH Terms] OR
"Quality of Life"[MeSH Terms] OR ("Compassion
Fatigue"[MeSH Terms] OR "alert fatigue, health
personnel"[MeSH Terms] OR "Fatigue"[MeSH Terms] OR
"Mental Fatigue"[MeSH Terms]) OR
("distress"[Title/Abstract] OR "retention"[Title/Abstract]
OR "burden"[Title/Abstract]))
Time limitation (2019-2023)

946,882

77,128

282

54

COVID-19
pandemic

118

Appendix A-2: Narrative Description of CINAHL Search
Theme

Care aides

LTC

Job
satisfaction
AND
COVID-19
pandemic

Title/Abstract Keywords

Number found

"Nursing assistant" OR "care aide" OR "personal support
workers" OR (MH "Health Personnel+") OR "health
worker" OR "health care assistant"

633,192

(MH "Nursing Homes+") OR "nursing home" OR "homes
for the aged" OR "residential home" OR (MH "Residential
Facilities+") OR "residential facilities" OR "assisted living
facilities" OR (MH "Long Term Care") OR "long term
care"

82,377

(MH "Job Satisfaction+") OR "job satisfaction" OR
"distress" OR "retention" OR "burden" OR (MH "Quality of
Life+") OR "quality of life" OR (MH "Fatigue+") OR
"fatigue" OR "exhaustion"
#1 AND #2 AND #3

529,647

With the time limitation of COVID-19 pandemic: 20192023

627

2,466

119

Appendix A-3: Narrative Description of Social Work Abstracts Search
Theme

Title/Abstract Keywords

Number found

Care aides

“Care aide” OR “nursing assistant” OR “personal support
workers” OR “health care assistant”

237

“Nursing homes” OR “homes for the aged” OR “residential
facilities” OR “assisted living facilities” OR “long term
care” OR “residential homes”

2,759

"Job satisfaction” OR “burden” OR “caregiver burden” OR
“quality of life” OR “compassion fatigue” OR “fatigue” OR
“distress” OR “retention”

3,825

(“Care aide” OR “nursing assistant” OR “personal support
workers” OR “health care assistant”) AND (“Nursing
homes” OR “homes for the aged” OR “residential facilities”
OR “assisted living facilities” OR “long term care” OR
“residential homes”) AND (“Job satisfaction” OR “burden”
OR “caregiver burden” OR “quality of life” OR
“compassion fatigue” OR “fatigue” OR “distress” OR
“retention”)
Time limitation of COVID-19 pandemic (2019-2023)

13

LTC

Job
satisfaction

AND

COVID-19
pandemic

1

120

Appendix A-4: Narrative Description of APA PsycINFO Search
Theme

Care aides

LTC

Job
satisfaction

AND
COVID-19
pandemic

Title/Abstract Keywords

Number found

“Care aide” OR DE "Paraprofessional Personnel" OR
“personal support worker OR PSW” OR “nursing assistant
OR nursing aides” OR “health care assistant OR health care
aides”

4,261

((DE "Long Term Care") OR (DE "Nursing Homes") OR
“homes for the aged” OR “DE "Residential Care
Institutions"

32,202

(((DE "Job Satisfaction" OR DE "Employee Well Being")
OR (DE "Stress" OR DE "Academic Stress" OR DE "Acute
Stress" OR DE "Caregiver Burden" OR DE "Chronic
Stress" OR DE "Environmental Stress" OR DE "Financial
Strain" OR DE "Minority Stress" OR DE "Occupational
Stress" OR DE "Perceived Stress" OR DE "Physiological
Stress" OR DE "Posttraumatic Stress" OR DE
"Psychological Stress" OR DE "Social Stress" OR DE
"Stress Reactions" OR DE "Trauma" OR DE "Distress")
OR DE "Retention” OR “quality of life” OR DE
"Compassion Fatigue" OR DE "Occupational Stress" OR
DE "Compassion Fatigue" OR DE "Stress Reactions" OR
DE "Burnout" OR DE "Compassion Fatigue" OR DE
"Burnout" OR DE "Occupational Stress" OR DE "Caregiver
Burden" OR DE "Fatigue"
#1 AND #2 AND #3

342,326

With the time limitation of COVID-19 pandemic: 20192023

38

213

121

Appendix B
Description of literature review databases search strategy
Appendix B-1: PubMed search strategy screenshot: July 2023

122

Appendix B-2: CINAHL Search Strategy Screenshot: July 2023

123

124

125

126

Appendix B-3: Social Work Abstracts Search Strategy Screenshot: July 2023

127

128

129

130

Appendix B-4: APA PsycINFO Search Strategy Screenshot: July 2023

131

132

133

134

135

136

Doyle, M., Louw, J. S., &
Corry, M. (2023).
Experiences of a nursing
team working in a residential
care facility for older adults
during the covid-19
pandemic. Journal of
Gerontological Nursing,
49(3), 40–46.
https://doi.org/10.3928/0098
9134-20230210-02
Bryant, N. S., Cimarolli, V.
R., Falzarano, F., & Stone, R.
(2023). Organizational
factors associated with
certified nursing assistants’
job satisfaction during covid19. Journal of Applied
Gerontology, 42(7), 1574–
1581.
https://doi.org/10.1177/0733
4648231155017
Morgan, J. C., Ahmad, W.,
Chen, Y.-Z., & Burgess, E.
O. (2023). The impact of
covid-19 on the personcentered care practices in
nursing homes. Journal of
Applied Gerontology: The
Official Journal of the
Southern Gerontological
Society, 42(7), 1582–1587.
https://doi.org/10.1177/0733
4648231154544
Titley, H. K., Young, S.,
Savage, A., Thorne, T.,
Spiers, J., & Estabrooks, C.
A. (2022). Cracks in the
foundation: the experience of
care aides in long‐term care
homes during the covid‐19
pandemic. Journal of the

Reference

Ireland

US

Georgia

Canada

2023

2023

2022

Country

2023

Year

"Care aides (n = 52)" P:3

Survey

semistructured
interviews

"Female 50
(94.3) from
n=52" P:3

"female= 317
(88.8%)
Male= 40
(11.2%)"
P:2&3

" Certified Nursing Assistant
(n = 116, 32%), Licensed
Practical Nurse (12.2%),
Housekeeping or Laundry
Aide (8.3%), and Dietary
Aide
(8.3%)" P:2&3

" 8 LTC homes in Alberta
and one in British
Columbia." P:1

"11 nursing homes" P:2

nursing homes, P:2,3

402 CNA at 59 nursing home
staff

Surveys

Certified
nursing
assistants
arepredominate
ly female
(90%), in
general not this
study, P:1

Work Setting of
Participants

"Publicly funded, 50-bed
LTCF" P:2

Gender

73% (n = 8)
were female
from n=11.

Population Studied

"RNs and health care
assistants n=11" P:2

“Descriptive
qualitative
design, data
were gathered
via one-to-one
semi
structured
interviews”
P:1

Study Design

Demographic Information from Literature Review

Appendix C

137

"Two themes emerged from our analysis: (1) Care
aides experienced mental and emotional distress
from enforcing resident isolation, grief related to
resident deaths, fear of contracting and spreading
COVID-19, increased workload combined with
staffing shortages, and rapidly changing policies.
(2) Care aides' resilience was supported by their

"Our research finds that the COVID-19 pandemic
has exacerbated many existing challenges to
delivering Person-Centered Care (PCC) and created
new ones. We also find, however, a few silver
linings in nursing home response to difficult
conditions. In terms of challenges, we find that
PCC in nursing homes was compromised by an
exacerbation of existing problems such as staff
shortage, burnout, and work overload, as
highlighted by existing research (Brady et al.,
2021; Husky et al., 2022;
Serrano et al., 2021)" P: 4

"The results indicate that CNAs who reported a
more optimal relationship with their supervisors,
felt appreciated for the job they do and worked in
NHs with lower COVID-19 resident infection rates
tended to report higher rates of job satisfaction. The
COVID-19 work-related stressors of increased
workload demands and understaffing were
associated with lower rates of job satisfaction.",P:1

"Visitation restrictions and staff shortages impacted
all aspects of work-life. Staff reported increased
stress and exhaustion with COVID-19 infection
resulting in long-term health issues." P:1

Key Findings

Franzosa, E., Mak, W., R
Burack, O., Hokenstad, A.,
Wiggins, F., Boockvar, K. S.,
& Reinhardt, J. P. (2022).
Perspectives of certified
nursing assistants and
administrators on staffing the
nursing home frontline
during the covid-19
pandemic. Health Services
Research, 57(4), 905–913.
https://doi.org/10.1111/14756773.13954
Mangialavori, S., Riva, F.,
Froldi, M., Carabelli, S.,
Caimi, B., Rossi, P., Delle
Fave, A., & Calicchio, G.
(2022). Psychological
distress and resilience among
italian healthcare workers of
geriatric services during the
covid-19 pandemic. Geriatric
Nursing, 46, 132–136.
https://doi.org/10.1016/j.geri
nurse.2022.05.012
Altintas, E., Boudoukha, A.H., Karaca, Y., Lizio, A.,
Luyat, M., Gallouj, K., & El
Haj, M. (2022). Fear of
covid-19, emotional
exhaustion, and care quality
experience in nursing home
staff during the covid-19

Muduzu, L., Wei, L., &
Cope, V. (2023). Exploring
nursing staff's experiences
and perspectives of covid-19
lockdown in a residential
aged care setting in australia.
Journal of Gerontological
Nursing, 49(3), 34–39.
https://doi.org/10.3928/0098
9134-20230210-01

American Geriatrics Society,
(20220909).
https://doi.org/10.1111/jgs.18
024

US

Italy

France

2022

2022

Australia

2022

2023

Most
participants
were women
(73.3%), p:2

"The
sample
included 107
females and 24
males" P:3

"53 were physicians (7.5%),
146 nurses (20.6%), 100
rehabilitation professionals
(14.1%, mostly
physiotherapists, speech, and
occupational
therapists), and 409
healthcare assistants
(57.8%)" P:1
"A sample of 129 native
French-speaking health
workers was
recruited from four nursing
homes in France. Those
health workers
eligible to participate in the
survey included physicians,

Crosssectional

Surveys

Female 53 from
n=56, p:3

6 administrators and 56
CNAs, P:1

Nursing staff, N=10, P:1,2

one male and
nine female
staff members,
P:2

Semistructured
interviews

exploratory
qualitative
study
with face-toface semistructured
interviews

"Four nursing homes in
France." P:2

“Geriatric and long-term care
services” P:1

six New York
metro area nursing homes.
P:1

“a residential aged care
facility" P:2

138

"The findings made by the present study focused on
the role of emotional coping responses to COVID
19. EE was associated positively with fear of
COVID-19 and negatively with care quality
experience. Furthermore, EE was found to mediate
the relationship between fear of COVID-19 and
care quality experience. We
discuss these findings as they relate to palliative

"Physicians reported significantly higher resilience
and distress levels than rehabilitation professionals
and healthcare assistants respectively. Women,
HWs aged above 45, physicians, and participants
reporting low resilience levels were at higher risk
for distress." p:1 "our results suggest that
interventions for supporting and promoting mental
well-being among healthcare workers of geriatric
services are necessary, especially for women and
for the professional categories of nurses and
physicians."p:4

CNAs and administrators identified chronic
staffing shortages thataffected resident care and
staff burnout as a primary concern moving forward.
CNAswho felt most supported and confident in
their continued ability to manage theirwork and the
pandemic described leadership efforts to support
workers' emotionalhealth and work–life balance,
teamwork across staff and management, and
accessibleand responsive leadership. However, not
all CNAs felt these strategies were in place, p:1

Five major themes were identified: Prolonged Use
and Shortage of Personal Protective Equipment;
“Blind Leading the Blind”; Communication and
Teamwork; Lack of Education; and Resident
Response. RACF staff described working under
stressful conditions during the initial COVID-19
pandemic lockdown; yet with experience, care staff
and the management team adapted to pandemic
requirements to meet the needs of residents in their
care. RACFs should be prepared for the impact of
pandemics on staff and ensure care resources and
support are available for the continuity of safe and
quality care of residents. p:1,3

strong relationships, faith and community, and
capacity to maintain positive attitudes." , p:1

2022

2022

Hapsari, A. P., Ho, J. W.,
Meaney, C., Avery, L.,
Hassen, N., Jetha, A., Lay,
A. M., Rotondi, M., Zuberi,
D., & Pinto, A. (2022). The
working conditions for
personal support workers in
the greater toronto area
during the covid-19
pandemic: a mixed-methods
study. Canadian Journal of
Public Health = Revue
Canadienne De Sante
Publique, 113(6), 817–833.

2022

Voth, J., Jaber, L.,
MacDougall, L., Ward, L.,
Cordeiro, J., & Miklas, E. P.
(2022). The presence of
psychological distress in
healthcare workers across
different care settings in
windsor, ontario, during the
covid-19 pandemic: a crosssectional study. Frontiers in
Psychology, 13.
https://doi.org/10.3389/fpsyg
.2022.960900

pandemic. Archives of
Gerontology and Geriatrics,
102.
https://doi.org/10.1016/j.arch
ger.2022.104745
Blanco-Donoso, L. M.,
Moreno-Jiménez, J.,
Gallego-Alberto, L., Amutio,
A., Moreno-Jiménez, B., &
Garrosa, E. (2022). Satisfied
as professionals, but also
exhausted and worried!!: the
role of job demands,
resources and emotional
experiences of spanish
nursing home workers during
the covid-19 pandemic.
Health & Social Care in the
Community, 30(1), 160.
https://doi.org/10.1111/hsc.1
3422

Canada

Canada

Spain

mixedmethods study

crosssectional
survey

"crosssectional
study" P:1

Personal support workers

"A total of 560 healthcare
professionals working in any
healthcare setting, 403 of
which (72%) completed the
full survey" P:3

Female= 528,
Male=57,
Other=3,
Missing=46

Female 74.2%,
Male 17.4%

"Home care in the
community, LTC, Other
(e.g., hospitals, shelters,
group homes, rehabilitation
centres)" P:6

"Hospital,community health
and social service, first
responder, primary care,
home, and LTC" P:1

nursing homes

139

"We found PSWs faced a range of challenges
related to COVID-19, including anxiety about
contracting COVID-19, reduced work hours, taking
leaves of absences, concerns about job security,
and losing childcare. While the COVID-19
pandemic highlighted the PSW workforce and their
importance to the healthcare system (especially in
the LTC system), preexisting poor work conditions
of insecure jobs with no paid sick days and benefits
exacerbated COVID-19–related challenges. Despite
these hardships, PSWs were able to rely on their
mental resilience and passion for their profession to
cope with challenges." P:1

" Common concerns included fear of transmitting
COVID-19 to family, safety on the job, and
balancing personal care with work demands. LTC
and homecare HCWs reported greater concern
about workload and staffing levels, whereas
community health workers were more anxious
about their financial security. Overall, 228 (74.2%)
HCWs who completed the K10 reported high
distress, with greater rates among hospital and LTC
HCWs. Distress was more likely in HCWs who
identified as female, younger than 55, perceived
lower respect among team, and experienced greater
worry about physical and mental health and
managing high workloads." P:1

"Nursing home workers in Spain experienced
high rates of satisfaction during the COVID-19
crisis despite the high job demands,
lack of job resources, fear of contagion and
exhaustion." P:1
"An important finding is that, according to the
quantitative analysis, lack of material and human
resources had no effect on professional satisfaction.
This paradox could be explained by the fact that the
dissatisfaction felt by workers regarding the lack of
material and human resources was directed more
toward the work organization and the political
management of the crisis." P:11

"The final sample consisted
of 183 professional staff (i.e.,
physicians, nurses, social
workers, psychologists,
occupational therapists,
physiotherapists) and 135
support staff (i.e., nurse
aides, geriatric assistants).
Five center managers also
participated." P:4
"269 women,
66 men" P:4

care issues in nursing homes and the manner in
which emotional
exhaustion ought to be addressed among nursing
home staff. " P:1

psychologists,
physiotherapists, dieticians,
psychometricians, nurses,
healthcare aides, and nursing
assistants." P:2

2021

Zhao, S., Yin, P., Xiao, L.
D., Wu, S., Li, M., Yang, X.,
Zhang, D., Liao, L., & Feng,
H. (2021). Nursing home
staff perceptions of
challenges and coping
strategies during covid-19
pandemic in china. Geriatric
Nursing, 42(4), 887–893.
https://doi.org/10.1016/j.geri
nurse.2021.04.024
China

Austria

Spain

2021

2021

Spain

2022

Hoedl, M., Thonhofer, N., &
Schoberer, D. (2022). Covid19 pandemic: burdens on and
consequences for nursing
home staff. Journal of
Advanced Nursing, 78(8),
2495–2506.
https://doi.org/10.1111/jan.1
5193

https://doi.org/10.17269/s419
97-022-00643-7
Navarro Prados, A. B.,
Jiménez García-Tizón, S., &
Meléndez, J. C. (2022).
Sense of coherence and
burnout in nursing home
workers during the covid-19
pandemic in spain. Health &
Social Care in the
Community, 30(1), 244–252.
https://doi.org/10.1111/hsc.1
3397
Blanco-Donoso, L. M.,
Moreno-Jiménez, J., Amutio,
A., Gallego-Alberto, L.,
Moreno-Jiménez, B., &
Garrosa, E. (2021). Stressors,
job resources, fear of
contagion, and secondary
traumatic stress among
nursing home workers in face
of the covid-19: the case of
spain. Journal of Applied
Gerontology, 40(3), 244–
256.
https://doi.org/10.1177/0733
464820964153

"Qualitative
study using
in-depth semistructured
interviews"
P:1

nursing home staff

Female P:3

Female % (n)
77·8 (14) from
n=18

"crosssectional
study" P:1

"Nursing home
staff (N = 18)
Nurses 45·4 (8)
Nursing aides 44·4 (8)
Care aides 11·1 (2)" P:4

"80.3% women,
19.7% men"
P:2

"Group 1: doctors and
nurses; Group 2: nursing
aides; Group 3: other
professionals)" P:6

"crosssectional
survey" P:3

“Qualitative
descriptive
interview
study” P:1

"89% were
women and
11% men" P:3

"The participants' positions at
work were 11.5% direction
and/or management, 35.6%
technical
staff, 39.1% direct care staff
and 13.8% other services"
P:3

Nursing home [5 public, 2
privates] P:3

,
“5 different nursing homes“
P:1

nursing homes

nursing homes

140

"The findings of the study showed that the main
stressors were associated with staff roles and
responsibilities worries about resident and staff
safety, and the heavy workloads." P:6

"Results show that the qualitative workload and
work organization were major concerns. Regarding
the qualitative workload, participants stated that
they were required to perform additional tasks to
care for residents, because the pandemic
interventions placed the residents under stress and
dealing with relatives presented significant
challenges. Nursing home staff reported that
psychological consequences such as uncertainty,
fear and stress represented major effects of the
COVID-19 situation.” P:1

"High levels of workload, social pressure from
work, contact with suffering, and fear of contagion
were found. In nursing homes where cases of
COVID-19 had been detected, workers experienced
higher levels of secondary traumatic stress. Social
pressure from work, high doses of exposure to
suffering, lack of personnel and personal protective
equipment, and minimal supervisor support were
significant in explaining traumatic stress.
Supervisor and coworker support moderated some
of these relationships." P:1

"This study contributes to justifying the need for
and relevance of implementing programs that can
promote and/or improve the biopsychosocial health
of nursing home workers and reduce and/or
eliminate burnout levels. There is evidence that
burnout experienced by nursing home workers not
only affects their well-being but also reduces their
abilities to provide valuable help for the older
adults and their families." P:6&7

Nestor, S., O’ Tuathaigh, C.,
& O’ Brien, T. (2021).
Assessing the impact of
covid-19 on healthcare staff
at a combined elderly care
and specialist palliative care
facility: a cross-sectional
study. Palliative Medicine,
35(8), 1492–1501.
https://doi.org/10.1177/0269
2163211028065
Chang. H. A. N. G.,
Chorong, G. I. L., Hyejin, K.
I. M., & Hanju, B. E. A.
(2020). Person-centered care,
job stress, and quality of life
among LTC nursing staff.
The Journal of Nursing
Research, 28(5), 5–5.
https://doi.org/10.1097/
jnr.0000000000000398

White, E. M., Wetle, T. F.,
Reddy, A., & Baier, R. R.
(2021). Front-line nursing
home staff experiences
during the covid-19
pandemic. Journal of the
American Medical Directors
Association, 22(1), 199–203.
https://doi.org/10.1016/j.jam
da.2020.11.022

Crosssectional

Crosssectional

South
Korea

2020

Survey

Ireland

US

2021

2021

N = 183, nursing staff

"Nursing: n = 103
Healthcare assistants: n = 47
Medical: n = 15
Administrative: n = 20
Allied healthcare
professionals: n = 17
Catering, household,
maintenance: n = 33
Other: n = 15" P:4

"The sample included 76
(50.0%) certified nursing
assistants, certified medical
assistants, or certified
medical technicians; 19
(12.5%) physicians; 15
(9.9%) advanced practice
clinicians;
14 (9.2%) registered nurses;
10 (6.6%) administrators;
and 9 (5.9%) licensed
practical nurses. Other
disciplines represented less
than 5%
of the sample." P:2

“Hospice (44 beds),
community and hospitals
and, Elderly Care Service
(long-term and respite care)”
P;1

“Three long-term care
hospitals” P:1,2

Female: n =
220; Male: n =
24; Other/not
specified: n = 6

Nearly all
(93.4%) of the
participants
were female
n=171

Nursing homes

141

"Significant factors found to be associated with
person centered care included the quality of life
(r=.411, p < .001) and job stress (r = −.305, p <
.001) of the participant. The regression model with
job stress and quality of life as predictor variables
accounted for 29.2% of the variance in personcentered care". p:1

"230 participants (92%) agreed that their
personalworkload had changed significantly in
response to COVID-19 and 182 (72.8%) agreed
that their responsibilities had increased.
196(78.4%) reported greater work-related stress.
Highest-rated sources of stress included fear of
contracting COVID-19 or transmitting it to
friends/family, interacting with isolated frail/dying
patients, changes to workplace protocols and
reduced social interaction withcolleagues.", P:1

"Nursing home staff described working under
complex and stressful circumstances during the
COVID-19 pandemic. These challenges have added
significant burden to an already strained and
vulnerable workforce and are likely to contribute to
increased burnout, turnover, and staff shortages in
the long term." P:1