Technology use in long-term care during the COVID-19 pandemic: A qualitative study of paid employees’ experiences in Western Canada

Abstract

Background

During the COVID-19 pandemic, governments across the world implemented processes and policies to limit the spread of COVID-19, especially in long-term care (LTC) homes. This led to changes in technology use for persons living in LTC homes, their families and friends, as well as the paid workforce dedicated to caring for them.

Objective

The study describes the role of technology and its impact on the experiences of LTC staff working in northern and rural areas in Western Canada during COVID-19.

Methods

A secondary analysis of semi-structured interviews with 52 LTC staff was conducted. Qualitative data was analysed thematically using Braun and Clarke's thematic analysis approach.

Results

Analysis of the study data revealed that new and innovative uses of technology emerged in the LTC setting during COVID-19, including technologies to support communication and collaboration with medical and health care professionals external to the LTC homes. Video-conferencing technology were rapidly implemented to facilitate virtual visits for LTC residents to connect to their families, further new streaming services were introduced to support recreational activities, including live music and spiritual services. LTC residents required significant support from staff to participate in virtual activities. Inadequate Internet infrastructure and scheduling difficulties in the context of severe staff shortages created challenges in technology adoption.

Conclusions

This research provides insight into how technology can support LTC teams in northern and rural communities, as well as supports needed for LTC residents and staff to integrate technology effectively. The study informs actionable insights for those working in rural LTC settings.

Background

As the Canadian population rapidly ages, more Canadians will require supportive care services in the community or in specialized facilities such as long-term care homes (LTCHs). The Canadian Institute of Health Information (CIHI) defines LTCHs (also called nursing homes, long-term care (LTC) facilities, and residential care homes) as facilities that, “provide a wide range of health and personal care services for Canadians with medical or physical needs who require access to 24-hour nursing care, personal care and other therapeutic and support services”. ¹ As of 2021, there are 2076 LTCHs in Canada, of which 46% are publicly owned, 23% are private not-for-profit and 29% are private for-profit. ¹ Several reports describe the long stressed and under-resourced state of Canada's LTC sector.^2–4 These reports highlighted serious problems within Canada's LTC sector that existed before COVID-19 which were exacerbated during the pandemic, including the increasing health complexity of the LTC resident population, aging infrastructure including numerous older buildings not built to meet LTC residents’ needs, ongoing LTC staffing shortages and service gaps.^2–4 There are a variety of technologies available that may be deployed in LTCHs for the purposes of communication, as well as the provision of care, supports and activities of daily living, such as communication and information technologies, assisted living technologies, wearables and remote monitoring technologies. ⁵ The prevalence of the use of technologies in Canadian LTCHs ranges greatly - many LTC buildings in Canada have outdated architectural designs with antiquated technological infrastructure which can inhibit access to basic Internet. ⁶ Technologies are used inconsistently to support core services, such as routine activities, programs and services for residents, as well as communication between residents and formal caregivers, family and friends across LTC settings. ⁵ Further technology adoption in LTC has been slower than other health sectors, such as acute care. ⁵

These issues are compounded by geography, especially in rural and remote in Canada where there is lack of affordable high-speed Internet access. While 87.4% households have access to Internet connections at broadband speeds (at least 50 Mbps download and 10 Mbps upload and access to unlimited data), only 45.6% Canadians living in rural and remote areas do. ⁷ In an April 2021 press release, the Canadian Internet Registration Authority (CIRA) reported a significant difference in the median download speeds in rural areas compared with cities at the start of COVID-19, and this divide has continued to widen further during the pandemic. ⁸ While median download speeds in rural areas have improved from 5.42 Mbps in 2020 to 9.74 Mbps in 2021, the median download speeds in cities improved significantly from 26.16 to 51.09 Mbps over the same period. ⁸ Compared to people living urban areas, people living in rural and remote areas without fast, reliable and affordable high-speed Internet access or mobile cellular services do not have the same access to services and opportunities that are increasingly being offered online, including government and medical services, digital education and digital work. ⁹

Many LTC residents have complex medical conditions and are at higher risk of developing more severe forms of the disease. ³ Living in congregate environments LTC residents experience close contact with other LTC residents as well as LTC staff. ¹⁰ In response to COVID-19, health and government authorities implemented new policies regarding infection prevention and control, use of personal protective equipment, staffing and other on-site work policies, visitation, outbreak management. ¹¹ LTC homes in Canada had strict visitor restriction policies such that visitors were all denied entry except for end-of-life or if visitors were deemed essential—these visitors allowed entry under exceptional situations.^6,12 Technology was valueable to facilitate social connections between those living and working in LTC with those outside, while adhering to social distancing requirements. ¹³ Social connection is critical for LTC residents—social connection is associated not just with improvements in both physical and mental health outcomes, residents experiencing cognitive impairment in particular greatly benefit from social interaction to thrive. ¹⁴ Social connectedness is part of social connection and may be defined as the sense of belonging and being cared for that arises from positive social relationships, countering feelings of loneliness. ¹⁴ In the context where technology became critical in the facilitation of social connections in LTC, here was a need to better understand how technology was used in LTC during the COVID-19 pandemic, as well as the perspectives of people who used technology within the LTC setting. The purpose of this research is to describe the role of technology and its impact on the experiences of LTC staff working in northern communities in Western Canada during the COVID-19 pandemic.

Methods

Study design, setting, and data collection

This was secondary analysis of a qualitative data set from the data corpus of qualitative component of the study titled “Assessing the Health and Human Resource Impact of COVID-19 in the LTC Setting in Northern BC” (Ethics Approval Number H21-01883). The primary study was a mixed methods study undertaken for the initial purpose of describing the lived experiences of LTC staff of different disciplines working in LTC in northern and rural communities in a Western Canadian province during the COVID-19 pandemic. LTC residents were not included in the current study due to restrictions related to social distancing requirements in LTC at the time. Healthcare services in this region are governed, planned, and delivered by one single regional health authority that provides healthcare services to a highly geographically dispersed population of 300,000 persons across 600,000 km². For the qualitative component of the primary study, LTC staff from all disciplines, including management and front-line direct care providers, that worked in northern BC were invited to participate in one-hour semi-structured interviews to share their work experiences in LTC during the COVID-19 pandemic. Prospective participants were informed of the study by leadership from the health authority who disseminated the information letter of the study via email to staff working in LTCHs within the health authority's catchment area. Individuals to participate were invited to reach out to the research team directly. Additionally, at the end of each interview participants were invited to share information about this study to prospective participants who may be interested to share their stories with the research team. Maximum variation sampling techniques were applied to ensure diversity of participants and that as many LTCHs were represented as possible. Interviews were held between October 2021 and February 2022 over zoom or by phone as was most convenient for the participants and to adhere to COVID-19 social distancing requirements in place at the time of data collection. Interviews were recorded and transcribed verbatim. Participants provided written informed consent for the primary study that included consent for secondary analysis. A copy of the interview script is available as a supplementary file.

Data analysis

The analysis was conducted by the first author HJC, SF, and DB. There were 53 original interviews conducted with participants of the primary study, of which it was determined that data saturation was met as no new major themes emerged. ¹⁵ Transcripts where participants who discussed technology use were included in the secondary analysis. The transcripts were uploaded to NVivo 12 Pro, ¹⁶ and the first-round of coding focused on assessing, identifying and labeling interview transcripts where participants commented on the use of any kind of technology, electronic technology or digital devices. The data were organized by themes using Braun and Clarke's thematic analysis approach. ¹⁷

Braun and Clarke's six-step thematic analysis describes “a method for identifying, analyzing and reporting patterns (themes) within data”.¹⁷ It is a flexible qualitative analytical method that is “independent of theory and epistemology, and can be applied across (emphasis by author) a range of theoretical and epistemological approaches”.¹⁷ Braun and Clarke's six-step thematic analysis process was conducted in an iterative process that began by first getting familiarized with the whole transcripts of participants that described the technology use in LTC homes and creating a list of interesting ideas and thoughts that are generated from the data.¹⁷ Step 2 involved generating initial codes from the data, and working systematically through the whole data set on NVIVO 12, and after all the technology-related data had been coded and collated, the codes were analyzed and sorted into different themes and subthemes—Step 3—and an initial thematic map was created.¹⁷ Step 4 involved reviewing and refining the themes and developing the thematic map further such that the themes formed cohesive patterns.¹⁷ Step 5 involved clarifying the specifics of the themes and coming up with clear names and definitions for them.¹⁷ Finally, when the themes were fully developed, the writer attempted to write a “concise, coherent, logical non-repetitive and interesting account of the story”.¹⁷ Thematic analysis assumes a simple relationship “between meaning and experience and language” as such the motivations, experience, and meaning were interpreted directly.¹⁷ Using the text directly in the transcripts, the themes were identified at a semantic level only such that the data was organized at an explicit level, summarized, and interpreted insofar as that the significance of these themes was theorized to their broader implications. ¹⁷ In accordance to the thematic analysis approach, the definitions used for all concepts, for example terms relating to “technology,” “presence” and “social connection” and others, were self-defined by the participants.

Rigour and trustworthiness

To assess rigour, the criteria for “trustworthiness” by Guba and Lincoln including the dimensions of credibility, dependability, confirmability, transferability, and authenticity were used (Table 1). ¹⁸

Table 1.

Criteria of Lincoln and Guba ¹⁹ trustworthiness framework and corresponding strategies used in this study.

Criterion	Definition	Strategies Used to Promote Trustworthiness for This Study
Credibility	“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” (787)	All steps taken for this study was documented and reported in the final research report. Transcripts were reread twice with audio recordings to ensure accuracy of the transcripts.
Dependability	“Stability (reliability) of data over time and conditions” (787)	While it was expected that the perspectives of participants may have shifted during different time frames of the pandemic, the close time frame between the conducting of the primary study and the secondary study should limit the effects of change in time and context of COVID-19.
Confirmability	“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” (788)	Immersion into data and use of researchers’ notes of the interviews themselves to ensure attention is paid to the context such that the codes truly emerged from the data. Regular check ins with research team members.
Transferability	“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” (788)	Descriptive data of the participants was reported, including sex, gender, job positions.
Authenticity	“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” (788)	Quotes from participants were used during the reports to illustrate the themes identified. The themes identified were triangulated with findings in the literature regarding technology in LTC.

Note. Definitions of the criteria by Lincoln and Guba ¹⁸ , taken from “Nursing Research: Generating and Assessing Evidence for Nursing Practice” by Polit and Beck ²⁰ .

Results

Of the 53 LTC staff interviewed in the primary study, only one did not discuss technology use and that transcript was excluded from analysis. Therefore, responses from 52 LTC staff from 15 LTC homes six LTC homes had less than 50 beds, five LTC homes had between 50 and 99 beds, and four LTC homes had more than 100 beds—were included in the analysis. All participants identified as being cis-gendered—the majority of identified as female (n = 43), and nine were male. Participant ages ranged from 24 and 69 years, with an average age of 45.5 years. The number of years that participants worked in LTC ranged between 1 and 40 years, with an average of 10.1 years.

Participants reported a wide range of work roles in the facility (see Figure 1). To further anonymize the job roles of the study participants during the presentation of results, roles were condensed into four categories: Leadership/Management (individuals in management roles, day-to-day tasks included meetings with Higher Level Management that discussed policies and processes); Nursing Staff (individuals who provided front-line nursing care such as registered nurses, licensed practical nurses, registered healthcare aides); Allied Healthcare Staff (individuals in allied healthcare roles such as registered dietitians, social workers, and recreation therapists); Administrative and Support Services Staff (individuals providing administrative and other support services roles such as clerks and food service staff).

Figure 1.

Work roles of participants in the study that discussed technology use in LTC in Northern British Columbia in 2021 (n = 52).

The experiences of participants with technology use within LTC differed significantly, with some participants reporting more integration of technology as part of routine operations, while other participants reported having to learn a new way to do their work, manage changes in their role, and/or support residents and their families with technology use. Variation on perceived technology literacy within the LTC setting was also reported: some participants stated they themselves were comfortable with technology, while others shared observations of struggles adapting to technology themselves or in other LTC staff. Despite the heterogeneity in experiences of LTC staff regarding technology use in LTC, four themes emerged (Figure 2).

Figure 2.

Themes and subthemes identified from the data.

Theme 1: Ameliorating geographical constraints with virtual alternatives

COVID-19 resulted in visitation restrictions that placed limitations on who could come into LTC homes, the physical distance between two people as well as the size of the gatherings for those within the LTC homes. Whether they were LTC staff and volunteers that provided in-person services that were no longer allowed to enter LTC homes or LTC residents that participated in large in-person group activities that were no longer allowed to be run, participants shared how they used technology to support these activities to continue despite space and distance restrictions. Participants described the ways technology bridged barriers in space within LTC when the in-person activity was no longer possible due to the COVID-19 pandemic related restrictions. Technology enabled communication between those within LTC and those outside LTC.

Work site flexibility and virtual team meetings

To meet with other people and/or provide services, often services were provided from another location despite all LTC staff not being physically present in the same room. Participants that typically came into LTC homes to provide services or attend meetings that were no longer allowed into LTC homes, or those that were allowed in but wanted to minimize the frequencies of them entering LTC homes, reported switching from in-person to virtual activities. The switch to the provision of services virtually allowed them to service a site from other locations, including from home.

I would communicate with the facility, with key people in the facility about what was going on if there was a reason for me to be there. I would go and I would take care of it, and other than that I would work out of my office at [off-site] using computer connections and phone connections, right, to get things done. (Allied Healthcare Staff)

The ability to work from alternative locations was perceived positively as it added flexibility. In contrast, the expectation to work from home was less desirable as it blurred the work-home division: many acknowledged the necessity, but did not like being expected take work and stress home and work outside of regular shift hours.

We all worked really hard to get this stuff done… we all have our iPhones, we’re all talking 24/7. If I’m awake and I’ve got an issue, [Person] is awake and he's answering the issue. I never was alone in any of this … like there was always somebody we could talk to. It was just so extensive, so much work and everybody's just really tired. (Leadership/Management)

Amongst the participants, some reported attending meetings virtually regularly before the COVID-19 pandemic while others reported most team meetings were face-to-face or a group phone call over the speaker phone. During the COVID-19 pandemic, team meetings were switched to virtual via videoconferencing. As one allied healthcare staff participant noted “Staff meetings going online have been the big thing.”

Changes in medical and clinical care practices, including care conferences

The LTC inter-professional team consisted of medical, nursing and allied healthcare professionals, of which some members of the team were in the LTC homes and others remained outside. As such, there were changes as to how medical and clinical care was provided to LTC residents. For example, nursing staff participants reported changes in how LTC residents accessed medical care from physicians and other healthcare professionals that previously came into the LTC homes and laid eyes on the residents. With the COVID-19 pandemic, physicians often provided consultations and assessments of LTC residents virtually, and nurses communicated with doctors and other healthcare professionals by phone calls, video calls, even by texting. This resulted in changes in the way nursing staff worked. One nursing staff participant noted, “We’ve been doing the med reviews with the pharmacist by Zoom, we’ve been doing telephone rounds with the doctor… We’re sending more pictures to wound care nurses and doctors cause they’re not in physically.”

Typically, care conferences for LTC residents were attended in-person by all healthcare members of the inter-professional team along with family. During the pandemic, these meetings were changed to tele- or video-conferencing so that all healthcare disciplines, as well as the residents’ families, could attend. With the use of tele- or video-conferencing technologies, families that were not in town could also participate in care decisions of LTC residents.

We didn’t really offer a teleconference number for families to be able to come in for things like care conferences and now we do, so family members who are involved but live out of town are now able to attend care conferences which is a small but I think pretty cool. (Allied Healthcare Staff)

Virtual visits and virtual activities for residents

The way LTC residents connected to families and friends and participated in social activities changed due to the visitation restrictions and physical distancing requirements in LTC. In-person visits by families and friends became virtual, and in-person group activities were changed to virtual alternatives. Residents struggled with the loss of contact with families in the context of strict visitation restrictions during the pandemic. In response, LTC homes brought in tablets with video-conferencing capabilities so that residents may have scheduled virtual visits and remain connected with their families and friends that previously came into LTC.

They brought in tons of iPads and stuff so at least they could communicate and they brought in extra staff just to help the residents with the iPads so they could talk to family. They really focused on how important family was and they really worked hard to ensure that there was some form of communication going on with family for the residents. (Nursing Staff)

Participants reported that for LTC residents, scheduled virtual visits were beneficial but not viewed as an adequate replacement for in-person visits. One management/leadership participant noted, “Technology itself it played a huge part in maintaining their sense of well-being to a point. Without it I don’t think they would’ve been through this completely unscathed.” Participants also reported having to support residents with virtual visits, “The residents didn’t have the ability to use it. The staff who dialed the number, you know, for the resident and the relative would come on and that's how they would talk” (Nursing Staff). As well, LTC staff invited families to send digital content in to be shared with residents, as well as created digital content themselves to be shared with families. One participant noted that the connection between the staff working in their LTC home and the families had improved because the increased communication resulted in families having an improved understanding of all the things that LTC staff did at work.

Visits from members of the community and volunteer entertainers into LTC were changed from in-person to virtual. Recreation staff noted that access to online content, such as YouTube, as well as streaming services on the Internet had been very helpful. For example, a YouTube video was shown on television instead of a live musician performing for residents, and LTC homes streamed local church services when they started offering virtual churches on zoom.

The iPad we are using, we use a lot. I think it made us discover what was really out there on YouTube and virtual music programs and stuff like that so we have used it a ton. And local church services we used quite a bit as well. That way the technology has been a positive thing. (Allied Healthcare Staff)

An allied healthcare staff participant noted expansion in technology use in the community for other services such as grocery ordering and delivery, retail, and government services, “[I was] supporting residents with accessing more online shopping… because of the pandemic I think there was an expansion in store capacities to do online delivery, like [Name of Supermarket] or whatever.” However, other participants noted that technology helped but did not entirely overcome the challenges from distancing restrictions on LTC residents. As noted by an allied healthcare staff, “…a lot of the places in [Name of Town], like the church, they would record their service, so we tried to get things that were familiar to the residents but sometimes it just didn’t work.”

Theme 2: Technology use for coordinating activities and communicating information

A range of communication technologies were used to coordinate work as well as other activities and to share information through synchronous and asynchronous communication, between different groups of people within LTC, such Organization-to-Staff or Staff-to-Staff. Purposes ranged from information sharing and coordination of activities to education and training. For education and training sessions, participants described the use of synchronous (such as video-conferencing technologies for virtual training sessions in real time) and asynchronous methodologies (such as training videos online that showed safe donning and doffing of personal protection equipment) for information dissemination.

Synchronous communication technologies for virtual meetings

Use of synchronous communication technologies such as telephones and video-conferencing technologies allowed users to interact, ask questions and receive answers in real time. Telephones transmitted audio only, while video-conferencing technologies on smartphones and laptops allow users to see and hear each other. Managers reported that they had regular virtual meetings with other managers in the region. These meetings were helpful in disseminating information about COVID-19 updates. Managers reported that they felt supported and less alone in the North.

you didn’t feel like oh my God, I’m the only one going through this because everyone still had, everyone had all the same questions so it kind of like, okay I can feel alone out in the rural northern BC, right. (Leadership/Management)

Some managers reported spending the majority of their time reading emails and attending meetings on MS Teams or Zoom, which was not the case before the COVID-19 pandemic.

Nursing and recreation staff also reported a shift from in-person meetings to virtual meetings for synchronous communications for team meetings between staff. As well, there was a shift from teleconferencing on the telephone to video-conferencing using video-conferencing software on computers, smart phones or tablets—this shift was welcomed as participants were able to see the faces of other people during the meetings and they liked that.

Me personally, just more like more teleconference things and all of a sudden video conferencing had to become a thing. We didn’t really use that before. Now we do quite a bit so that's pretty cool … like times that you might not usually meet with them, like it just made it easier for sure. (Administrative and Support Services Staff)

Synchronous communication technologies were used between physicians that were outside LTC and nurses that were providing care to LTC residents inside the homes, and also for the care conferences for LTC residents that were attended by the inter-professional team as well as the residents’ families.

Asynchronous communications for information sharing and regular updates

Asynchronous communication technologies, such as emails, websites, written memos, and pre-recorded videos, were those that were available on the Internet to be accessed at a different time. Information during the COVID-19 pandemic from health systems leaders was disseminated through both synchronous communications, such as virtual meetings, as well as asynchronously in the form of emails, memos, and postings on the health authority intranet site accessible to staff only. While policies changed constantly, staff received regular updates by email which many found to be easy and indicated that they were kept well informed.

…we received emails, like a daily COVID briefings, I can’t exactly remember what they’re called, I still get them, and then obviously if there are outbreaks or things like that we would receive those as well, like I didn’t have to go into to find that, it was just sent to me automatically which was nice. (Nursing Staff)

However, participants noted that the intranet site was not easy to navigate, and it was difficult to look up specific information—the documents may be stored in a different section than participants expected. Participants often received the same email from multiple sources, which led to staff having to manage a high volume of information via email as well as difficulty in finding the most current policies and processes. This volume of emails led to communication inefficiencies that participants pointed out could be made more efficient with less technology, such as in-person huddles. A participant who was in a LTC leadership role described printing important emails on paper and putting them into a binder so that all staff had easy access to the most up to date COVID-19 processes and policies.

Unequal access to information

The ease of access to information described by some participants in management/leadership roles, as well as for nurses and other allied healthcare professionals, was not observed across all LTC staf an example was registered care aides. That registered care aides did not have easy access to information was an observation that was not self-reported by participants that were registered care aides, but instead noted by participants that were nurses. They observed the challenges that registered care aides faced when using work computers and/or accessing COVID-19 related information from their emails but did not receive additional supports from the health authority. As a nurse that worked closely with registered care aides described in detail-

There's four to five [registered care aides] and there is one computer for them to use. That one computer is used for anyone taking any Zoom conferences, anyone orientating and these people are on the computer all day, like their whole shift, which happens I would say four days out of seven. So [registered care aides] in reality are expected to research or do whatever and read any emails and stuff on their breaks in the coffee room. The coffee room fits five people. There's one computer. You have 15 minutes for your coffee break, well you have a half hour lunch break but you need to eat during your lunch break and perhaps have a rest. But then you’re expected to do in-services, and emails and look up any information you might want… things like clicking on a link in an email and understanding this and that does not come automatically to [registered care aides] … I had to learn that stuff, right. And I was lucky that I was employed during the time when all this computer stuff was new and staff were trained for that. Like you weren’t expected to just know all this right away like [registered care aides] are now … . Our [registered care aides] are the backbone of extended care, they are the people and these are the people that need that information and they do not have ease of access by any stretch of the imagination. It could not be more difficult for them to obtain this information. And they’re expected to do it on their break, when they need a break, emotionally and physically (Nursing Staff)

When discussing technology challenges, registered care aides participants focused on difficulties faced by LTC residents with technology use instead of their own. Only one registered care aide participant alluded to challenges in technology use experienced by other registered care aides, noting “…they came up in the form of electronic communication … but let's face it, a lot of care aides aren't in their email and it's only because it's what I do that has me in technology.”

Theme 3: Technology use for communicating presence and connectedness

While technology was an invaluable tool for communication, participants described challenges and dissatisfaction with technology-mediated interactions for the communication of presence and connectedness.

Perceptions of lack in virtual technology-mediated interactions

While some participants viewed virtual meetings positively as effective and efficient, others expressed dissatisfaction preferring in-person meetings to connect with people. They described not having the same kind of in-person connection without eye contact and ability to see body language. Some participants felt that managers were absent. This was further confirmed by some managers who shared that they were not able to support staff adequately from a distance. A participant in a Leadership/Management role noted, “It did affect my availability for the team in that I was no longer face to face, elbow to elbow, I was more like, you know, by email and by phone and by Zoom.” This perceived lack of in-person engagement could be ameliorated to some extent—one participant that attended virtual meetings regularly described steps they took to build relationships and promote team dynamics virtually:

We need a team, I’m a real team person, really, so one of the things that I’ve always done and I just seem to be the, I call myself the cruise director of the group and so we do a lot of things that are extra that are kind of just team-building so we just did a virtual Christmas party. (Nursing Staff)

LTC staff providing clinical care and counseling services expressed misgivings about the effectiveness of virtual interactions in establishing rapport, building relationships, as well as providing person-centered care. They described that there was something lacking when the sessions were virtual. An allied healthcare staff noted, “…it was mostly remote work which is really hard to do this kind of job remotely. You know, it wasn't face to face, virtual … and doing counseling it's hard, right. Hard to reach people.”

Participants expressed concern about the quality of medical and clinical care that the residents received from healthcare professionals outside LTC, noting that these healthcare professionals were dependent solely on the information sent to them by LTC staff, such as text messages, pictures, and via phone or video calls. Participants noted that healthcare professionals missed information relating to both the work context as well as the person connection by not coming into the LTC home and seeing residents and staff within the LTC environment that they lived and worked in.

It was a time where we actually built relationship with the pharmacist that we work with and that they actually physically came to the care home … [now that meetings were on zoom only] it's depersonalized … the job is still getting done but it's not as person-centred. They’re not seeing how the nurses, the pharmacist isn’t seeing how the nurses’ area is set up, how the cart is set up, how things are done. The doctors are not seeing the resident, it's just different so some of the function is still being met and it's probably more efficient but the personal part is being lost and that is not great when your whole business is people, right. (Nursing Staff)

Less interest for virtual alternates compared to in-person

There was variation in reported interest and participation rates of virtual activities compared to the in-person versions. Participants that talked about virtual activities for LTC residents as well as in-person training sessions for LTC staff noted differences in attendance rates. For example, participants noted that LTC residents showed lower interest and participation rates for virtual activities, including entertainment or spiritual programming, whereas the in-person versions were more popular and well attended.

…like they’re not seeing the person, they’re not getting the full experience of the recreation program. Ya, and we no longer have church services so we’re trying to do everything virtually, so ya, it just isn’t the same for them…. we kind of do a spiritual program once a week but even like it has decreased the number of people coming out each week. (Allied Healthcare Staff)

Another example was that of training for hands-on procedures, such as the safe donning and doffing of personal protection equipment. A participant involved in the provision of education and training of LTC staff regarding IPC policies and processes for COVID-19 noted the low staff turnout for education on virtual platforms compared with in-person education. As well, they questioned the effectiveness of the use of videos in providing education for a hands-on procedure that was the safe donning and doffing of personal protection equipment.

Staff ambivalence toward virtual visits for residents

Participants noted that some LTC residents had telephones or tablets that they were already using to connect with family outside LTC. With significant amounts of time and supports from LTC staff, more LTC residents as well as their family members were able to adjust to virtual visits and either learnt to manage tablets or used the telephone for these visits.

I look at one of the fellows who had a lot of hard time initially, he's a rock star now and he's [in his 70 s] … and he just knows how to do it now, right. But I mean that's, we’re pushing two years right, so it's a lot of time and chances to learn it. (Nursing Staff)

However, participants also noted that many LTC residents struggled with the virtual visits due to their physical and cognitive limitations.

I my own personal experience I didn’t really see very many, it would be less than 10% that adapted so much. Most of them it's still kind of shocking to them that their loved one is on that screen. (Allied Healthcare Staff)

Participants reported that LTC residents were unfamiliar with and unsure about the technology, and had difficulties seeing, hearing and/or holding the tablets. Residents that had more serious or severe cognitive impairments could not understand what they were looking at nor able to engage with their families via the tablets.

For seniors who are not cognitively well, we’ve had folks who tried virtual visits and it went really badly because they get really confused. They think it's a window and the person is there but they’re not really there. Like why won’t you come through. (Allied Healthcare Staff)

Participants noted that while some families adapted to connecting with their loved ones in LTC via tablets and chose activities that were appropriate for the medium, others struggled. Many directed comments and questions to the LTC staff in the room instead of talking to the LTC resident.

I mean some of them you set up with the iPad and they’ll, some families get it and are great and will sit and sing and show old pictures and converse, but I don’t think everyone has that knowledge of what, at what stage they’re at and how to deal with it. … You get questions like how old are you, Mom? Do you know how old you are or who am I and how many kids do you have and I’m like don’t ask those questions, right. But it frustrates the resident, anyway. (Allied Healthcare Staff)

Participants reported between caught between the desires of families that wanted the virtual visits and the residents that did not. An allied healthcare staff noted, “…there were sometimes when the client was sleeping, there were sometimes when the clients wouldn’t want to talk but the loved one would so there were conflicts some of the time.”

Theme 4: Managing major technology-related changes and challenges

Participants described changes and challenges that they had had to deal with at LTC regarding the use of technologies as well as the resulting emotional toll.

Technology setup and getting used to the new and unfamiliar quickly

Participants that were registered care aides or in recreation roles reported that prior to the COVID-19 pandemic their work did not involve the use of much technology. The restriction of movement of staff and visitors into LTC meant that not only were staff required to come up with alternative ways to provide services and coordinate work using technology themselves, they also had to set up these devices for themselves as well as for other people. Participants reported that there was inadequate institutional support and thus the technology took a lot of time to set up:

My rec therapist spent hours and hours with certain clients trying to get them set up where there was no real, I would say that was no real support from [Health Authority], it's just like here's the iPads, you guys do it. (Leadership/Management)

While participants in different roles, management, nursing, allied health—described having to make adaptations to work, participants in recreation reported significant changes to their jobs with relation to technology. Some recreation staff described how their job scope changed from therapeutic recreation programming to the organization of virtual visits for residents. Prior to the COVID-19 pandemic the therapeutic recreation department ran regular programming consisting of one-to-one activities and group programs for LTC residents.

When the visitation restrictions came to effect, recreation staff took on additional work connecting LTC residents with their families, including set up, providing residents and families with technical support, coordinating the schedules and logistics of the virtual visits on top of regular therapeutic recreation programming, cleaning the devices between the virtual visits, and, for residents with cognitive limitations, staying with the resident and chatting with their families during the virtual visits.

Normally in our department we will have a high functioning program and a low functioning program so we’ll do hand massages and music for the lower functioning and maybe the higher functioning you might do an exercise class or take them on an outing, but now we had to scrap those from the schedule and just focus on virtual visits …  and you’re not having these bigger group programs where you can actually engage 6–8 people, 12 people in a program because you have to focus on bringing the stand and doing the visit and making sure that both the resident and the family member either are able to engage or their questions are answered, so it kind of changed things up quite a bit. (Allied Healthcare Staff)

One participant shared details about an issue related to the increased deployment of technology that was little discussed by other participants—that of cleaning protocols that were also necessary for infection control, especially if the devices were to be shared between residents. Cleaning took time, and therefore, had associated labour costs. As they described:

I sometimes feel that we’re dishonest to infection control because we don’t want to be and or you know what, to follow all these rules is going to cost more money so don’t let infection control know about it. … wait a minute where are your cleaning protocols? … And of course there's nothing, absolutely nothing and I said you can’t do this and who cleans your equipment now? (Nursing Staff)

Only one other participant in the study talked about the need to clean tablets between residents during virtual visits, and this was discussed in passing, in the context of heavy workload:

We added on virtual visits, is what we call them. So sometimes there would be five a day. They last about half an hour, sometimes longer and you’d have to run between people, clean equipment between people, dial up the families, some residents it was easy, you would get down there, you would set the cleaned equipment up, hook up with their families, say hello and they could converse without you having to help. (Allied Healthcare Staff)

Technical issues, inadequate infrastructure, and hardware problems

In the shift to a different way of service provision from in-person to one mediated by technology, LTC staff faced issues regarding the use of technology, including problems with infrastructure and hardware. For example, some staff reported hardware issues with older equipment that limited their ability to participate in virtual meetings. As noted by an allied healthcare staff, “…there's a bit of a slight shift using more like video chats rather meeting in person, although I still prefer meeting in person. I find, especially because my laptop is terrible, like I’m not able to participate.”

Connectivity issues, poor Wi-Fi, and lack of computer hardware within the LTC homes led to difficulties with virtual visits and virtual meetings. In many cases, the Wi-Fi network that supported the electronic medical records and systems involved with direct care was limited as was access to public Wi-Fi network that was for all other activities including recreation. The public Wi-Fi network was not able to support the bandwidth demands that virtual recreation activities required. An allied healthcare staff noted, “We’re on the public [Wi-Fi] system and it's been a struggle cause sometimes we can’t get the programs… we can’t have smart TV's cause our Wi-Fi can’t support it.” Participants supporting virtual visits for LTC residents also reported having to stay in the room with the resident because, in the event of a dropped signal, they would have to help the resident with logging in and reconnecting the call.

There was a demand for access to work computers by staff but there was a lack of availability of computers in general due to the additional activities that had been moved from in-person or on paper to the computer, including training, virtual meetings and new staff orientation. As well, remote access to internal information disseminated through the Intranet or to check work emails was difficult or for many to connecting from home due to complicated and unfamiliar remote sign in processes.

Most people have computers at home, that's true, lots of people don’t have access to [Health Authority] stuff and now they have all these billion very complicated things to set up to get into [Health Authority] stuff now with all this encryption and I don’t know the words of all that computer stuff…even going onto my [Health Authority] and it is not an easy site by any means. I still write down step by step the clicks I have to do to get into places on [Health Authority]. I do. It's hard. (Nursing Staff)

Impact from changes in work responsibilities and high workload

Increased technology led to increased staff workload at a time of significant staff shortages. While participants of different disciplines shared their challenges with increased workload and staff shortages, all participants involved in recreation described the increased amount of work required to support virtual visits as well as their preference to stop supporting them.

We’ve kind of had to go through the list and say okay, well, can we stop some of these virtual visits? Not because again that we don’t want to do them but because we’re so short staffed and our resources are so hard pressed … (Allied Healthcare Staff)

Participants described job scope changes, especially those worked after-hours, such as helping with activities related to connecting residents with families and others:

Recreation let us have access to the tablet that they used even though that's not technically our job, like if a loved one called and said oh can I FaceTime with my mom it's my birthday, we would try to work that in so they could have some time to talk to that person even though I guess that's not technically not part of our job, it would be more of a recreation job. (Nursing Staff)

Emotional load from technology-mediated activities

While technology enabled people in LTC to remain connected with those outside LTC, participants noted that technology itself contributed to the emotional load that the LTC staff faced. Participants reported that they observed emotionally charged conversations and events through Internet and communication technologies (ICTs), especially when there was differing expectations, and that required some deftness in handling by the LTC staff. For example, a participant in a management role reported providing emotional support to residents after video-calls with their families.

You’d see them having a FaceTime call and you could see them getting emotional because they can’t touch them, they can’t hold them, they can’t kiss them. They were missing out on their great-grandchildren or their grandchildren's lives so now you’re contending with okay I need to and I used to say this to some of my care aides, I need to go and spend some time with them, I’m going to be in this room, I’m probably going to be there for at least half an hour because I needed to allow them to decompress over their emotions. (Leadership/Management)

Participants that were present during virtual visits between residents and families reported that families had questions about resident care that the participants were not able to answer due to scope of practice and thus had to redirect these questions.

Sometimes they’d [Families of Residents] asked questions that we weren’t allowed to answer because it wasn’t to do with the visit, it was to do with the residents’ health and they needed to talk to the nurse or the doctor about that or their concerns about the care and stuff. (Allied Healthcare Staff)

Participants with work phones described taking calls from families that were upset when they could not come into LTC. A nursing staff shared, “Now everybody has our nursing cellphone number and they would call us and they would berate us and be like it's a hoax, why aren't you letting people in, I can't see my loved one.” Participants also talked about feeling the impact of negative information coming from traditional media and social media. Controversies regarding the management of the COVID-19 pandemic, including policies regarding the use of masks, visitation, vaccines, as well the occurrence of outbreaks, played out in mass media and social media, and spilled into LTC.

I don’t think people realize just what sacrifices we had to make in order to keep those that they loved so dearly so safe. And every time there was an outbreak in another facility there was … fear mongering [in the media] … and all of a sudden it became of case of okay I don’t even want to admit that I work in long-term care (Leadership/Management)

Participants discussed dealing with the emotional fallout from the media and not being able to respond.

We can’t share with them well ya, you did that down in the family room and now I’ve got [a number of] elders that are sick, so who's going to take responsibility for that? I have to be quiet, I have to let the [Health Authority] system message out what we want them to message out and trying to keep my nurses from reacting to that in social media is very hard. (Leadership/Management)

A participant in a Leadership/Management role expressed concern that the negativity may result in recruitment challenges, especially in smaller LTC homes in more rural and remote areas.

But when you see your name in Facebook or your [facility] in Facebook to hear the uncaring and almost professional slander, I fear that the small [facilities] are going to pay the price for that because we won’t be able to staff. I hope I’m wrong. (Leadership/Management)

Discussion

Despite the existence of a wide range of technologies that could be deployed in LTC, ⁵ there was no apparent breadth of technologies that was reported in use in northern BC during the COVID-19 pandemic. The technologies described by northern BC LTC staff were limited to only one type—ICTs in the form of cell phones, tablets, laptops with Internet access connectivity. Further research in this area may be to proactively examine how a broader range of technologies may be deployed in this region beyond ICTs.

It was clear that the experiences of LTC residents and the quality of care that the residents received was of critical importance to LTC staff in northern BC—the LTC staff spent a lot of interview time describing in detail the increases in technology-mediated activities for the LTC residents and the impact of these changes on the residents. Resident-centered technologies included the use of ICTs, such as tablets by LTC residents for social interactions to improve the quality of life of residents in the form of virtual visits with families, virtual activities such as virtual spiritual services, access to entertainment content on the Internet such as music and videos on YouTube, and personal content sent from families to the LTC home. The devices were originally designed for general consumers living in the community and not for LTC and the lack of tailoring for technologies to address the wide range of user abilities among LTC residents and the technology literacy levels necessary to adopt to new technologies may have contributed to the challenges described by participants in supporting LTC residents to transition to broader use of technology during the COVID-19 pandemic. While the implementation of virtual programs was due to the necessity of meeting residents’ social interaction needs within the context of the COVID-19 pandemic, an unprecedented healthcare crisis, the wide variety of activities that were able to be implemented even under such difficult circumstances suggests that there is under-tapped potential of the use of technology to improve the quality of life of LTC residents. There is need for further research in North America to design technologies and devices more suited for use by LTC residents in the LTC setting: technologies that are designed for use in LTC may help alleviate some of the workload needed to support residents in technology use that was described by the participants that worked in LTC.

In this study, ICTs for telehealth applications in the form of residents attending virtual medical appointments or clinical staff conducting virtual assessments for residents were not a focus that was identified. Instead, the use of ICTs for interprofessional communication with care providers to discuss residents’ medical care needs was pointed out. This is in contrast with other North American studies in the literature that showed increased technology use for the provision of telehealth applications in the United States,^21–23 including virtual medical doctor appointments on videoconferencing software,^21–23 and the use of integrated stethoscopes and otoscopes. ²² Further research would be helpful to investigate the current extent, as well as future potential, of telehealth services for LTC residents in northern BC.

Technology enables residents to maintain relationships with family and friends and participate in social connection activities, ¹⁴ though the role of technology in fostering or hindering social presence is influenced by factors such as communication context, individual traits, and the specific features of the technology itself. ²⁴ Thus, while technology offers valuable opportunity for social connection, careful consideration is essential to maximize its positive impact on social connection for residents in LTC. The increased social isolation of LTC residents due to the visitation restrictions had negative effects on residents’ health and well-being. It was important for LTC residents to remain connected to their families, and thus LTC homes organized virtual visits for residents and families to allow residents and families to maintain some contact and communication. This was a common occurrence in other LTC homes in North America with commonly reported increases in social isolation by LTC residents^25–30 as well as increases in the availability of ICTs in LTC for residents to connect with families.^25,29–32 However, participants questioned the effectiveness of ICT-mediated communications in virtual visits as LTC residents struggled with virtual visits, especially those with physical or cognitive challenges. The concern that LTC residents with physical or cognitive challenges may not be able to use ICTs effectively for virtual visits was also reflected in Freidus et al. who interviewed LTC staff, ³³ in Chu et al. and in Hardy et al., who interviewed families of LTC residents,^25,31 as well as in Ford et al. which investigated telehealth applications in LTC homes in the United States during COVID-19. ²¹

Staff-centered activities reported in this study included the use of ICTs to support staff to communicate with other staff and with medical and healthcare professionals outside LTC. This supported overcoming social distancing requirements as per IPC processes and policies. Participants accessed a range of ICTs including virtual education and training, virtual meetings with LTC between and within departments, virtual interdisciplinary meetings, as well as communication between LTC nursing staff and medical professionals outside LTC. There were significant differences in perspectives of the participants regarding the impact of technology on work based on their work roles and the purposes and settings for which technology was used.

Allied healthcare participants reported already using technology as part of their daily desk-based work for information and communication before the COVID-19 pandemic, though there were limitations on how much they could do remotely since medical charts and other information needed for assessments were not all available online. Telephone-based clinical assessments and counseling with the residents was challenging and did not really work for their clinical practices. Assessments continued to be provided in person rather than using video-conferencing technologies to assess LTC residents virtually. Lack of access to the necessary medical information was reported in previous studies, highlighting the low level of interoperability between systems and showing how a lack of access to medical information was a barrier for telehealth expansion in LTC.^21,22,34 The needs of allied health professionals to provide care virtually to LTC residents via telehealth technologies, however, is underexplored in the literature—only one study from North America described the experiences of rehabilitation staff that reported a shift from in-person group sessions to individual bedside sessions via telehealth technologies and this was seen as beneficial for LTC residents. ³⁵ More research is required from North America post-COVID-19 pandemic lockdown on this topic.

Research studies in North America that investigated telehealth implementation during the COVID-19 pandemic reported increased access to specialists for LTC residents living in rural or remote areas, and saving transportation costs in sending residents for in-person appointments.^21,22,36 However, these benefits were not mentioned by the participants that worked in northern BC. Instead, participants described misgivings about the quality of medical care that was provided to LTC residents using telemedicine technologies: they were concerned that remote medical care was impersonal and not resident-centered while acknowledging its convenience for physicians.

Online education and training were identified as technology-mediated activities, though little information was provided beyond stating that online training was available. For example, it was unclear whether the training sessions were synchronous or asynchronous, in the form of self-paced slides, online videos or virtual meetings with other people. This is in contrast with the descriptions of different synchronous and asynchronous methods of training and education during the COVID-19 pandemic in North American studies in the literature,^29,37–41 all of which reported positive responses and interest by the staff that attended the training. In these studies, the researchers found that online education and training was effective and staff retained information from these sessions,^{29,37,39–41} it supported peer engagement and emotional support,^29,37,39,40 and it was flexible with staff schedules.^38,39 On the other hand, researchers also noted low digital literacy of some LTC staff, lack of access to tablets and computers, and to protected time for virtual training as barriers to online training and education. ³⁹ Future North American research is warranted to investigate online education and training modalities that are more suited for LTC staff, especially for more hands-on processes such as donning and doffing of personal protective equipment, techniques for nursing care and safe feeding for LTC residents with dementia, and others.

Barriers to technology use in LTC

Several key technological challenges emerged from the analysis, including poor Wi-Fi connectivity in LTC homes, access to adequate equipment, and having to set up and use unfamiliar programs without adequate support in the form of more staff or training from the Health Authority. The lack of adequate existing technology support and digital infrastructure in LTC, as well as connectivity issues, are pervasive problems across a range of care settings and geographic locations.^{21,23,25,26,28,34,42,43} Ease of access is necessary to promote technology uptake, ²⁹ as such, more research may be warranted regarding the role of improved digital infrastructure in the encouragement of uptake of technologies in LTC for residents and staff, such as ICT-based telehealth technologies for remote medical care.

Ongoing struggles with staff shortages and high workload greatly affected those that provided direct nursing care to residents. The volume of work increased significantly though technology did not significantly change the type of tasks from their daily routine. There was more coordination with other departments to work with and around virtual visits. Those that provided therapeutic recreation described complete changes in their daily work as well as significant increases in technology use and significant increases in workload since that department was responsible for setting up and scheduling virtual visits for residents during visitor restriction in LTC. As well, participants in the study also described that there was work required to sanitize equipment that was shared by staff and residents between every use to meet IPC guidelines.

The perspectives shared by the participants in this study, as well as other studies,^21,22 demonstrate that challenges of staff shortages and high workload are considerable in the LTC setting and not unique to northern BC. However, the study by Cruz et al., in which researchers reported that registered care aides working in two LTC homes in Alberta showed high acceptance of a tablet-compatible app that allowed them to do their work more easily, ⁴⁴ is evidence that these challenges may not be insurmountable to the promotion of technology use in LTC.

Strengths and limitations of the study

While Canadian provinces adopted different COVID-19 policies and responses, the findings of this study are likely transferrable with respect to access to technology for LTC homes in rural and remote areas. Furthermore, the large number of diverse participants (n = 52) add a fulsome understanding of the issue, in particularly allowing perspectives of technology to be understood from numerous vantage points.

Despite the strengths, some limitations exist. The themes to be addressed by interview questions used in this study were generated with input and feedback from LTC managers working in the field at the time, but were not validated or pilot-tested due to the rapid changing context of the COVID-19 pandemic. Due to social distancing requirements of LTC residents, this study has focused solely on the experiences of LTC staff. Amongst the LTC staff that participated in the study, none were physicians. Further research should integrate experiences of residents and those around them since this may yield additional valuable insights. Furthermore, the study was undertaken in one rural and northern provincial region. Expanding this lens to include diverse LTC settings may provide further learnings.

Conclusion

Technology played a significant role in LTC in northern BC during the COVID-19 pandemic—nearly all study participants described the impact of technology on their work. The technologies that were deployed in LTC were limited to ICTs though the staff's descriptions and experiences of these technologies varied in terms of usability, feasibility, and impact. Technology was useful for accessing information and collaboration, and the ability to communicate with others on video calls in real-time was beneficial. However, technology was also less desirable for those who wanted in-person connection with others. The ability to see and hear people on video calls did not satisfy the need for an in-person presence for all residents. These issues were more acute for residents with physical or cognitive impairments. Even when a technology solution worked, some participants expressed concerns and questioned whether virtual care could truly be considered resident-centered care. These findings suggest the importance of choosing technologies to implement that are specific to the needs and context of the LTC setting, as well as ensuring staff support in the prioritization and implementation of technologies in LTC. While barriers exist that need to be addressed, there is great potential for increased use of technology in LTC in northern BC for both resident-focused and staff-focused applications.

This study provides insight into how technology can support LTC teams in northern and rural communities, as well as supports needed for LTC residents and staff to integrate technology effectively. As such, the study informs actionable insights for those working to promote and implement new technological solutions in northern, rural and remote LTC settings.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076241303195 - Supplemental material for Technology use in long-term care during the COVID-19 pandemic: A qualitative study of paid employees’ experiences in Western Canada

Supplemental material, sj-docx-1-dhj-10.1177_20552076241303195 for Technology use in long-term care during the COVID-19 pandemic: A qualitative study of paid employees’ experiences in Western Canada by Hui-Jun Chew, Shannon Freeman, Piper Jackson, Dawn Hemingway, Tammy Klassen-Ross, Melinda Martin-Khan and Davina Banner in DIGITAL HEALTH

Supplemental Material

sj-docx-2-dhj-10.1177_20552076241303195 - Supplemental material for Technology use in long-term care during the COVID-19 pandemic: A qualitative study of paid employees’ experiences in Western Canada

Supplemental material, sj-docx-2-dhj-10.1177_20552076241303195 for Technology use in long-term care during the COVID-19 pandemic: A qualitative study of paid employees’ experiences in Western Canada by Hui-Jun Chew, Shannon Freeman, Piper Jackson, Dawn Hemingway, Tammy Klassen-Ross, Melinda Martin-Khan and Davina Banner in DIGITAL HEALTH