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Abstract
Objective To examine reported cases of abuse in long-term care (LTC) homes in the province of Ontario, Canada, to determine the extent and nature of abuse experienced by residents between 2019 and 2022.
Design A qualitative mixed methods study was conducted using document analysis and descriptive statistics. Three data sources were analysed: LTC legislation, inspection reports from a publicly available provincial government administrative database and articles published by major Canadian newspapers. A data extraction tool was developed that included variables such as the date of inspection, the type of inspection, findings and the section of legislation cited. Descriptive analyses, including counts and percentages, were calculated to identify the number of incidents and the type of abuse reported.
Results According to legislation, LTC homes are required to protect residents from physical, sexual, emotional, verbal or financial abuse. The review of legislation revealed that inspectors are responsible for ensuring homes comply with this requirement. An analysis of their reports identified that 9% (781) of overall inspections included findings of abuse. Physical abuse was the most common type (37%). Differences between the frequency of abuse across type of ownership, location and size of the home were found. There were 385 LTC homes with at least one reported case of abuse, and 55% of these homes had repeated incidents. The analysis of newspaper articles corroborated the findings of abuse in the inspection reports and provided resident and family perspectives.
Conclusions There are substantial differences between legislation intended to protect LTC residents from abuse and the abuse occurring in LTC homes. Strategies such as establishing a climate of trust, investing in staff and leadership, providing standardised education and training and implementing a quality and safety framework could improve the care and well-being of LTC residents.
- Health policy
- Nursing homes
- Quality improvement
- Safety culture
- Standards of care
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Abuse is an acknowledged societal issue, and many background studies are available.
Physical, emotional and verbal abuse in long-term care (LTC) homes has been documented internationally, demonstrating the need for further research.
WHAT THIS STUDY ADDS
This study is the first to use a Canadian administrative database to identify reported incidents of abuse in LTC homes.
Findings confirm that abuse has been a persistent issue in LTC.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The study provides evidence that a quality and safety framework is necessary to improve conditions in LTC.
To safeguard LTC residents, the prevention of abuse must be prioritised in policy and practice.
Evidence from this study indicates that reforms to date have been inadequate to address the seriousness of the issue.
Introduction
Long-term care (LTC) homes in Canada provide accommodation, assistance with activities of daily living and 24/7 on-site care for adults, including elderly persons, who have significant medical, physical or cognitive needs. Nationally, the LTC sector has been characterised by policy failures; persistent deficits in wages, staffing and care; and lack of accountability.1 2 All of which affect the well-being, quality of life and safety of LTC residents. An analysis conducted in 2023 identified ‘critical modifiable components of Canada’s poor performance: inadequate attention to growing LTCH resident complexity, chronic failure to support LTCH staff and a lack of LTCH integration within health and social care systems’.(Estabrooks et al, p23)
Due to worsening conditions stemming from COVID-19, teams of healthcare workers, including more than 1600 members of the Canadian Armed Forces, were deployed to support targeted LTC homes. Team members described substandard care and incidents that were ‘borderline abusive, if not abusive’.(Stephenson et al, §24) These issues have continued beyond the pandemic despite new legislation and standards to improve the sector.5–7 The Government of Canada defines abuse as ‘harm done to anyone by a person in a position of trust or authority’ (Government of Canada, §2.38), and it may be physical, sexual, psychological (eg, emotional, mental, verbal) or financial.
A systematic review of survey data from 28 countries indicated that 1 in 6 elderly persons in community settings had experienced abuse.9 The incidence is estimated to be higher in institutional settings.10 In the USA, almost ‘1 out of 3 nursing homes… has been issued citations for abuse,’11 and occurrences have been reported in 99% of care homes in England.12 Studies conducted in Norway and Sweden documented individual, societal, institutional and environmental factors that contribute to abuse in LTC settings and showed how the intersection and interaction of these factors contribute to the phenomenon.13 14 Researchers have also found that ‘abuse was perceived ambiguous’ (Hirt et al, p115) and ‘different interpretations on what constitutes abuse and its severity complicate its detection, reporting and management in nursing homes’. (Myhre et al, p216) Furthermore, fear of retaliation by staff prevents LTC residents from voicing concerns and reporting abuse.17
Abuse in LTC settings is underreported worldwide,15 18 19 and there are concerns it is a ‘low global priority’. (Mikton et al, p53120) Few empirical studies have investigated the issue. To address this gap, this study focused on abuse in LTC homes in Ontario, Canada. As the nation’s most populous province, Ontario has the most LTC homes (n=627). These homes may be publicly funded with public or private ownership, and those privately owned may be designated with for-profit or not-for-profit status. As of March 2021, there were 2076 LTC homes nationwide, of which 54% had private ownership and 46% had public ownership.21
The purpose of this study was to determine the extent and nature of abuse experienced by LTC residents in Ontario. The objectives were to (i) examine provincial LTC legislation to identify how abuse is defined, regulated and monitored; (ii) analyse inspection reports to identify the number of incidents and categorise the type of abuse; (iii) describe characteristics of LTC homes with reported cases of abuse; and (iv) examine newspaper articles to corroborate findings of abuse and obtain resident and family perspectives.
Methods
Design
A qualitative mixed methods approach was used that included document analysis, ‘a systematic procedure for reviewing or evaluating documents’ and ‘finding, selecting, appraising (making sense of) and synthesising data contained in documents’. (Bowen, p28–2922) Various data sources are used to achieve convergence and validation. Three data sources were analysed in this study: LTC legislation, inspection reports from a publicly available provincial government administrative database23 and articles from major Canadian newspapers. The data collection and analysis period was January 1, 2019, to December 31, 2022.
Patient and public involvement
There was no patient or public involvement in any aspect of this study, including design, conduct, analysis, reporting or dissemination.
Data collection and analysis
Legislation
During the study period, homes in Ontario were licensed by the Ministry of Long-Term Care (MLTC) and governed initially by the Long-Term Care Homes Act (LTCHA), 2007 and later by the Fixing Long-Term Care Act (FLTCA), 2021.24 25 The legislation was reviewed to identify and extract sections relevant to the documentation and prevention of abuse.
Inspection reports
The MLTC maintains an administrative database of publicly available reports of all LTC home inspections conducted in Ontario. A data extraction tool was developed to categorise reports into a dataset. Data included the date of inspection, the type of inspection, findings and the section of legislation cited. Reports with findings of abuse were identified and further analysed. Variables were developed using definitions from the legislation (online supplemental appendix 1) and included the following: the perpetrator of abuse (staff, non-staff), type of abuse (physical, emotional, verbal, sexual, financial), designation of staff involved (unregulated, regulated), home ownership status (for-profit, not-for-profit, municipal (municipal homes are publicly owned and operated)), location of home (urban, rural) and size of home (small, <100 beds; medium, 100–149 beds; and large, >150 beds). Descriptive statistical analyses, including counts and percentages, were calculated to identify the number of incidents and the type of abuse reported.
Supplemental material
For the document analysis, a stratified purposeful sample of 50 reports containing staff-to-resident abuse was selected and thematically analysed.26 Stratification facilitates identification of information-rich cases.27 During preliminary coding, three members of the research team coded several texts independently. Team members then collaborated to refine the coding scheme. Additional codes were assigned as new themes emerged. Major themes were highlighted, and key findings were categorised under the appropriate heading.
Newspaper articles
Four major national newspapers were searched for articles that described cases of abuse in LTC homes across Ontario: the Toronto Star, the Canadian Press, the Globe and Mail and the National Post. Articles published between January 1, 2019, and December 31, 2022, were searched using keywords ‘abuse’ and ‘long-term care’. The initial search yielded 610 articles. After screening the titles for keywords, 183 articles remained, which were reviewed, categorised and thematically analysed for corroboration of findings and to obtain resident and family perspectives.22
Results
LTC legislation
As defined in the legislation, a ‘LTC home is primarily the home of its residents and is to be operated so that… they may live with dignity and in security, safety and comfort’. (Government of Ontario, p524, Legislative Assembly of Ontario, p625) The legislation emphasises homes have a ‘duty to protect residents’ and create a ‘policy to promote zero tolerance of abuse and neglect’ (Government of Ontario, p12–1324, Legislative Assembly of Ontario, p1625), and it defines abuse ‘in relation to a resident… (as) physical, sexual, emotional, verbal or financial’. (Government of Ontario, p524, Legislative Assembly of Ontario, p725)
The legislation also describes compliance and enforcement to prevent abuse and outlines the powers and responsibilities of inspectors, which include determining what actions homes must take to achieve compliance. (Government of Ontario, p58–5924, Government of Ontario, p58–5928) As stipulated in the legislation, inspectors are appointed by the MLTC and can enter homes with or without notification. They can review all relevant documentation, conduct interviews and call on experts to assist in the inspection. The legislation specifies fines for failure to comply with the prevention of abuse: CAD $5500 for the first infraction up to CAD $250 000 for additional infractions.28 In severe cases, consequences can be applied such as withholding funds, revoking a home’s license or taking over management and operations.25
Inspection reports
Number of incidents
Table 1 shows the total number of inspection reports from 2019 to 2022. Overall, 9% (n=781) of the reports had findings of abuse, and the percentage of abuse reports remained consistent over time.
Count of inspection reports and inspection reports with abuse findings for long-term care homes in Ontario, Canada, 2019–2022
Type of abuse documented
The 781 reports of abuse came from 385 homes, and 441 (56%) of the reports cited staff-to-resident abuse. These reports were analysed to determine the type of abuse and the role of staff involved. The most common type of staff-to-resident abuse was physical (37%), followed by verbal (24%), emotional (21%) and financial, sexual and unspecified (18%). Unregulated staff were involved in 62% of cases, and regulated staff or management were involved in 10% of cases. The remaining 28% of abuse reports did not indicate the role of the staff involved. Based on the frequencies, three types of abuse were identified for further analysis: physical, verbal and emotional.
Thematic analysis of inspection reports by the type of abuse revealed that incidents of physical abuse cited by inspectors included shoving, pushing and use of excessive force. In one case, a healthcare worker ‘had struck (a) resident in the mid-section (to) which the resident responded, “You're hurting me”’. The same healthcare worker ‘sprayed (another) resident in the face with a spray, to which the resident responded, “My eyes burned”’. Additional examples of physical abuse included ‘an agency (staff who) slapped a resident on the back’ and a healthcare worker who ‘bent back the fingers of a resident during care, causing pain’. In each incident, there were witnesses and evidence such as video recordings.
Incidents of verbal abuse included swearing, aggressive language and inappropriate communication. An inspector documented that a healthcare worker ‘yelled at the resident… in a loud, rude and condescending manner’. In another case, a staff member was seen ‘using assertive and forceful language to direct the resident during care’. Incidents of emotional abuse included residents crying because of negative comments, threats and dismissive behaviour from staff. An inspector noted that a staff member was ‘rushing and criticising a resident’ during care, causing the resident to become visibly upset. In a different report, the inspector wrote that a staff member had observed a healthcare worker ‘put a cloth in the resident’s mouth and telling them to “shut up”’.
Challenges documenting abuse
An emerging theme identified during the analysis was challenges in documenting issues related to abuse. One inspector recorded that multiple staff in a home ‘confirmed that they had witnessed abuse but had not reported it because they were not trained on the prevention of abuse and were not aware of the reporting structure’. In a different home, the inspector found that management had branded a staff member a ‘troublemaker’ for reporting ongoing abuse of residents by a co-worker. A report on another home revealed that a member of management disregarded staff abuse and failed to investigate because the resident had cognitive impairment and ‘was known to be weepy/teary at times’. However, the inspector determined that verbal and emotional abuse of this resident had in fact occurred. An inspector in a separate case emphasised that had the staff reported earlier incidents of abuse in the home, ‘the most recent incident towards three residents would likely not have happened’.
Characteristics of homes with abuse findings
Figure 1 shows 62% of the 627 LTC homes in Ontario had at least one reported case of abuse between 2019 and 2022. More than half of these homes (55%) had repeated incidents of abuse and multiple inspection reports during the 4 years. The number of inspection reports citing multiple incidents of abuse ranged from 2 to 10 per home.
Number of long-term care homes in Ontario, Canada, with cases of abuse and frequency of incidents, 2019–2022.
With regard to ownership status, 221 (57%) of the homes with cases of abuse were for-profit, 96 (25%) were not-for-profit and 68 (18%) were municipal. Although the homes were distributed across all regions of the province, the majority were in urban settings (79%). We analysed the size of the homes to determine the relationship between the number of beds and reported cases of abuse and found that large homes (more than 150 beds) had a greater number of abuse cases compared with small homes (less than 100 beds).
Newspaper articles
Articles published during the study period described neglect29 and ‘flagrant abuse’ of LTC residents by registered staff, sometimes resulting in fatal outcomes. (DiManno, §1430) A healthcare worker recounted how ‘over a one-month period… she witnessed two incidents of staff hitting residents and one time when a worker pinched a resident’s nose’. (Mahoney et al, §631) Newspaper accounts documented other examples of physical abuse such as staff smacking and pulling residents, handling them roughly and being aggressive during care and activities of daily living such as feeding, repositioning, transfers and changing incontinence products.31–34
The articles identified numerous incidents of verbal and emotional abuse by staff, resulting in resident distress. Examples included ‘degrading or inappropriate comments’ (DiManno, §832), abandonment and failure to provide assistance.35 A healthcare worker recalled overhearing staff telling residents to ‘shut up, I am sick of you giving me a hard time’. (Howlett et al, §434) An article detailed the ‘horrific conditions in five of Ontario’s LTC homes—including residents left in soiled diapers and crying out for help for hours’. (Howlett et al, §436) An additional report highlighted the inappropriate use of chemical restraints on fearful residents and the devastating isolation of confinement during the pandemic lockdown.37
Similar to the inspection reports, the articles identified underreporting of abuse as a challenge.38–40 There were accounts of family members facing bans, punishment and accusations of staff harassment because they spoke up for LTC residents traumatised by ongoing abuse in homes.38 One article described how ‘a staff member first physically assaulted a resident, then warned a witness “not to tell anyone”…. Two staff members who were aware of the abuse didn't report it’. (Welsh and McLean, §141)
Discussion
This study provides evidence that the LTC legislation in Ontario is clear regarding the definition of abuse, the inspection process and possible sanctions for homes with cases of abuse. Furthermore, there is a well-defined legislative role and established process for inspectors42 43 and a publicly available administrative database of inspection reports. Our analysis of this database showed the absolute number of abuse incidents recorded by inspectors was significant. The newspaper articles corroborated the abuse documented in the inspection reports and provided resident and family testimony. Although there have been some positive changes such as revising LTC legislation, increasing the number of inspections, implementing an investigation unit6 and publishing new national LTC standards,7 more needs to be done.
We situated the findings from the study within the wider literature to identify strategies to minimise abuse in LTC homes and improve the care and well-being of residents. These include (i) establishing a climate of trust, (ii) investing in staff and leadership to make necessary cultural changes, (iii) providing standardised education and training on the reporting of abuse and (iv) implementing a quality and safety framework.
Establishing a climate of trust can facilitate communication about abuse. As noted in the literature, fear of retaliation contributes to the underreporting of incidents.44 At the home level, organisations should promote ‘see something, say something’ in their operational policies. They should enforce whistle-blower protection as enshrined in the LTC legislation and ensure staff awareness that such protection exists. Homes should also invite residents and their families to share their concerns, observations and recommendations regarding abuse and solicit their participation in safety planning via the Residents' Council and the Family Council outlined in the FLTCA, 2021.28
The legislation stipulates the minimum requirements that LTC homes must meet in creating a policy for zero tolerance, but the application and dissemination are left to the discretion of the homes. Thus, investments in leadership development are vital. The literature demonstrates that leaders set the organisational climate, shape organisational culture through their behaviours and actions and impact staff and resident satisfaction and organisational outcomes.45–47 Studies have found leaders in LTC settings must encourage consistent, clear and continuous messaging and communication at all levels.46 48 In addition, they must establish and maintain ‘the culture of practice, especially as it relates to quality and safety of care, as… prior qualification, training or skills development may not be assumed’. (Rand et al, p249)
Recognising that education and training related to abuse vary among staff, as do competence and qualifications,15 care providers should be supervised and supported. The staff in the LTC homes in our analysis included a mix of regulated and unregulated workers. The latter were responsible for the majority of abuse incidents recorded in the inspection reports. However, studies reflect that unregulated workers provide most of the direct care in LTC homes, and there are concerns over staffing mix and low numbers of regulated workers.50 Increasing the number of staff and the ratio of regulated to unregulated staff is suggested to enhance resident safety. The use of a standardised provincial curriculum that includes an in-depth study of abuse and focuses on identification, prevention and reporting is also suggested.
We found that the current legislative process is largely reactive and focuses on meeting minimum standards set externally. Therefore, implementing a quality and safety framework is strongly encouraged. One option is the Safety Measurement and Monitoring Framework (SMMF), which has ‘five dimensions relevant to safety monitoring and measurement (harm, reliability, sensitivity to operations, anticipation and preparedness, integration and learning)’. (Rand et al, p249) The SMMF emerged from the wider healthcare sector but has direct applicability to LTC. Another option is the Measurement and Monitoring of Safety Framework (MMSF), which ‘expand(s) the narrow range of approaches available to healthcare organisations to analyse, monitor and learn… (and) offer(s) a broader framework for safety’. (Goldman, p47151) The MMSF has elements germane to LTC such as consistent processes, accurate documentation, anticipation of problems, adequate staff support and proactive safety monitoring. The use of a quality and safety framework could reduce the incidence of abuse and the challenges inspectors encounter in documenting abuse by facilitating staff awareness of what constitutes abuse and clarifying reporting structures.
Limited availability of data makes abuse in LTC a difficult phenomenon to study, and most studies to date have used self-report surveys. The current study used administrative data, but the lack of standardisation in how abuse incidents were recorded and reported necessitated extensive data cleaning to prepare for analysis. A scoping review of international literature determined that a ‘gap… exists in adequately capturing information on the incidence of abusive or neglectful care practice’.49 A key strength of our study is that it was the first to systematically examine a provincial government administrative database to determine the extent and nature of abuse experienced by LTC residents.
Conclusion
This study demonstrates that inspection reports provide critical insights into how abuse is reported, documented and managed in the LTC sector in Ontario, Canada. Findings show there are substantial differences between legislation intended to protect LTC residents from abuse and the reality of what is occurring in LTC homes. The prevention of abuse must be prioritised in policy and practice. This study provides strategies to improve the care and services LTC residents receive.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors AB is the guarantor and was responsible for study conception and design. MC-A, DIW, VS, VA and AB contributed to data extraction, analysis and validation. All authors read, edited and approved the final manuscript.
Funding The Canadian Institutes of Health Research provided funding for this research (VR4-172764).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.