Introduction
In late 2019 (WHO 2020a), a novel acute respiratory illness called Covid-19, and characterized by new or worsened respiratory symptoms, fatigue, headaches, and muscle aches, was first documented (WHO 2020b). On 25 January 2020, Canada recorded its first case (Government of Canada 2020) in Toronto, Ontario (Marchand-Senécal et al. Reference Marchand-Senécal, Kozak, Mubareka, Salt, Gubbay, Eshaghi, Allen, Li, Bastien, Gilmour, Ozaldin and Leis2020). On 11 March 2020, the World Health Organization (WHO) declared the Covid-19 pandemic (WHO 2020a). As older adults, and those with pre-existing medical conditions, were identified at a high risk for severe disease when infected with Covid-19 (WHO 2020b), residents of long-term care (LTC) homes (e.g. nursing homes or residential care homes) were recognized as the group most vulnerable to Covid-19 owing not only to age and co-morbidities but also to environmental factors such as congregate living, shared living spaces and close-contact care delivery (Lai et al. Reference Lai, Wang, Ko, Yen, Lu, Lee and Hsueh2020).
In Canada, LTC encompasses a spectrum of services that provide varying levels of support to people that are unable to independently care for themselves (CIHI n.d.b), often because of frailty (Kojima Reference Kojima2018), dementia (Maxwell et al. Reference Maxwell, Mondor, Hogan, Campitelli, Bronskill, Seitz and Wodchis2019) and associated co-morbidities (Barth et al. Reference Barth, Vatterrott, Zhou, Fink and Doblhammer2016; Roquebert et al. Reference Roquebert, Sicsic, Santos-Eggimann, Sirven and Rapp2021). Services range from basic assistance to people living in their homes, to 24-hour care to residents living in an LTC facility or LTC home (Carpenter and Ersek Reference Carpenter, Ersek, Ferrell and Paice2019). Long-term care homes provide the highest level of care in this spectrum of supports (Garner et al. Reference Garner, Tanuseputro, Manuel and Sanmartin2018). This includes access to supervision and monitoring (Ontario 2021), living accommodations (National Institute on Aging 2023), assistance with activities of daily living (e.g. eating, dressing), services such as meals, laundry and housekeeping, and 24-hour access to nurses who provide medical assistance and medication management (Saskatchewan 2024). Although some of these supports are funded through Canada’s universal health-care umbrella, LTC homes are not fully government-insured, and residents also contribute a monthly co-pay fee for room and board (Braedley et al. Reference Braedley, McWhinney, Barclay and Jensen2019). Continuing care assistants, nurses, food services workers, housekeepers and recreation workers comprise most of the LTC staff complement (Braedley et al. Reference Braedley, McWhinney, Barclay and Jensen2019). Long-term care service delivery varies across Canada, given provincialized health-care systems and variability in population needs. For instance, although staffing ratios are poorly publicized, Ontario proposed a goal to increase their direct care hours for personal support workers and nurses from three direct care hours per resident per day in 2021 to four hours in 2025 (Ontario 2025). Some provinces, including Saskatchewan, do not have a minimum requirement (Saskatchewan 2024).
Canada’s LTC sector underwent intense change due to public health risk management strategies implemented during the Covid-19 pandemic. In March 2020, standard infection control strategies (e.g. mask use, surface cleaning, handwashing, self-screening, quarantining) were emphasized alongside policies designed to interrupt viral transmission by disrupting social contacts, including ‘social distancing’ and suspension (or, later, restriction) of volunteer and family visits (Government of Canada 2021). These policies were similar to those implemented in other countries across the globe including those such as Australia (Australian Government Department of Health 2020), Italy (Gnasso et al. Reference Gnasso, Iommazzo, Corbi, Celi, Iannicelli, Ferrara and Ruosi2022), Ireland (Cornally et al. Reference Cornally, Kilty, Buckley, O’Caoimh, O’Donovan, Monahan, O’Connor, Fitzgerald and Hartigan2022) and the United States (Shaw and Csikai Reference Shaw and Csikai2023). Other countries, including the Netherlands, diverged by maintaining infection control policies but reinstating family engagement in care within the first few months of the Covid-19 pandemic (Verbeek et al. Reference Verbeek, Gerritsen, Backhaus, de Boer, Koopmans and Hamers2020).
Policies restricting family visits had a profound effect on LTC communities, leading to intense debate (Van der Roest et al. Reference Van der Roest, Prins, van der Velden, Steinmetz, Stolte, van Tilburg and de Vries2020; Paananen et al. Reference Paananen, Rannikko, Harju and Pirhonen2021; Chu et al. Reference Chu, Yee and Stamatopoulos2022; Hardy et al. Reference Hardy, Fanaki, Savoie, Dallaire, Wilchesky, Gallani, Gagnon, Laberge, Voyer, Côtéc, Couture and Dallaire2022; Hunter et al. Reference Hunter, Ward and Puurveen2023). Colloquially, Canadians began to speak of the near-total suspension of family visits in the first year of the Covid-19 pandemic as ‘the lockdown’ of LTC. For LTC staff, being required to implement changes that resulted in the increased social isolation of residents was morally weighty and presented a stark contrast to the type of holistic care that LTC staff felt a responsibility to provide (Van der Geugten et al. Reference Van der Geugten, Jacobs and Goossensen2022). These changes also exacerbated an existing vulnerability to social isolation (Prieto-Flores et al. Reference Prieto-Flores, Forjaz, Fernandez-Mayoralas, Rojo-Perez and Martinez-Martin2011). Staff witnessed decrements in residents’ mental and physical health as a direct result of losing access to social contact with family and friends during a prolonged lockdown (Paananen et al. Reference Paananen, Rannikko, Harju and Pirhonen2021). They also became aware of the compromised wellbeing of residents’ family members, secondary to disruption of familial and care-giving relationships (Paananen et al. Reference Paananen, Rannikko, Harju and Pirhonen2021).
Similar experiences were reported internationally. For example, staff in Norway compared confining residents to their rooms for social distancing to turning LTC into ‘prisons’ (Hillestad et al. Reference Hillestad, Rokstad, Tretteteig, Julnes, Lichtwarck and Eriksen2023). Internationally, LTC staff described residents’ difficulty understanding the Covid-19 pandemic and associated restrictions, and expressed concern about reductions in quality of life, physical health and emotional wellbeing among residents in response to social distancing and visitation restrictions in Norway (Tingvold et al. Reference Tingvold, Moholt, Førland, Jacobsen and Tranvåg2023), Sweden (Ariander et al. Reference Ariander, Olaison, Andersson, Sjödahl, Nilsson and Kastbom2024) and Australia (Tierney et al. Reference Tierney, Doherty and Elliot2020). The results of these studies are supported by direct reports from residents in LTC in Spain (Crespo-Martín et al. Reference Crespo-Martín, Palacios-Ceña, Huertas-Hoyas, Güeita-Rodríguez, Fernández-Gómez and Pérez-Corrales2022) and family care-givers of LTC residents in the Netherlands and the United Kingdom (Giebel et al. Reference Giebel, de Boer, Gabbay, Marlow, Stoop, Gerritsen and Verbeek2023), as well as Canada (Gibson et al. Reference Gibson, Alford, Ward and Hunter2025).
As the detrimental impact of public health policy to family relationships was recognized, LTC homes quickly adapted to mitigate the associated harms and alleviate resident isolation during the lockdown by supporting alternative forms of family contact within the required parameters (Luo et al. Reference Luo, Hawkley, Waite and Cacioppo2012; Van der Roest et al. Reference Van der Roest, Prins, van der Velden, Steinmetz, Stolte, van Tilburg and de Vries2020; McArthur et al. Reference McArthur, Saari, Heckman, Wellens, Weir, Hebert, Turcotte, Jbilou and Hirdes2021; Paananen et al. Reference Paananen, Rannikko, Harju and Pirhonen2021). For example, in Canada, distanced outdoor visits were arranged in warmer seasons. Some homes introduced ‘window visits’ with family, supported by telephone technology and a clear view through a window. Most LTC homes turned to ‘virtual visits’ mediated by telephone and videoconference technology to connect residents with their families.
International research examining the advantages of these methods in an LTC setting has documented mixed results. Despite expressing a preference and desire for unrestricted in-person contact with relatives, as experienced prior to the Covid-19 pandemic, family care-givers in Switzerland (Bernardi et al. Reference Bernardi, Fiordelli, Rubinelli, Spagnoli, Malacrida and Martignoni2024), Norway (Badawy et al. Reference Badawy, Solberg, Obstfelder and Alnes2023), Australia (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023), the Netherlands and the United Kingdom (Giebel et al. Reference Giebel, de Boer, Gabbay, Marlow, Stoop, Gerritsen and Verbeek2023) also described appreciation for the opportunity to have telephone, virtual and socially distanced (outdoor, window and pod) visits. For example, family care-givers in Australia described how virtual visits allowed them to monitor the health status and care quality of their relatives by observing their physical appearance, behaviour and environment (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023). These visits sometimes facilitated social enrichment as family care-givers held conversations, observed non-verbal communication, and shared pictures and videos through screensharing (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023).
Nevertheless, studies conducted in Australia (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023), Switzerland (Bernardi et al. Reference Bernardi, Fiordelli, Rubinelli, Spagnoli, Malacrida and Martignoni2024), the Netherlands and the United Kingdom (Giebel et al. Reference Giebel, de Boer, Gabbay, Marlow, Stoop, Gerritsen and Verbeek2023) also identified that many residents, particularly those living with cognitive decline and hearing loss, struggled to understand and effectively engage with outdoor and virtual visits, even when support was provided by staff. Challenges with the privacy (Giebel et al. Reference Giebel, de Boer, Gabbay, Marlow, Stoop, Gerritsen and Verbeek2023; Hardy et al. Reference Hardy, Fanaki, Savoie, Dallaire, Wilchesky, Gallani, Gagnon, Laberge, Voyer, Côtéc, Couture and Dallaire2022) and frequency (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023) of availability of virtual and socially distanced visits were also identified due to the reliance on technology and support from staff (particularly with virtual visits) (Giebel et al. Reference Giebel, de Boer, Gabbay, Marlow, Stoop, Gerritsen and Verbeek2023; Hardy et al. Reference Hardy, Fanaki, Savoie, Dallaire, Wilchesky, Gallani, Gagnon, Laberge, Voyer, Côtéc, Couture and Dallaire2022) and the fact that socially distanced visits (e.g. outdoor, pod visits) were often held in communal spaces (Giebel et al. Reference Giebel, de Boer, Gabbay, Marlow, Stoop, Gerritsen and Verbeek2023). Finally, practical issues organizing technology-mediated virtual visits have also been described. Within LTC homes, these practical issues included a lack of access to hardware, software and internet access; difficulties with scheduling visits given staff roles/assignments, ratios and shortages; ethical dilemmas involving privacy; and inexperience with the required technology (Chu et al. Reference Chu, Yee and Stamatopoulos2022; Kelly et al. Reference Kelly, Xing, Baker and Waycott2023).
It is important to evaluate whether and how to operationalize technology-mediated communication in LTCs in future epidemics and pandemics (Chu et al. Reference Chu, Yee and Stamatopoulos2022; Hardy et al. Reference Hardy, Fanaki, Savoie, Dallaire, Wilchesky, Gallani, Gagnon, Laberge, Voyer, Côtéc, Couture and Dallaire2022). Accordingly, this study aimed to understand how Canadian LTC staff experienced virtual visits between residents and family care-givers during the Covid-19 pandemic, with a particular focus on how recreation staff members adjusted their practice to implement the visits, what challenges arose, what supports were available and how they evaluated the practice of virtual visits.
Research context
This study focused on the coordination of virtual visits in publicly funded rural LTC homes in the Western Canadian province of Saskatchewan during the Covid-19 pandemic. Recreation teams played a significant role in the coordination of these visits. In Canada, recreation therapists are generally required to obtain a bachelor’s degree in recreation with a specialization in therapeutic recreation, and certification as a recreational therapist (Government of Canada 2023). Supervised training is often required (Government of Canada 2023). Recreational therapists are responsible for assessing residents’ recreational capabilities and needs, creating and implementing individual and group treatment plans (e.g. art, music and dance programmes) and co-ordinating, designing and implementing specialized therapy programmes for the LTC community (Government of Canada 2023). They may be employed as therapists or as coordinators who plan and oversee the work of recreation workers, who have no specialized training. Rural LTC homes can be supported by recreation workers, therapists or coordinators.
Methodology and methods
This study involved a qualitative analysis of semi-structured interview data. Qualitative interviews support the exploration of the unique personal experiences of interviewees in relation to a particular phenomenon (McGrath et al. Reference McGrath, Palmgren and Liljedahl2019). Additionally, semi-structured interviews provide a few predetermined questions to guide the interviewee to key topic areas (McGrath et al. Reference McGrath, Palmgren and Liljedahl2019) but also permit researchers to explore statements and ideas that are brought up during the interview, which can enhance understanding of the phenomenon being explored (Adeoye‐Olatunde and Olenik Reference Adeoye‐Olatunde and Olenik2021).
Participants and recruitment
A recreation specialist (i.e. recreation therapist responsible for supporting provincial policy) was asked to send out a pre-formatted email invitation to all recreation team members (i.e. workers, therapists or coordinators) in four rural LTC homes in the province. At about the same time, LTC home managers were asked to circulate a poster reminder to recreation workers twice in the span of two weeks. Any LTC recreation staff interested in participating in the study were asked to contact the researcher directly by email. The research interviewer also invited participation from supervisors (including directors, care coordinators and nurse supervisors), given their unique perspective on the organization of LTC staff work, including the deployment of recreation workers to coordinate virtual visits.
Interviews
One-on-one semi-structured interviews were conducted over the course of three months, from June to August of 2021, by a research interviewer who met with each participant using WebEx video conferencing software or telephone. The interview focused on the experiences of LTC staff when implementing virtual visits during the Covid-19 pandemic. Specific questions included which methods of distance communication were utilized to connect residents with their family, what challenges arose, what supports were available and the overall quality of virtual visits. Interviews lasted approximately 60 minutes and were conducted in a semi-structured, conversational style. All participants were asked the same questions. Recordings of the interviews were software auto-transcribed verbatim and then edited to correct any auto-transcription mistakes.
Ethical considerations
Prior to each interview, the researcher confirmed and documented free, informed consent, using an oral consent process. All participants consented. To maximize participant confidentiality and freedom of consent, potential participants contacted the researcher directly through email to express interest in participating, and interviews were conducted remotely. The use of WebEx videoconferencing for some interviews presented some risk to confidentiality of information due to WebEx’s third-party storage of interview data. Participants were made aware of relevant risks, and audio/video recordings and transcripts were transferred from WebEx or from digital audiorecording devices (in the event of a telephone interview) to secure university storage and then deleted from the interviewer’s WebEx account and from a backup digital audiorecorder. Additionally, researchers accessing participant data signed confidentiality agreements and completed a training module on research ethics.
Analysis
Interview data were analyzed using reflexive thematic analysis as described by Braun and Clarke (Reference Braun and Clarke2019, Reference Braun and Clarke2022). In this approach to data analysis, a core concept – in this case, the experiences of staff in LTC when implementing virtual visits – is explained by interpreting patterns or themes discerned across participant interviews. As this approach is flexible enough to examine a variety of research questions (Braun and Clarke Reference Braun and Clarke2006; Clarke and Braun Reference Clarke and Braun2013), it has become widely used in health and social science research.
Analysis involved six phases including: (1) familiarization; (2) data coding; (3) initial theme generation; (4) theme development and review; (5) theme refining, defining and naming; and (6) writing up (Braedley et al. Reference Braedley, McWhinney, Barclay and Jensen2019; Braun and Clarke Reference Braun and Clarke2006, Reference Braun and Clarke2022). Phase 1 began with a review of all transcripts to anchor the analysis. Afterward, in Phase 2, each transcript was inductively coded, with attention to specific phrases and potential underlying meanings related to the study aim. Transcripts were then recoded, confirming the continued relevance of the codes. Next, in Phase 3, codes were grouped into higher-level categories. At this stage, analysis was further engaged by constructing a mind-map of codes and categories to examine the potential meanings of the thematic categories, including their interconnections. In Phase 4, the categorized codes and theorized interconnections were introduced and explained to other members of the research team, who shared their own perspectives and reflections (anchored in Covid-19 pandemic experience, research and/or clinical practice) to further engage the analyst’s own reflections. Following this, the analyst worked in collaboration with the last author to determine which themes were most salient to the study aim. In Phase 5, the analyst described each of these themes based on its defining factors, seeking to encapsulate all data found within the theme, while remaining concise (Braun and Clarke Reference Braun and Clarke2006). Lastly, in Phase 6, the analyst engaged the research team in reviewing the thematic summaries, and used their comments to refine the translations of the resulting themes.
A reflexive approach was cultivated in several ways. For example, the analyst (i.e. the first author) actively reflected on the ways in which Covid-19 pandemic policy shaped their own experience, including as a volunteer in a health department. Ethical issues and dilemmas were a prominent feature of this volunteer role, and also salient in the interview data, prompting further reflection on these issues, and how they might be experienced or interpreted from different vantage points. The analyst also participated in weekly research team reflection on multiple projects, including this one, engaging further attention to the social context of LTC and to the distinct perspectives of each study’s participant groups. These internal and social processes engaged the analyst in actively reflecting on what participants were experiencing and how these experiences might best be communicated with others.
Findings
Eight people participated in the study. Five participants were recreation team members (i.e. recreation workers, therapists, coordinators) and three were supervisors (i.e. nurse supervisors, care coordinators and directors). Participants ranged in age from 33 to 55 years, and had anywhere from 6 to 33 years of work experience. An overarching theme of holding it together: working with the imperfect to support resident and family communication was generated using the LTC staff’s experiences with implementing virtual visits to maintain connection between residents and family. This central theme encompassed four additional themes: adapting to distanced communication as a temporary ‘new normal’, tolerating the discomfort of new roles, needing to rely on each other in difficult circumstances, and disconnect between policy and on-the-ground experience.
Adapting to distanced communication as a temporary ‘new normal’
The switch to virtual communication during the Covid-19 pandemic impacted everyone in the LTC community. Staff reported that since residents and family were no longer allowed to visit each other in person, staff were expected to lead a smooth transition to an entirely new form of communication. Many noted that their LTC homes had not previously needed any forms of distanced communication, requiring them to develop the associated infrastructure, devices, applications, skills and workflow from scratch. Not only was there a sudden need for significantly more access to internet and associated technologies within the LTC homes but there was also an immediate need to develop skills in interacting with that technology.
The use of virtual visits required a compatible communications strategy at both the LTC end and the family end. In particular, participants described the need for flexibility and effort to accommodate the range of devices, applications and skills available to family care-givers. As one participant noted:
And then we had to get Skype because that’s the only way some could communicate, and then some have, of course, FaceTime. We need to know ourselves how to navigate through that stuff. (Participant 6, recreation team member)
Several participants reported that some family members were entirely unfamiliar with some applications and initially had trouble setting up the applications and associated accounts. They reported being unable to assist directly but nevertheless offering recommendations and encouragement.
Staff found that residents also initially struggled to adapt, since the technology was not always ‘user friendly’ (Participant 8, supervisor); that is, it was not always adjusted to the level of sensory, motor or cognitive function of LTC residents. They reported, for instance, that screen size, volume levels and software accessibility were not always accommodating, and in some situations, extra adaptations had to be made. For example, in some cases, to enable residents to properly see and hear their families, images were shared from a tablet or telephone to a television. As one staff member explained:
I was able to mirror it. There’s a big screen TV in there so I would mirror the FaceTime video on the television, and they would actually be able to see their family, because an iPad is small. (Participant 2, recreation team member)
Since residents in LTC often need support for physical and cognitive functional changes, many could not independently meet with their families. Thus, more staff time was required to maintain resident and family contact when family care-givers were not permitted to enter LTC homes:
For dementia, for instance, well they might not want to do what you want to do at that exact minute. So, a lot of time was put into gathering the residents, bringing them to where we’re supposed to go, and then dialing up the process. So, it was very time-consuming. (Participant 5, recreation team member)
At this time, staff supported residents by ensuring that they were available and ready to have a virtual visit when the time came, setting up the technology and software programs, remaining nearby to assist in maintaining the visits, communicating on behalf of residents with dementia and assisting residents to and from locations that best supported virtual visits. For example, one staff member stated:
Sometimes I have to take them to the place where there’s better internet service. A little bit of running around and then I stay with them during the phone call because sometimes it hangs up, or it gets disconnected, or sometimes family members have little questions. And then when it’s done, I would take them back. (Participant 7, recreation team member)
Staff reported that to achieve this, a great deal of coordination was required, including creating schedules for residents, families and staff; changing work routines; and implementing new forms of teamwork to facilitate residents’ attendance at and participation in scheduled virtual visits. When describing the cooperation that was required between departments, one staff member explained:
[The health authority] had said [all virtual visits have] to go through recreation, but in all honesty, a lot of people got phone calls and whatnot via FaceTime, or Skype, when we [recreation staff members] weren’t here. And our care staff was very, very willing and able to accommodate getting them set up on that whenever it was needed. (Participant 1, recreation team member)
Since there was no new information technology support or virtual visiting support role in LTC homes, the work of coordinating virtual visits necessarily supplanted other work. For instance, recreation staff found that new assigned work associated with virtual visits reduced their availability for recreational programming. Seeing that this programming was important to quality of life during the Covid-19 pandemic, recreation staff felt pressed to meet both needs:
I have to do a [recreation] programme twice a day too, so [for] people who are wanting FaceTimes in those programme times I would tell them ‘no’ and we would pick a time where I’d have a little break between the programme and my lunch break, or just after lunch I would try to fit them in that way. So the other guys could still have programming. (Participant 7, recreation team member)
Despite experiencing the work of coordinating virtual visits as competing with the goal of providing meaningful recreational experiences, these staff reported using their time differently or flexibly to avoid compromising either aspect of care.
More generally, participants reported that this new way of promoting resident and family contact presented a steep learning curve for all involved, even though most reported adapting reasonably well to this approach with time and experience. For example, when speaking about residents’ responses to virtual visits, participants noted that it took time to get used to this way of communicating:
That’s the generation that we have in here. The FaceTime and whatnot was pretty weird for them at first. (Participant 1, recreation team member)
Many staff members, residents and family members had to learn how to use various types of technology and programming that they did not have much experience with previously. When speaking about staff specifically, one participant stated:
Some of us aren’t as technologically inclined as the others. (Participant 5, recreation team member)
However, with repeated exposure, the same participant described that for many staff, ‘we learned quickly’ (Participant 5, recreation team member). Overall, there was an adjustment period required for everyone involved in the process of running and attending these virtual visits. Still, residents seemed to enjoy seeing their family members in this format:
… overall, they were just happy to be able to see their loved ones even if it was on a screen. (Participant 4, supervisor)
Some interviewees reported that families also adjusted well to distanced communication, especially when the technology allowed them to confirm that their relative was doing well:
Most of them took to it really well … I think overall the families are pretty happy with [it]. If their loved ones are content, they were content. (Participant 4, supervisor)
Although virtual visits were not a seamless method, participants understood them as a stop-gap strategy that importantly allowed for some level of communication between residents and their families during a period of separation.
Tolerating the discomfort of new roles
Given the new requirements to set up virtual visits, recreation staff began to take a high volume of phone calls and emails that they were not used to, as family members enquired about residents and tried to set up visits. Family members checked in by telephone and email often due to their fears about Covid-19. Whereas prior to the Covid-19 pandemic, families could connect with residents without necessarily needing to contact staff, now staff needed to connect with family members much more directly than previously, especially to relay information to worried families when uncertainty arose, as described here:
It was harder at first, just because you get so many phone calls and, you know, worried emails, so I think once we started sending out that regular communication to the families, then it kind of kept them informed, so they weren’t all calling the facility to figure out what was going on. (Participant 4, supervisor)
The relatively sudden change in their involvement in supporting families left some recreation staff feeling uncomfortable about their level of knowledge and skill. For instance, one stated:
And then I would get kind of really nervous because you don’t really know the families that well. And sometimes they’ll want to ask you questions that you can’t give an answer [to]. (Participant 7, recreation team member)
At times, they felt they were not entirely cut out for the new role that was required of them. Many recreation staff described feeling less like recreation staff and more like social workers. Several would have preferred that people be hired specifically for this role, instead of having the role absorbed by recreation staff. They felt that their recreation activities and programme planning became disrupted and overshadowed:
I felt that they should have hired somebody specifically for that purpose, rather than taking our departments away from the other residents. (Participant 1, recreation team member)
However, understanding the significance of these adaptations to residents and families, staff persevered in adapting to significantly altered work roles.
The need to rely on each other in difficult circumstances
In many instances, the challenges brought forth by the Covid-19 pandemic required a group effort from within the LTC community, inclusive of residents, families, staff, leaders and others with an interest. Staff reported that one significant way in which the community came together for LTC at the outset of the pandemic was related to technology. Many family members and outside organizations realized the need for updated and increased technology in LTC for the purpose of virtual communication and went as far as donating the technology that LTC homes needed but could otherwise not attain. One staff member noted how they ‘were gifted two iPads’ (Participant 1, recreation team member), while another mentioned:
I think it was because of the outbreak that we received two iPads that have data and I believe the data is paid by someone of a donation … the data has helped. (Participant 2, recreation team member)
Staff believed that this allowed virtual visits to begin more quickly than would have otherwise been possible and helped to address the needs of residents and families.
Staff began to rely more on each other, as well. Some reported that since Wi-Fi often only worked in certain areas of the building, they would work together to make sure that those spaces were available for residents when they needed them. Several reported that they had to assume each other’s roles at times; for instance, if recreation staff were not available, then continuing care assistants and nurses assisted with scheduling or setting up virtual visits. Recreation staff, in turn, reported that they were also helping with mealtimes, getting residents out of bed, taking them to the washroom or helping with morning self-care, such as dressing and styling hair. Staff had to work around each other’s schedules and make numerous changes throughout the day to ensure that residents were supported in general and able to attend virtual visits with their families. As one staff member described:
We had a heavy schedule [of] FaceTimes. That’s where we juggled. … so, I mean, we did accommodate everybody as best we could. … Because we felt that was important. (Participant 5, recreation team member)
As work changed rapidly, and the psychosocial needs of residents and families demanded attention, daily schedules were less certain, and staff communicated actively to assist each other in supporting residents’ needs.
Staff, residents and families relied on each other during virtual visits. For instance, to support the participation of residents with cognitive impairment, staff needed to remain present during family visits to orient residents to the meeting and avoid residents accidentally exiting the meeting. For instance, one staff member described:
If they couldn’t [handle it on their own] because some of them liked to push buttons and play around, and they might get hung up on and [recreation staff] would stick around just to make sure that that call continued. (Participant 4, supervisor)
Despite the new demands, many of the staff found this work rewarding and experienced a sense of community in navigating these experiences in a mutually supportive way:
But we’re here every day for them. With them. Going through this with them. Experiencing it with them. (Participant 6, recreation team member)
Staff understood that both residents and family members were relying on them during a particularly difficult time and viewed their relationships and connections with each other as important to getting through the Covid-19 pandemic together. Regardless of the challenges presented, many staff were willing to do all that they could to make sure that residents remained safe, healthy and connected with their families throughout the pandemic.
Disconnect between policy and on-the-ground experience
Although staff were willing to adapt to new requirements to support residents’ needs during the Covid-19 pandemic, they expressed concerns about whether the policies they were asked to implement had taken the LTC context into full account. For instance, recreation staff commented that their teams had been understaffed to provide effective recreation programming to residents, even prior to the Covid-19 pandemic. To properly maintain programming, it would have been important to provide adequate staffing and time to do things like research potential activities, as well as plan, schedule and execute their recreation and leisure activities. One participant commented:
I know that [management says] it should be like twenty-something [residents per recreation team member] but it’s just not enough. There’s a lot that could be done more effectively if we had more staff. (Participant 2, recreation team member)
The extensive involvement of recreation staff in supporting virtual visits further compromised capacity for their traditional work of planning and supporting recreation and leisure activities.
Concerns about the appropriateness of staffing levels were exacerbated by staff absences due to illness, and by a decision, early in the Covid-19 pandemic, to ‘cohort’ staff by assigning them to a single unit or health-care setting to potentially reduce viral spread. Since staff had previously been working across two or more homes or units (a situation that was reportedly more common in rural health-care settings that were sharing some staff roles), this directly compromised staffing within some homes or units. One staff member noted:
It was too difficult to make up the schedule and then, you know, when people were sick, and there was relief coming in it was like ‘oh no, that person couldn’t work over there’ so … it was unobtainable/ (Participant 3, supervisor)
Most staff reported concerns about the effects of a restricted workforce on the quality of care. Since there was less flexibility to relieve absences or share staff across units, those available to the unit often found themselves obliged to accommodate by offering more than their usual part- or full-time work commitment. Nevertheless, some staff viewed cohorting measures as a safety-promoting policy.
When the recommendation to support virtual visiting was introduced, LTC staff and supervisors felt intensely frustrated and let down that their requests for improved technological infrastructure, more devices, staff support and additional resources often went unanswered. This is exemplified by Participant 6, whose frustration was clear one year after the onset of the Covid-19 pandemic:
Oh, we still don’t have internet over in my ward. The internet is not good here at all. … we were promised it, but we never did get it. (Participant 6, recreation team member)
The sense that they were being asked to do new kinds of work without adequate resources led to rising tensions within the organization. Several participants noted that they did not feel supported by more senior personnel:
Maybe involve all departments too, in the planning, and in the meetings, and the – recreation has always [been] kept in the dark, so to speak, and that shouldn’t be. (Participant 5, recreation team member)
Overall, some staff felt that the situation could have been mitigated through additional consultation and communication.
Many staff also found some of the health and safety orders to be counter-intuitive and struggled to keep up with the constant changes to regulations. Since a number of different authorities provided regulations during the Covid-19 pandemic period, staff perceived that they were given differing sets of rules that resulted in confusion. In relation to this, one staff member commented:
We literally didn’t get a system in place. We just kind of winged it every day. Every day was a new day … rules changed every day. (Participant 6, recreation team member)
Since there was always new and different information coming in, and supervisors were not always immediately available, staff felt that they needed to interpret what was intended. Supervisors, too, confirmed that continuous (e.g. daily) changes and competing instructions were coming from different authorities (e.g. local advice from medical health officers, public health advice from the Ministry of Health and universal requirements from the provincial health authority). They noted that, although LTC homes received the same information and instructions, the pace and volume of new policies resulted in inconsistencies in interpretation and implementation across homes. Considering how this affected staff, one supervisor reported:
There’s a lot of frustration on the part of the staff. Things were not very consistently done. Different facilities were doing different things based on their interpretation of the [health authority directives] or the public health orders. (Participant 8, supervisor)
Even when policies were clear, they sometimes introduced double standards that staff members had difficulty understanding. This was a particular concern for policies that did not appear to provide any additional level of safety for LTC residents or seemed to otherwise compromise care. For instance, one staff member explained that the rules for dining and recreation were inconsistent:
You can have your tablemate [at breakfast], but yet, when it comes to programming, you have to sit six feet away from them. (Participant 5, recreation team member)
Situations such as these activated a sense of disconnect with policy makers. Although staff understood the intention behind each of the decisions, they were frustrated that policy makers were missing the benefit of staff members’ direct experience and knowledge. One staff member said:
They make these changes and decisions and whatever, but they need to walk a mile in our shoes before judging or thinking they know. (Participant 5, recreation team member)
Many wished for the perspectives of staff to be included through consultation processes in future epidemic or pandemic responses.
Staff advocated to have heard not only their own voices but those of the residents and families as well. Before the Covid-19 pandemic, family and residents were able to provide input more easily through options like forums and regular meetings. However, the pandemic prevented these things from happening, as one staff member described:
We’ve always had the family resident council meetings that, you know, family comes in if they want to as well as any of the residents that want to participate, and we would have regular meetings with them. That’s something that hasn’t happened since the pandemic [began]. (Participant 4, supervisor)
Staff felt that, regardless of one’s role in the LTC community, as a resident, family member or staff, there was very little one could do or say to influence the direction of plans made during the Covid-19 pandemic. This often left staff frustrated, as they felt that residents deserved more out of their living situation. Staff understood that LTC homes were ultimately designed to support residents and believed that everything done within them should be done for the sake of the residents. As one commented:
They don’t live in our workplace, we work in their home, right? [Administrators] have to start focusing on these residents and how it’s their home. … They need to be in a place where they feel safe and at home … [Administrators] need to focus on that more. (Participant 5, recreation team member)
In this way, the Covid-19 pandemic helped staff see residents’ and families’ unmet needs and human rights more clearly, and staff aimed to translate these needs and rights, advocating on their behalf.
Discussion
This study examined the experiences of staff and supervisors who were involved in supporting virtual visits in rural LTC homes in one Canadian province during the Covid-19 pandemic. Their experiences can be summarized by the theme holding it together: working with the imperfect to support resident and family communication. This overarching theme encapsulates four subthemes: adapting to distanced communication as a ‘new normal’, tolerating the discomfort of new roles, needing to rely on each other in difficult circumstances, and disconnect between policy and on-the-ground experience. The findings of this study contribute to a body of evidence supporting future epidemic and pandemic planning in the LTC sector, highlighting the importance of staff involvement in planning.
Consistent with findings documented in other research, LTC staff initially found the adjustment to virtual visits challenging. Long-term care homes did not have the technological infrastructure required to efficiently run virtual visits (Chu et al. Reference Chu, Yee and Stamatopoulos2022). Internet access and technological availability was not guaranteed, seemingly related to factors such as geographical location, infrastructure, building age and historic adoption of technology. Family and community support was paramount to navigating such challenges throughout the Covid-19 pandemic. For example, when many LTC homes struggled to provide enough of the technological devices necessary to run consistent virtual visits, family members often stepped in to purchase Wi-Fi or devices and data plans for their family members or others at the home (Chu et al. Reference Chu, Yee and Stamatopoulos2022). It was also common for the community at large to donate devices or internet plans or enhancements for the residents (Hockley et al. Reference Hockley, Hafford-Letchfield, Noone, Mason, Jamieson, Iversholt, Musselbrook, Palattiyil, Sidhva, Quinn, Jain, McKie and Tolson2021). Similar challenges related to the limited availability of technological devices were noted by family care-givers in Australia (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023) and Switzerland (Bernardi et al. Reference Bernardi, Fiordelli, Rubinelli, Spagnoli, Malacrida and Martignoni2024), as well as staff in LTC in the United Kingdom (Collingridge Moore and Cotterell Reference Collingridge Moore and Cotterell2025). For instance, in some cases, staff provided personal devices for residents to use for virtual visits to supplement the small number of available devices in the LTC homes (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023; Collingridge Moore and Cotterell Reference Collingridge Moore and Cotterell2025). Additionally, family care-givers in Australia (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023) also noted how unreliable internet access impacted the quality of virtual visits, while family care-givers in Switzerland (Bernardi et al. Reference Bernardi, Fiordelli, Rubinelli, Spagnoli, Malacrida and Martignoni2024) described delays in accessing internet as the LTC facility had to have it set up after the onset of the pandemic.
Beyond a new use of technology to support communication, virtual visits became an important new form of work to support residents’ quality of life. Yet, access to adequate staffing to support this and other aspects of quality of life was a concern. This concern predated the Covid-19 pandemic and was exacerbated during the pandemic by resignations, lay-offs and sick days (Fisher et al. Reference Fisher, Cárdenas, Kieffer and Larson2021), as well as the implementation of staff cohorting measures, which reduced the number of staff available to work at a specific home (Hung et al. Reference Hung, Yang, Guo, Sakamoto, Mann, Dunn and Horne2022). Staffing shortages were prominent in Canadian LTCs prior to the Covid-19 pandemic; moreover, some rural health-care organizations relied on shared positions to promote greater access across health-care roles. Thus, the requirement to cohort staff had unforeseen consequences for staffing and access to care, and reduced trust in policy makers.
Providing technological support for virtual visits and psychosocial support for families was something that many staff did not anticipate as part of their pandemic work role. Beyond this, as staff responsibilities in some areas increased, capacity in other areas decreased. Specifically, with the addition of new, time-consuming roles, staff were less able to perform their usual responsibilities at the same capacity that they were able to prior to the Covid-19 pandemic. These findings are consistent with previous research examining the experiences of recreation staff in Canadian LTC homes during the Covid-19 pandemic (Genoe and Johnstone Reference Genoe and Johnstone2021). For instance, staff described how during the pandemic they were responsible for coordinating and facilitating virtual visits, which shifted their focus and time away from their typical duties such as providing programming and assessment. Additionally, in the current study, many staff members remained uncomfortable with these new roles more than one year into the Covid-19 pandemic. Previous research has also found similar discomfort resulting from these new roles, as other staff from LTC homes reported increased communication with families to ease their worries during the Covid-19 pandemic (Havaei et al. Reference Havaei, MacPhee, Keselman and Staempfli2020; Hockley et al. Reference Hockley, Hafford-Letchfield, Noone, Mason, Jamieson, Iversholt, Musselbrook, Palattiyil, Sidhva, Quinn, Jain, McKie and Tolson2021). Since family support is imperative to the 69 per cent of Canadian LTC residents living with dementia (CIHI n.d.a), and to most people, generally (Ayalon et al. Reference Ayalon, Zisberg, Cohn-Schwartz, Cohen-Mansfield, Perel-Levin and Siegal2020), it is surprising that this was initially an uncomfortable role for LTC staff.
Digital accessibility has been recognized for its usefulness to those living with disability (Botelho Reference Botelho2021). However, consistent with findings from previous research, the available technological devices and software were often challenging for LTC residents with sensory, cognitive or mobility impairment to use without additional support or adaptation due to factors such as screen size (Kelly et al. Reference Kelly, Xing, Baker and Waycott2023) and volume levels (Chu et al. Reference Chu, Yee and Stamatopoulos2022). Further adaptation and testing of solutions is therefore needed. In Norway, an interactive technology known as ‘KOMP’ responds to some of these challenges. A KOMP device is described as having a small 17-inch TV screen, built-in Wi-Fi, no touch screen and only one button which turns the device on and off. A study conducted by Badawy et al. (Reference Badawy, Solberg, Obstfelder and Alnes2023) examining the use of this device found that family care-givers described KOMP as a convenient way to interact with their relatives in LTC as the only requirement for residents is to turn the device on and off and family care-givers are able to facilitate communication without waiting or scheduling with staff.
Recommendations for future pandemic-related policy
This study helps to illustrate that public health policy development for LTC, and for analogous integrated health settings in rural areas, requires a more robust understanding of these settings and the needs and experiences of those living and working within them. It is unclear, for example, why in some Canadian jurisdictions recreation workers (rather than social workers, family visit coordinators or information technology coordinators) were hired for the job of connecting families through technology. More worrisome is that many evaluations, including this one, have focused on what was done, and was perceived necessary, rather than on available alternatives. For instance, it remains important to validate the use of videoconferences for residents with mid- to late-stage dementia, and to demonstrate the kinds of adaptations that are necessary. There is also a need to closely evaluate the use of short- and long-term policies separating residents and families, both for effectiveness as an infection control measure and on human rights grounds. Based on the outcomes of this study, and contextualized in the associated evidence review, we therefore advance recommendations to support policy development for virtual visits during future epidemics and pandemics. Given the similarities between challenges experienced by staff in this study and those reported by staff internationally (Collingridge Moore and Cotterell Reference Collingridge Moore and Cotterell2025), the following recommendations should be considered both within and outside of the Canadian LTC context:
1. Determine whether there are alternate policy mechanisms to achieve reduced risk in LTC without precluding family contact.
2. Develop staff competencies in family-centred care to support skill and efficacy in interacting with and supporting family care-givers in LTC.
3. Conduct additional research to gain perspectives on virtual visiting in LTC from a more diverse sample of staff – and also, especially, from residents and families.
4. Consider, develop and test the digital communication formats that best enable resident participation. In doing so, consider the circumstances (e.g. technologies, abilities, preferences, supports and contexts) that best enable residents with sensory and cognitive impairments to participate in virtual visits. Also consider and evaluate alternatives to technology-mediated solutions.
5. Introduce standards and policies regarding the required availability of and access to communication resources within LTC homes, including internet and internet-compatible devices, to ensure that all homes, regardless of location or infrastructure, are provided with the same level of support. Identify the range of circumstances for which digital accessibility may be an advantage, and coordinate evaluation.
6. Support LTC homes in rural and remote locations with technology access, including service reviews, staff training that includes consideration of the local context, and regular dialogue with government about service structures, processes and funding.
7. Determine how LTC staff will be supported to implement non-standard practices in emergencies and pandemics; for instance, through increased staff involvement in decision-making, and collaborative efforts among the government, upper-level management and health authorities.
8. Determine how non-standard practices implemented in LTC during emergencies and pandemics will be evaluated in a timely fashion and adjusted accordingly.
9. Finally, given that the LTC sector is likely to be a high-risk setting in future epidemics, we recommend that these mechanisms be developed and tested collaboratively and proactively.
Strengths and limitations
This study contributes to knowledge of the experience of implementation of virtual visits in Canadian LTC homes during the Covid-19 pandemic. Qualitative research allows for a better understanding of subjective experiences of participants, which are not directly observable. Additionally, the use of semi-structured interviews provided flexibility to explore areas identified as important by participants that may not have been identified by the research team (Gill et al. Reference Gill, Stewart, Treasure and Chadwick2008). Furthermore, although qualitative research is not assumed to be ‘generalizable’, it is assumed that some findings may be transferable to the degree that there is similarity across contexts. In this case, it is important to acknowledge that results were generated in a subset of LTC homes in one Canadian province and may not be directly transferable to all LTC contexts internationally (or even within Canada, given Canada’s provincialized health-care system). Additionally, the occupational roles represented in this study were recreation staff and supervisors within LTC, which does not represent all occupational roles involved. Furthermore, LTC staff perspectives might differ from resident and family perspectives, which were not included in this study. The temporal and geographical contexts of the study are also important. Interviewees reflected on their experiences over approximately the first year of the Covid-19 pandemic, with interviews taking place in Canada’s warm summer season in 2021, after vaccines had been released and contact restrictions began to be lifted. Thus, participants were recalling their experiences of more restrictive policies retrospectively, and not reporting them as they happened, potentially reducing access to more specific details, a limitation also noted in other studies of emergencies and disasters (Galea et al. Reference Galea, Maxwell and Norris2008). Specifically, recalling memories is a reconstructive process (Schacter et al. Reference Schacter2012). During memory recall, information from the past is pieced together to form a coherent narrative (Schacter et al., Reference Schacter2012). During this process, memories are subject to distortion, and factors such as suggestive cues (Lindsay et al. Reference Lindsay, Hagen, Read, Wade and Garry2004) and interviewing style (Weinberg et al. Reference Weinberg, Wadsworth and Baron1983) can increase the probability that memories will become distorted. However, there is evidence to suggest that while the quantity and richness of episodic memories may decline, details that are recalled can remain accurate over time (Diamond et al. Reference Diamond, Armson and Levine2020).
Conclusion
The results from this study shed light on the experiences of recreation staff and leaders implementing virtual visits in LTC during the pandemic. Staff highlighted a number of difficulties including the lack of availability of technology within LTC, challenges with accessibility and usability of technology for residents and family care-givers, the significant amount of time needed for recreation staff to facilitate virtual visits and disconnects between pandemic policies and on-the-ground experience. However, staff also discussed how they adapted their roles to integrate virtual visits and how the LTC community worked together to support virtual visitation. The current study contributes to the literature on LTC homes and their experiences during the Covid-19 pandemic and highlights some of the recommendations made by staff that could be useful when developing infection control policies and when introducing technology-mediated work in LTC. When developing policies for LTC, there are several relevant population, resource and context considerations to consider. The information gathered from this study provides evidence of specific areas of ‘policy disconnect’ and could be useful in facilitating further dialogue and planning about suspension of family contact, implementation of technology-mediated work and policy alignment across work areas. The results of this study underscore that successful policies that support safe, high-quality care must be informed, workable and appropriately paced, to encourage trust and strong implementation. To achieve this, it is important to involve staff and supervisors, as well as residents and family members, in a way that takes their various experience into account.
Author contributions
Y. Tendulkar, K. M. Ottley, T. Qiao and P. V. Hunter conceptualized the study and designed the interview guide in consultation with I. Myge. Y. Tendulkar completed the interviews. M. Hamilton led the analysis and wrote all drafts of this manuscript. I. Myge and P. V. Hunter consulted on and supported the data analysis and manuscript drafting. P. V. Hunter provided research team support and supervision through all stages of the project. All authors edited and approved the manuscript before submission. We thank Arden Poppel for reviewing and copyediting this manuscript.
Financial support
N/A.
Competing interests
The authors declare none.
Ethical standards
Ethics approval for this study was initially granted by the University of Saskatchewan Behavioural Research Ethics Board (# 2504).
Open access
