Lived Experiences of Long-Term Care Administrative Staff Responsible for the Admissions Process

Abstract The process of admission of, typically, older residents into long-term care (LTC) has been greatly examined from the perspectives of the residents and their family members/caregivers. However, the viewpoint of the administrative staff directly involved has been left relatively unexamined. This article highlights findings from a qualitative study focused on exploring the lived experiences of LTC administrative staff working with residents-to-be and families/caregivers during the admissions process. Data from semi-structured interviews with seven participants indicate that these individuals often take on roles/tasks that go beyond the scope of their official work descriptions. Participants acknowledged the heavy toll of the stressful nature of their work on their health/well-being, but often normalized the pressures as part of their professional, if not personal, responsibilities to help others. Recommendations on improving the admissions process highlighted the lack of critique of the LTC system, despite its responsibility for the challenges that shape their day-to-day work.


Introduction
The admissions process into a long-term care (LTC) facility is a stressful process that prospective residents and their family members/caregivers have to maneuver prior to ensuring a space for the resident-to-be. The current study, which was conducted before the pandemic, emphasizes the need for paying closer attention to the administrative staff in the LTC system, as improvement of the LTC admissions system cannot occur without the inclusion of all major stakeholders involved. Little is known about this stakeholder group in the LTC system even though, in practice, administrative staff figure centrally in the lives of residents-to-be, residents, and their family members/caregivers, especially during such stressful events and care transitions, such as the LTC admissions process.
As defined by the Ontario Long-Term Care Association (Ontario Long-Term Care Association, 2017), LTC facilities are healthcare institutions that provide a variety of services on a 24hour basis to meet both the medical and non-medical needs of residents. This type of facility is synonymous with a "nursing home", as LTC typically provides care to older residents over longer periods of time to support the management of chronic illnesses and/or disabilities (Medline Plus, 2018). In Ontario, Canada, public LTC facilities, the focus of this study, are heavily subsidized by the provincial government so that the residents and/or their family members/caregivers do not services (C-Care, 2016). Whereas provincial subsidies suggest greater accessibility to LTC facilities, the situation in this province (certainly before the pandemic) has been the opposite with inaccessibility or difficult accessibility to public LTC facilities being predominant. A recent report illustrates the current wait time for a basic LTC room in the Toronto Central region, the area of this study, is anywhere between 608 days, at the earliest, to 2,339 days for the vast majority of those who apply for LTC residency (Toronto Central Local Health Integration Network, 2021).
In Ontario, the LTC admissions process involves the coordination of multiple stakeholders and numerous stages of application, review, and evaluation. Residents-to-be and/or their family members/caregivers have to apply for a potential placement at an LTC facility through the Local Health Integration Network (LHIN); a collective body governed by the Ministry of Health and Long-Term Care (hereafter referred to as the Ministry). The LHIN assumes responsibility for assessing the eligibility criteria of those who potentially need to move into a public LTC facility, and for providing information about the availability of beds in various public LTC facilities (Province of Ontario, 2014). Typically, this process begins with an online application as the LTC admissions process is predominantly a virtual procedure. As such, family members/ caregivers go through multiple steps online before finally coming face-to-face with the administrative staff at an actual LTC facility. The family members/caregivers must communicate their top five LTC facilities, in order of preference, to the LHIN and wait for availabilities within any of their selected locations. Once a space (a bed or room) becomes available at an LTC facility, the administrative staff of the LTC facility are responsible for informing the LHIN. An individual from the LHIN waitlist will then be assigned as a potential resident of the LTC facility, and the administrative staff at that LTC facility will be notified by the LHIN coordinator to examine the applicant's file for final review and approval. If it is then deemed that an offer should be made, the resident-to-be or, in most cases, the family members/caregivers (i.e., the personal power of attorney) have only 24 hours to accept the offer to move in. If the resident-to-be is not selected for a placement within the particular facility, they will continue to remain on the waitlist. If a room is accepted, the resident-to-be and/or their family members/caregivers will sign the admission agreement, move in, and initiate the week-long process of nursing examinations and meetings with the different multi-disciplinary teams at the LTC facility. If a room is not accepted by the prospective resident and/or family members/ caregivers, the resident-to-be is moved to the bottom of the waitlist for one of their preferred locations once again. Given the high likelihood that the resident-to-be has already experienced a long wait time, this becomes a major deterrent to rejecting any offer that is made.
Furthermore, most times, the decision to have a typically older family member enter an LTC facility is a last resort for family members/caregivers, as older persons often prefer living at home (Cheek & Ballantyne, 2001). The most common emotions experienced by family members during this process are guilt, helplessness, stress, and relief (Cheek & Ballantyne, 2001;Kellett, 2001;Nolan & Dellasega, 2001;Pearson et al., 2004). Ultimately, the inability to cope with taking care of an older person, the inability of the older person to cope alone, the lack of support from other family members, and the demanding health needs of the older individual outweigh the desire for, or ability to, provide unpaid care for a family member (Buhr et al., 2006;Cheek & Ballantyne, 2001;Davies & Nolan, 2004;Dellasega et al., 1995;Pearson et al., 2004;Ryan & Scullion, 2000).
From the previous description, it is evident that navigating the assessment and admissions process into an LTC facility can be challenging, confusing, and charged with many emotions. It is common to hear stories of residents-to-be and family members/ caregivers finding this admissions process frustrating and tedious, as they must undertake a large and complex application and intake process (e.g., collect a vast amount of medical information) before selecting an LTC facility to be waitlisted for, for future admission of the resident-to-be. In some cases, residents-to-be or their caregivers/family turn to specialized community organizations or forprofit placement agencies for assistance. But, in the majority of the cases, the most important support system for those navigating into and through the LTC admissions process is the actual administrative staff of the public LTC facilities themselves.
Existing research on the topic of LTC facilities has focused predominantly on areas such as the quality of life of the residents within facilities, variations in and the impacts of different types of care services provided in facilities, and the issues, concerns, and occupational welfare of the nursing and staff teams (e.g., Bloemen et al., 2015;Conner et al., 2010;Homer & Gilleard, 1990;Schiamber et al., 2012). In addition to this extensive body of literature, the lived experiences of the family members/caregivers of residents have also garnered great attention in the academic community (Armstrong, 2009;Pillemer et al., 2008;Smyer et al., 1992). Despite the stressful and emotional reality of the admissions process, the viewpoints of the administrative staff directly involved remain largely unexamined, especially in a Canadian context.
As key navigators of the admissions process, administrative staff work with and support family members/caregivers of the residentto-be. Wheras there is extensive interest in understanding the experiences of the families/caregivers, and rightfully so given the stressful and emotional nature of the admissions process, there is little attention directed towards administrative staff who are also involved in and affected by these interactions. Understanding the admissions process relies on a comprehensive examination of all stakeholders. This gap prompted a qualitative case study aimed at exploring the perspectives and experiences of the administrative staff working face-to-face with, typically, older persons and their family members/caregivers during the admissions process in Ontario. 1 For the purposes of this study, the term "administrative staff" is used to define the individuals responsible for performing the duties of working face-to-face with, typically, older persons and their family members/caregivers during the admissions process in Ontario, as there may be variations in job titles in different LTC facilities.

Qualitative Approach and Research Paradigm
Interpretive description (ID) was used as the qualitative research approach for this study, to examine the lived experiences of administrative staff working face-to-face with residents-to-be and their family members/caregivers during admission into LTC facilities. ID allows for the provision of a coherent conceptual description of subjective experiences of participants (Burdine, Thorne, & Sandhu, 2020;Ghorbani & Matourypour, 2020;Thorne, Kirkham, & O'Flynn-Magee, 2004). ID accounts for both common and unique experiences of the group to establish themes while also reporting variations among individuals (Burdine et al., 2020;Thorne et al., 2004). As a small-scale qualitative research approach, ID allows for the production of evidence-based data that can be used for future research and by relevant stakeholders, to develop a deeper understanding of the experiences of participants (Burdine et al., 2020;Thorne et al., 2004).

Researcher Characteristics
This study was conducted as a master's thesis project of Ms. Sedaghat-Modabberi with the supervision of Dr. Meisner and Dr. Safai. At that time, Ms. Sedaghat-Modabberi had volunteered at a public LTC facility in the City of Toronto for 5 years. The area of LTC was of interest given their personal experiences and the relationships that they had fostered with residents of an LTC facility. Upon reviewing literature, it became evident that there was a comparative lack of attention directed towards administrative staff of LTC facilities, especially in the context of admitting residents-to-be. It should be highlighted that the administrative staff of the LTC facility at which Ms. Sedaghat-Modabberi volunteered were not participants of this study; therefore, presenting no conflict of interest.

Research Setting
Six public LTC facilities located within the City of Toronto were enlisted for this study. The names of these facilities can not be disclosed, to maintain the privacy and confidentiality of the facilities and participants. Face-to-face interviews were arranged in accordance with participant availability. Participants were provided with the flexibility to choose a comfortable/accommodating location for the interview (e.g., LTC facility, a public space in their local community). Ultimately, the interviews were conducted in a private room or office at the respective LTC facility of each participant.

Participants and Recruitment
This study included seven participants representing the administrative staff of the six LTC facilities, operationally defined as the individuals responsible for the coordination of the resident-to-be from their pre-admission residences into an LTC facility setting. The general title of "administrative staff" is used for consistency, considering that the admission process role can be allocated to different official position titles across different LTC facilities. The majority of participants had many years of experience either with working in administrative positions or for the City of Toronto, ranging from 4 to ≥ 30 years of experience. More specific characteristics of participants can not be disclosed, given that participant identification may become a possibility as the number administrative staff in the City of Toronto's public LTC facilities is relatively small.
Participants were recruited using a purposive sample selection by reaching out to the public facilities within the City of Toronto and providing study information via a recruitment letter. In addition, an administrator of one LTC facility contacted administrators of other locations to identify facilities with administrative staff who would also be interested in participating. Given the specificity of the role (i.e., administrative staff working face-to-face with family members/caregivers of residents-to-be during the admissions process), there are typically one or two individuals at each LTC facility who fit the study criteria. After being informed of the different facilities by the administrator gatekeeper, administrators of each facility were contacted via email to receive the contact information of the eligible participant(s) within that facility. It is crucial to highlight that the participants had the right to refuse or withdraw their participation without consequence. Therefore, there was no risk or perception of coercion. Lastly, there was no interaction or collaboration with the LHIN or the Ministry, as participant recruitment strategies occurred via the gatekeeper administrator at the level of the LTC facilities.

Data Collection
A semi-structured interview guide was used as this format allowed for some measure of consistency across the interviews in terms of topics to be raised by the interviewer (Ms. Sedaghat-Modabberi) with the participants, while also allowing flexibility and flow within the guided conversations via unscripted probing questions. The open-ended nature of the questions allowed for the interviewer to follow topical trajectories and seek clarification. Participants also had the opportunity to elaborate and emphasize perspectives that they felt were most meaningful during the interviews.
The duration of the interviews ranged between 45 and 80 minutes with the average interview lasting 60 minutes. All participants gave permission for follow up questions or clarification if needed. Interviews were audio-recorded and were complemented with field notes. One participant declined to have their interview audio-recorded but agreed to allow for more detailed note taking during the interview. This study received approval from both university and municipal research ethics boards prior to the start of data collection.

Data Processing
Before interview transcription, all audio-recordings were listened to multiple times, and notes were taken on words, statements, and passages that resonated with Ms. Sedaghat-Modabberi as being significant to the research question of the project: What are the lived experiences of LTC administrative staff working with family members/caregivers during the admissions process? Field notes from the interviews supplemented this process. Following multiple listening sessions, non-verbatim transcription of the audio-recorded interviews was performed. This type of denaturalized transcription excludes pauses, stutters, or involuntary vocalizations to elucidate meanings and perceptions that form an individual's reality (Oliver et al., 2005). Denaturalized, non-verbatim transcription, is an attempt at verbatim transcription but with greater focus on the content of the interview as opposed to the involuntary vocalizations (Oliver et al., 2005). Given the nature of this research project and the openness in discussion of personal experiences and feelings, usage of a non-verbatim transcript is not believed to detract from the effective analysis of emergent themes. Because of Ms. Sedaghat-Modabberi's immersion in the extant literature on this topic and in conducting the interviews, as well as Ms. Sedaghat-Modabberi's personal experiences in the LTC system, great vigilance was used in identifying significant words, sentences, passages, and exchanges from the transcripts. Furthermore, the fact that the audio-recordings were listened to multiple times and compared with notes allowed the transcribed interviews to remain reflective of the content provided by each participant. After the transcripts were completed, audio-recordings were listened to again to ensure that the passages were accurately presented. Due to the small but representative number of participants, and to anonymize the participants, pseudonyms and pluralized pronouns (they/them) were used.

Data Analysis
Following the mixed-methods approach put forward by Halcomb and Davidson (2006), Transcripts were read over multiple times and free codes were added. Free coding enabled Ms. Sedaghat-Modabberi to highlight preliminary interpretations of the data while identifying personal preconceptions and biases (Larkin & Thompson, 2012). This type of coding initiated prior to the transcription process via listening to the audio recordings of interviews and comparing them with notes. After the completion of free codes, open codes were created by conducting a systematic line-by-line coding while being mindful of the initially identified free codes. After the open codes, Ms. Sedaghat-Modabberi carefully read over the data and each code in relation to one another to identify themes. Although this procedure seems systematically linear because of its step-by-step description, there was a great amount of overlap between the systematic coding process. This data-driven inductive approach to coding ensured that there was rigor in the qualitative analytical methods. Upon establishing the themes, findings were discussed with Ms. Sedaghat-Modabberi's thesis supervisory committee, Dr. Meisner and Dr. Safai. Specific quotes that were used were returned to the participants from whom they originated, to provide them with the opportunity to review and provide additional information, if necessary. This member checking technique helped generate the accuracy of the transcriptions as it allowed the participants to provide further information and clarify statements, and to reduce interjection of personal biases as representative descriptors for participants' experiences.

Results
Interviews with participants offered a tremendous amount of insight into the lived experience of the admissions process for LTC administrative staff as well as for residents-to-be and their families/caregivers. In the following section, we highlight the three themes that demonstrate the challenges of this process as reported by administrative staff.

Lots of Moving Parts under Pressure: The Stressful Context of LTC Admissions
As noted, admissions to an LTC facility involve multiple stakeholders and a fairly long, complicated, and partly virtual process. In many cases, the admissions staff at a specific LTC facility represent the first occasion that a resident-to-be and/or their family/caregivers interacts with an actual human being. When asked to describe their work, all participants spoke about both the complex managerial elements of their official duties and responsibilities (i.e., as defined by their contracts of employment) and the complex coordination of work that they engage in on a routine basis with the other major stakeholders in the admissions process, such as the case coordinator at the LHIN, other staff in their own LTC facility (e.g., nursing staff, housekeeping staff, personal support workers), the resident-tobe, and the family/caregivers. To illustrate, Charlie's thorough description of the coordinated admissions procedure offers a glimpse of all the moving parts involved in getting someone into an LTC facility: [The] LHIN provides us an applicant list through their software. We have to go in and provide that list to the administrator of the home where then it is reviewed to make sure that, physiologically and cognitively, the individual is suitable for our facility. So, she would look at the various criteria: behavioural, medical history. Once that is approved, I would go back into the system and provide the "Okay" or "Rejection" to the LHIN to say whether that individual has been accepted to our waitlist or if there's a rejection. Then, usually [name of a colleague] will write a follow-up rejection letter which is provided to the LHIN and the Ministry and to the families that is required. That is the initial process.
Once the individuals are in the waiting list-and it is an extensive waiting list with more than 500 individuals at the moment-as beds become available, and it's usually one of two ways: a discharge or death, we provide the information to the Ministry, to the LHIN. They will provide someone that they think is suitable. We again review because in the meantime they might have been on the waitlist for months or years to see if there have been changes in their behaviour, cognitive impairment, whatever it may be, to see if they're still suitable for that particular unit.
[…] A lot of cases it's fine, but sometimes we reject because they might not be suitable for the unit… 'cause they're wandering or exitseeking or they're more resistive to care. So, we would have to send the LHIN a letter or message to say, "No, not for this particular room at this particular time." The bureaucratic nature of the admissions process, as described by Charlie, is a striking and significant reality for all stakeholders. Between the criteria set out by the LHIN, and the resources available at the LTC facility, much of the admissions process becomes equated with meeting the requirements of a checklist. Considering that the waitlist for admission into an LTC facility is based on the level of urgency and need for 24-hour medical and non-medical care, this checklist highlights the discrepancies between what is expected and what can be provided by the LTC facilities.
In addition, the many moving parts to the admissions process between the LHIN and the LTC facility highlight the potentially conflicting nature of the bureaucracy of the LHIN with the aims and needs of the facilities themselves. The aim of the LHIN is to get residents-to-be placed into LTC facilities as fast as possible, whereas the aim of the facility is to ensure that adequate care and safety are provided to all residents. Every physical, cognitive, and behavioural assessment is carefully analyzed to gauge the likelihood of each resident-to-be's integration into the LTC facility's environment. The administrative staff also extend their assessment by incorporating the limits and capabilities of other staff members within the LTC facility prior to providing an ultimate decision. If or when problems arise in the assessment of fit, the work of collecting, communicating, and coordinating next steps fall often onto the shoulders of the LTC administrative staff. Charlie noted: It is very hard for us to reject [a potential resident] unless [they demonstrate] blatant aggressiveness, really disruptive behaviours even though their medications been adjusted. Once we reject, we have to provide substantiation for that to the Ministry, to the family [about why] it is difficult for placement. So, if the LHIN feels that the justification, our rationale, is somewhat weak, they will fight back. Hospitals like to fight back and to push, "Why, why, why?" Okay. I mean, their mandate is "Clear that [hospital] bed." It's just a reality, the whole system is under pressure.
Despite the level of support and attempts of coordinated and effective admission of residents into an LTC facility, the expectations of the LHIN can create a stressful environment for many individuals. The long wait times for admittance into an LTC facility, the demand for constantly updated health information, the difficulty in refusing resident-to-be applications, and the short time frame in which residents-to-be or family members/caregivers have to accept a room when an offer is made, render the admissions process a pressurized and frustrating experience for many administrative staff. Participants all spoke about the ways in which the demand for beds/rooms drastically outweighs the resources present, and the challenges that this reality presents for them in their daily work. Robin's comments were particularly noteworthy insofar as they captured how administrative staff often feel that their voices will not be heard within the LTC system despite their important vantage point of observing and experiencing where changes need to be made to improve the LTC system. Long wait times for a bed or room were commonly referenced by participants, for example, noted previously in Charlie's observation of "an extensive waiting list with more than 500 individuals at the moment". The waitlist is created by the LHIN based on the degree of need of the resident-tobe for 24-hour care service. As a result, an individual may be continuously pushed down the waitlist if more urgent cases happen to be presented to the LHIN. This is beyond the control of the administrative staff working at the LTC facilities and, in a very telling statement, Emma voiced that there was a need for: "Just more homes in general so that nobody ever has to die waiting to get in. Makes me emotional." These observations clearly highlight the participants' perspectives of what is needed in the LTC setting. Robin described that before offering an empty room to an individual on the waiting list, LTC facilities have internal transfers that allow individuals who are interested in moving into a different type of room or individuals who may not have received their first choice of facility an opportunity to relocate. Robin labelled this priority advantage as unfair to those who may have been on the waitlist for years, or to those who are just starting the process of applying through the LHIN. However, this feeling was followed by the statement: "That's my personal opinion; but, I'm not the Ministry, so they probably don't care." These types of seemingly "throw-away" defeatist sentences occurred across many of the interviews, and potentially suggest a sense of disempowerment experienced among the administrative staff as they perceive that their on-the-ground observations and experiences are not being effectively heard within the LTC system.

Unofficial and Challenging Duties of the Administrative Staff
The admissions process was understood by participants as a highly stressful, anxiety-inducing, and often emotional experience for all involved. In addition to their official administrative duties and responsibilities (e.g., managing waitlists, verifying application details, liaising between different stakeholders), discussed under "Lots of Moving Parts Under Pressure: The Stressful Context of LTC Admissions", participants spoke a great deal about the "unofficial" work associated with roles that they occupy and the responsibilities that they have given that they are often the first person contacted in the admissions process. Although the experiences associated with the official and unofficial duties are related, this section, "Unofficial and Challenging Duties of the Administrative Staff", focuses on the non-bureaucratic aspects of duties and their emotional implications on administrative staff.
Drawing from the participants' own words, they are often handholders (not to infantilize families/caregivers, but to empathize), listeners, counsellors, arranging welcome packages, introducing families/caregivers to LTC staff, addressing problems that arise after moving in, and more. Thus, administrative staff assume responsibility for an extensive range of work and activities that reside outside of their job descriptions. Managing (and, by extension, coping with) the emotional experiences of the resident-to-be and/or their family members/caregivers was a common "unofficial" duty taken on by administrative staff. For example, Robin stated that part of the admissions process requires them to: "Let people cry it out and be a shoulder, sounding board, a nonjudgemental, encouraging, and assuring [voice that tells family members/caregivers] that they're doing the right thing." Further to Robin's experience, Emma noted: A lot of the times the challenge is with the families 'cause they're the ones who are grieving. The residents are fine, they're here, they're just trying to fit in and get adjusted to their home. We have social workers who work with the residents and families to kind of reduce the relocation trauma of being in a new place. Families are usually the ones who have the most difficulty and because they're grieving, because they're feeling guilty, we're the ones that they take it out on.
Arguably, two noteworthy elements of Emma's comments are the description of the families' reactions to the admissions process in terms of grief, and the assertion that the administrative staff are the ones who bear the brunt of the families' grief-and stress-related responses. Emma later stated in the interview: "There's lots of lingering effects in this job" when it comes to working with the family members/caregivers who are experiencing many emotions, and: "They're going through the grieving process. They're going through their own guilt." Emma continued by adding: "If you're human, it has to affect you, to be thinking about, 'How is that daughter when she went home? How is she feeling right now?'" Although administrative staff are not formally responsible for managing the emotions of the family members/caregivers during the admissions process, they do so, and the impact of their interactions on the families/caregivers intrude on their personal lives. 2 Isabella noted: "When you're doing the admissions, you get to be the sounding block for a lot of [things]: Quality control, pacifying the situation, and educating as well. But with some people it makes no difference." Isabella's brief statement succinctly points to the "things"-listening, quality assurance, mediation, educationthat administrative staff juggle when working with residents-to-be and their families/caregivers, none of which can be easily categorized as an official job-or process-related function. Furthermore, Isabella's final words, "But with some people it makes no 2 Participants noted that, at times, the resident-to-be can be the person who causes/stimulates stress; however, some participants attributed their behaviour to illness. For example, Charlie commented: "Sometimes their nature might be because of their illness and that has to be understood." This comment could be interpreted as an attempt to reinforce the need for understanding and patience that administrative staff are required to have while working with the residentto-be during the admissions process. However, by employing an amorphous concept like "nature," and by implying that certain behaviours from residentsto-be need to be accepted, the potential difficulties experienced by the administrative staff during their interactions with the resident-to-be are deemed as normal and expected components of the job. While this understanding removes a potentially negative outlook toward the physically and/or cognitively impaired resident-to-be, it nonetheless depreciates the challenges experienced by administrative staff. difference," allude to the challenging emotions that sometimes arise during the admissions process when their advice, information, support, or comfort offered is rejected or resisted. Charlie elaborated on why such resistance behaviour may arise based on their own experience of having loved ones in LTC facilities: [I] try to calm them down, and try to, what's the word, empathize, that's the word. Because they've been fighting the system. Finally, they got a bed offer and the dam has opened. It's a swell of emotion. I've got lots of people crying on the phone. So, a lot of it now is listening to them for a bit and saying, "Look, it's going to be okay. You're doing the right thing." I mean, guilt is huge! I say, "You're doing the right thing for your loved one, and not only that, you're doing the right thing for you," which is not going out on a limb, and I will explain that to them. I said, "Look, you're the caregiver, and they said, "Yes, yes, nobody understands. My siblings don't understand. I've been doing this forever. I've got my own issues." And when I hear that I say, "Right, and if this was to continue a little longer, your issues might become more complex and how are you going to be helping or benefiting your loved one? The pain is going to grow exponentially, so you're going to be in a tough bind." I say, "You're doing this for you and your loved one." But they have to take the lead, I mean this is someone I don't know and they're home in their environment. I've been through it myself with two parents, so that helps. My grandmother was in long-term care for nine and a half years, and two parents who were resistive to going into long-term care until they got to a point where it was just misery. It was heartbreaking.
There is a great deal of insight in the foregoing excerpt, and particular attention should be paid to Charlie's characterization of individuals "fighting the [LTC] system." When framed in this manner (i.e., a fight), we identify part of the origin for the stress, anxiety, and emotion among residents-to-be and their families/ caregivers, including their rejection or resistance of the outreach of administrative staff members. It is challenging to transition into an LTC facility because those involved have had to endure a strained LTC system and a demanding admissions process, and essentially have "fought" to claim admittance for the resident-to-be. When combined with the emotional weight of the desire to take care of their family member, or a sense of filial duty, the admissions process is when many of the concerns and emotional experiences of these individuals are vocalized. The LTC admissions staff are the ones who often receive these concerns first. Isabella articulated how the LTC system stimulates heightened stress leading up to the point of admission by stating: "To live every day wondering when it [the admissions process] is going to happen, when you're going to get that call, and to psychologically be prepared to just have everything ready to go [when it happens]" can be incredibly stressful for the family members/caregivers and the resident-to-be.
For participants, the role of being a listener also meant that, under certain circumstances, they were the ones to field questions and concerns from family members/caregivers that extended beyond the duties and responsibilities of administration. During such situations, the administrative staff took on the work of identifying who is responsible for particular issues, for redirecting questions to the appropriate LTC staff member to retrieve potential solutions to concerns, and, as previously mentioned, for managing the emotional experiences of the family members/caregivers by illustrating that they are there to help guide the family members/ caregivers through this difficult time. As stated by both Amelia and Isabella, this extra level of care went beyond the act of listening to incorporating a need for triaging issues as problem solvers or, in certain cases, as counsellors. Juggling these duties was stressful and sometimes exhausting for the administrative staff, especially considering the nature of such responsibilities (i.e., consistently supporting and managing the emotions of others). Although every participant viewed these intangible complexities as a part of their job, and devoted themselves to assisting the family members/ caregivers, it cannot be overlooked that this emotional management workload is a lot to handle for many administrative staff, depending on the LTC facility, the division of labour employed within the facility, and the level of effective collaboration present among team members.
The burden of constantly managing the stress and anxieties of residents-to-be and/or their family members/caregivers was clearly captured in Charlie's description of what happens when an LTC facility rejects an application: Sometimes in the admissions process we will encounter applicants who, for some reason, will perhaps be rejected and, because of the demand and what the family is expecting, there will be push back. They will go to the Ministry, they will go to the LHIN, and it's difficult because we're not doing it personally; but, in a case like that, it can be a little unnerving. If somebody has called and stated, "Look, you guys are out of touch, here's the situation, you told me this, and now it's this," we try to substantiate our perspective and point of view, what our obligations are to that individual, and that we have to protect our vulnerable population. They might not be in agreement to that… It will rattle you up emotionally because I personally feel like, yes, I know it's somebody fighting to place their loved one and they feel that we're not doing our job properly, or misrepresenting, or something like that, and basically we're in the wrong. So, we now have to substantiate ourselves and where we're coming from. It's difficult when you have a confrontation with someone whether we're justified or not. We have to be fair to everyone, we have to treat everyone equally, so when somebody gives us a push back with that regard, yes, I take it personally. It will affect me personally, I mean, I'm only human.
It is important to acknowledge that all participants described their encounters with residents-to-be and family members/caregivers as also including affirming experiences and positive emotions -no matter how challenging the situation or how demanding individuals may have been. However, we cannot disregard Charlie's frustrations with how rejections have to be greatly substantiated, as LHIN's primary goal is to get residents-to-be off of the waitlist and into homes. In those instances when a rejection has been approved on the grounds of the resident-to-be not being a fit for a facility, the family members/caregivers may decide to fight back out of frustration and, in so doing, take their frustrations out on the administrative staff who serve as the first point-of-contact for the resident-to-be and their family members/caregivers.

Accepting the Burdens? Recommendations of the Administrative Staff
In exploring their experiences of LTC admission, participants were asked if they had or wanted to offer recommendations on how to improve the admissions process, the LTC system, or even the work associated with their roles as administrative staff. These recommendations are in response to the issues and experiences that were previously highlighted by the administrative staff as detailed in the first two themes. The responses underscored the challenges and consequences of the stressful administrative process, as participants reflected on not only their views about the job, their duties and responsibilities, but also on their ideas of what is needed to improve the LTC system for all. Participants' responses also highlighted how normalized the problems of the LTC system had become for them and how easily they assumed individual responsibility for navigating through the constraints of the system. For example, when offering suggestions for future applicants to administrative staff positions in an LTC facility, Denver stated: Some of the things I would say is, learn in-house policies and procedures thoroughly, understand what different positions in the home do according to their departmental manuals, take as much education as you can from the Ministry of Health in regards to the accommodation process and fees that are being charged, and don't be afraid to be a continued resource for family members of residents and staff.
Similar to Denver's statement, Isabella echoes the points raised by Denver but emphasized that being a continued resource for others requires efficiency, time management skills, and an ability to manage the unexpected on the part of the administrative staff: For somebody doing this job, prioritize and [use] time management. Again, there are so many variables in the position that you never know, you never know. There's no such thing as planning out your day. It doesn't happen. So, staying on top of everything so you're prepared, and you can allow for these interruptions to happen, that'll be key, that'll be key to being successful.
Other beneficial attributes for the role were raised by participants. For example, a number of participants spoke of the need for administrative staff to be effective communicators and "team players", whereas others noted the value of hands-on training and experience in the role both in regards to helping support residents-to-be and their family/caregivers and in terms of reducing stress for the administrative staff member themselves. Denver noted "[The stress] doesn't [affect me] because I'm a veteran doing the admissions process. I've done it for a long, long time," and added: Usually when we're dealing with the stress and the families, it's the families that want to talk. So, it's about having the ability to lengthen the admissions process with the power of attorney so that we can hear them out and answer all their questions and help them with next steps as [they] need time for [themselves]. They're going through grief, there's a huge sense of guilt by families for leaving their loved ones here and, for some, if it's a husband leaving his wife here, we tell them to take time for themselves, to get some sleep because some families are sleep deprived. But we welcome them back into the home so that they can share the daily experiences that their loved ones are going through.
[…] For me, it was stressful initially 'cause I had to get to know personality types of family members.
Understandably, Denver's ability to rely on experience provided them with the perspective and the capacity to better distinguish between their work and the sense of stress (or lack of).
Other participants spoke about increasing capacity in various ways. Denver stated: "I would want there to be hospitals for the elderly," whereas Jackie said: "Hire more nurses." Elsewhere in their interview, Charlie stated: "I think initially there's more respite care required. How that would come about? I don't know. I think the system probably has to look, or the Ministry, at providing more beds." However, when examining the recommendations identified by participants as a whole, in combination with the highly pressurized nature of the LTC admissions system, bookended by extremely long wait times and then a hyperaccelerated acceptance of admissions and move-in period, as well as the myriad of official and unofficial duties assumed by administrative staff in LTC facilities, there exists a tension between the challenges participants experience and live through in the LTC admissions process on a regular or daily basis, and the foci of the recommendations themselves. At face value, these recommendations highlight certain individual skills and attributes that were believed to be beneficial for future applicants to and current professionals in the position of "administrative staff". However, these recommendations broadly define and normalize the implicit and challenging duties as well as the multiple roles of the administrative staff during the admissions process. Recommendations also reinforce the individualized nature of managing duties and accepting the pressurized and sometimes stressinducing responsibilities that are not being acknowledged at the LTC system level. More specifically, having time management and communication skills, and actively learning the policies of the LTC system, may be posed as necessary tools for the completion of tasks, but these do not attend to or address the larger or more structural problems with the LTC admissions system.
To summarize, the findings illustrate that the admission process of residents-to-be into an LTC facility is a complex bureaucratic procedure with many official and unofficial responsibilities that must be managed by the administrative staff. The downloading of work compounds the already stressful and emotional admission process, as administrative staff are expected to take on so much more than administrative duties when interacting with residents-to-be and their family members/caregivers. Despite the potentially burdensome nature of their work, for the most part, many have accepted and normalized these additional expectations as part of their job and often as part of their personal and/or moral responsibility. As such, many of the recommendations on improving the admissions process or the LTC system reflect internalization of such views and the enhanced focus on an individualistic approach.

Discussion
This study provides an account of the lived experiences of LTC administrative staff as an important stakeholder with significant insight into the admissions process into an LTC. Drawing on the accounts shared by seven participants, findings highlighted some key themes including: the stressful context of the LTC system at large, and the multiple duties undertaken by administrative staff that fall outside of their official job descriptions and that add to their workload and influence their personal lives, as well as the ways in which the participants normalized the constraints of the LTC system and focused on individualized responses to "system" improvements.
Given the paucity of previous research on the experiences of LTC administrative staff, findings from this study make it clear that administrative staff are an integral part of the LTC admissions process. This is not only because they are often the first point of human contact in the LTC admissions process for residents-to-be and their families/caregivers, but also because of their expertise in managing the complex and multi-stakeholder bureaucratic and administrative processes involved in the LTC admissions system, and the fact that they often take on so much more in their interactions with incoming residents and the families/caregivers. Many of these actions, activities, and contributions are not found in their official job descriptions, and yet administrative staff are performing, and feel expected to perform them, as professional roles and personal responsibilities.
Long wait times, the lack of beds and infrastructure to support the demand on the LTC system, limited funding, and waitlist policies ensuring priority placement/relocation to current residents are all critiques of the LTC system highlighted in both this study and past research (Born, Dhalla, & Laupacis, 2011;Goffin, 2016;Ontario Long-Term Care Association, 2017). None of these issues can be addressed by administrative staff or even at the level of the facility. Yet, the emphasis on leadership, gauging situations/emotions of residents-to-be and their families/caregivers, being coordinators of information, and being effective team workers were routinely highlighted as the crucial components of successfully managing the admissions system within the facilities (cf., Finley et al., 2007;Garman et al., 2004;Kash et al., 2014;Vogelsmeier & Scott-Cawiezell, 2011). The risk in the emphasis of individual attributes falsely ingrains the idea that complications regarding the LTC admissions process can be sufficiently resolved at the level of the individual administrative staff member or the individual facility. Therefore, the LTC admissions system remains stagnant and unchanging as administrative staff bear the circumstances and deal with receiving the brunt of the negative emotions of family members/caregivers as a result of systems problems. The professional roles of administrative staff strain their personal lives, and the pattern of normalizing the burden/expectation of work within the LTC admissions system needs to be recognized for the system to change in a way that can prevent these experiences from happening in the first place.
The depiction offered by one participant, and supported by others, that families/caregivers are "fighting the system" to get their family member admitted into an LTC facility is also striking. This was a noteworthy observation because it captured the perceived and, in some cases, real battle that family members/caregivers struggle through to obtain admittance for the resident-to-be. Although there is a vast amount of literature examining the unnecessary and challenging experiences of the family members/caregivers because of the gaps in the LTC system (e.g., Buhr et al., 2006;Cheek & Ballantyne, 2001;Davies & Nolan, 2004;Dellasega et al., 1995;Kellett, 2001;Nolan & Dellasega, 2001;Pearson et al., 2004;Ryan & Scullion, 2000), the involvement of LTC administrative staff in "the battle" and the in/direct impact of the stress that arises from "the fight" on the administrative staff have been left unexamined.
Findings from this study indicate that certain events with residents-to-be and their families/caregivers within the current system have the power to leave profound and lingering emotions that negatively (and, to a lesser extent, positively) impact the experiences and well-being of the administrative staff. This was a key aspect of this study as participants highlighted how the LTC system left it to the administrative staff to figure out their own ways to cope with the unpleasant elements of their work and the system itself. It is unclear how much attention is being paid by LTC facility management, or even higher levels of governance such as the Ministry of Health and Long-Term Care, in terms of providing supports and resources that administrative staff may need. A lack of attention is evidenced by the fact that there exists a considerable amount of intangible work that administrative staff do that is not recognized in their job descriptions or likely in the training or pay that they receive. This is troubling, as it individualizes the challenges associated with managing the admissions process, such that it falls on the shoulders of the individual rather than being approached collectively or systemically. Therefore, it can be argued that the Ministry and the LHIN should better recognize that being more-than-administrative staff (i.e., listeners, welcomers, supporters) to the residents-to-be and their family members/caregivers can dramatically affect the emotional and mental state of the administrative staff. Yet, these additional responsibilities are not treated or addressed with the appropriate level of attention, whether in the form of providing training or providing methods to effectively cope with the unpleasant elements of the admissions process. There is no clear indication that these issues are being addressed by the Ministry or the LHIN, which leads to administrative staff feeling that they are and being responsible for seeking support and managing their emotions on their own. The downloading of work to the level of individuals and the subsequent individualization of coping techniques devalues the work that administrative staff perform-as supporters of residents and family members/caregivers-during the admissions process, and places the burden of care on the individual instead of taking a more standardized and systemic approach across facilities and administrative staff. The admissions system has created a situation in which individuals have become responsible for managing its shortcomings. Further, although there is no clear indication that these issues are being formally addressed by the Ministry or the LHIN, there is some indication that administrative staff themselves have consented, to certain degrees, implicitly, their need to manage the systems challenges of resident admission into an LTC facility specifically, and the LTC system more broadly, on their own. The recommendations provided by participants relating to improving the LTC work site in particular, in addition to other comments and anecdotes about their lived experiences, underscore this point. Given their significant involvement in the LTC admissions system, the recommendations of the unnecessarily burdened administrative staff need to be taken into account in order to provide appropriate support.

Strengths and Limitations
This study explored the lived experiences of administrative staff who work face-to-face with prospective LTC residents and their family members/caregivers. As significant stakeholders in LTC admittance, their experiences and perspectives have been largely excluded from the body of literature on the admissions process. As a result, this study provides the necessary analysis to advance this important perspective of LTC admissions. Future research involving administrative staff will continue to further address the gap in literature by including and acknowledging this group as significant contributors to the LTC system. Findings of this study may have benefitted from the inclusion of specific demographic information (e.g., age, gender, race/ethnicity, level of education, relevant training, amount of experience in current or similar roles) to better describe and contextualize the experiences of the administrative staff. However, participants came from a very small population of administrative staff from a few available public LTC facilities in Toronto. Therefore, a detailed examination and presentation of specific demographic factors was not possible without potentially identifying participants. Furthermore, considering the regional specificity on the City of Toronto, and inclusion of only public LTC facilities, the population size of the administrative staff operationally defined by this study was small. Large scale examination of the administrative staff involved in the face-to-face admittance of residents-to-be could potentially address some of the limitations identified in this study (e.g., beyond the City of Toronto, recruitment of all public and private LTC facilities).

Conclusion
This research explored the lived experiences of the administrative staff working with family members/caregivers during the admissions process. Findings were novel, as they examined the perspective of this relatively under-studied population. This study demonstrates that it is crucial to understand the perspectives of different LTC system stakeholders to eventually seek systematic improvements that in turn better the professional and personal lives of administrative staff. Evidence-based improvements to the LTC admissions system would have a positive impact on the lived experiences of the administrative staff and others involved in the admissions process. It is also important to recognize that the experiences of the administrative staff expand beyond understanding the professional nature of their work (i.e., the explicit duties and responsibilities outlined in their job description) and that workplace stress can be a consequence of interactions not directly linked to explicitly listed duties and responsibilities. In doing so, the value of the work performed by the administrative staff can be acknowledged, and efforts can be made appropriately to better support them within an improved LTC system.