Introduction
Between March and September of 2020, long-term care (LTC) workers in Nova Scotia completed an online survey about their work experience during the early parts of the pandemic. The findings are critical to understanding the state of long-term care now, in 2026. What lessons were learned from the pandemic? What did workers share about their working conditions that should have informed policy and systems change? While this article is not a full analysis of what has happened in long-term care since the pandemic, given the current strike by long-term care workers in Nova Scotia, many challenges clearly remain. The details on the methodology, participants, survey findings and references can be found in the survey backgrounder.
As is summarized here, our findings demonstrate, not surprisingly, that working during the early pandemic increased stress and decreased well-being. Most importantly, our findings show that the reasons were largely attributable to poor working conditions in LTC that preceded and were then compounded by the pandemic. In LTC, the quality of work impacts the quality of care. We concluded that without policy commitment to improving working conditions in LTC, staff and residents would continue to face preventable risks to health and well-being. Deaths in LTC settings drew media attention to flaws in the organization of LTC work and care. However, participants were ambivalent about whether this attention would lead to positive change. They seem to have been proven correct; the long-term care heroes seem to have been forgotten.
First, it is important to understand what has shaped LTC working conditions in a Canadian context, which we describe as neoliberalism, including, and especially, the negative effects of a privatized model of care that prioritizes cost savings over care and safety, and the undervaluing of care work by its gendered and racialized workforce.
Long-term care in Canada under Neoliberalism
While Canada has universally funded public health care, the personal support and nursing services provided in LTC homes are not covered by the Canada Health Act. Funding models and standards for LTC are provincial in jurisdiction (Liu et al., 2020). Canadian provinces began to implement neoliberal models of LTC in the 1990s (Armstrong et al., 2020b). Following El-Bialy et al (2022), we understand neoliberalism “to encompass the interconnected set of beliefs, practices, and policies that promotes free trade, market competition, privatization, and the erosion of government intervention in social welfare.” Advocates of neoliberalism argue that a private, for-profit model improves the efficiency of the provision of public goods and services and empower individuals as citizen-consumers (Tronto, 2013). As scholars of LTC have documented, however, the application of neoliberal governance to this sector of the care economy has negative implications for both staff and patients. This is because LTC facilities are at once a home and a workplace, leading to a situation in which “…the conditions of work are the conditions of care” (Armstrong et al., 2020a).
Privatization has been an important component of these neoliberal models of LTC (Molinari and Pratt, 2023; Badone, 2021; Armstrong et al., 2020a; Armstrong et al., 2020b). Depending on the province, facilities operate under a mix of public and private funding models, often blending public funding with private ownership (Armstrong et al., 2020b). In their report “Re-imagining Long-term Residential Care in the COVID-19 Crisis”, Armstrong et al. (2020a) find that the trend towards increased privatization of LTC has been detrimental both to the health status of residents and the work lives of staff, which are profoundly entwined. For-profit LTCs, they note, hire just enough staff, pay the lowest possible wages, and rely on part-time and casual workers to save on benefits (see also Daly and Armstrong, 2016). This exploitation of LTC staff has implications for the provision of care. As Armstrong et al.’s report states, “homes run on a for-profit basis tend to have lower staffing levels, more verified complaints, and more transfers to hospitals, as well as higher rates for both ulcers and morbidity” (2020a: 6). The search for finding “efficiencies” in the provision of LTC also leads to contracting out (e.g., privatizing) essential services, such as laundry and food service, which can impact the quality of care and working conditions of LTC residents and staff (see Armstrong and Day (2017)).
The LTC workforce in Canada is highly gendered and increasingly racialized (Lightman, 2021; Syed, 2020; Braedley et al., 2018). The exploitation of LTC staff, including through low pay and casualization, is rooted in the generally gendered and racialized nature of caring labour as well as the forms of neoliberalism described above. The gendered nature of health care stems from the social construction of masculinity and femininity in relation to care. Not only is feminized labour such as carework devalued in capitalist economies that prioritize the accumulation of wealth (Tronto, 2013; Federici, 2012), “unpaid work is endemic to the care sector and is generally expected by employers, who strategically adopt a gendered, naturalistic view of their predominantly female labor force as having a propensity to care endlessly” (Baines and Daly 2021: 391).
Further, care work is increasingly racialized. One aspect of this racialization relates to the composition of the LTC workforce. For example, Iffath Unissa Syed’s (2020) study of an LTC facility in Toronto demonstrates that racialized women are overrepresented in front-line roles like personal support workers and nurses. A second aspect of racialization relates to “social norms that suggest these people do this work because it is ‘natural’ or ‘culturally appropriate’” (Braedley et al., 2018: 101). Tronto argues (2013: 106) that “care work itself is often demanding and inflexible. People who do such work recognize its intrinsic value.” While the primarily female and racialized LTC workforce may be intrinsically motivated to provide care, this work is not selfless or altruistic. Adequate compensation and material benefits will affect what jobs care workers take, how long they stay in those jobs, and their work outcomes (England, Folbre, and Leana 2012: 22-25).
Since the 1990s, when neoliberal models began to be implemented in LTC by provincial governments, scholars and activists have identified their deleterious effects on both residents and workers. The need to better support worker wellbeing has been a repeated, but largely unimplemented, call in reports on LTC in Canada (Wong et al., 2021; Estabrooks et al., 2020). While these problems are longstanding, our data from Nova Scotia builds on other Canadian and international cases that demonstrate how the COVID-19 pandemic brought LTC facilities under renewed public scrutiny and exposed the harms inherent in the current model of care, prioritizing cost savings over care and safety.
Nova Scotia context
Given Nova Scotia’s aging population, LTC policy is a critical concern. As of 2024, 22.5 per cent of the provincial population was 65 or older, well above the Canadian national average of 19.5 per cent (Statistics Canada, 2025b). There are approximately 8,000 residents in LTC (Communications Nova Scotia, 2023), with a waitlist of 2,084 people as of December 2025 (Government of Nova Scotia, n.d.). Among the LTC homes in Nova Scotia, only 14 per cent are public, with the remaining split between private-for-profit (45 per cent) and private-not-for-profit (41 per cent) (Canadian Institute for Health Information, 2024). There are 16,000 continuing care workers in Nova Scotia and 9,000 are CCAs (Campbell, 2025).
Policies by different governments created openings for neoliberal practice in LTC. The Continuing Care Strategy (CCS) implemented by Nova Scotia’s government in 2006 opened the door for greater privatization. According to the Nova Scotia Government (2020b, p. 93), 19 new nursing homes in Nova Scotia were supported through the CCS, of which 13 (68 per cent) were private, including many operated by chain owners. Currently, Nova Scotia Government data show that (as of April 2026) among the 53 replacement and new builds of LTC facilities, 32 (60 per cent) are not-for-profit (including municipal and Build NS projects) and 19 for-profit (36 per cent), with two projects unidentified (Department of Seniors and Long-Term Care, 2026).
Nova Scotia governments also enacted major changes to the model of senior care. In the 2015 and 2016 budgets, LTC funding was cut, shifting resources to encourage older people to age in place (Gorman, 2016). Regardless of the value of this policy approach, these budget cuts were significant, initially amounting to $8.2 million, and disproportionately affected public, non-profit LTC facilities. Reports by the Nova Scotia Nurses’ Union (NSNU) and the Nursing Homes of Nova Scotia Association (NHNSA) have pointed out that the province’s policy shift toward supporting aging at home means that people tend to be frailer and have increasingly complex health needs when they finally enter care (Harrington, 2020; NHNSA, 2020; Curry, 2015). As historian Peter L. Twohig (2021:102) discusses in the Nova Scotia context, among the forces driving health care reorganization is a “drive for efficiency,” an approach that can lead to precarious work.
Understaffing in LTC facilities is a critical problem in Nova Scotia, as it is elsewhere. It directly impacts the quality of care provided to residents and negatively impacts the health of workers (NHNSA, 2020) by creating “heavy workloads, routinized care, and unsafe conditions” (Lowndes and Struthers, 2016: 372). In 2015, 66 per cent of LTC nurses reported always or often working below necessary staffing levels (Curry, 2015: 41). Staffing shortages persist in Nova Scotia, with 7.3 per cent of LTC positions left unfilled (Department of Labour, Skills and Immigration, 2025). In March 2025, a government official reported that in the previous ten months, 5.8 per cent of long-term care workers had left the field (Department of Labour, Skills and Immigration, 2025).
Staffing shortages lead to conditions of overwork. A 2018 Minister’s Expert Advisory Panel noted that “It was most profound to hear from staff, and many of the sector representatives about the guilt and shame they feel not being able to provide adequate care” (Keefe et al., 2018: 46). Understaffing is also driven by retention problems linked to poor working conditions and low wages. Nursing staff in LTC often have less generous pay and benefits—and lower levels of unionization—than nurses in acute care settings such as hospitals (Curry, 2015). This has led some nurses to leave LTC for better-paid positions. The Nova Scotia Government Employees Union has argued that (NSGEU, 2020: 3) “government wage restraint measures imposed on low-paid caregivers made it difficult to recruit and retain workers,” exacerbating an existing problem of recruitment and retention in the sector. The NSGEU claimed, further, that wage restraints pushed people to work in more than one facility, which may have contributed to the spread of COVID-19 in 2020 (NSGEU, 2020: 3).
A throughline across the various assessments of LTC in the province heading into the pandemic is that, despite the difficulty of the work, the skill level of staff, and the importance of providing quality care to residents, LTC policy and resourcing have been underprioritized. Well before the pandemic, the NSNU lamented that although public interest in the LTC sector peaks after a tragedy, there is insufficient “sustained public interest to mount pressure for immediate reform” (Curry, 2015: 9). Although the pandemic primarily amplified the long-standing issues with staff shortages and burnout making it challenging to replace workers who retired or left the sector, there were a few reforms (Murphy, 2021). The government introduced changes to LTC in December 2021 which included a $57 million investment which would go towards more staff and beds. Another improvement was to cover the cost of tuition for more than 2,000 students in CCA programs (Campbell, 2025). Following these changes, 6,700 public-sector CCAs received a 23 per cent wage increase in February 2022 (Renić, 2022). However, this wage increase does not address lower wages for CCAs in the private-sector and other employees such as those working in laundry, the kitchen, and housekeeping. In 2025, 40.6% of “care providers and other support workers” earned less than $20 per hour, 92.1% of which were women (Statistics Canada, 2025a).
We argue that at the core of these structural problems is an inherent devaluing of the people who live in LTC facilities, rooted in sexism, ageism and ableism, and a devaluing of highly skilled, critical labour of their caregivers. These were the contexts shaping funding and work in the LTC sector when the COVID-19 crisis reached Nova Scotia. Twohig has pointed to “understanding the labour of care, and how it has been experienced by working people in the neoliberal age” (2021: 104-105) as an important area for those researching LTC. There is a paucity of published empirical work on the LTC sector in Nova Scotia. Such an evidence gap can mean that policy makers in Nova Scotia rely on studies from larger and more studied provinces. Nova Scotia has distinct demographic, political, and social contexts that help shape our health care context and local evidence is needed to inform policy solutions.
Summary of Survey Findings
Reports over the last decade have highlighted understaffing and overwork in the LTC sector in Nova Scotia (Keefe et al., 2018; Curry, 2015). Nova Scotia’s government (2013-21) cut funding to the LTC sector, redirecting money to support people aging at home. These changes meant residents entering LTC required higher levels of care (Gorman, 2016). The budget cuts affected public LTC facilities (NSGEU, 2020), where over 70 per cent of our participants worked. Before the pandemic, there were red flags drawn to under-funding, poor infrastructure, over-crowding, and a lack of staff (Communications Nova Scotia, 2020b; Henderson, 2020a; 2020b)—conditions that presented challenges given the large population of older people needing care in Nova Scotia (MacDonald, 2016).
Inadequate staffing approaches in LTCs, which preceded the pandemic, left the sector vulnerable to pressures during the pandemic (Hsu and Lane, 2020: 10). Most of our participants experienced short staffing, the loss of coworkers, and an inability to take time off during the pandemic. Our quantitative data included Likert scale questions (0 =positive emotion to 10 =negative emotion) relating to feelings before the pandemic and during the pandemic. We found significant increases among staff reporting negative feelings during the pandemic such as feeling overworked (6.6 to 8.2) and under-supported (6.9 to 7.8), and high stress levels (5.1 to 8.0).
The report “Re-imagining Long-term Residential Care in the COVID-19 Crisis” identifies staffing levels as “the most obvious condition of work” in LTC and suggests that the evidence showcasing inadequate staffing in Canadian LTC facilities has been largely ignored. The report concludes that higher levels of staffing are a “necessary but not sufficient condition to keep those who live, work and visit in care homes safe” (Armstrong et al., 2020a: 7).
The longstanding problems in LTC were a repeated focus of participants’ written responses to a wide range of questions. We heard frustration that the government describes LTC as a priority, yet has done little to improve problems that have existed for more than 20 years. Despite their frustration at having to keep doing more with less, workers continued to provide quality care to residents to the best of their ability. Our participants’ assessment that the problems in the sector pre-existed COVID was similar to the findings of a qualitative study of LTC workers and resident family members in Ontario, in which “The picture painted by respondents is not one of sudden crisis. Rather, they attest to ‘ordinary’ lapses in institutional care before COVID-19, which were mitigated by family members’ efforts to provide additional care” (Badone, 2021: 399). Rather than attributing the distress we describe herein to the pandemic as such, workers tended to attribute it to longstanding issues at their workplace. These problems can be attributed to failures of regulation and investment: privatization, the lack of minimum staffing levels, and the outsourcing of labour are all examples of how neoliberal policy approaches have limited safety in LTC for workers and residents.
The longstanding nature of problematic staffing and funding structures provides additional context for the pandemic when we consider participants’ survey responses and qualitative reflections on their well-being and practices. Nova Scotia had relatively few cases of COVID-19 during the first wave of the pandemic: as of October 24th, 2020, Nova Scotia reported 1,100 COVID-19 cases and 65 deaths (April, 2020). Of these cases, 392 occurred within long-term care facilities (259 among residents and 133 among staff) and resulted in 57 deaths, 53 of which occurred in the Northwood facility in Halifax (Lata and Stevenson, 2020; Rankin, 2020). Most cases were likely introduced by asymptomatic staff (Delorey 2020). However, even with limited cases, there was significant scrutiny of LTC facilities and workers as cases began to escalate in other provinces. LTC workers in our study expressed fear of an outbreak in both closed- and open-ended questions. The potential to transmit disease either to their vulnerable patients or to bring it from a health facility back to their home and family members was a distinct source of concern to our participants.
Participants’ vigilant hygiene practices at home suggest that a way to allay their fears was to maintain control over those spaces and contacts they could. They had limited control over practices at work, where close contact with other staff and with residents was necessary to the provision of care, and where hygiene practices such as changing a mask were controlled by employer policy and by availability. This lack of control was a focus of participants’ understanding of media coverage, as some felt they were accorded more agency in preventing an outbreak than was realistic. A qualitative study of posts in an online COVID-19 forum for health employees at a Canadian university hospital found similar areas of concern, including “contamination, appropriate personal protective equipment, and worker safety” (Berkhout et al., 2021), noting that institutional responses to the pandemic tended not to align with worker concerns. Worker experiences of stress stemmed from the way their workplace was structured before the pandemic, as well as from the way the pandemic response was rolled out.
Scholarly and public writing on media coverage of health care (and other essential) workers during the early waves of the pandemic suggests that the ambivalence expressed by our participants is warranted. For example, Cox (2020) argues that the rhetoric of heroism increases workers’ stress and promotes the expectation of heroic behaviour as the norm, rather than fostering a dialogue about the duties of healthcare workers and how they should be supported. This is consistent with participants’ concern that workers’ ability to prevent an outbreak was overestimated, given the limitations of infrastructure and staffing.
Data Limitations
We acknowledge that our study had a few limitations of scope and reach. First, this is a cross-sectional study of LTC workers in one Canadian province. The sample size is small (n=72) and is not a representative sample of all LTC workers in Nova Scotia. See the research backgrounder for more information about the participants. The survey was quite in-depth and took more than 30 minutes to complete, which likely contributed to low completion numbers. Finally, the survey was launched at the same time as a large union-led survey, which may have impacted recruitment. Despite our relatively small sample, we present self-reported data from workers on their work experience before and during the pandemic. Moreover, the data provide us with rich, descriptive, and unique qualitative and quantitative information that allows us to understand what was happening in LTC in Nova Scotia during the early stages of the pandemic.
Conclusion
LTC facilities are noteworthy as homes for residents and workplaces for staff, as well as for including family and volunteers in unpaid carework (Daly and Armstrong, 2016). In an illustrative quotation, a CCA vented their frustration: “Working during the pandemic has made all of our existing issues that much worse and has strained an already strained situation. If nothing serious is done in the next few years, I fear that the system will collapse.” A provincial review of LTC facilities during the first wave recognized the problem of understaffing, but resources were concentrated on improving facilities (Delorey, 2020). Understaffing, resulting from “poor wage rates, a lack of full-time work and sparse benefits” (Hirdes et al. 2020: 1) and the related practice of working part-time and multiple sites, is not only bad for worker wellbeing, but was a probable contributing factor to cases and deaths in LTC (Hirdes et al. 2020).
Across the literature and our findings, a consistent causal chain emerges: policy decisions that prioritize cost containment, particularly through privatization and labour casualization, produce understaffing and instability, which in turn degrade both worker well-being and resident care outcomes.
As in other parts of Canada, LTC workers in Nova Scotia were lauded by the public as heroes for doing essential work during the first wave of the pandemic. Our research demonstrates that without significant reinvestment in the material conditions of LTC work, including workers’ ability to protect their own well-being, such discourses are little more than platitudes. Participants were clear, particularly in their long answer responses, that the major stressors at work, including understaffing and poor pay, were a result of a longstanding lack of investment in the LTC sector, which stems from neoliberal approaches to structuring care provision. This leads to poor conditions for both staff and the residents who depend on them for care.
The current labour dispute in Nova Scotia’s long-term care sector should not be understood as an isolated conflict over wages or contracts. Rather, it reflects the cumulative effects of longstanding structural issues identified by workers well before and during the pandemic, which have remained insufficiently addressed. It is thus especially concerning that this sector, along with others in the broader public sector, are now facing a three per cent cut each year over the next four years (Gorman, 2026a). While the nursing home staff had a reprieve this year after public outcry (Gorman, 2026b), what will happen next year?
Recommendations
- Enhance wages and benefits: every worker in long-term care facilities must earn enough to maintain a quality of life that enables them to live securely. No worker, whether providing hands-on care, housekeeping, dietary, laundry, clerical, or recreation services, should earn less than a living wage (which in 2025 was $27.60 provincially ($29.40 in Halifax and $24.50 in Cape Breton). Pay equity should be established among long-term care, home care and hospital care settings. All staff should have access to pensions and benefits; At a minimum, all staff need 10 paid sick days and 14 paid sick days during a pandemic.
- Prioritize stable, full-time, secure, working conditions: establish a minimum percentage of full-time positions (70 per cent), lessen overtime and part-time positions, and invest in staff retention and recruitment to strengthen the quality of care by ensuring adequate resources, support, time, and workforce capacity.
- Enforce minimum staffing levels and regulations: 4.1 hours of hands-on direct care per day is an outdated standard and is not even being met due to staff shortages.
- Implement enforceable national standards for long-term care: the province should review the status of LTC with a view to ensuring quality and safe care, from staffing to infrastructure are up to national standards.
- End the expansion of private for-profit facilities and ensure non-profit or public ownership, and require for-profit facilities to negotiate with the government for purchase before putting them on the market.
- Facilities should meaningfully involve staff, unions, residents, families and volunteers in decisions to improve communication and care.
- All staff should be in-house: stop contracting out food, housekeeping, and most laundry services, and bring those services back in-house.
- Recognize that care work is skilled work: provide paid and free opportunities for ongoing education and training.
- Establish an office of the Senior’s Advocate to ensure there is a strong voice to monitor seniors’ services and make recommendations for addressing systemic issues, as well as respond to concerns of seniors and their caregivers.
Acknowledgements
We offer our sincere condolences to the family and friends who lost loved ones during the COVID-19 pandemic. This includes the preventable deaths that occurred among residents and staff in long term care.
We would like to thank the other members of our research team—Jesse Carlson, Lesley Frank, and Elisabeth Rondinelli–as well as Jenn Munroe, who helped with survey development. Liam Swiss, Christine Saulnier, and Ruby Harrington provided helpful feedback.
Funding Details
This work was supported by an SSHRC Institutional Grant from Acadia University.
