Ontario let a ‘flood’ of temp agencies into long-term care during COVID-19. How precarious work put residents and caregivers at risk

Who are these people? she asked a colleague. “They said: they’re from the agencies.”

Birch is a personal support worker in York Region, who asked not to be identified by her real name because her employer has not given her permission to speak to the media.

But Birch is speaking out because she’s worried. Her chronically understaffed workplace has always relied on temporary staffing companies but ever since the pandemic, there’s been a “flood of agencies” unlike anything she’s seen in 20 years on the job. These are precarious workers, she said, often recent immigrants with no benefits or sick pay — and very little training.

Her experience reflects a broader trend across Ontario, with a devastating impact. In a study recently provided to Ontario’s long-term-care commission investigating COVID’s deadly spread, the Canadian Institute for Health Information linked high resident mortality during the first wave — defined as 20 per cent or higher — to two key factors: shortages of personal support workers (PSWs) and the use of temp agencies, which experts say usually signals deeper issues in the home.

But just how many temporary workers have been deployed to the COVID-19 front lines? Nobody knows — not even the provincial ministry overseeing long-term care. While temp workers have played a crucial role in keeping the health system afloat, there is almost no official accounting of who they are, where they have worked, or how qualified they are.

They are uncounted.

“They’re an invisible workforce,” said Dr. Nathan Stall, a geriatrician and researcher at Sinai Health System. “These workers are poorly paid, aren’t afforded the same protections, are likely afforded little to no actual training (before) entering these outbreak situations that they’re thrust into.

“(But) if you’re an invisible workforce, you can neither capture data on them, nor can you afford them the protection they deserve.”

Last February, as the first cases of a relatively unknown virus appeared in Ontario, the province began studying personnel issues within long-term-care homes.

One area of particular concern was the role of personal support workers, lower-paid positions where 48 per cent of employees are part-time. Of those, half reported wanting more hours and often needed to juggle multiple jobs.

When COVID hit, this movement between work sites became a huge risk factor. The problem was recognized early in British Columbia, which moved quickly to limit workers to a single employer. Importantly, the province also offered all workers full-time pay, regardless of how many shifts were available — a move that stabilized B.C.’s workforce and, “frankly, set them up for success during their first wave,” said Dr. Samir Sinha, director of geriatrics at Toronto’s Mount Sinai Hospital.

Ontario also issued an emergency order limiting workers to a single site, but only after nearly 150 long-term-care homes were in outbreak. Unlike B.C., Ontario did not standardize pay — triggering staffing shortages as low-wage PSWs gravitated toward the most desirable employers or left the long-term-care sector.

The directive also had a loophole: temporary agencies were exempted, leaving their workers free to roam.

Meanwhile, the province started spending to help facilities guard against COVID-19 and hire badly needed staff.

Ontario, in other words, created an even larger market for temporary workers just as the pandemic was taking hold, Sinha suggested. “Did the demand for agency workers go up?” he said. “One hundred per cent.”

Understanding the scale of this increased demand, however, requires knowing the baseline — the number of temp workers working in the sector pre-pandemic.

But this data is lacking. The Ministry of Long-Term Care only has estimates, based on its annual staffing surveys, a spokesperson said by email. The most recent estimate — from 2018 — is that fewer than two per cent of nurses, registered practical nurses and PSWs in the sector were agency workers at that time.

This survey isn’t mandatory; 24 LTC facilities did not respond. The ministry would not provide its 2018 survey data without a freedom of information request.

As for retirement homes, the Ministry for Seniors and Accessibility said it also uses a survey to estimate that four per cent of staff are from temporary agencies. The ministry did not respond to several emails from the Star requesting a copy of its most recent survey results.

The number of temporary workers infected by COVID-19 at LTC or retirement homes is also unknown. The Star contacted Ontario’s 34 public health units and only two had data on the number of temp worker infections in these settings. One was North Bay—Parry Sound, which saw no temp worker infections in LTC or retirement home outbreaks.

The other was Huron Perth, which reported 17 infections among agency staff in homes that hired external workers during outbreaks — 15 per cent of all staff infections in these eight homes.

While LTC homes know how many temporary staff they’ve hired, this information is not publicly shared. The Star contacted the 20 hardest-hit LTC homes to ask how many workers were hired from agencies during the pandemic, and how many tested positive.

Only three homes responded; one said it didn’t hire any agency workers and two declined to provide figures.

But working conditions and quality of care are deeply connected. Several studies have shown an inverse relationship between staffing levels or care hours and poorer outcomes, like infection rates or resident hospitalizations.

This is why collecting better information on temp agency workers is so important, said Pat Armstrong, a distinguished research professor of sociology at York University. Relying on agency staff is “harder on everybody, on the residents, on the staff that’s there, and on the (agency) people,” she said.

“You’re not part of the team in the same way … you’re an outsider coming in.”

In its damning assessments of the chaos inside some nursing homes, the Canadian Armed Forces identified this as a problem, too; new and agency workers, it noted, were not receiving adequate training and sometimes did not know where to find basic supplies.

“There’s an entire informal workforce today,” said Sinha. “Right now we don’t even have a standard for what it takes to become a PSW.”

At Birch’s long-term-care home, she has had to train many of the new agency workers brought in during the pandemic. “They don’t even know how to put a diaper on,” she said. “The level of care is not there with these agencies … It’s not fair to the older folks; they are at risk.”

For new Canadians, jobs in the least regulated and “most casualized” corners of the health-care system often serve as workers’ introduction to the sector, said Cynthia Cranford, an associate professor of sociology at the University of Toronto.

“They might have worked at a hospital but as a contracted cleaner,” said Cranford. “They might have worked in a long-term-care home, but their employer was the temp agency, or a family.”

Darryl Singer, head of the commercial and civil litigation practice group at Diamond & Diamond Law, is part of a team of firms representing loved ones of COVID-19 victims in a mega-class action naming around 100 hard-hit LTC homes and government authorities. In that capacity, Singer has taken “hundreds and hundreds of calls” from families, workers and managers; many, he says, expressed grave concerns about precarious jobs and staff turnover in homes.

“We’ve said as part of a lawsuit that by allowing this to occur, they have essentially invited the virus in.”

While temp agencies may serve as a stopgap, relying on them is “an insidious way, as an employer, to operate your business,” especially in LTC facilities

“They’re looking to save money on the wage burden and shift the responsibility for the employer-employee relationship to somebody else,” said Singer. “And in doing so, they’re risking lives.”

But the heightened demand for temp work created business opportunities for some agencies, without a corresponding increase in regulation and oversight. Well-established agencies in the care sector are noticing the sudden arrival of new players, some of which don’t have the experience and skills needed to work with vulnerable clients.

“We’ve seen a number of practices where the safety measures have been thrown out the window in order to maximize” the bottom line, said Robert Handelman, head of the Richmond Hill-based agency Staff Relief Health Care. “To have a PSW come in and take up a shift is not exactly the same as having somebody pick up a shift at a restaurant washing dishes at the back, or serve food.”

There are more than 200 health-care-related temp agencies registered at the workers’ compensation board, data requested by the Star shows. While some have formal offices, other listed addresses that are suburban homes; one shares an address with a taco restaurant.

The registered temp agencies do not include home care providers, although these sometimes act as quasi-temp agencies and workers into a variety of settings including nursing homes, said Cranford, who recently authored a book on Ontario’s home care sector.

“Many of them are essentially acting like temp agencies in that they have a list of people that they send out with very little management or oversight, and they barely treat them as employees.”

In fact, some workers — hired through home care providers, agencies, and now even apps — are not classified as employees at all, excluding them from even the most basic protections under provincial employment law.

While many of these workers are often paid less for doing the same work as permanent staff, the pandemic has examples of this gap working in reverse. Birch said at her long-term-care home, some agency PSWs who are underqualified have been getting $35 an hour, while she makes $22.95. “You don’t want to hire regular staff, but you would bring in an agency and pay them $35 an hour?”

Even if some agency workers may receive premiums, they lack access to the benefits for permanent staff, including paid sick days. To Matt Cathmoir, head of strategic research at SEIU Healthcare, a union representing front-line workers, dependency on these workers is a choice.

Many homes, he noted, are reluctant to increase their complement of full-time staff because it means additional wage and benefit entitlements — even though doing so could reduce staffing gaps.

The Ford government has recently announced new investments towards improving senior care, including funding to train 8,200 PSWs and create more than 27,000 LTC jobs over four years.

But Sinha is skeptical the system can be fixed without understanding who’s actually working in this sector, and “how we can actually make it a better place to work in the first place.”

“Whatever strategy we have (going forward) is built on a house of cards,” Sinha said. “Unless you get the fundamentals of staffing right, where you have staff that are well trained and well supported, all of our long-term-care homes will be a constant revolving door.”

Friday, Part 2: The ‘Uber-ization’ of health-care jobs

Jennifer Yang is a Toronto-based health reporter for the Star. Follow her on Twitter: @jyangstar