The effects of COVID-19 in Quebec public long-term care facilities on various stakeholder groups: a mixed-methods retrospective study across all waves of the pandemic

The effects of COVID-19 in Quebec public long-term care facilities on various stakeholder groups: a mixed-methods retrospective study across all waves of the pandemic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effects of COVID-19 in Quebec public long-term care facilities on various stakeholder groups: a mixed-methods retrospective study across all waves of the pandemic Isabelle Marcoux, Emilie Allard, Genevieve Lavigne, Gina Bravo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9163441/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract The COVID-19 pandemic had devastating consequences for long-term care facilities (LTCFs), particularly in Quebec where mortality rates were especially high during the early waves. Although the psychological toll on frontline healthcare workers has been more frequently documented, less is known about the experiences of managers and of residents and relatives, especially in the context of end-of-life care across the course of the pandemic. This study aimed to integrate multiple stakeholder perspectives to provide a more comprehensive understanding of the psychological effects of the pandemic within Quebec’s public LTCFs over all seven pandemic waves. Methods. A mixed-methods design was employed. In the quantitative phase, an online survey was conducted with managers of public LTCFs across six regional health and social service centres in Quebec (Canada). Measures included the Peritraumatic Distress Inventory related to the pandemic effects, sociodemographics, as well as organizational and COVID-19 related data. In the qualitative phase, semi-structured interviews were conducted with healthcare workers and relatives of deceased residents to explore their experiences of the pandemic and their perspectives on communication and care. We used descriptive and bivariate analyses for survey data and a conceptual categorization approach for qualitative narratives. Results. Seventy-seven managers completed the survey (57% response rate). Nearly half (48.6%) scored above the clinical threshold for peritraumatic distress, indicating substantial risk of post-traumatic stress disorder. No significant differences were found for gender, age, or working experience, although trends suggested higher stress among women and those aged ≤ 50 years. Qualitative findings reinforced and enriched these results: healthcare workers identified the first waves as the most critical period, marked by uncertainty, high mortality, and restricted visitation. They also reported exhaustion, moral distress, and professional grief, while relatives described helplessness and constrained grieving amid organizational instability. Conclusions. This study demonstrates the profound psychological and organizational toll of the pandemic on Quebec’s LTCFs. Findings highlight the need for systemic recognition of persistent psychological effects, accessible mental health and grief supports, and leadership training that equips managers to support frontline teams. Psychosocial support must be treated as a core component of emergency preparedness in LTCFs, not as an afterthought once crises unfold. Long-term care facilities End-of-life care COVID-19 Peritraumatic stress Managers Healthcare workers Relatives Mixed-methods Figures Figure 1 Figure 2 Background The COVID-19 pandemic has had an unprecedented impact on health systems worldwide, with particularly devastating consequences for long-term care facilities (LTCFs). From the earliest waves of the pandemic, LTCF residents faced disproportionately high rates of infection, hospitalization, and mortality compared with community-dwelling older adults (Organisation for Economic Co-operation and Development [OECD], 2021; Rocard et al., 2021 ). Across OECD countries, up to 50% of COVID-19–related deaths during the initial waves of the pandemic occurred among LTCF residents, reflecting a combination of population vulnerability, close living arrangements, and longstanding underinvestment in infection prevention and control (Karimi-Dehkordi et al., 2024; Yin et al., 2024 ; Zhou et al., 2020 ). In Canada, the crisis was particularly severe: during the first two waves of the pandemic (March 1, 2020, to February 15, 2021), 69% of all COVID-19 deaths occurred among LTCF residents, with Quebec reporting the highest associated mortality rate among all provinces (Canadian Institute for Health Information (CIHI), 2021). Although these figures declined in subsequent waves, LTCF residents remained at elevated risk throughout the pandemic. Beyond its epidemiological toll, the COVID-19 pandemic profoundly reshaped the lived experiences of those who resided in, worked within, and managed LTCFs, as well as the families who remained closely connected to these settings. The crisis exposed the interdependence of clinical care, organizational conditions, and leadership practices, setting the stage for widespread psychological and moral challenges across all stakeholder groups, yet existing research has largely examined these experiences in isolation or within limited phases of the pandemic. For residents of LTCFs and their relatives, pandemic-related infection prevention measures, particularly prolonged visitation restrictions, fundamentally altered daily life and end-of-life care. Residents experienced prolonged social isolation and disruptions to routine care, while families were often excluded from in-person contact and unable to be present during their loved ones’ final moments. Studies conducted across multiple countries document significant psychological distress among both residents and relatives, including heightened anxiety, loneliness, and complicated grief (e.g., Chu et al., 2022 ; Cornally et al., 2022 ; Schneider et al., 2023 ; Shaw & Csikai, 2023 ). Notably, a review emphasize that protective measures were primarily designed to mitigate physical risk, often with limited consideration of their psychological consequences for residents and relatives (Schneider et al., 2023 ). However, relatives’ experiences have tended to be examined separately from those of other stakeholders, like healthcare workers and managers who were directly involved in decisions or the provision of end-of-life care for residents in LTCFs, thus limiting a more comprehensive understanding of the effects of the pandemic. The unprecedented mortality and restrictive care environment also placed a substantial psychological burden on LTCF workers. A growing body of research documents high levels of anxiety, depression, burnout, and post-traumatic stress symptoms among LTCF personnel during the COVID-19 pandemic (e.g., Boamah et al., 2023 ; Reynolds et al., 2022 ; Sarfjoo Kasmaei et al., 2025 ). Healthcare workers were required to adapt to rapidly evolving public health directives, increased workloads, and staffing shortages, while simultaneously enforcing visitation restrictions and assuming surrogate family roles for residents (e.g., Collingridge Moore & Cotterell, 2025 ; Havaei et al., 2022 ). Across studies, healthcare workers distress has been closely linked not only to workload and staffing shortages but also to organizational policies, such as visitation restrictions, sick-time rules, and staffing models, that shaped daily care practices and ethical tensions (Boamah et al., 2023 ; Havaei et al., 2022 ; Reynolds et al., 2022 ). Although this literature clearly establishes the magnitude of healthcare workers’ distress, it often focuses on specific professional groups or limited periods of the pandemic, offering a partial view of how healthcare workers experiences were shaped by broader organizational conditions. Qualitative research from Quebec and Ontario suggests that gaps in protocols and communication contributed to heightened organizational strain within LTCFs (Baumann et al., 2022 ; Lavoie-Tremblay et al., 2022 ). Within this organizational context, LTCF managers faced a distinct yet interconnected set of challenges. Evidence from qualitative studies indicates that leadership, alongside clear protocols and effective communication, played a decisive role in shaping organizational responses during the pandemic, underscoring the central position of managers within LTCFs (Baumann et al., 2022 ; Lavoie-Tremblay et al., 2022 ). Responsible for implementing evolving public health directives, ensuring infection prevention and control, securing scarce resources, and maintaining workforce stability, managers also served as key intermediaries between healthcare workers, residents, families, and external authorities. Beyond these operational responsibilities, managers were tasked with supporting healthcare workers emotionally and mediating tensions between healthcare workers and families, positioning them at the intersection of organizational crisis management and frontline care delivery (Leland et al., 2024 ). In addition, managers were responsible for pandemic-specific initiatives such as vaccine rollout and acceptance, while simultaneously addressing the deteriorating well-being of their workforce, further compounding role strain (Fahim et al., 2025 ; Leland et al., 2024 ). Emerging evidence suggests that these responsibilities were associated with substantial psychological strain, role conflict, and increased turnover intentions among managers (e.g., Estabrooks et al., 2023 ; Fahim et al., 2025 ; Nelson et al., 2024 ). Despite this dual burden and their pivotal role in shaping organizational responses, managers’ experiences remain comparatively underexamined, particularly in relation to the experiences of healthcare workers, the residents and their relatives. Existing research highlights the profound psychological and organizational impacts of the COVID-19 pandemic on residents, relatives, healthcare workers, and managers in LTCFs. However, this literature remains fragmented across stakeholder groups and methodological approaches. Reviews and primary studies have largely examined the experiences of frontline healthcare workers (e.g., Boamah et al., 2023 ; Havaei et al., 2022 ; Sarjoo Kasmaei et al., 2025), residents and relatives (e.g., Schneider et al., 2023 ), or managers (e.g., Estabrooks et al., 2023 ; Nelson et al., 2024 ) in isolation. Even studies that have included more than one stakeholder group have typically been conducted during limited phases of the pandemic or within specific organizational contexts. For example, Reynolds et al. ( 2022 ) examined healthcare workers and managers during the early phase of the pandemic, whereas Baumann et al. ( 2022 ) and Lavoie-Tremblay et al. ( 2022 ) focused on selected long-term care facilities, such as exemplar homes or facilities without COVID-19 outbreaks, offering important but necessarily partial insights. Moreover, few studies document these experiences across the full span of the pandemic. Methods Aim and objectives. The aim of this paper is to describe the effects of the COVID-19 pandemic on various stakeholders (managers, healthcare workers, relatives of deceased residents, and recipients of end-of-life care) within Quebec’s LTCFs, with the goal of capturing their distinct yet interrelated experiences. The objectives were to (1) assess the psychological distress of managers and associated factors; (2) explore the effects of the COVID-19 pandemic on healthcare workers (including their psychological distress), and on relatives of deceased residents, as well as the effects they perceived on residents who died during the pandemic; and (3) integrate the quantitative and qualitative findings to provide a comprehensive understanding of how the pandemic affected LTCF stakeholders and to identify opportunities to strengthen organizational resilience and psychosocial support systems for future health crises. Design and setting. A mixed-methods design was utilized to examine the multifaceted impacts of the COVID-19 pandemic within LTCFs. The study was conducted in Quebec’s LTCFs, publicly funded facilities providing 24-hour nursing care to individuals experiencing significant loss of autonomy, primarily older adults living with multiple comorbidities or cognitive impairments. Ethical considerations. The study was approved in 2021 by the primary investigators' Laval research ethic board (MP-35-2022-720). The process of securing institutional approvals across the six selected healthcare regions was carried out from July 2021 to August 2022. Participation was voluntary, and informed consent was obtained electronically before data collection (survey or interview). Data confidentiality and security were strictly maintained, with survey data anonymized prior to analysis, and transcript interview anonymized using codes and pseudonyms in the article to ensure confidentiality. Quantitative Phase: Survey of LTCF managers Participants. For feasibility reasons (e.g. institutional considerations, time-sensitive nature of the study, availability of human and financial resources), a non-probabilistic sampling strategy for healthcare regions, namely purposive with maximum variation (Patton, 1990 ) was employed based on the following criteria: facility size (e.g. number of public LTCFs and total number of beds), resident populations (e.g. distinctive characteristics), and regional COVID-19 effects (e.g. COVID-19 mortality burden, including the number of deaths and changes in mortality rates during the first and second waves). Regions were excluded if they reported no COVID-19-related deaths during the first two waves or if they were already engaged in a separate pilot project (Allard et al., 2021 ). Based on these criteria, six out of 13 regional health and social service centres were selected. The maximum eligible population consisted of 143 LTCFs located within the selected regions, out of a total of 246 LTCFs that met the inclusion criteria across the province. This represents 58% of the total target population. A participation rate of 50% was established as the goal, representing approximately 70 LTCFs. To ensure adequate statistical power to explore the effects of the pandemic on managers (refer to data analysis section), a sample size calculations indicated that a minimum of 52 managers was required to detect a large effect size (Cohen’s d = 0.50) with an alpha level of 0.05 and a power of 0.95 (Cohen, 2013 ; Faul et al., 2007 ). All LTCF managers working within the six selected regional health and social service centres were invited to participate. Questionnaire. The Peritraumatic Distress Inventory (PDI) (Brunet et al., 2001 ), validated in French (Jehel et al., 2005 ), was used to assess psychological distress experienced by managers during the most critical moment they had encountered in their role since the onset of the COVID-19 pandemic (from one of the seven waves 1 ). The original PDI comprises 13 items rated on a five-point Likert-type scale ranging from 0 (not at all true) to 4 (extremely true). Following pre-testing with managers, one item (“I felt like urinating and defecating”) was removed because it was considered inappropriate for the context of this study. Consequently, the total possible score ranged from 0 to 48, compared to 0 to 52 in the original version. The modified PDI demonstrated strong internal consistency with a Cronbach’s alpha of 0.87. In the full version, a cut-off score of 14 or higher is considered the optimal threshold for identifying individuals at risk of developing post-traumatic stress disorder (PTSD) (Guardia et al., 2013 ). For this study, the threshold was proportionally adjusted to 13 to reflect the modified scoring range. In addition to the PDI, sociodemographic data and other measures were collected to contextualize managers’ experiences. These included variables such as age, gender, and years of managerial experience. Facility-level data were also gathered for each participating LTCF (directly from the regional health and social service centres), including number of residents, the number of COVID-19-related deaths for each of the seven pandemic waves, and the total number of deaths from all causes since the beginning of the pandemic. Procedure. The online questionnaire was hosted on the secure LimeSurvey platform. In order to assess clarity of the wording, survey length, navigation flow, and overall usability (van Teijlingen & Hundley, 2002 ), the questionnaire was pretested with eight individuals who met the inclusion criteria but were not part of the potential participant pool. Adjustments were made to improve wording and flow, and two team members subsequently carried out a final verification to ensure that the survey was free of technical or content errors before launch. Data collection took place between September and December 2022. Invitations to participate were sent by email to all eligible LTCF managers through their respective regional centres administrative offices. To maximize the response rate, we employed a modified version of Dillman’s Tailored Design Method (Dillman et al., 2014 ), which involved up to four personalized contact attempts spaced at two-week intervals. Data analysis. Data were exported into SPSS version 29.0 for analysis. Descriptive statistics were used to characterize managers’ demographic, organizational, and COVID-19–related characteristics. Chi-square tests examined associations between critical peritraumatic distress (PDI ≥ 13) and categorical manager characteristics (i.e., age, gender, and experience in the current position). T-tests were used to compare COVID-19–related mortality indicators across PDI groups, including the number of resident deaths during each pandemic wave and total deaths from all causes relative to the number of residents. Statistical significance was set at p < .05. Qualitative phase : Semi-structured interviews with healthcare workers and relatives Participants and Sampling Strategies. For healthcare workers, the inclusion criteria was having worked at any point during the pandemic in a public LTCF within one of the participating regional health and social service centres. For relatives, the inclusion criteria were: (1) being related to a resident of a LTCF who died during the pandemic, regardless of whether the death was associated to COVID-19, and (2) the deceased resident must have lived in a publicly funded LTCF within one of the participating regional health and social service centres. Two complementary sampling strategies were employed to recruit healthcare workers and relatives. First, invitation emails were sent by the administrative offices to all healthcare team members with institutional email addresses within the six included regions. In parallel, social media announcements were posted through university networks and local caregiver organizations to reach relatives and additional care providers, including those who had been temporarily reassigned to LTCFs during the pandemic. Second, a snowball sampling strategy was implemented to broaden recruitment. Participants were invited to share a standardized recruitment message with potentially eligible individuals within their networks. This ensured consistency in study information while maintaining voluntary participation. Data Collection. Individual semi-structured interviews were conducted by trained researchers between May 2023 and November 2024. They took place remotely via Zoom or telephone, each lasting between 45 and 90 minutes. Throughout the process, interviewers maintained reflexive memos to document their positionality and experience of doing research in time of pandemic, idea on data generation and participants’ non-verbal communication. The interview guide (supplementary file) was tailored separately to healthcare workers and relatives to ensure questions relevance to each group’s experience. In addition to sociodemographic questions used to describe the sample (e.g., age, gender, role, years of experience, relationship to the deceased resident), the guide explored participants’ experiences of end-of-life care during the COVID-19 pandemic across multiple domains (e.g., communications, workload, psychological experience, quality of care). Also, consistent with part of the objective 2, healthcare workers were invited to complete the PDI to quantitatively assess pandemic-related psychological distress. This measure, collected towards the end of the interview, also served to compare the results obtained for the various items on the scale with those of managers. Data collection continued until meaning saturation (Rahimi & Khatooni, 2024 ) was reached, ensuring a deep understanding of the issues and a rich analysis where no new insights regarding the codes or their relationships emerged. To acknowledge participants’ contributions, each received a $ 10 electronic gift card. Data Analysis. All interviews were fully transcribed using the Noota software and reviewed to ensure accuracy and completeness. Data were analyzed using the categorizing analysis method (Paillé & Mucchielli, 2016 ), which involved a systematic process of iterative coding and conceptualization. Using Excel as an analysis tool (Meyer & Avery, 2009 ), each interview was coded line by line independently by two members of the research team. Initial codes were developed as closely as possible to the participants’ own words to remain faithful to their perspectives. Each code was then assigned a brief definition to clarify its meaning. Codes were compared across transcripts and grouped into broader explanatory categories informed by findings from a previous pilot project (Allard et al., 2021 ) as well as results from the quantitative phase of the current study. Discrepancies or interpretative conflicts between coders were resolved through discussion within the analysis team, ensuring consensus and reinforcing the credibility and trustworthiness of the findings. Integration of Data from the Two Phases of the Study A narrative integration of the results was determined to be the most appropriate as it allowed for a more nuanced presentation of the findings, highlighting convergences and divergences across stakeholder effects of the pandemic. Integration occurred during the interpretation stage, where qualitative themes were used to complement and contextualize quantitative results, yielding a broader understanding of the pandemic’s effects on stakeholder groups. Results Of the 143 managers initially invited to participate in the survey, seven were considered non valid cases (lacked the necessary knowledge to complete the questionnaire or no longer had ties to the position), and were therefore excluded. From the 136 eligible managers, 77 completed the questionnaire, yielding a 57% response rate. Most participants were women (83.8%), and aged 50 or younger (73.0%). In their current role, 41.9% had two years or less of experience. A total of 21 individuals participated in the semi-structured interviews: 16 healthcare workers and 5 relatives of residents who had died in a LTCF during the COVID-19 pandemic. The healthcare workers represented four of the six regional health and social service centres included in this study, with the majority (10/16) having more than five years of experience in their workplace. Reflecting the interdisciplinary nature of LTCF care teams, half of the participants (8/16) held nursing roles, three were nursing assistants/orderlies, two were social workers, and three in the field of rehabilitation. Most participants were women (11/16), and the majority were between 31 and 40 years old (10/16). Five relatives took part in the qualitative interviews, all of whom were women. Their ages were as follows: 31–40 years (n = 2), 51–60 years (n = 1), and over 60 years (n = 2). Four were adult children of deceased residents, while one was a spouse. All had completed at least a college-level education. The deceased residents were all over 70 years of age and in most cases lived with a major neurocognitive disorder. Managers' psychological distress and associated factors Of the 74 managers for whom we have peritraumatic distress (PDI) scores, most often identified the first wave of the pandemic as the most critical moment experienced in the course of their duties (42%), followed by the second wave (21%) and the fifth wave, corresponding to the Omicron surge (19%). Total PDI scores ranged from a minimum of 2 to a maximum of 45 (out of a possible 48) with an average score of 13.86 (SD = 8.00). Thirty-six managers (48.6%) obtained a total score of 13 or higher, the clinical threshold indicating a risk of developing PTSD. A closer examination of individual PDI items provided valuable insight into the specific experiences most frequently reported by managers. As shown in Figure 1, the emotions most frequently rated as extremely true or very true were helplessness (64%), worry about the safety of others (46%), sadness and grief (42%), and frustration and anger (42%). In contrast, more intense reactions such as shame about one’s emotional responses (1%), fear of dying (3%), or feeling as though they might faint (3%) were rarely reported. Table 1 presents the results of chi-square and t-test analyses examining associations between the dichotomized PDI scores (clinical threshold) and demographic, professional, and pandemic-related characteristics. No statistically significant associations were found for gender, age, experience in the current role, number of COVID-19-related deaths for each of the seven pandemic waves, and the total number of deaths from all causes since the beginning of the pandemic by the number of residents (all p > .05). However, trends approaching statistical significance were observed for gender ( p = .073) and age dichotomized at 50 years ( p = .051), with female managers and those aged 50 years or younger more frequently classified in the critical stress group compared with their counterparts. Although these differences did not reach conventional levels of statistical significance, they may indicate the presence of potentially vulnerable subgroups warranting further investigation. Table 1. Critical peritraumatic distress among 74 LTCF managers by demographic, professional, and contextual characteristics Complete sample N (%) Critical stress (PDI ≥ 13) N (%) Chi-square test Gender Female Male 62 (83.8) 12 (16.2) 33 (53.2) 3 (25.0) Χ 2 (1) = 3.21, p = .073 Age 18 to 50 years old 51 years old and older 54 (73.0) 20 (27.0) 30 (55.6) 6 (30.0) Χ 2 (2) = 3.82, p = .051 Experience 0 to 2 years More than 2 years 31 (41.9) 43 58.1) 12 (38.7) 24 (55.8) Χ 2 (1) = 2.11, p = .146 X (SD) X (SD) t-test Wave 1 – death X = 7.78 (SD = 17.22) X = 7.47 (SD = 19.10) t(72) = .15, p = .881 Wave 2 – death X = 5.42 (SD = 9.18) X = 4.93 (SD = 8.96) t(58) = .39, p = .696 Wave 3 – death X = 0.15 (SD = 0.58) X = 0.17 (SD = 0.60) F(58) = -.29, p = .774 Wave 4 – death X = 0.02 (SD = 0.13) X = 0.03 (SD = 0.19) t(58) = -1.04, p = .305 Wave 5 – death X = 1.52 (SD = 2.28) X = 1.76 (SD = 1.96) t(58) = -.79, p = .431 Wave 6 – death X = 0.95 (SD = 1.64) X = 0.79 (SD = 1.42) t(58) = .71, p = .478 Wave 7 – death X = 0.72 (SD = 1.51) X = 0.66 (SD = 1.23) t(58) = .30, p = .763 Total death from all causes / number of residents X = 1.76 (SD = 2.68) X = 1.48 (SD = 0.82) t(57) = .75, p = .454 Note: X = mean, SD = Standard Deviation. Data on the number of resident deaths during Waves 2 through 7 were not provided from one regional health and social service centre out of six (accounted for 14 LTCFs); analyses involving these variables were therefore conducted on a sample of 60 managers, of whom 29 met the criterion for critical peritraumatic distress (PDI ≥ 13). In contrast, data on total deaths (all causes) relative to the number of residents were unavailable for 15 LTCFs, resulting in a reduced analytic sample of 59 managers, of whom 28 met the criterion for critical peritraumatic distress (PDI ≥ 13). Effects on healthcare workers, including their psychological distress Among the 16 healthcare workers interviewed, all met the criterion for critical peritraumatic distress (PDI ≥ 13), and most identified the first two waves of the pandemic as the most psychologically challenging period they experienced. This period was primarily attributed to the sudden arrival of the first COVID-19 cases, the high number of deaths in LTCFs, and the negative media discourse surrounding long-term care settings. Peritraumatic distress scores (see Figure 2) indicated substantial acute psychological strain among healthcare workers. The PDI items that most strongly reflected their experiences were feelings of frustration and anger (88%), a sense of helplessness (75%), worry for the safety of others (75%), as well as feelings of distress and grief (62%). Notably, one in four healthcare workers expressed very strong agreement (extremely true) with statements related to fear for their own safety (25%). Intense physical reactions such as sweating, trembling, or palpitations and loss of emotional control were endorsed as extremely true or very true by one in four (25%). Approximately one in five described heightened experiences of guilt (18.8%), feeling faint (18.8), or being horrified by what they witnessed (18.8%). In contrast, more intense reactions such as shame about one’s emotional responses (6.3%) and fear of dying (6.3%) were rarely endorsed. These quantitative findings were further illuminated by qualitative accounts, which provided contextual depth to the emotional patterns reflected in the PDI results. The majority of healthcare workers interviewed reported experiencing high levels of stress and persistent fatigue throughout the pandemic. Early fears were primarily linked to the unknown nature of the virus and its potential effect on the highly vulnerable LTCF population. Yet participants, like Louison, emphasized that the absence of clear and consistent guidance was a major source of stress and anxiety. “What made the work environment so anxiety-inducing during the first wave was that the health directives kept changing constantly, every single day… It wasn’t very reassuring.” (Louison, healthcare worker) Chronic staff shortages, compounded by additional responsibilities and extended working hours, contributed to a widespread sense of exhaustion and demoralization . Participants also described the emotional toll of frequent and rapid resident decline and deaths. Many had cared for residents over several years and had built relationships with relatives, but the public health context prevented these relationships from being properly concluded, leaving a sense of unfinished mourning. To cope, many healthcare workers described having to suppress their emotions and operate on “autopilot” to continue providing care. Several participants spoke of experiencing a profound and underrecognized grief stemming from the accumulation of losses during the pandemic—both of the residents they cared about and of their relatives they bonded with. They felt that this grief was largely underestimated by managers and organizations, underscoring a critical gap in institutional support for staff well-being during such crises. This accumulation of losses gave rise to a form of professional grief that many felt was underestimated or unrecognized by their organizations. "We underestimated the grief that we, as employees, could experience. It caused a great deal of suffering. (…) We grow close [to the residents], without crossing the line of professionalism, but there are people we see every day who become part of our lives. A bond is created." (Élie, healthcare worker) Beyond their relationships with residents and relatives, the sense of isolation also deeply affected healthcare workers, who were accustomed to gathering in common areas or spaces dedicated to staff members. The required physical distancing reduced opportunities for interaction and weakened the sense of belonging within care teams. "When the team can no longer gather, in places like dining rooms, team cohesion is less present, it becomes fragile […] And when the team is fragile, the quality of services suffers." (Paula, healthcare worker) Despite these challenges, some participants highlighted moments of solidarity, describing how staff came together and mobilized to lend support during particularly difficult times in LTCFs. In particular, healthcare workers tip their hats to those who volunteered to lend a hand in LTCFs. "Team spirit and compassion were the two positive things that stood out. Because there were also people who were reassigned to the long-term care facility, but who never wanted to leave. They wanted to stay until the end! That was beautiful to see. Yet the conditions were really very difficult." (Susan, healthcare worker). Overall, these findings underscore the substantial psychological burden experienced by healthcare workers during the pandemic. Perceived effects on residents living in LTCFs All participants, healthcare workers and relatives, emphasized the profound effects of the protective measures (e.g., masks, visit limitations and room isolation) and organizational changes (e.g., suspension of recreational activities and closure of common areas) on residents living in LTCFs. Reactions of confusion, misunderstanding, and frustration were commonly observed in response to the implementation of protective measures. Several healthcare workers mentioned that residents struggled to understand the guidelines or to recognize them and their relatives when they were wearing protective equipment. “The introduction of mask was very disruptive [for the residents], because there were no mouths anymore. No one had a mouth anymore. It was all about smiling with the eyes. I think it created a barrier for some residents with cognitive disorders, making it harder for them to recognize and understand.” (Dominique, healthcare worker) The use of protective equipment altered interactions between healthcare workers and residents by limiting non-verbal communication, contributing to more impersonal care encounters and heightened feelings of isolation during the pandemic. Using the example of her mother's hygiene care, Frédérique explains how bedridden and confused residents could experience a form of violence. "Imagine when my mother was bedridden all the time. Constantly, someone would come near her bed, masked. (…) Most of the time, they didn’t identify themselves. They would come in, grab her, shake her, turn her over, and then remove her clothes." (Frédérique, relative) Prolonged physical distancing measures, which in some settings lasted for several months or even years, further disrupted the usual living environment activities, limiting opportunities for meaningful interaction. Residents seated two metres apart in common areas were unable to converse effectively, a situation that many staff described as contributing to deconditioning and reinforcing isolation. “I found it really striking. We had put X’s on the floor to mark where to place people in the common room to maintain social distancing (…) It was so far apart. Since they had cognitive impairments and hearing devices, they couldn’t hear each other. It didn’t work; they couldn’t talk to one another. It wasn’t better in the end. They saw other people, but they couldn’t actually talk to them.” (Alexis, healthcare worker) Several participants discussed the effects of prolonged isolation on the physical and mental health of residents living in LTCFs. The suspension of social and recreational activities, as well as physiotherapy sessions, contributed to a marked decline in residents’ overall condition, a change observed by all healthcare workers interviewed, like Jamie: “[The pandemic] was not good for their mental health. Some people experienced greater decompensation; they became more physically rigid, but also mentally.” Effects on relatives of deceased residents in LTCFs Room isolation measures significantly shaped the experiences of relatives, who were not permitted to leave residents’ room and prohibited from removing their protective equipment, even for basic activities such as eating. Several participants reported adverse events linked to this poorly adapted environment, including fainting episodes, underscoring the strain of such restrictive conditions. Room isolation also reduced opportunities for social interaction and mutual support among relatives within the LTCF. Families are often regarded as an integral part of the care environment, offering informal emotional support and companionship during the difficult process of end-of-life care. However, the pandemic and strict distancing measures effectively eliminated these exchanges, depriving relatives of important sources of comfort and shared understanding. “Sometimes it can be nice to chat with other relatives. I remember seeing two sisters—I’m not sure if it was their mother or father who was dying—we knew they were there for that reason too, but we were never able to talk to them. [The pandemic] placed so many limits on the social aspect, on the support we could have received, and on the connections we could have built.” (Sacha, relative) Discussion The aim of this mixed-methods retrospective study was to integrate quantitative measures of peritraumatic distress among managers with qualitative accounts from healthcare workers and relatives, thereby providing a comprehensive understanding of the multifaceted effects of the COVID-19 pandemic on Québec’s LTCFs. The findings demonstrate the profound psychological toll of the pandemic on LTCFs. Nearly half of surveyed managers exceeded the clinical threshold for peritraumatic distress, indicating a substantial risk of PTSD. While no statistically significant associations were found based on gender, age, managerial experience, number of COVID-19-related deaths for each of the seven pandemic waves, and total number of deaths from all causes since the beginning of the pandemic by number of residents, trends suggested that female managers and those aged 50 years or younger were more likely to fall into the critical stress category. These patterns may reflect the predominance of women in LTCF leadership roles and the added burden of work–family demands, particularly among younger managers who may have greater caregiving responsibilities. These results underscore the widespread psychological strain faced by managers, while also pointing to potentially vulnerable subgroups within this population. Qualitative findings enriched the quantitative results by revealing how the first waves of the pandemic were consistently perceived as the most critical and distressing period across stakeholder groups. This phase was characterized by uncertainty, high mortality, and strict visitation bans. Both managers and healthcare workers reported intense emotions including helplessness, concern for others’ safety, sadness, frustration, and anger. While managers highlighted these feelings during the early waves, healthcare workers emphasized that the first resident deaths were particularly impactful, leaving lasting impressions that many continued to recall vividly years later. Overall, these findings suggest that the psychological consequences of the pandemic were not only acute but also enduring, underscoring the importance of examining the persistence of traumatic memories and distress across stakeholder groups over time. Taken together, the quantitative and qualitative strands converge to depict a multi-level pattern of distress within Quebec’s LTCFs, in which organizational pressures, repeated exposure to death, and relational disruptions intersected across roles. Managers’ elevated peritraumatic distress scores provide measurable evidence of acute strain, while qualitative accounts from healthcare workers and relatives illuminate how these stressors were experienced, interpreted, and sustained over time. This integrative perspective underscores the interconnected nature of psychological burden, organizational functioning, and end-of-life care during the pandemic. In addition to these emotional responses, healthcare workers spoke extensively about fatigue and exhaustion, with mental health concerns, including burnout, stress, and moral distress, emerging as prominent themes. Such experiences mirror survey-based research, including Haslam-Larmer et al.’s ( 2023 ) study of 227 healthcare workers and Estabrooks et al.’s ( 2023 ) survey of 181 managers, both of which documented substantial psychological strain in the long-term care workforce. Broader meta-analyses also confirm high prevalence of anxiety, depression, and PTSD symptoms among LTCF staff globally (Boamah et al., 2023 ; Reynolds et al., 2022 ; Sarfjoo Kasmaei et al., 2025 ). Aligning with previous research on the detrimental effects of systemic stressors on managers, such as staffing shortages, inconsistent directives, and the burden of enforcing restrictive visitation policies (Estabrooks et al., 2023 ), our qualitative findings underscore the profound effects of protective measures and organizational changes on residents, their relatives and healthcare workers. The qualitative data also shed light on the professional grief experienced by healthcare workers, which emerged as a recurrent theme in the interviews. Participants emphasized that working in LTCFs often fostered close bonds with residents and their relatives, making them part of daily professional and even personal life. The abrupt rupture of these ties, caused by sanitary measures that limited family presence and by repeated resident deaths, sometimes involving individuals they had known for months or years, was experienced as a profound loss. Several healthcare workers reported that this grief was not acknowledged by their superiors, leaving them to cope largely on their own. This aligns with the concept of disenfranchised grief, in which legitimate forms of mourning are overlooked or minimized (Doka, 1999 ). Comparable dynamics have been observed in home care and nursing home settings, where relationship losses are underestimated and grief is frequently conflated with routine job stress (Ådland et al., 2023 ; Tsui et al., 2019 ). Notably, Phillips et al.’s ( 2024 ) scoping review during COVID-19 underscores how such unrecognized grief undermines staff well-being and organizational resilience, reinforcing the need for grief-informed supports in long-term care. Overall, these findings demonstrate that the pandemic’s effects on LTCF healthcare workers and managers extended far beyond immediate workload pressures and infection control challenges. Emotional exhaustion, cumulative grief, and moral distress were shaped not only by systemic organizational conditions, such as staff shortages and rapidly changing directives, but also by deeply personal bonds with residents and relatives. By integrating the perspectives of managers and frontline healthcare workers with those of relatives of deceased residents, and by capturing experiences across the pandemic as a whole, this study offers a more comprehensive and relational understanding of how distress and resilience were produced within LTCFs. Acknowledging and addressing these experiences is crucial for developing trauma-informed organizational supports that can foster resilience among care teams. Without such recognition and support, unresolved grief and sustained distress risk undermining workforce well-being and retention, with long-term consequences for the quality of care provided in LTCFs (Estabrooks et al., 2023 ; Nelson et al., 2024 , 2025 ). Implications and recommendations for LTCFs Our study makes several important contributions. It is among the rare mixed-methods investigations to integrate the perspectives of managers, healthcare workers, and relatives on both their own experiences and the perceived effects of the pandemic on residents in the context of COVID-19 and end-of-life care in LTCFs. By triangulating these viewpoints, the study offers a more comprehensive account of the pandemic’s multifaceted effects on LTCFs, extending a literature that has often examined stakeholder experiences in isolation. The study also demonstrates the value of the PDI in quantifying acute psychological distress among both managers and healthcare workers, providing measurable evidence of peritraumatic strain across professional roles during the pandemic. Furthermore, managers are an often-overlooked stakeholder group whose psychological burden throughout the whole pandemic has received limited attention in prior research. Finally, it highlights the presence of professional grief among healthcare workers, a theme rarely addressed in policy discourse despite its profound implications for both workforce resilience and quality of care provided to residents and relatives. In light of these findings, several critical implications for policy and practice emerge. The enduring psychological effects of the pandemic on managers, healthcare workers, residents at the end of life, and their relatives need to be explicitly recognized within institutional discourse. These effects should not be viewed as temporary distress but acknowledged as potentially enduring effects with serious consequences for workforce retention, quality of care, and public trust in LTCFs. To mitigate these risks, LTCFs must invest in the systematic development and evaluation of targeted interventions and psychosocial resources. Accessible mental health services, grief support programs, and structured opportunities for staff debriefing and collective mourning are essential to address the risks of burnout, unresolved grief, and moral injury. At the same time, managerial training should be strengthened to prepare leaders to support frontline teams through uncertainty and loss, with emphasis on communication, emotional validation, and the management of moral distress. This recommendation is consistent with findings from Lavoie-Tremblay et al. ( 2022 ) who identified strong leadership and clear communication as key protective factors during the pandemic. Embedding these competencies within leadership development programs across LTCFs could foster greater organizational resilience. Ultimately, psychosocial support must be recognized as a core component of emergency preparedness in long-term care, rather than a reactive measure introduced only after a crisis has subsided. These recommendations align with those of Grinspun and colleagues ( 2023 ), who emphasize that preparedness for future health crises in LTCFs must prioritize the well-being of care providers. Neglecting the mental health of managers and staff not only diminishes compassion and professionalism but also contributes to increased burnout, depression, anxiety, fatigue, and anger (e.g., Garnett et al., 2023 ; Vracevic et al., 2025 ). Such outcomes compromise care delivery and leave professionals with enduring emotional scars that threaten both individual well-being and system sustainability. Treating psychosocial support as a core element of emergency preparedness, rather than an afterthought once crises subside, is therefore essential for building resilient long-term care systems. Strengths and limitations This study has several notable strengths. The mixed-methods design allowed for the integration of quantitative measures with qualitative accounts, offering both breadth and depth of insight into the effect of COVID-19 on LTCFs. The inclusion of multiple stakeholder groups (i.e., managers, healthcare workers, and relatives) provided a more comprehensive understanding of end-of-life care during the pandemic. Importantly, the study captured experiences spanning all seven waves of the COVID-19 pandemic, drawing on retrospective accounts to reflect the full course of the crisis. In addition, the use of validated psychological instruments, such as the PDI, enhanced the rigor of measurement. Nonetheless, certain limitations must be acknowledged. While the 57% response rate among managers exceeded our expectations and surpasses benchmarks for online surveys (Wu et al., 2022 ) and surveys of managers (Baruch & Holtom, 2008 ), results should be interpreted with caution given potential systematic differences between respondents and non-respondents. For the qualitative study, only five relatives participated, which may limit the diversity of perspectives captured. The cross-sectional design prevents conclusions about the persistence or evolution of psychological distress over time. In the event of other similar health crises, adopting a prospective design would make it possible to collect data on people’s experiences at the very moment they are experiencing the effects, thereby reducing recall bias in particular. This approach could also make it possible to survey residents directly, while remaining mindful of the associated ethical and methodological issues, to explore the effects of the crisis on them, rather than through a third party. As the study was conducted exclusively in Quebec’s publicly funded LTCFs, findings may not be generalizable to private LTCFs or to other provincial and international contexts. A further limitation relates to the psychological outcomes themselves. Nearly half of managers scored above the clinical threshold for peritraumatic distress, with a subset reaching levels that would typically warrant immediate clinical intervention. Because such high levels of distress had not been anticipated, no specific follow-up procedures were included in the consent process. In consultation with the research ethics board, the research team responded by providing all participants with debriefing emails, tailored lists of psychosocial resources, and follow-up in the qualitative phase, including one referral for urgent psychological support. While these responsive measures mitigated risk, this experience underscores the importance of anticipating high levels of distress when using sensitive psychological instruments and integrating explicit safety protocols into research design from the outset. Conclusions This study highlights the lasting psychological and organizational consequences of the COVID-19 pandemic for LTCFs in Quebec. Managers, healthcare workers, and relatives described experiences of distress rooted in grief, moral injury, and systemic challenges. Addressing these issues requires more than strengthening infection prevention and control; it also demands sustained strategies to support psychological well-being and organizational resilience. Recognizing professional grief, embedding accessible mental health supports, and expanding leadership training should be considered core components of crisis preparedness in long-term care. By integrating these measures into institutional planning, LTCFs can better safeguard the well-being of healthcare workers, foster trust among relatives, and enhance the quality of care for residents during future public health emergencies. Abbreviations LTCFs Long-term care facilities PTSD Post-traumatic stress disorder PDI Peritraumatic Distress Inventory Declarations Ethics approval and consent to participate. The present study received ethical approval from the research ethics committee of the Centre intégré de santé et de services sociaux de Laval (MP-35-2022-720). All participants provided informed consent to participate. Consent for publication. Non applicable. Availability of data and materials. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests. The authors declare that they have no competing interests. Funding. This project was funded by the Quebec Ministry of Health and Social Services. Authors' contributions. I.M., E.A., and G.B made substantial contributions to the conception of the work. I.M. was in charge of the research team that collected the quantitative data. I.M. and G.L. analysed the quantitative data. E.A. was in charge of the research team that collected and analysed the qualitative data. I.M., G.L and E.A. prepared the manuscript. All authors approved the final manuscript, and have accept accountability for all aspects of the work. Acknowledgements. The participants to the research project: the managers, the healthcare workers and relatives of deceased residents. The research staff: Sabrina Fournelle, Tania Crnich-Côté, Sarah Caouette, Clémence Coupat. 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Drivers of COVID-19 outcomes in Long-Term care facilities using Multi-Level analysis: A systematic review. InHealthcare 2024 Apr 8 (Vol. 12, No. 7, p. 807). MDPI. Lavoie-Tremblay M, Cyr G, Aubé T, Lavigne G. Lessons from long-term care facilities without COVID-19 outbreaks. Healthc Policy. 2022;17(SP):40. Leland NE, Brown C, Shore AD, Cary MP Jr, Reed K, Saliba D. Efforts to Support the Mental Health and Well-being of Nursing Home Staff: Insights From Leaders. J Am Med Dir Assoc. 2024;25(8):105051. Meyer DZ, Avery LM. Excel as a qualitative data analysis tool. Field methods. 2009;21(1):91–112. Nelson HW, Yang BK, McSweeney-Feld MH, Jerome GJ, Barry TT. Psychological and structural burdens and nursing home administrator turnover intentions during the COVID-19 Pandemic. J Appl Gerontol. 2024;43(6):706–15. Nelson HW, Weil J, McSweeney-Feld MH, Yang BK, Barry TT, Thayer N. Nursing Home Administrators’ Experiences of Work Stress and Intention to Quit During the COVID-19 Pandemic. Gerontologist. 2025;65(2):gnae165. Organisation for Economic Co-operation and Development (OECD). Rising from the COVID 19 Crisis: Policy Responses in the Long-term Care Sector. OECD Publishing; 2021. Paillé P, Mucchielli A. L'analyse qualitative en sciences humaines et sociales. A. Colin; 2016. Patton MQ. Qualitative evaluation and research methods. SAGE Publications, inc; 1990. Phillips CS, Trainum K, Hebdon MCT. Hidden in plain sight: A scoping review of professional grief in healthcare and charting a path for change. Palliat Support Care. 2024;22(4):469–82. Rahimi S, Khatooni M. Saturation in qualitative research: An evolutionary concept analysis. Int J Nurs Stud Adv. 2024;6:100174. Reynolds K, Ceccarelli L, Pankratz L, Snider T, Tindall C, Omolola D, Feniuk C, Turenne-Maynard J. COVID-19 and the experiences and needs of staff and management working at the front lines of long-term care in central Canada. Can J Aging/La Revue canadienne du vieillissement. 2022;41(4):614–9. Rocard E, Sillitti P, Llena-Nozal A. COVID-19 in long-term care: Impact, policy responses and challenges. OECD Publishing; 2021. Sarfjoo Kasmaei M, Freeman S, Banner D, Klassen-Ross T, Martin-Khan M. Job Satisfaction and Well-Being of Care Aides in Long-Term Care During the COVID-19 Pandemic: A Comprehensive Literature Review. World. 2025;6(2):62. Schneider P, Abt M, Cohen C, Marmier N, Ortoleva Bucher C. The impact of protective measures against COVID-19 on the wellbeing of residents in nursing homes and their relatives: a rapid review. BMC Geriatr. 2023;23(1):649. Shaw SL, Csikai E. No visitors allowed! The impact of COVID-19 restrictions on the psychosocial well-being of nursing home residents. J Long-Term Care. 2023;2023:54–66. Tsui EK, Franzosa E, Cribbs KA, Baron S. Home care workers’ experiences of client death and disenfranchised grief. Qual Health Res. 2019;29(3):382–92. van Teijlingen E, Hundley V. The importance of pilot studies. Nurs Standard (through 2013). 2002;16(40):33. Vracevic M, Pavlovic V, Todorovic N, Milic NM, Matejic B, Brkic P, Milic NV, Savic M, Masic S, Pavlovic A, Stanisic V. Compassion fatigue and satisfaction among frontline staff in long term care facilities: psychometric properties of the Serbian version of the professional quality of life scale. Front Psychiatry. 2025;16:1479190. Wu M-J, Zhao K, Fils-Aime F. Response Rates of Online Surveys in Published Research: A Meta-Analysis. Comput Hum Behav Rep. 2022;7:100206. Yin C, Mpofu E, Brock K, Ingman S. Nursing home residents’ COVID-19 infections in the United States: A systematic review of personal and contextual factors. Gerontol Geriatric Med. 2024;10:23337214241229824. Zhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. lancet. 2020;395(10229):1054–62. Footnotes The timeframes corresponding to the successive waves of COVID-19 in Quebec are: First wave: February 25 2021 to July 11 2020; second wave: August 23, 2020 to March 20, 2021; wave 3: March 21 to July 17, 2021; wave 4: July 18 to December 4, 2021; wave 5 (Omicron): December 5, 2021 to March 12, 2022; wave 6: March 13 to May 28, 2022; and wave 7: May 29, 2022 to present. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9163441","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":623637182,"identity":"e6a0d0cc-51d6-4d4a-9fe7-2e4f015f0003","order_by":0,"name":"Isabelle Marcoux","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACNhiDn3Qtkg0MjA0HSLLO4ACxWvjEDj/78KPicOLmG8nHH3+oOSzPwH74AX6HSacZz+w5c9jY7EZaYsOBY4cNG3jSDAhoSTBmZmw7LGd2I8ew4QDbbcYGCQZCWtI/g7TwGM8Aafl3275Bgv0DAS05EFsMJIBaDrbdTmyQ4CFkS04xY8+ZdGOJM88SZ5zt+5/cxpNTgFeL/Oz0zQw/KqwT+9uTD3yo+JZm289+fANeLVjsJVH9KBgFo2AUjAIsAADQGkZmo+EoKgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Ottawa","correspondingAuthor":true,"prefix":"","firstName":"Isabelle","middleName":"","lastName":"Marcoux","suffix":""},{"id":623637183,"identity":"507f2a59-1824-4541-9c68-236cbc7cb933","order_by":1,"name":"Emilie Allard","email":"","orcid":"","institution":"University of Montreal","correspondingAuthor":false,"prefix":"","firstName":"Emilie","middleName":"","lastName":"Allard","suffix":""},{"id":623637184,"identity":"0cb82413-58bd-4653-88e6-a449de453be7","order_by":2,"name":"Genevieve Lavigne","email":"","orcid":"","institution":"Université du Québec en Abitibi-Témiscamingue","correspondingAuthor":false,"prefix":"","firstName":"Genevieve","middleName":"","lastName":"Lavigne","suffix":""},{"id":623637185,"identity":"b0f2f19b-fbe0-4db1-ab70-5cf1fb1e1f47","order_by":3,"name":"Gina Bravo","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Gina","middleName":"","lastName":"Bravo","suffix":""}],"badges":[],"createdAt":"2026-03-18 23:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9163441/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9163441/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107407321,"identity":"599de021-e2aa-4923-a9ab-f0ddc18aafdf","added_by":"auto","created_at":"2026-04-21 08:36:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92854,"visible":true,"origin":"","legend":"\u003cp\u003eManagers’ PDI item ratings (n = 74)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9163441/v1/4cb4ab2b543889dac9818b7d.png"},{"id":107486765,"identity":"f55b7faa-fe0e-4350-b4f8-d802a493af39","added_by":"auto","created_at":"2026-04-22 02:38:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":87416,"visible":true,"origin":"","legend":"\u003cp\u003eHealthcare workers’ PDI item ratings (n = 16)\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9163441/v1/d0bca67637c847f772d07ba8.png"},{"id":107705478,"identity":"3be9dca7-f2f6-4839-8301-e0459184c60d","added_by":"auto","created_at":"2026-04-24 09:13:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":479596,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9163441/v1/38d4818a-6c0e-4204-bdf0-a0f90b35e1f3.pdf"},{"id":107407320,"identity":"9b945f99-96fd-424e-96df-7831a8f0b611","added_by":"auto","created_at":"2026-04-21 08:36:40","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":36342,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryfileExcerptfromtheInterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-9163441/v1/2e4052b0650de4a66dc72ea1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe effects of COVID-19 in Quebec public long-term care facilities on various stakeholder groups: a mixed-methods retrospective study across all waves of the pandemic\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe COVID-19 pandemic has had an unprecedented impact on health systems worldwide, with particularly devastating consequences for long-term care facilities (LTCFs). From the earliest waves of the pandemic, LTCF residents faced disproportionately high rates of infection, hospitalization, and mortality compared with community-dwelling older adults (Organisation for Economic Co-operation and Development [OECD], 2021; Rocard et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Across OECD countries, up to 50% of COVID-19\u0026ndash;related deaths during the initial waves of the pandemic occurred among LTCF residents, reflecting a combination of population vulnerability, close living arrangements, and longstanding underinvestment in infection prevention and control (Karimi-Dehkordi et al., 2024; Yin et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Zhou et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In Canada, the crisis was particularly severe: during the first two waves of the pandemic (March 1, 2020, to February 15, 2021), 69% of all COVID-19 deaths occurred among LTCF residents, with Quebec reporting the highest associated mortality rate among all provinces (Canadian Institute for Health Information (CIHI), 2021). Although these figures declined in subsequent waves, LTCF residents remained at elevated risk throughout the pandemic.\u003c/p\u003e \u003cp\u003eBeyond its epidemiological toll, the COVID-19 pandemic profoundly reshaped the lived experiences of those who resided in, worked within, and managed LTCFs, as well as the families who remained closely connected to these settings. The crisis exposed the interdependence of clinical care, organizational conditions, and leadership practices, setting the stage for widespread psychological and moral challenges across all stakeholder groups, yet existing research has largely examined these experiences in isolation or within limited phases of the pandemic.\u003c/p\u003e \u003cp\u003eFor residents of LTCFs and their relatives, pandemic-related infection prevention measures, particularly prolonged visitation restrictions, fundamentally altered daily life and end-of-life care. Residents experienced prolonged social isolation and disruptions to routine care, while families were often excluded from in-person contact and unable to be present during their loved ones\u0026rsquo; final moments. Studies conducted across multiple countries document significant psychological distress among both residents and relatives, including heightened anxiety, loneliness, and complicated grief (e.g., Chu et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Cornally et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Schneider et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Shaw \u0026amp; Csikai, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Notably, a review emphasize that protective measures were primarily designed to mitigate physical risk, often with limited consideration of their psychological consequences for residents and relatives (Schneider et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, relatives\u0026rsquo; experiences have tended to be examined separately from those of other stakeholders, like healthcare workers and managers who were directly involved in decisions or the provision of end-of-life care for residents in LTCFs, thus limiting a more comprehensive understanding of the effects of the pandemic.\u003c/p\u003e \u003cp\u003eThe unprecedented mortality and restrictive care environment also placed a substantial psychological burden on LTCF workers. A growing body of research documents high levels of anxiety, depression, burnout, and post-traumatic stress symptoms among LTCF personnel during the COVID-19 pandemic (e.g., Boamah et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Reynolds et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sarfjoo Kasmaei et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Healthcare workers were required to adapt to rapidly evolving public health directives, increased workloads, and staffing shortages, while simultaneously enforcing visitation restrictions and assuming surrogate family roles for residents (e.g., Collingridge Moore \u0026amp; Cotterell, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Havaei et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Across studies, healthcare workers distress has been closely linked not only to workload and staffing shortages but also to organizational policies, such as visitation restrictions, sick-time rules, and staffing models, that shaped daily care practices and ethical tensions (Boamah et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Havaei et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Reynolds et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Although this literature clearly establishes the magnitude of healthcare workers\u0026rsquo; distress, it often focuses on specific professional groups or limited periods of the pandemic, offering a partial view of how healthcare workers experiences were shaped by broader organizational conditions. Qualitative research from Quebec and Ontario suggests that gaps in protocols and communication contributed to heightened organizational strain within LTCFs (Baumann et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Lavoie-Tremblay et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin this organizational context, LTCF managers faced a distinct yet interconnected set of challenges. Evidence from qualitative studies indicates that leadership, alongside clear protocols and effective communication, played a decisive role in shaping organizational responses during the pandemic, underscoring the central position of managers within LTCFs (Baumann et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Lavoie-Tremblay et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Responsible for implementing evolving public health directives, ensuring infection prevention and control, securing scarce resources, and maintaining workforce stability, managers also served as key intermediaries between healthcare workers, residents, families, and external authorities. Beyond these operational responsibilities, managers were tasked with supporting healthcare workers emotionally and mediating tensions between healthcare workers and families, positioning them at the intersection of organizational crisis management and frontline care delivery (Leland et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In addition, managers were responsible for pandemic-specific initiatives such as vaccine rollout and acceptance, while simultaneously addressing the deteriorating well-being of their workforce, further compounding role strain (Fahim et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Leland et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Emerging evidence suggests that these responsibilities were associated with substantial psychological strain, role conflict, and increased turnover intentions among managers (e.g., Estabrooks et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Fahim et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Nelson et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Despite this dual burden and their pivotal role in shaping organizational responses, managers\u0026rsquo; experiences remain comparatively underexamined, particularly in relation to the experiences of healthcare workers, the residents and their relatives.\u003c/p\u003e \u003cp\u003eExisting research highlights the profound psychological and organizational impacts of the COVID-19 pandemic on residents, relatives, healthcare workers, and managers in LTCFs. However, this literature remains fragmented across stakeholder groups and methodological approaches. Reviews and primary studies have largely examined the experiences of frontline healthcare workers (e.g., Boamah et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Havaei et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sarjoo Kasmaei et al., 2025), residents and relatives (e.g., Schneider et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), or managers (e.g., Estabrooks et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Nelson et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) in isolation. Even studies that have included more than one stakeholder group have typically been conducted during limited phases of the pandemic or within specific organizational contexts. For example, Reynolds et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) examined healthcare workers and managers during the early phase of the pandemic, whereas Baumann et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and Lavoie-Tremblay et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) focused on selected long-term care facilities, such as exemplar homes or facilities without COVID-19 outbreaks, offering important but necessarily partial insights. Moreover, few studies document these experiences across the full span of the pandemic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cem\u003eAim and objectives.\u003c/em\u003e The aim of this paper is to describe the effects of the COVID-19 pandemic on various stakeholders (managers, healthcare workers, relatives of deceased residents, and recipients of end-of-life care) within Quebec\u0026rsquo;s LTCFs, with the goal of capturing their distinct yet interrelated experiences. The objectives were to (1) assess the psychological distress of managers and associated factors; (2) explore the effects of the COVID-19 pandemic on healthcare workers (including their psychological distress), and on relatives of deceased residents, as well as the effects they perceived on residents who died during the pandemic; and (3) integrate the quantitative and qualitative findings to provide a comprehensive understanding of how the pandemic affected LTCF stakeholders and to identify opportunities to strengthen organizational resilience and psychosocial support systems for future health crises.\u003c/p\u003e \u003cp\u003e \u003cem\u003eDesign and setting.\u003c/em\u003e A mixed-methods design was utilized to examine the multifaceted impacts of the COVID-19 pandemic within LTCFs. The study was conducted in Quebec\u0026rsquo;s LTCFs, publicly funded facilities providing 24-hour nursing care to individuals experiencing significant loss of autonomy, primarily older adults living with multiple comorbidities or cognitive impairments.\u003c/p\u003e \u003cp\u003e\u003cem\u003eEthical considerations.\u003c/em\u003e The study was approved in 2021 by the primary investigators' Laval research ethic board (MP-35-2022-720). The process of securing institutional approvals across the six selected healthcare regions was carried out from July 2021 to August 2022. Participation was voluntary, and informed consent was obtained electronically before data collection (survey or interview). Data confidentiality and security were strictly maintained, with survey data anonymized prior to analysis, and transcript interview anonymized using codes and pseudonyms in the article to ensure confidentiality.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Phase: Survey of LTCF managers\u003c/h2\u003e \u003cp\u003e \u003cem\u003eParticipants.\u003c/em\u003e For feasibility reasons (e.g. institutional considerations, time-sensitive nature of the study, availability of human and financial resources), a non-probabilistic sampling strategy for healthcare regions, namely purposive with maximum variation (Patton, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1990\u003c/span\u003e) was employed based on the following criteria: facility size (e.g. number of public LTCFs and total number of beds), resident populations (e.g. distinctive characteristics), and regional COVID-19 effects (e.g. COVID-19 mortality burden, including the number of deaths and changes in mortality rates during the first and second waves). Regions were excluded if they reported no COVID-19-related deaths during the first two waves or if they were already engaged in a separate pilot project (Allard et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Based on these criteria, six out of 13 regional health and social service centres were selected.\u003c/p\u003e \u003cp\u003eThe maximum eligible population consisted of 143 LTCFs located within the selected regions, out of a total of 246 LTCFs that met the inclusion criteria across the province. This represents 58% of the total target population. A participation rate of 50% was established as the goal, representing approximately 70 LTCFs. To ensure adequate statistical power to explore the effects of the pandemic on managers (refer to data analysis section), a sample size calculations indicated that a minimum of 52 managers was required to detect a large effect size (Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.50) with an alpha level of 0.05 and a power of 0.95 (Cohen, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Faul et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). All LTCF managers working within the six selected regional health and social service centres were invited to participate.\u003c/p\u003e \u003cp\u003e \u003cem\u003eQuestionnaire.\u003c/em\u003e The Peritraumatic Distress Inventory (PDI) (Brunet et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2001\u003c/span\u003e), validated in French (Jehel et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2005\u003c/span\u003e), was used to assess psychological distress experienced by managers during the most critical moment they had encountered in their role since the onset of the COVID-19 pandemic (from one of the seven waves\u003csup\u003e1\u003c/sup\u003e). The original PDI comprises 13 items rated on a five-point Likert-type scale ranging from 0 (not at all true) to 4 (extremely true). Following pre-testing with managers, one item (\u0026ldquo;I felt like urinating and defecating\u0026rdquo;) was removed because it was considered inappropriate for the context of this study. Consequently, the total possible score ranged from 0 to 48, compared to 0 to 52 in the original version. The modified PDI demonstrated strong internal consistency with a Cronbach\u0026rsquo;s alpha of 0.87. In the full version, a cut-off score of 14 or higher is considered the optimal threshold for identifying individuals at risk of developing post-traumatic stress disorder (PTSD) (Guardia et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). For this study, the threshold was proportionally adjusted to 13 to reflect the modified scoring range.\u003c/p\u003e \u003cp\u003eIn addition to the PDI, sociodemographic data and other measures were collected to contextualize managers\u0026rsquo; experiences. These included variables such as age, gender, and years of managerial experience. Facility-level data were also gathered for each participating LTCF (directly from the regional health and social service centres), including number of residents, the number of COVID-19-related deaths for each of the seven pandemic waves, and the total number of deaths from all causes since the beginning of the pandemic.\u003c/p\u003e \u003cp\u003e \u003cem\u003eProcedure.\u003c/em\u003e The online questionnaire was hosted on the secure LimeSurvey platform. In order to assess clarity of the wording, survey length, navigation flow, and overall usability (van Teijlingen \u0026amp; Hundley, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2002\u003c/span\u003e), the questionnaire was pretested with eight individuals who met the inclusion criteria but were not part of the potential participant pool. Adjustments were made to improve wording and flow, and two team members subsequently carried out a final verification to ensure that the survey was free of technical or content errors before launch.\u003c/p\u003e \u003cp\u003eData collection took place between September and December 2022. Invitations to participate were sent by email to all eligible LTCF managers through their respective regional centres administrative offices. To maximize the response rate, we employed a modified version of Dillman\u0026rsquo;s Tailored Design Method (Dillman et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), which involved up to four personalized contact attempts spaced at two-week intervals.\u003c/p\u003e \u003cp\u003e \u003cem\u003eData analysis.\u003c/em\u003e Data were exported into SPSS version 29.0 for analysis. Descriptive statistics were used to characterize managers\u0026rsquo; demographic, organizational, and COVID-19\u0026ndash;related characteristics. Chi-square tests examined associations between critical peritraumatic distress (PDI\u0026thinsp;\u0026ge;\u0026thinsp;13) and categorical manager characteristics (i.e., age, gender, and experience in the current position). T-tests were used to compare COVID-19\u0026ndash;related mortality indicators across PDI groups, including the number of resident deaths during each pandemic wave and total deaths from all causes relative to the number of residents. Statistical significance was set at p \u0026lt; .05.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative phase : Semi-structured interviews with healthcare workers and relatives\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eParticipants and Sampling Strategies.\u003c/em\u003e For healthcare workers, the inclusion criteria was having worked at any point during the pandemic in a public LTCF within one of the participating regional health and social service centres. For relatives, the inclusion criteria were: (1) being related to a resident of a LTCF who died during the pandemic, regardless of whether the death was associated to COVID-19, and (2) the deceased resident must have lived in a publicly funded LTCF within one of the participating regional health and social service centres.\u003c/p\u003e \u003cp\u003eTwo complementary sampling strategies were employed to recruit healthcare workers and relatives. First, invitation emails were sent by the administrative offices to all healthcare team members with institutional email addresses within the six included regions. In parallel, social media announcements were posted through university networks and local caregiver organizations to reach relatives and additional care providers, including those who had been temporarily reassigned to LTCFs during the pandemic. Second, a snowball sampling strategy was implemented to broaden recruitment. Participants were invited to share a standardized recruitment message with potentially eligible individuals within their networks. This ensured consistency in study information while maintaining voluntary participation.\u003c/p\u003e \u003cp\u003e\u003cem\u003eData Collection.\u003c/em\u003e Individual semi-structured interviews were conducted by trained researchers between May 2023 and November 2024. They took place remotely via Zoom or telephone, each lasting between 45 and 90 minutes. Throughout the process, interviewers maintained reflexive memos to document their positionality and experience of doing research in time of pandemic, idea on data generation and participants\u0026rsquo; non-verbal communication. The interview guide (supplementary file) was tailored separately to healthcare workers and relatives to ensure questions relevance to each group\u0026rsquo;s experience. In addition to sociodemographic questions used to describe the sample (e.g., age, gender, role, years of experience, relationship to the deceased resident), the guide explored participants\u0026rsquo; experiences of end-of-life care during the COVID-19 pandemic across multiple domains (e.g., communications, workload, psychological experience, quality of care). Also, consistent with part of the objective 2, healthcare workers were invited to complete the PDI to quantitatively assess pandemic-related psychological distress. This measure, collected towards the end of the interview, also served to compare the results obtained for the various items on the scale with those of managers. Data collection continued until meaning saturation (Rahimi \u0026amp; Khatooni, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) was reached, ensuring a deep understanding of the issues and a rich analysis where no new insights regarding the codes or their relationships emerged. To acknowledge participants\u0026rsquo; contributions, each received a \u003cspan\u003e$\u003c/span\u003e10 electronic gift card.\u003c/p\u003e \u003cp\u003e\u003cem\u003eData Analysis.\u003c/em\u003e All interviews were fully transcribed using the Noota software and reviewed to ensure accuracy and completeness. Data were analyzed using the categorizing analysis method (Paill\u0026eacute; \u0026amp; Mucchielli, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), which involved a systematic process of iterative coding and conceptualization. Using Excel as an analysis tool (Meyer \u0026amp; Avery, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), each interview was coded line by line independently by two members of the research team. Initial codes were developed as closely as possible to the participants\u0026rsquo; own words to remain faithful to their perspectives. Each code was then assigned a brief definition to clarify its meaning. Codes were compared across transcripts and grouped into broader explanatory categories informed by findings from a previous pilot project (Allard et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) as well as results from the quantitative phase of the current study. Discrepancies or interpretative conflicts between coders were resolved through discussion within the analysis team, ensuring consensus and reinforcing the credibility and trustworthiness of the findings.\u003c/p\u003e\n\u003ch3\u003eIntegration of Data from the Two Phases of the Study\u003c/h3\u003e\n\u003cp\u003eA narrative integration of the results was determined to be the most appropriate as it allowed for a more nuanced presentation of the findings, highlighting convergences and divergences across stakeholder effects of the pandemic. Integration occurred during the interpretation stage, where qualitative themes were used to complement and contextualize quantitative results, yielding a broader understanding of the pandemic\u0026rsquo;s effects on stakeholder groups.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 143 managers initially invited to participate in the survey, seven were considered non valid cases (lacked the necessary knowledge to complete the questionnaire or no longer had ties to the position), and were therefore excluded. From the 136 eligible managers, 77 completed the questionnaire, yielding a 57% response rate. Most participants were women (83.8%), and aged 50 or younger (73.0%). In their current role, 41.9% had two years or less of experience.\u003c/p\u003e\n\u003cp\u003eA total of 21 individuals participated in the semi-structured interviews: 16 healthcare workers and 5 relatives of residents who had died in a LTCF during the COVID-19 pandemic. The healthcare workers represented four of the six regional health and social service centres included in this study, with the majority (10/16) having more than five years of experience in their workplace. Reflecting the interdisciplinary nature of LTCF care teams, half of the participants (8/16) held nursing roles, three were nursing assistants/orderlies, two were social workers, and three in the field of rehabilitation. Most participants were women (11/16), and the majority were between 31 and 40 years old (10/16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFive relatives took part in the qualitative interviews, all of whom were women. Their ages were as follows: 31\u0026ndash;40 years (n = 2), 51\u0026ndash;60 years (n = 1), and over 60 years (n = 2). Four were adult children of deceased residents, while one was a spouse. All had completed at least a college-level education. The deceased residents were all over 70 years of age and in most cases lived with a major neurocognitive disorder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eManagers\u0026apos; psychological distress and associated factors\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 74 managers for whom we have peritraumatic distress (PDI) scores, most often identified the first wave of the pandemic as the most critical moment experienced in the course of their duties (42%), followed by the second wave (21%) and the fifth wave, corresponding to the Omicron surge (19%). Total PDI scores ranged from a minimum of 2 to a maximum of 45 (out of a possible 48) with an average score of 13.86 (SD = 8.00). Thirty-six managers (48.6%) obtained a total score of 13 or higher, the clinical threshold indicating a risk of developing PTSD. A closer examination of individual PDI items provided valuable insight into the specific experiences most frequently reported by managers. As shown in Figure 1, the emotions most frequently rated as extremely true or very true were helplessness (64%), worry about the safety of others (46%), sadness and grief (42%), and frustration and anger (42%). In contrast, more intense reactions such as shame about one\u0026rsquo;s emotional responses (1%), fear of dying (3%), or feeling as though they might faint (3%) were rarely reported.\u003c/p\u003e\n\u003cp\u003eTable 1 presents the results of chi-square and t-test analyses examining associations between the dichotomized PDI scores (clinical threshold) and demographic, professional, and pandemic-related characteristics. No statistically significant associations were found for gender, age, experience in the current role, number of COVID-19-related deaths for each of the seven pandemic waves, and the total number of deaths from all causes since the beginning of the pandemic by the number of residents (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05). However, trends approaching statistical significance were observed for gender (\u003cem\u003ep\u003c/em\u003e = .073) and age dichotomized at 50 years (\u003cem\u003ep\u003c/em\u003e = .051), with female managers and those aged 50 years or younger more frequently classified in the critical stress group compared with their counterparts. Although these differences did not reach conventional levels of statistical significance, they may indicate the presence of potentially vulnerable subgroups warranting further investigation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Critical peritraumatic distress among 74 LTCF managers by demographic, professional, and contextual characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplete sample\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCritical stress (PDI\u0026nbsp;\u003c/strong\u003e\u0026ge;\u003cstrong\u003e\u0026nbsp;13)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChi-square test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Female\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62 (83.8)\u003c/p\u003e\n \u003cp\u003e12 \u0026nbsp;(16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33 (53.2)\u003c/p\u003e\n \u003cp\u003e3 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026Chi;\u003csup\u003e2\u003c/sup\u003e(1) = 3.21,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 18 to 50 years old\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 51 years old and older\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e54 (73.0)\u003c/p\u003e\n \u003cp\u003e20 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (55.6)\u003c/p\u003e\n \u003cp\u003e6 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026Chi;\u003csup\u003e2\u003c/sup\u003e(2) = 3.82,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 0 to 2 years\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; More than 2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e31 (41.9)\u003c/p\u003e\n \u003cp\u003e43 58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (38.7)\u003c/p\u003e\n \u003cp\u003e24 (55.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026Chi;\u003csup\u003e2\u003c/sup\u003e(1) = 2.11,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .146\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWave 1 \u0026ndash; death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eX = 7.78\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(SD = 17.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eX = 7.47\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(SD = 19.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003et(72) = .15, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .881\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWave 2 \u0026ndash; death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eX = 5.42\u003c/p\u003e\n \u003cp\u003e(SD = 9.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eX = 4.93\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(SD = 8.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003et(58) = .39, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .696\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWave 3 \u0026ndash; death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eX = 0.15\u003c/p\u003e\n \u003cp\u003e(SD = 0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eX = 0.17\u003c/p\u003e\n \u003cp\u003e(SD = 0.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eF(58) = -.29, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWave 4 \u0026ndash; death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eX = 0.02\u003c/p\u003e\n \u003cp\u003e(SD = 0.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eX = 0.03\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(SD = 0.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003et(58) = -1.04, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .305\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWave 5 \u0026ndash; death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eX = 1.52\u003c/p\u003e\n \u003cp\u003e(SD = 2.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eX = 1.76\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(SD = 1.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003et(58) = -.79, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .431\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWave 6 \u0026ndash; death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eX = 0.95\u003c/p\u003e\n \u003cp\u003e(SD = 1.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eX = 0.79\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(SD = 1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003et(58) = .71, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .478\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWave 7 \u0026ndash; death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eX = 0.72\u003c/p\u003e\n \u003cp\u003e(SD = 1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eX = 0.66\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(SD = 1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003et(58) = .30, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .763\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal death from all causes / number of residents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eX = 1.76\u003c/p\u003e\n \u003cp\u003e(SD = 2.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eX = 1.48\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(SD = 0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003et(57) = .75, \u003cem\u003ep\u003c/em\u003e = .454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: X = mean, SD = Standard Deviation. Data on the number of resident deaths during Waves 2 through 7 were not provided from one regional health and social service centre out of six (accounted for 14 LTCFs); analyses involving these variables were therefore conducted on a sample of 60 managers, of whom 29 met the criterion for critical peritraumatic distress (PDI \u0026ge; 13). In contrast, data on total deaths (all causes) relative to the number of residents were unavailable for 15 LTCFs, resulting in a reduced analytic sample of 59 managers, of whom 28 met the criterion for critical peritraumatic distress (PDI \u0026ge; 13).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEffects on healthcare workers, including their psychological distress\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 16 healthcare workers interviewed, all met the criterion for critical peritraumatic distress (PDI \u0026ge; 13), and most identified the first two waves of the pandemic as the most psychologically challenging period they experienced. This period was primarily attributed to the sudden arrival of the first COVID-19 cases, the high number of deaths in LTCFs, and the negative media discourse surrounding long-term care settings.\u003c/p\u003e\n\u003cp\u003ePeritraumatic distress scores (see Figure 2) indicated substantial acute psychological strain among healthcare workers. The PDI items that most strongly reflected their experiences were feelings of frustration and anger (88%), a sense of helplessness (75%), worry for the safety of others (75%), as well as feelings of distress and grief (62%). Notably, one in four healthcare workers expressed very strong agreement (extremely true) with statements related to fear for their own safety (25%). Intense physical reactions such as sweating, trembling, or palpitations and loss of emotional control were endorsed as extremely true or very true by one in four (25%). Approximately one in five described heightened experiences of guilt (18.8%), feeling faint (18.8), or being horrified by what they witnessed (18.8%). In contrast, more intense reactions such as shame about one\u0026rsquo;s emotional responses (6.3%) and fear of dying (6.3%) were rarely endorsed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese quantitative findings were further illuminated by qualitative accounts, which provided contextual depth to the emotional patterns reflected in the PDI results. The majority of healthcare workers interviewed reported experiencing high levels of stress and persistent fatigue throughout the pandemic. Early fears were primarily linked to the unknown nature of the virus and its potential effect on the highly vulnerable LTCF population. Yet participants, like Louison, emphasized that the absence of clear and consistent guidance was a major source of stress and anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;What made the work environment so anxiety-inducing during the first wave was that the health directives kept changing constantly, every single day\u0026hellip; It wasn\u0026rsquo;t very reassuring.\u0026rdquo;\u003c/em\u003e (Louison, healthcare worker)\u003c/p\u003e\n\u003cp\u003eChronic staff shortages, compounded by additional responsibilities and extended working hours, contributed to a widespread sense of exhaustion and demoralization\u003cem\u003e.\u0026nbsp;\u003c/em\u003eParticipants also described the emotional toll of frequent and rapid resident decline and deaths. Many had cared for residents over several years and had built relationships with relatives, but the public health context prevented these relationships from being properly concluded, leaving a sense of unfinished mourning. To cope, many healthcare workers described having to suppress their emotions and operate on \u0026ldquo;autopilot\u0026rdquo; to continue providing care.\u003c/p\u003e\n\u003cp\u003eSeveral participants spoke of experiencing a profound and underrecognized grief stemming from the accumulation of losses during the pandemic\u0026mdash;both of the residents they cared about and of their relatives they bonded with. They felt that this grief was largely underestimated by managers and organizations, underscoring a critical gap in institutional support for staff well-being during such crises. This accumulation of losses gave rise to a form of professional grief that many felt was underestimated or unrecognized by their organizations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We underestimated the grief that we, as employees, could experience. It caused a great deal of suffering. (\u0026hellip;) We grow close [to the residents], without crossing the line of professionalism, but there are people we see every day who become part of our lives. A bond is created.\u0026quot;\u003c/em\u003e (\u0026Eacute;lie, healthcare worker)\u003c/p\u003e\n\u003cp\u003eBeyond their relationships with residents and relatives, the sense of isolation also deeply affected healthcare workers, who were accustomed to gathering in common areas or spaces dedicated to staff members. The required physical distancing reduced opportunities for interaction and weakened the sense of belonging within care teams.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When the team can no longer gather, in places like dining rooms, team cohesion is less present, it becomes fragile [\u0026hellip;] And when the team is fragile, the quality of services suffers.\u0026quot;\u003c/em\u003e (Paula, healthcare worker)\u003c/p\u003e\n\u003cp\u003eDespite these challenges, some participants highlighted moments of solidarity, describing how staff came together and mobilized to lend support during particularly difficult times in LTCFs. In particular, healthcare workers tip their hats to those who volunteered to lend a hand in LTCFs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Team spirit and compassion were the two positive things that stood out. Because there were also people who were reassigned to the long-term care facility, but who never wanted to leave. They wanted to stay until the end! That was beautiful to see. Yet the conditions were really very difficult.\u0026quot;\u003c/em\u003e (Susan, healthcare worker).\u003c/p\u003e\n\u003cp\u003eOverall, these findings underscore the substantial psychological burden experienced by healthcare workers during the pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived effects on residents living in LTCFs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants, healthcare workers and relatives, emphasized the profound effects of the protective measures (e.g., masks, visit limitations and room isolation) and organizational changes (e.g., suspension of recreational activities and closure of common areas) on residents living in LTCFs. Reactions of confusion, misunderstanding, and frustration were commonly observed in response to the implementation of protective measures. Several healthcare workers mentioned that residents struggled to understand the guidelines or to recognize them and their relatives when they were wearing protective equipment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The introduction of mask was very disruptive [for the residents], because there were no mouths anymore. No one had a mouth anymore. It was all about smiling with the eyes. I think it created a barrier for some residents with cognitive disorders, making it harder for them to recognize and understand.\u0026rdquo;\u003c/em\u003e (Dominique, healthcare worker)\u003c/p\u003e\n\u003cp\u003eThe use of protective equipment altered interactions between healthcare workers and residents by limiting non-verbal communication, contributing to more impersonal care encounters and heightened feelings of isolation during the pandemic. Using the example of her mother\u0026apos;s hygiene care, Fr\u0026eacute;d\u0026eacute;rique explains how bedridden and confused residents could experience a form of violence.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Imagine when my mother was bedridden all the time. Constantly, someone would come near her bed, masked. (\u0026hellip;) Most of the time, they didn\u0026rsquo;t identify themselves. They would come in, grab her, shake her, turn her over, and then remove her clothes.\u0026quot;\u003c/em\u003e (Fr\u0026eacute;d\u0026eacute;rique, relative)\u003c/p\u003e\n\u003cp\u003eProlonged physical distancing measures, which in some settings lasted for several months or even years, further disrupted the usual living environment activities, limiting opportunities for meaningful interaction. Residents seated two metres apart in common areas were unable to converse effectively, a situation that many staff described as contributing to deconditioning and reinforcing isolation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I found it really striking. We had put X\u0026rsquo;s on the floor to mark where to place people in the common room to maintain social distancing (\u0026hellip;) It was so far apart. Since they had cognitive impairments and hearing devices, they couldn\u0026rsquo;t hear each other. It didn\u0026rsquo;t work; they couldn\u0026rsquo;t talk to one another. It wasn\u0026rsquo;t better in the end. They saw other people, but they couldn\u0026rsquo;t actually talk to them.\u0026rdquo;\u003c/em\u003e (Alexis, healthcare worker)\u003c/p\u003e\n\u003cp\u003eSeveral participants discussed the effects of prolonged isolation on the physical and mental health of residents living in LTCFs. The suspension of social and recreational activities, as well as physiotherapy sessions, contributed to a marked decline in residents\u0026rsquo; overall condition, a change observed by all healthcare workers interviewed, like Jamie: \u003cem\u003e\u0026ldquo;[The pandemic] was not good for their mental health. Some people experienced greater decompensation; they became more physically rigid, but also mentally.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEffects on relatives of deceased residents in LTCFs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRoom isolation measures significantly shaped the experiences of relatives, who were not permitted to leave residents\u0026rsquo; room and prohibited from removing their protective equipment, even for basic activities such as eating. Several participants reported adverse events linked to this poorly adapted environment, including fainting episodes, underscoring the strain of such restrictive conditions.\u003c/p\u003e\n\u003cp\u003eRoom isolation also reduced opportunities for social interaction and mutual support among relatives within the LTCF. Families are often regarded as an integral part of the care environment, offering informal emotional support and companionship during the difficult process of end-of-life care. However, the pandemic and strict distancing measures effectively eliminated these exchanges, depriving relatives of important sources of comfort and shared understanding.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes it can be nice to chat with other relatives. I remember seeing two sisters\u0026mdash;I\u0026rsquo;m not sure if it was their mother or father who was dying\u0026mdash;we knew they were there for that reason too, but we were never able to talk to them. [The pandemic] placed so many limits on the social aspect, on the support we could have received, and on the connections we could have built.\u0026rdquo;\u003c/em\u003e (Sacha, relative)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this mixed-methods retrospective study was to integrate quantitative measures of peritraumatic distress among managers with qualitative accounts from healthcare workers and relatives, thereby providing a comprehensive understanding of the multifaceted effects of the COVID-19 pandemic on Qu\u0026eacute;bec\u0026rsquo;s LTCFs. The findings demonstrate the profound psychological toll of the pandemic on LTCFs. Nearly half of surveyed managers exceeded the clinical threshold for peritraumatic distress, indicating a substantial risk of PTSD. While no statistically significant associations were found based on gender, age, managerial experience, number of COVID-19-related deaths for each of the seven pandemic waves, and total number of deaths from all causes since the beginning of the pandemic by number of residents, trends suggested that female managers and those aged 50 years or younger were more likely to fall into the critical stress category. These patterns may reflect the predominance of women in LTCF leadership roles and the added burden of work\u0026ndash;family demands, particularly among younger managers who may have greater caregiving responsibilities. These results underscore the widespread psychological strain faced by managers, while also pointing to potentially vulnerable subgroups within this population.\u003c/p\u003e \u003cp\u003eQualitative findings enriched the quantitative results by revealing how the first waves of the pandemic were consistently perceived as the most critical and distressing period across stakeholder groups. This phase was characterized by uncertainty, high mortality, and strict visitation bans. Both managers and healthcare workers reported intense emotions including helplessness, concern for others\u0026rsquo; safety, sadness, frustration, and anger. While managers highlighted these feelings during the early waves, healthcare workers emphasized that the first resident deaths were particularly impactful, leaving lasting impressions that many continued to recall vividly years later. Overall, these findings suggest that the psychological consequences of the pandemic were not only acute but also enduring, underscoring the importance of examining the persistence of traumatic memories and distress across stakeholder groups over time. Taken together, the quantitative and qualitative strands converge to depict a multi-level pattern of distress within Quebec\u0026rsquo;s LTCFs, in which organizational pressures, repeated exposure to death, and relational disruptions intersected across roles. Managers\u0026rsquo; elevated peritraumatic distress scores provide measurable evidence of acute strain, while qualitative accounts from healthcare workers and relatives illuminate how these stressors were experienced, interpreted, and sustained over time. This integrative perspective underscores the interconnected nature of psychological burden, organizational functioning, and end-of-life care during the pandemic.\u003c/p\u003e \u003cp\u003eIn addition to these emotional responses, healthcare workers spoke extensively about fatigue and exhaustion, with mental health concerns, including burnout, stress, and moral distress, emerging as prominent themes. Such experiences mirror survey-based research, including Haslam-Larmer et al.\u0026rsquo;s (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) study of 227 healthcare workers and Estabrooks et al.\u0026rsquo;s (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) survey of 181 managers, both of which documented substantial psychological strain in the long-term care workforce. Broader meta-analyses also confirm high prevalence of anxiety, depression, and PTSD symptoms among LTCF staff globally (Boamah et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Reynolds et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sarfjoo Kasmaei et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Aligning with previous research on the detrimental effects of systemic stressors on managers, such as staffing shortages, inconsistent directives, and the burden of enforcing restrictive visitation policies (Estabrooks et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), our qualitative findings underscore the profound effects of protective measures and organizational changes on residents, their relatives and healthcare workers.\u003c/p\u003e \u003cp\u003eThe qualitative data also shed light on the professional grief experienced by healthcare workers, which emerged as a recurrent theme in the interviews. Participants emphasized that working in LTCFs often fostered close bonds with residents and their relatives, making them part of daily professional and even personal life. The abrupt rupture of these ties, caused by sanitary measures that limited family presence and by repeated resident deaths, sometimes involving individuals they had known for months or years, was experienced as a profound loss. Several healthcare workers reported that this grief was not acknowledged by their superiors, leaving them to cope largely on their own. This aligns with the concept of disenfranchised grief, in which legitimate forms of mourning are overlooked or minimized (Doka, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). Comparable dynamics have been observed in home care and nursing home settings, where relationship losses are underestimated and grief is frequently conflated with routine job stress (\u0026Aring;dland et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Tsui et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Notably, Phillips et al.\u0026rsquo;s (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) scoping review during COVID-19 underscores how such unrecognized grief undermines staff well-being and organizational resilience, reinforcing the need for grief-informed supports in long-term care.\u003c/p\u003e \u003cp\u003eOverall, these findings demonstrate that the pandemic\u0026rsquo;s effects on LTCF healthcare workers and managers extended far beyond immediate workload pressures and infection control challenges. Emotional exhaustion, cumulative grief, and moral distress were shaped not only by systemic organizational conditions, such as staff shortages and rapidly changing directives, but also by deeply personal bonds with residents and relatives. By integrating the perspectives of managers and frontline healthcare workers with those of relatives of deceased residents, and by capturing experiences across the pandemic as a whole, this study offers a more comprehensive and relational understanding of how distress and resilience were produced within LTCFs. Acknowledging and addressing these experiences is crucial for developing trauma-informed organizational supports that can foster resilience among care teams. Without such recognition and support, unresolved grief and sustained distress risk undermining workforce well-being and retention, with long-term consequences for the quality of care provided in LTCFs (Estabrooks et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Nelson et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eImplications and recommendations for LTCFs\u003c/h2\u003e \u003cp\u003eOur study makes several important contributions. It is among the rare mixed-methods investigations to integrate the perspectives of managers, healthcare workers, and relatives on both their own experiences and the perceived effects of the pandemic on residents in the context of COVID-19 and end-of-life care in LTCFs. By triangulating these viewpoints, the study offers a more comprehensive account of the pandemic\u0026rsquo;s multifaceted effects on LTCFs, extending a literature that has often examined stakeholder experiences in isolation. The study also demonstrates the value of the PDI in quantifying acute psychological distress among both managers and healthcare workers, providing measurable evidence of peritraumatic strain across professional roles during the pandemic. Furthermore, managers are an often-overlooked stakeholder group whose psychological burden throughout the whole pandemic has received limited attention in prior research. Finally, it highlights the presence of professional grief among healthcare workers, a theme rarely addressed in policy discourse despite its profound implications for both workforce resilience and quality of care provided to residents and relatives.\u003c/p\u003e \u003cp\u003eIn light of these findings, several critical implications for policy and practice emerge. The enduring psychological effects of the pandemic on managers, healthcare workers, residents at the end of life, and their relatives need to be explicitly recognized within institutional discourse. These effects should not be viewed as temporary distress but acknowledged as potentially enduring effects with serious consequences for workforce retention, quality of care, and public trust in LTCFs. To mitigate these risks, LTCFs must invest in the systematic development and evaluation of targeted interventions and psychosocial resources. Accessible mental health services, grief support programs, and structured opportunities for staff debriefing and collective mourning are essential to address the risks of burnout, unresolved grief, and moral injury. At the same time, managerial training should be strengthened to prepare leaders to support frontline teams through uncertainty and loss, with emphasis on communication, emotional validation, and the management of moral distress. This recommendation is consistent with findings from Lavoie-Tremblay et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) who identified strong leadership and clear communication as key protective factors during the pandemic. Embedding these competencies within leadership development programs across LTCFs could foster greater organizational resilience. Ultimately, psychosocial support must be recognized as a core component of emergency preparedness in long-term care, rather than a reactive measure introduced only after a crisis has subsided.\u003c/p\u003e \u003cp\u003eThese recommendations align with those of Grinspun and colleagues (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), who emphasize that preparedness for future health crises in LTCFs must prioritize the well-being of care providers. Neglecting the mental health of managers and staff not only diminishes compassion and professionalism but also contributes to increased burnout, depression, anxiety, fatigue, and anger (e.g., Garnett et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Vracevic et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Such outcomes compromise care delivery and leave professionals with enduring emotional scars that threaten both individual well-being and system sustainability. Treating psychosocial support as a core element of emergency preparedness, rather than an afterthought once crises subside, is therefore essential for building resilient long-term care systems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study has several notable strengths. The mixed-methods design allowed for the integration of quantitative measures with qualitative accounts, offering both breadth and depth of insight into the effect of COVID-19 on LTCFs. The inclusion of multiple stakeholder groups (i.e., managers, healthcare workers, and relatives) provided a more comprehensive understanding of end-of-life care during the pandemic. Importantly, the study captured experiences spanning all seven waves of the COVID-19 pandemic, drawing on retrospective accounts to reflect the full course of the crisis. In addition, the use of validated psychological instruments, such as the PDI, enhanced the rigor of measurement. Nonetheless, certain limitations must be acknowledged. While the 57% response rate among managers exceeded our expectations and surpasses benchmarks for online surveys (Wu et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and surveys of managers (Baruch \u0026amp; Holtom, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2008\u003c/span\u003e), results should be interpreted with caution given potential systematic differences between respondents and non-respondents. For the qualitative study, only five relatives participated, which may limit the diversity of perspectives captured. The cross-sectional design prevents conclusions about the persistence or evolution of psychological distress over time. In the event of other similar health crises, adopting a prospective design would make it possible to collect data on people\u0026rsquo;s experiences at the very moment they are experiencing the effects, thereby reducing recall bias in particular. This approach could also make it possible to survey residents directly, while remaining mindful of the associated ethical and methodological issues, to explore the effects of the crisis on them, rather than through a third party. As the study was conducted exclusively in Quebec\u0026rsquo;s publicly funded LTCFs, findings may not be generalizable to private LTCFs or to other provincial and international contexts.\u003c/p\u003e \u003cp\u003eA further limitation relates to the psychological outcomes themselves. Nearly half of managers scored above the clinical threshold for peritraumatic distress, with a subset reaching levels that would typically warrant immediate clinical intervention. Because such high levels of distress had not been anticipated, no specific follow-up procedures were included in the consent process. In consultation with the research ethics board, the research team responded by providing all participants with debriefing emails, tailored lists of psychosocial resources, and follow-up in the qualitative phase, including one referral for urgent psychological support. While these responsive measures mitigated risk, this experience underscores the importance of anticipating high levels of distress when using sensitive psychological instruments and integrating explicit safety protocols into research design from the outset.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights the lasting psychological and organizational consequences of the COVID-19 pandemic for LTCFs in Quebec. Managers, healthcare workers, and relatives described experiences of distress rooted in grief, moral injury, and systemic challenges. Addressing these issues requires more than strengthening infection prevention and control; it also demands sustained strategies to support psychological well-being and organizational resilience. Recognizing professional grief, embedding accessible mental health supports, and expanding leadership training should be considered core components of crisis preparedness in long-term care. By integrating these measures into institutional planning, LTCFs can better safeguard the well-being of healthcare workers, foster trust among relatives, and enhance the quality of care for residents during future public health emergencies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLTCFs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLong-term care facilities\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost-traumatic stress disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeritraumatic Distress Inventory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u0026nbsp;\u003c/strong\u003eThe present study received ethical approval from the research ethics committee of the \u003cem\u003eCentre int\u0026eacute;gr\u0026eacute; de sant\u0026eacute; et de services sociaux de Laval\u003c/em\u003e (MP-35-2022-720). All participants provided informed consent to participate.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u0026nbsp;\u003c/strong\u003eNon applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials.\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests.\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u0026nbsp;\u003c/strong\u003eThis project was funded by the Quebec Ministry of Health and Social Services.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions.\u0026nbsp;\u003c/strong\u003eI.M., E.A., and G.B made substantial contributions to the conception of the work. I.M. was in charge of the research team that collected the quantitative data. I.M. and G.L. analysed the quantitative data. E.A. was in charge of the research team that collected and analysed the qualitative data. I.M., G.L and E.A. prepared the manuscript. All authors approved the final manuscript, and have accept accountability for all aspects of the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants to the research project: the managers, the healthcare workers and relatives of deceased residents.\u003c/p\u003e\n\u003cp\u003eThe research staff: Sabrina Fournelle, Tania Crnich-C\u0026ocirc;t\u0026eacute;, Sarah Caouette, Cl\u0026eacute;mence Coupat. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSerge Daneault for his contribution to the conception of the work.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u0026Aring;dland AV, Pedersen R, F\u0026oslash;rde R, Bollig G. They stay with you: Nursing home staff\u0026rsquo;s emotional experiences of close relationships with residents. 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MDPI.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLavoie-Tremblay M, Cyr G, Aub\u0026eacute; T, Lavigne G. Lessons from long-term care facilities without COVID-19 outbreaks. Healthc Policy. 2022;17(SP):40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeland NE, Brown C, Shore AD, Cary MP Jr, Reed K, Saliba D. Efforts to Support the Mental Health and Well-being of Nursing Home Staff: Insights From Leaders. J Am Med Dir Assoc. 2024;25(8):105051.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer DZ, Avery LM. Excel as a qualitative data analysis tool. Field methods. 2009;21(1):91\u0026ndash;112.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson HW, Yang BK, McSweeney-Feld MH, Jerome GJ, Barry TT. Psychological and structural burdens and nursing home administrator turnover intentions during the COVID-19 Pandemic. J Appl Gerontol. 2024;43(6):706\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson HW, Weil J, McSweeney-Feld MH, Yang BK, Barry TT, Thayer N. Nursing Home Administrators\u0026rsquo; Experiences of Work Stress and Intention to Quit During the COVID-19 Pandemic. Gerontologist. 2025;65(2):gnae165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganisation for Economic Co-operation and Development (OECD). Rising from the COVID 19 Crisis: Policy Responses in the Long-term Care Sector. OECD Publishing; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaill\u0026eacute; P, Mucchielli A. L'analyse qualitative en sciences humaines et sociales. A. Colin; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatton MQ. Qualitative evaluation and research methods. SAGE Publications, inc; 1990.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips CS, Trainum K, Hebdon MCT. Hidden in plain sight: A scoping review of professional grief in healthcare and charting a path for change. Palliat Support Care. 2024;22(4):469\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahimi S, Khatooni M. Saturation in qualitative research: An evolutionary concept analysis. Int J Nurs Stud Adv. 2024;6:100174.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReynolds K, Ceccarelli L, Pankratz L, Snider T, Tindall C, Omolola D, Feniuk C, Turenne-Maynard J. COVID-19 and the experiences and needs of staff and management working at the front lines of long-term care in central Canada. Can J Aging/La Revue canadienne du vieillissement. 2022;41(4):614\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocard E, Sillitti P, Llena-Nozal A. COVID-19 in long-term care: Impact, policy responses and challenges. OECD Publishing; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarfjoo Kasmaei M, Freeman S, Banner D, Klassen-Ross T, Martin-Khan M. Job Satisfaction and Well-Being of Care Aides in Long-Term Care During the COVID-19 Pandemic: A Comprehensive Literature Review. World. 2025;6(2):62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchneider P, Abt M, Cohen C, Marmier N, Ortoleva Bucher C. The impact of protective measures against COVID-19 on the wellbeing of residents in nursing homes and their relatives: a rapid review. BMC Geriatr. 2023;23(1):649.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaw SL, Csikai E. No visitors allowed! The impact of COVID-19 restrictions on the psychosocial well-being of nursing home residents. J Long-Term Care. 2023;2023:54\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsui EK, Franzosa E, Cribbs KA, Baron S. Home care workers\u0026rsquo; experiences of client death and disenfranchised grief. Qual Health Res. 2019;29(3):382\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Teijlingen E, Hundley V. The importance of pilot studies. Nurs Standard (through 2013). 2002;16(40):33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVracevic M, Pavlovic V, Todorovic N, Milic NM, Matejic B, Brkic P, Milic NV, Savic M, Masic S, Pavlovic A, Stanisic V. Compassion fatigue and satisfaction among frontline staff in long term care facilities: psychometric properties of the Serbian version of the professional quality of life scale. Front Psychiatry. 2025;16:1479190.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu M-J, Zhao K, Fils-Aime F. Response Rates of Online Surveys in Published Research: A Meta-Analysis. Comput Hum Behav Rep. 2022;7:100206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYin C, Mpofu E, Brock K, Ingman S. Nursing home residents\u0026rsquo; COVID-19 infections in the United States: A systematic review of personal and contextual factors. Gerontol Geriatric Med. 2024;10:23337214241229824.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. lancet. 2020;395(10229):1054\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e The timeframes corresponding to the successive waves of COVID-19 in Quebec are: First wave: February 25 2021 to July 11 2020; second wave: August 23, 2020 to March 20, 2021; wave 3: March 21 to July 17, 2021; wave 4: July 18 to December 4, 2021; wave 5 (Omicron): December 5, 2021 to March 12, 2022; wave 6: March 13 to May 28, 2022; and wave 7: May 29, 2022 to present.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Long-term care facilities, End-of-life care, COVID-19, Peritraumatic stress, Managers, Healthcare workers, Relatives, Mixed-methods","lastPublishedDoi":"10.21203/rs.3.rs-9163441/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9163441/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe COVID-19 pandemic had devastating consequences for long-term care facilities (LTCFs), particularly in Quebec where mortality rates were especially high during the early waves. Although the psychological toll on frontline healthcare workers has been more frequently documented, less is known about the experiences of managers and of residents and relatives, especially in the context of end-of-life care across the course of the pandemic. This study aimed to integrate multiple stakeholder perspectives to provide a more comprehensive understanding of the psychological effects of the pandemic within Quebec\u0026rsquo;s public LTCFs over all seven pandemic waves.\u003c/p\u003e \u003cp\u003eMethods. A mixed-methods design was employed. In the quantitative phase, an online survey was conducted with managers of public LTCFs across six regional health and social service centres in Quebec (Canada). Measures included the Peritraumatic Distress Inventory related to the pandemic effects, sociodemographics, as well as organizational and COVID-19 related data. In the qualitative phase, semi-structured interviews were conducted with healthcare workers and relatives of deceased residents to explore their experiences of the pandemic and their perspectives on communication and care. We used descriptive and bivariate analyses for survey data and a conceptual categorization approach for qualitative narratives.\u003c/p\u003e \u003cp\u003eResults. Seventy-seven managers completed the survey (57% response rate). Nearly half (48.6%) scored above the clinical threshold for peritraumatic distress, indicating substantial risk of post-traumatic stress disorder. No significant differences were found for gender, age, or working experience, although trends suggested higher stress among women and those aged\u0026thinsp;\u0026le;\u0026thinsp;50 years. Qualitative findings reinforced and enriched these results: healthcare workers identified the first waves as the most critical period, marked by uncertainty, high mortality, and restricted visitation. They also reported exhaustion, moral distress, and professional grief, while relatives described helplessness and constrained grieving amid organizational instability.\u003c/p\u003e \u003cp\u003eConclusions. This study demonstrates the profound psychological and organizational toll of the pandemic on Quebec\u0026rsquo;s LTCFs. Findings highlight the need for systemic recognition of persistent psychological effects, accessible mental health and grief supports, and leadership training that equips managers to support frontline teams. Psychosocial support must be treated as a core component of emergency preparedness in LTCFs, not as an afterthought once crises unfold.\u003c/p\u003e","manuscriptTitle":"The effects of COVID-19 in Quebec public long-term care facilities on various stakeholder groups: a mixed-methods retrospective study across all waves of the pandemic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-21 08:36:36","doi":"10.21203/rs.3.rs-9163441/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-15T12:32:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T10:24:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258671736158685033453205343495007317419","date":"2026-04-15T10:22:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T08:17:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116916564394633932796803006081554346629","date":"2026-04-14T15:37:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-14T11:34:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-09T08:16:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-25T16:44:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T14:42:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2026-03-25T14:16:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"00354c81-cb30-407f-bd07-79d7bd3553be","owner":[],"postedDate":"April 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T08:36:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-21 08:36:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9163441","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9163441","identity":"rs-9163441","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}