Long-term care in Canada fails to treat either residents or care providers with dignity and respect. The single most important factor in this failure is the inadequate staffing levels. There are simply not enough people to provide quality care. The official data on staffing levels indicate that Canada does not meet the standards for the number of direct care providers established by experts as necessary for adequate care. Moreover, the official numbers often hide the fact that workers are not replaced when they are ill or on vacation, or when a vacancy occurs.
Many of the other problems long-term health care workers identify stem from this single issue of staffing. Residents, for example, often become violent towards care providers because they are frustrated beyond endurance with the lack of care. They sit in soiled diapers for hours because there are no workers available to answer their call. They are rushed through dinner because there are too many who need to be fed. Or they miss their bath because there are not enough staff the get everyone adequately bathed. And they sit in their rooms without exercise or conversation because the workers have no time to chat, to explain, or provide social support.
Workers become injured because they rush to provide services. Or they come to work when they are injured or sick because they know that otherwise there will be no one there to provide care. They work unpaid hours to make up for the care deficit. They go home physically exhausted because they looked after far too many residents, or they go home emotionally drained because they could not provide the care they knew should have been provided but couldn’t be in spite of their best efforts.
These health issues spill out onto their families, making it difficult to cope with the unpaid domestic work these mainly female providers face once they leave paid work. Workers experience overload and stress, products of structural violence.
Although more money has of late gone into long-term residential care in Canada, this new money has not gone primarily to hiring more staff relative to the number of residents. Especially in Ontario, funding priorities have been directed towards increasing the size of the long-term care sector, either through building more institutions or renovating older ones. This concern with the availability of “beds,” important as it is, hides quality of care issues that deeply affect the residents occupying these beds and the workers who care for them.
The results of our research (detailed in our recent CCPA book They Deserve Better) clearly indicate that there is a need to direct policy attention and financial resources towards quality of care issues by addressing the staffing levels that are so integral to the provision of quality care. Staff working in long-term care report that whatever additional funding has been allocated to the long-term care sector, it is being felt on the floor neither by the workers nor by the residents.
“Funding never seems to go directly to hands-on care,” according to one personal support worker with over 20 years of experience in the field, prompting her to wonder “if the Ministry of Health really understands what goes on in nursing homes. It’s easy to mandate, but how do we implement without proper staff?”
Several the workers we surveyed also told us that the manner by which care needs are determined is inadequate and fails to provide an accurate assessment of what is required to offer proper care. According to one Registered Nurse: “The Ministry’s classification system for funding in long-term care is for the birds. They classify residents once a year, for annual funding. They don’t get a true picture of how heavy some of the residents are throughout the year.”
But staffing levels are far from the only issue. Work organization and lack of autonomy are also critical factors. Although it is necessary to provide 24-hour care, it is not necessary to schedule so many irregular shifts that prevent both continuity of care for the residents and a reasonable home life for the workers. It is not necessary to deny workers any choice in scheduling. It is not necessary to hire so many workers on a part-time basis, also preventing continuity of care for residents and secure employment for staff. Nor is it necessary to prevent workers from making their own decisions about how to respond to residents’ needs in ways that both allow workers to use their knowledge and allow residents to have their individual needs met.
Lack of choice and of autonomy is in turn related to the failure to involve workers in decision-making or to consult them on changes. Workers are the experts on daily needs in long-term care because they are there. Yet they are rarely asked about work organization or resident needs. Indeed, the problems with accurately assessing care needs – and therefore providing sufficient funding for direct care – would seem to stem from a more general disjunction (an abyss, according to staff) between what goes on “on the floor” and administration at the level of both governmental policy-making and facility management.
Workers fail to report the violence, racism, and sexual harassment they face, in part because they feel their complaints will not be heard or, worse, that they will be blamed for the problem. This is particularly an issue for women, who too often assume the blame when residents act up or who are not believed when they do complain. The excessive bureaucracy required to report such complaints, or to report workplace injuries of other sorts, also prevents workers from recording the problems they face. And it serves to hide the actual number of workplace injuries. Instead of real consultation or actual monitoring, accountability takes the form of increasing numbers of forms to fill out, few of which, these workers say, reflect what happens in daily practices.
Physical space is also an issue for both residents and providers. Buildings are too often not designed to meet the care needs of current residents. Nor are they designed to provide adequate space for workers to do their jobs. Equally important, many are not maintained to standards that promote the health of either workers or residents. We need to think of the needs of current residents and providers in developing long-term care, and to provide funds to ensure adequate standards of maintaining facilities to promote rather than undermine health.
The workers in these long-term care facilities are low-paid relative to their counterparts in the hospital sector and to the skills as well as the experience involved in their work. They are not often provided with the pay and support for the training required as the complexity in resident care rises. This low pay and the limits on training reflect, at least in part, the value attached to this female-dominated work and is related as well to the high number of immigrant and racialized women employed in this sector.
Equally important, the low pay and limited training are related to the low value attached to the residents, most of whom are elderly women without significant financial resources. The low pay, and the low benefits, both reflect and reinforce the limited power of the women who care and the women with care needs.
Even though the Canadian approach to long-term care in terms of organization and physical structures is increasingly medically-based, the work organization remains primarily one of custodial care. Neither approach seems appropriate for the population today, and should be replaced with a social care model that emphasizes supportive care based on meeting the goals of assuring dignity and respect for both worker and resident. Only by shifting the paradigm can governments achieve a commitment to these goals.
Better pay and benefits, as well as more full-time work, would also help keep workers on the job and doing the work in a way that allowed continuity of care for the residents, an especially important issue for the growing numbers with dementia. More pay and time for training and for breaks would also help, but neither addresses the fundamental problem of too few people to provide care, the failure to involve workers in decision-making, or to grant them the right to decide about aspects of care in ways that would allow them to provide compassionate social care.
Alternative approaches to care are frequently represented as unsustainable in the face of the growing number of elderly, or impossible, given the diagnosis of residents. But our research reveals significant variations among provinces that challenge this notion of inevitability. The data from the Nordic countries provide a greater challenge to ideas about the impossibility of alternatives. Even with significantly more dependent elderly, those countries are able to provide higher staffing levels and more time for social support, as well as more choice and autonomy for workers and residents. As a result, workers face less violence and lower injury rates. And they enjoy better health as they provide better quality care.
This is not to suggest that things are perfect in the Scandinavian countries for either residents or workers. Workers there are not without complaints and there is certainly room for improvement, especially in areas like pay and recognition. It is rather to suggest that there are choices to be made, choices that can improve conditions for workers and residents. To do so means recognizing that the conditions of work are the conditions for care.
In planning for an alternative approach to long-term residential care, it is worth taking seriously a question posed to us by a Registered Nurse with over 25 years of experience in this field. Recognizing long-term care as an issue that should concern every one of us, she asks: “Is this what we all have to look forward to?” What our study shows – and in particular our Nordic comparisons – is that we can do better. They – we -- deserve better.
(Dr. Pat Armstrong is a sociology professor at Toronto’s York University with expertise in social policy and women’s studies. This article is adapted from a study of long-term care in Canada and the Scandinavian countries which she conducted with colleagues Albert Banerjee, Marta Szebehely, Hugh Armstrong, Tamara Daly, and Stirling Lafrance. The results of their study are contained in a recent CCPA book, They Deserve Better.)