Thank you. I'm as ready as I'm going to get, I guess.
Thanks very much for the invitation to appear before you on the important issue of the abuse of older women. I'm here as a researcher who has, with Professor Pat Armstrong and others, for the last 15 years or so been examining the health of older women and men.
As I'm sure you all know, the majority of older Canadians are female, and this female majority increases with age. Their care providers, both paid and unpaid, are overwhelmingly female, and are on average getting older as well.
I mention the providers along with the recipients of care, because we know that the better the working conditions for care, the better the care is likely to be.
Our research has of late focused on the essential but relatively unexamined group of providers usually called personal support workers, or PSWs. They particularly work in home care and in long-term residential care facilities. They are typically unlicensed, not considered to be professionals, and often not even counted as health care providers.
Not only are PSWs relatively invisible in academic and policy discussions, so too are long-term residential care facilities--nursing homes, as they're often labeled. These homes are typically seen to indicate failure: failure of the individual to remain sufficiently independent, failure of the individual's family to provide needed care, and indeed failure of the medical profession to provide cure.
How are we to understand abuse in nursing homes, where about 200,000 Canadians live and more will live in the years to come? By one estimate, an additional 120,000 will live there by 2041. About one in five aged 85-plus now lives there. About 70% are women, and their paid care is provided by a workforce that is as high as 95% female.
So we're talking about a gendered living and working environment. Its female domination, in terms of numbers if not power, combined with its reputation as a site for failure, goes a long way to explaining why the nursing home sector is under-resourced, undervalued, and under-researched, and why it is a site for the abuse of workers as well as residents.
Our approach to the study of abuse owes much to what Paul Farmer calls structural violence. He is a U.S. medical doctor who has long worked in the central plateau of rural Haiti, where he has analyzed what, for example, lies behind the death of a young woman with AIDS. What lies behind is a set of human decisions, decisions that are responsible, directly or indirectly, for the death of this woman and other deaths--so too with our examination of the abuse experienced by both workers and residents in Canadian nursing homes.
Structural violence defies easy description. The specific instances are often hidden from view. The victims are typically anonymous, with little opportunity to have their voices heard. The distribution of the violence is embedded in cultural, historical, and political economy contexts that are difficult to disentangle. But with some persistence, the violence veil can be lifted.
In one survey conducted in 2006, we asked PSWs how often they experienced physical violence at the hands of nursing home residents and their relatives. Fully 43% reported suffering such violence on a daily or almost daily basis.
It need not be this way. Our survey was adapted from one conducted the previous year in four Nordic countries, where 6.6% of comparable workers in comparable facilities reported experiencing daily or almost daily violence.
In other words, the Canadian experience with violence was over six times greater than that found in Denmark, Finland, Norway, and Sweden taken together. The weekly rate in Nordic Europe was an additional 11.1%, by contrast with the Canadian rate of an added 23.1%.
Moreover, the Canadian survey question was restricted to actual violence. The Nordic question also included the threat of violence, making the Canada-Nordic gap even greater than over sixfold.
When we conducted follow-up group interviews with Canadian PSWs to validate, elaborate on, and explain the survey findings, we learned of widespread under-reporting of the violence—not only to management and to workers' compensation, but also to our survey itself.
The paperwork involved in preparing written reports is onerous and time-consuming. Management too often blames the workers for any reported incident. The workers in turn don't want to make life worse for their residents—for instance, through the imposition of physical or medication restraints.
Most importantly, violence in long-term care is normalized. It is seen as just part of the job, in Canada if not in Nordic Europe.
What lies behind this stark contrast between Canada and Nordic Europe? It's not differences in the characteristics of the resident populations, for they have similar age and sex profiles and similar percentages with cognitive impairments. Instead, we must look at the underlying working conditions.
We asked, for example, about basic tasks that are left undone. You'll perhaps be encouraged to learn that the Canadian residents are almost always fed. Other tasks left undone, in increasing order of frequency, are bed changing, changing clothes, turning, toileting, bathing, teeth brushing, and, at the bottom of the list, foot care.
With only 15% of residents always receiving needed foot care in Canada, can we be surprised that mobility is so low and pain and frustration so high?
Staffing levels in Canada, and especially in our for-profit facilities, are too low to provide adequate care. Moreover, the official staffing numbers tend to conceal how many workers are actually at work. Short-staffing occurs when workers who are sick or on vacation are not replaced and when positions are left vacant. Among Canadian workers, 46.2% report working short-staffed more or less every day. For Nordic countries, the figure is 15.4%, or one-third, as prevalent.
In addition to staffing levels, there are differences in the degree of worker control and autonomy. Only 24.4% of the Canadian workers can influence the planning of their day's work all or most of the time, as against 45% for their Nordic counterparts. The Canadians report being not trusted and report being too closely monitored by their supervisors, 27.4% versus 7.9% in Nordic Europe. They lack sufficient time to discuss difficulties with colleagues all or most of the time, 80.5% as against 46.6%.
Facing all these working conditions--and more, which I lack the time to discuss this afternoon—it is no surprise that frustrated and uncomfortable residents strike out at PSWs.
So far, I've touched on basic physical activities like eating, dressing and toileting. Also important for health and well-being is what might be termed social care. When we asked PSWs about sitting for a cup of coffee or tea with a resident, over half responded that this rarely, if ever, occurs. Surprisingly, it is even more uncommon in Finland, but in the rest of Nordic Europe this is the case for less than a third. In Denmark, only one in six report that this seldom if ever happens.
Another social care question concerns how often workers accompany residents for a walk. We were frankly surprised to learn that the Canadian rates were higher, so we pursued the issue. It turns out that in Nordic Europe this question was interpreted to mean a leisurely walk outside the facility, whereas in Canada it meant walking a resident to a meal or to a toilet. When we asked in Canadian group interviews about walks outside the facilities, a common response was laughter to this bizarre question or suggestion.
I am going to close with another instance of what we term structural violence--that is to say, abuse that need not occur.
We asked in the group interviews about the use of incontinence pads, or adult diapers. Here's what they told us.
They talked about the recent introduction—this was five years ago—of disposable paper diapers that are made available only grudgingly, perhaps only one per resident per shift. The workers try to “steal”—that's their term—and hide extra diapers for their residents, but they face “diaper police”—again their term—or managers who search out and repossess all the hidden stuff.
The innovation contained in these disposable diapers is that they indicate when the saturation level reaches 75%. The workers are firmly instructed not to change the diapers until this level is reached.
They do their best to care for their residents, but they don't feel good about what they have to do. Indeed, they feel abused themselves, and fully understand the violence they experience from residents confronted by such discomfort and indignity. As one PSW put it to us, “I'd hit out too if you left me in that.”
Abuse needs to be understood as the direct or indirect consequence of decisions made by people in power. The abuse may be experienced by the workers, the residents, or both. My focus has been primarily on what the workers experience, but the abuse against workers and the abuse against residents are linked, just as, in my view, the presentations by Judith Wahl and I are complementary. Care is a relationship, and the conditions of care work establish the conditions of care.
Thank you.