Rethinking labour in long-term care

Short-staffed. Underpaid care workers. Neglected patients. Needless deaths. Stories abound of dangerous and strenuous conditions of long-term care homes in Canada. Researchers say long-term care does not have to be this way and encourage a rethinking of approaches to long-term care, starting with the lives of those who do the work.

At a webinar on Dec. 11, host Anne Lagacé Dowson of the Canadian Health Coalition spoke with Pat Armstrong, Hugh Armstrong and Marta Szebehely on their ideas for long-term care labour force strategies. The webinar is now available for viewing here –

The webinar marked the launch of the new book, The Labour Crisis in Long-term Care: The Right to Care, edited by Pat Armstrong, Hugh Armstrong and Jacqueline A. Choiniere. The book can be read online here.

Long-term care homes can be places of joy

Pat Armstrong is a Distinguished Research Professor Emeritus at York University, a Fellow of the Royal Society of Canada and a long-time member of the Canadian Health Coalition’s board. Known for the saying, “the conditions of work are the conditions of care,” she has conducted research on long-term care in not just Canada but also in Germany, Norway, Sweden, the UK and the US.

Armstrong explained that care homes can be “a positive choice and places that can bring joy in work and in living.”

Her team examined Norway, Sweden and the Canadian provinces of Nova Scotia and Ontario, identifying overlapping strategies employed in all three countries. They group the strategies as reduce, reorganize, replace, recruit and retain.  

Armstrong noted that although the strategies overlap, they are often introduced in isolation from each other, reflecting assumptions about how the problem is understood. When the overall problem is identified by governments, it’s frequently framed primarily in terms of the need to reduce cost in the face of an aging population.”

Armstrong and her collaborators attempt to reframe the strategies in terms of assessing the extent to which they promote the right to care. For Armstrong, that means “both the right to access quality care services and the right to provide quality care.”

Armstrong argued their approach contrasts with literature and policies that tend to focus on either the rights of residents or of families or of staff, without recognizing that they are integrally related.

“New models of resident-focused care frequently talk about empowering residents but fewer strategies address empowering staff or the working conditions that allow this focus or the differing needs of staff and families,” stated Armstrong.

“We emphasize that staff and families too have individual needs, experience trauma and abuse, have household and housing needs, require places to eat and places to grieve. They too need support from others who share their issues and conditions. We stress that women and men on staff can face specific challenges and have specific needs,” explained Armstrong.

“Our approach also contrasts with the framing of rights in terms of the individual rather than of the collective or in terms of piecemeal strategies designed to deal with a single aspect of the crisis,” clarified Armstrong. “We also challenge the notion that managerial practices taken from the for-profit sector especially in relation to the organization and monitoring of the work can simultaneously reduce costs and increase accountability while improving quality.”

Armstrong explained the problems related to “failing to keep up with the demand for places in publicly-funded nursing homes” and the “promotion of aging-in-place,” drawing attention to how aging-in-place is regarded as the primary choice of older people, but is also the cheapest way for government to address the aging population and in the process costs in labour are transferred to individuals and families.”

“Meanwhile little is done to expand the home-care labour force or to improve their conditions. Those with extensive care needs are left with few choices and the skilled nature of the work goes unrecognized,” said Armstrong.

“At the same time as the location of care is being reorganized within care homes, staff are being reorganized to alter the skill mix and decrease reliance on full-time employees,” added Armstrong. “In Norway and Canada, care work is being shifted to those defined as the least skilled. This is happening even as resident care needs are becoming more complex as a result of more restricted access to nursing homes and to hospitals.”

On the problem of replacement, Armstrong shared that recent research from Japan indicates that “the famous robots that replaced care workers are now being relegated to greeting customers at a fast-food chain.”

Armstrong noted that governments are increasingly relying on foreign workers to do care work, creating care deficits in sending countries and fostering challenges with training recognition, language and racism in the host countries.

Enough workers can be recruited

Marta Szebehely is a Professor Emeritus of Social Work with the Department of Social Work at Stockholm University in Stockholm, Sweden. For over four decades, she has conducted several Nordic and international comparative research projects on eldercare.

Szebehely argued that Sweden is like Canada in terms of public spending not keeping pace with an aging population. “We have seen a drastic reduction of nursing home beds, much more drastic than in any other country. We started off at a fairly high level, but since the year 2000, the proportion of older people, 80 plus, living in a nursing homes has gone down from 20 per cent to 10 per cent.”

Szebehely noted that Sweden has a much more developed home care sector than in Canada, but home care has not compensated for the reduction in long-term care homes.   

“We have seen an increase of family care and privately purchased services. This has happened without any change in the legislation, but it has happened through stricter local guidelines and raised user fees,” stated Szebehely.

For Szebehely, the idea that an aging population as an unsolvable problem needs addressing. She argues that enough workers can be recruited with political will, but instead, in the place of recruitment, strategies of replacing and reorganizing are done.

Szebehely noted that men are increasingly joining the long-term care workforce in Sweden, at an increase of 10 per cent in 10 years. “This is a very rapidly changing sector and 42 per cent of the care workers are born outside country… We wouldn’t survive without the young refugees from Afghanistan and Syria.”

“You can recruit workers with less or no formal skills and limited Swedish language to do certain tasks and at the same time this would make it more attractive for the more formally skilled workers because they would be allowed to focus on care work rather than cleaning for instance. These are ideas that are quite popular among certain groups but of course it also leads to new hierarchies in the care workforce, which might be problematic.”

“Effective retention strategies is not optional but a fundamental necessity”

Hugh Armstrong is a Distinguished Research Professor and Professor Emeritus of Social Work and Political Economy at Carleton University in Ottawa. He serves as a member of Ontario Health Coalition’s board.

For Armstrong, addressing the labour crisis means doing a better job of retaining what we have and addressing how recruitment takes time, “as long as three or four years for registered nurses, and months to bring in and work out appropriate credentials for foreign-trained staff.”

Armstong noted that many workers will leave upon entering if “unsavoury working conditions remain.”

“Attractive conditions of work promote not only job satisfaction and commitment but also quality care by fostering continuity,” added Armstrong.

Armstrong explained that traditional approaches focus on increases in wages and benefits in full-time and permanent employment, in predictable scheduling in opportunities for advancement, and in workplace safety. “Progress on all of these strategies begins with having sufficient staff present to do the work,” said Armstrong.

“The traditional approaches while crucial are insufficient. They reflect too narrow an understanding of what makes for a fulfilling job and for increased worker well-being. Without this fulfillment and well-being, our efforts to achieve greater retention rates and more quality care are doomed to be incomplete,” argued Armstrong.

Armstrong shared an ethnographic encounter at an Ontario home. “A housekeeper had put down his broom and was slowly walking with an elderly resident to lunch, chatting along the way. During a subsequent interview with us, he indicated that he was expected to spend about 20 per cent of his time chatting and getting to know his residents better. His housekeeping colleague that day seemingly and automatically took over his assigned area to clean. During the episode, we observed management expecting both workers to act as they did. These and other workers know and support each other. This is much less likely to occur if some of the workers are part-time or contracted out.”

Armstrong said care workers should have space readily available where they can take restful breaks. Nutritious food should be available to them during the long shifts. They need space and time to share gossip and complaints. Resident deaths need to be respectfully observed and private space made available for family members to be with their residents near the end and to meet with staff members who also need time and space in which to grieve. Building effective teamwork entails building trust.”

Armstrong described that a few years ago both Sweden and Norway established trust initiatives involving workers and residents. Together, they engaged in organizing aspects of care that reduced the required performance and reporting of detailed time regulated tasks.

“Trust, however, takes time to build whether at the national or the facility level and it may be resisted if it overly emphasizes the documenting of task completion thus diverting attention from heavy workloads,” said Armstrong.

Armstrong noted profound challenges involving the resistance to systemic change, the threat of penetration of for-profit care cost cutting measures, and the reluctance to commit to long-term investments.

For Armstrong, “the costs of inaction are far greater in terms of human suffering and societal burden. Implementing effective retention strategies is not optional but a fundamental necessity to ensure the right to receive quality care and to provide joy all around.”