1. We are drawing on our survey data collected a decade ago….

2. Hearing Voices, Mapping Domains: Care workers’ experiences of their work comparing Canada & Sweden Tamara Daly, Ph.D. Marta Szebehely, Ph.D. May 20 th, 2015 …adding in observations and key informant interviews to contextualize care workers’ experiences

3. Outline Context Who are the front-line care workers? –What do gender and ethnicity have to do with it? What tasks are done? What skills are needed? Under what conditions can workers use their skills to provide good care? Which occupational categories should be present in LTC?

4. Context: Canada and Sweden are two rich countries with different approaches to residential care CanadaSweden Ratio LTC FTE / 80+ in population13.533.2 Spending (% GDP)1.3%1.8% Staffing intensity: Frontline staff to residents  % private rooms  # residents / unit25 - 308 - 10 Composition of workforce (estimates): - Registered Nurses - Support Staff - RPN / LPN / Assistant Nurses - PSW / Care Aides 20% 15% 45% 5% 60% 30%

5. Who are the front-line care workers? What do gender & ethnicity have to do with it?

6. In both countries… Similar gender compositions –Women are 90% + of the workers Increasing proportion born outside country (20-25%) –Women are 70 - 80% of the residents Exposure to health and safety risks Under-valued

7. In both countries… They might say … racist insults…They don’t want to be washed. They don’t want us to help them. We know they’re sick. I don’t take it personally…I don’t think of it as an insult to me personally. It’s part of the job…generally. (...) They have trouble accepting care from a Black person. They’re not used to it. And there are some who are racist, too. Canadian PSW “…elderly people want to have a Swedish person to help them.…it’s harder…the darker skin you have and if the language is a problem then they also can be angry or aggressive.” Swedish Assistant Nurse (translated by team member)

8. What tasks do front-line care workers perform?

9. Different division of labour – different workdays and different tasks CanadaSweden LPNs / RPNs Care Aides Assistant Nurses Care Aides Average # Residents helped per workday331599 Do the following tasks every day (%): Assist with personal hygiene579998 Sit down for a coffee with a resident21335148 Administration72325938 Hand out medications8739192 * Care Aides are also referred to as PSWs (personal support workers)

11. What skills do front-line care workers need?

12. Skills Needed in Both Countries “People” skills –“You also have to love working with people.” Swedish Assistant Nurse “Tacit knowledge” skills –“I do everything for them. [laughs] I feed them. I bathe them. Get them up, dress them, change them. A lot of the times I spend time with them. When I have the time I take my time to spend the time with them. I get to know them and I go see them at night and make sure they’re tucked in right because a lot of them have certain ways that they like to be put into bed and I always know. I don’t know why but I know they like that so I do that.” Canadian Care Aide

13. Skills Needed in Both Countries Dementia Care Skills –“I like to make them laugh. [laughs] We joke a lot with them. After a while even if they’re Alzheimer’s it’s funny. But it’s another language. We communicate with them. We got no problem…It’s too bad it doesn’t count, eh? [laughter]” Swedish Assistant Nurse (translated by team member) –“Each person has a special form of dementia with different forms of communication. Take one person who is very aggressive, I can’t use the same technique as when I go to another who is very passive.” Swedish Assistant Nurse (translated by team member)

14. Under what conditions can the skills be used?

15. Scope to Use One’s Skills CanadaSweden LPN / RPN PSWs Assistant Nurses Care Aides Can affect the planning of each day’s work (% ALL or MOST of the time) 24 47 Have enough time to discuss difficulties in your work with colleagues (% ALL or MOST of the time) 22145958 “Too often I feel that I am the only one responsible for my residents” (% Strongly agree) 273854 “I feel like the supervisors don’t trust the staff. There is too much monitoring and control” (% Strongly agree) 292788 ”More and more of my working time is used for paperwork that does not feel very meaningful” (% strongly agree) 411768

16. Canadian Conditions of Care Excessive paperwork –“Too much documentation. Too much. That’s something -- you don’t even have time to do certain things but you have to do documentation. Too much documentation but what are you going to do? You have to do it. They have to keep a record of the resident so we have to do it.” Canadian Care Aide Sharp Division of Labour –“…we report to the nurse and they will write it down” Canadian Care Aide

17. Swedish Conditions of Care Time to care –“When she starts getting agitated, there are small signals. When we arrive in the morning she runs back and forth in the corridor. (…) Then you have to go directly up to her and talk nicely to her. “Good morning; how nice to see you”… try to distract her from her anxiety. Then she immediately sees that there is someone who has time for her. You maybe need to stay with her for half an hour, but you back that time as she otherwise would have winded up herself, wouldn’t eat, taking her pills and cannot relax. We step in at the right time.” Swedish Assistant Nurse

18. Swedish Conditions of Care Flexible Care –"You have routines, but you can also break them. For instance, a shower, it can take time to get someone into the shower, then you can postpone the lunch half an hour, that's no problem. So you can be flexible” Swedish Assistant Nurse

19. Swedish Conditions of Care Continuity –“…if someone can’t speak you have to watch them... every day you start to know them better.. why they get mad…why don’t they want to eat, why they’re sad…Because you see them every day you know why…continuity is very important for that reason.” Swedish Assistant Nurse

20. Swedish Conditions of Care Relational & Consistent Care –“…the contact person is very important because you learn to know the person very well. You know when they want to get up, what they want to have to eat and dress and so on and that’s an important part in the care work I think both for the staff and for the elderly.” Swedish Assistant Nurse (translated by team member)

21. Swedish Conditions of Care Care that addresses a person’s needs –“[The contact person] can go and buy clothes for the residents -- because the family doesn’t have time -- with the resident’s money and she brings the receipts.” Swedish Assistant Nurse (translated by team member)

22. In summary Women, increasingly from immigrant communities, provide vast majority of care Frontline care workers have different division of labour in Canada and Sweden – different workdays and different tasks Among skills needed in LTC: –People skills –Tacit knowledge skills –Dementia care skills

23. In Summary Scope to use one’s skills –Canadian conditions involve under-staffing; excessive paperwork; and a sharp division of labour –Swedish conditions involve more time to care, with more flexibility and continuity. The care is more relational and can address specific person’s needs

24. Which occupational categories should be present in LTC? Should there be only one category of front- line care worker with higher educational requirements? –(care aides / practical nurses) Should there be a role for paid companions?

25. Hearing Voices, Mapping Domains: Tamara Daly, Ph.D. dalyt@yorku.ca Marta Szebehely, Ph.D. Marta.Szebehely@socarb.su.se