"If we don't die young, we're all going to age." Serena Palmer, a personal support worker (PSW) working in a long-term care facility in Toronto, reminded me of this when we sat down together recently to talk about her job - and the impact of racism, sexism, and violence on her work. It's a truism, but one that all of us, including our government, need to take a lot more seriously when thinking about the way our society treats its elderly, and those who care for them.
Originally from Jamaica, Palmer (a pseudonym) has been working as a personal support worker in Toronto for more than 15 years. Although in Jamaica she had worked in a credit union, she was not able to carry on in that field once she arrived in Canada. "Unfortunately, like many immigrants, we have responsibilities, so we have to hit the ground running. We have no time to go back to school, or to get accredited, because we have a family to take care of. So you sacrifice things for your children." The opportunity to begin working as a personal support worker presented itself to Palmer and she took it.
In Ontario, long-term care facilities, built for residents who need 24-hour care, are either known as nursing homes or homes for the aged. Homes for the aged, according to the City of Toronto's website, are owned by either a municipality or a charitable institution. Nursing homes are primarily owned by for-profit companies.
In long-term care facilities, whether privately or publicly owned, PSWs are responsible for a wide range of tasks, including assisting residents with personal hygiene, serving meals, taking and recording vital statistics, assisting with residents' rehabilitation, and providing emotional support to residents and their families.
These responsibilities are not inherently troubling; they are important tasks that need to be done and should be valued. But the pace of the work makes it difficult for PSWs to manage, especially since many long-term care facilities are chronically understaffed.
During her regular morning routine, Palmer cares for nine patients before breakfast, a process that involves waking them and helping them rise, shower, dress, and take their medication. Then she immediately moves on to a new task. By 8:30, "I'm in the dining room to do a waitress job for 28 to 30 individuals." Since some staff members are on break, there are only two or three on the floor at this time. It's a juggling act because, as they're serving, they're required to input the food that they're serving into residents' computer files. And they may need to drop everything to respond to a call if a patient needs assistance. There's no time for conversations with the patients and barely any time to communicate with co-workers. "As staff," says Palmer, "we can only say, in passing, 'I need help to do a transfer,' or we have little signals to indicate 'I need help.'"
THE ASSEMBLY LINE
Although there may be individual exceptions, most long-term care centres are best described as assembly lines as staff try to balance too many responsibilities and care for too many patients without adequate support. The result is that patients' needs are compromised. "A lot of them feel neglected, rejected, and very angry because you're always in a hurry," says Palmer.
Residents' families may react badly as well, and their anger is usually directed at the caregiver rather than those who run the facility. Palmer experiences this frequently. "A patient I was caring for had a UTI [urinary tract infection] and she was feeling very bad. I dressed her; I got her out for breakfast in the main dining room. As I was serving, she was by herself in the washroom. I was called into the manager's office because the family had threatened to call a social worker. I asked: 'What should I do? Should I remain with her or go finish serving people breakfast?'"
The fact that their patients' needs aren't reflected in the time and resources allocated is extremely frustrating for personal support workers. For example, says Palmer, "the patient who can walk a bit, but not a distance, uses a wheelchair. Management will tell me that I have to do restorative care - parking the chair at the elevator, for instance, and assisting that person to walk to the washroom." But residents move slowly and time isn't provided for the PSWs to do that restorative work. Disturbingly, Palmer's management is known to ask PSWs to sign off on rehabilitative care that wasn't done.
Individual personal support workers push back against this where they can and may spend time on their breaks talking to patients who are feeling down. But, when compassion eats into the time the PSWs are supposed to be spending on other tasks, it can create problems with their employers.
RACISM ON THE JOB
There are many reasons personal support workers find their work difficult, including the often negative interactions with patients. Palmer finds that residents often make hateful and derogatory comments to their caregivers, who are overwhelmingly women of colour. "I have a patient right now," she says, giving an example. "Some mornings, I go to give her a shower and she says, 'Don't touch me. I'm white and you are black so don't touch me.' Sometimes she hits me; she will call me a 'bastard;' she'll say that she will get me fired."
Palmer believes this racism is deeply embedded. "Even though they have dementia, they see colour," she says. "That's the last thing to go." However, she takes the point about the role that age and life experience play. "I personally don't get upset with that, because you can't change an old person who was raised like that. In their time, that's the way they spoke, and that's the way they were brought up."
If racism coming from the elderly residents can be partially explained by their generation, the same can't be said about their children, whose behaviour varies, according to Palmer. "You have some very decent people. But there are families that come in and treat you very badly. They will go right by you and look around for a lighter-coloured nurse. It's like you're invisible. They only come to you when there's a complaint or their parent needs assistance to go to the washroom."
Verbal abuse is related to physical abuse. In Canada, the rate of physical violence against workers in long-term care centres is shockingly high. A 2008 study by researchers at York University called "Out of Control: Violence against Personal Support Workers in Long-Term Care" found that almost all PSWs have experienced some form of violence and nearly half experience physical violence on a daily basis. This is in line with Palmer's experience: "There are many infractions. Just today we had a patient bite one of my co-workers. I've been scratched. I had a diaper thrown at me. You'll have people drinking their coffee and then just throw it at you."
JUST PART OF THE JOB?
Because abuse against PSWs is so prevalent in Canada, we typically think of it as a regrettable occupational hazard. It's certainly treated by employers in this way. But it's important to think about the structural reasons that this violence occurs, looking beyond the behaviour of individual residents.
The rate of violence against PSWs is not the same everywhere. The report from researchers at York University showed that the rate of violence against workers in long-term care facilities in Canada is nearly seven times higher than in Nordic countries. While PSWs in Canada experience violence nearly every day, this is not the case in Nordic countries. As the study's authors note, "Clearly, the high level of violence in Canadian facilities is not a necessary feature of work in long-term care and can be reduced."
The rate of violence is related to working conditions; it is not simply behaviour inherent in being elderly or infirm, and therefore unavoidable. Being short-staffed in long-term care facilities is not uncommon in Canada (although it need not be, for, as Palmer notes to me, her employer is always quick to bump up the number of staff when the ministry alerts them that an inspection is coming). In the Nordic countries represented in the study, working short-staffed is much less common, there is more flexibility on the job, and greater communication among staff.
As Palmer points out, the equation is pretty straightforward: "If more funding goes in, you get a better quality. People will be disorderly, but it will be minimized," she says. "When you get to know a patient, they're more cooperative, less vindictive, less angry. They feel like they're a human being. But, if you keep going like you're on an assembly line, pushing and pushing, well, put yourself in that person's shoes. You would be angry."
CARE AS A BUSINESS
Palmer says there is no difference between a grocery store and a nursing home, from the perspective of the employer - they're both businesses. Privatization of long-term care is happening at an increasing pace across Canada. And, as a 2009 CUPE report on senior care called "Residential Long-Term Care in Canada: Our Vision for Better Seniors' Care" points out, "there is convincing research evidence that for-profit ownership leads to lower staffing levels, poorer quality of care, and higher costs for residents."
Understaffing and overwork make sense when you think about things from the employer's perspective: it's about making a profit, and profits are not invested in care - they go straight to the owners. Palmer sees the budget being spent on "salaries and more managers." "Obviously to help you out," I say. She laughs. "That's a big laugh for sure. It's about the bottom line."
As a workplace steward, Palmer frequently raises the question of staffing at labour-management meetings, but she says that whenever it is put on the table, "the first thing they tell you is that it's within the government guidelines." With weak guidelines and even weaker enforcement, the likelihood that owners or managers will make a serious effort to improve care and working conditions is nil.
Interactions between personal care workers and management are frequently tense, according to Palmer. It's difficult to get management to act on reports of racism by residents and their families when the management is racist as well. "There are biases," says Palmer. "Say you and I were called down to the office for a similar reason. [Note to reader: I'm white.] I would get a suspension or a firing and you would get just a reprimand. And that's ongoing." This can also cause animosity among staff, which is something that Palmer tries to address through organizing as a steward to build solidarity among her co-workers.
That long-term care facilities are run as businesses means that when a complaint is lodged by clients or their families, workers aren't supported by management. "You have to hold back," says Palmer. "You have to be the one in the wrong. They're not going to tell the family that mom or dad did so and so to a worker. The customer is always right. The first thing management does is get rid of the staff, even if the staff did not do anything." Unionization has offered some job protection to PSWs, but this remains an issue.
WOMEN'S WORK UNVALUED
Like other "low-skill" caring workers, PSWs are overwhelmingly women of colour. In addition to daily experiences of racism and sexism, structural racism is at play in the way that immigrants and women of colour are marginalized through Canada's economic and social institutions. We can see this in Canada's immigration system and in the devaluation of caring work in general.
Immigrant women of colour are siphoned off into "deskilled" labour in a number of ways. Their skills may be unrecognized in Canada. Immigrant women may be forced by circumstance to set aside their skills and either devote themselves solely to unpaid work within the home or to work in a low-paid job to subsidize their partner's efforts to integrate into the skilled labour market in Canada. Or, like Palmer, they may simply need to "hit the ground running" and take the first job they can get.
The categorization of the jobs that many women of colour do as "unskilled," and the corresponding low wages and benefits they receive, are also troubling. As anti-racist feminists have argued, skill definitions are steeped with racial and sexual bias, and often don't correspond to the amount of training or ability that are required to do the jobs. The work is often viewed as inferior because of who is doing it. Women in our society are overwhelmingly responsible for caring work, so those skills are seen as "natural" and aren't recognized or rewarded.
When I ask Palmer, "At the end of the day, how do you feel?," she takes a moment to answer. "Drained. Mentally, emotionally, physically. It wears you down because you keep looking at that person and you say, 'This could be me, this could be my parent, this could be my aunt, this could be my uncle,' and you're not satisfied in the way you're able to deliver. This person is depending on you. You've got to be their eyes, their ears, their hands, their feet, their family, for those who don't have a family. There are times we have to sit on the bed and to be that daughter that they never had or that is somewhere far away, maybe out of the country, maybe working. And, at the last minute, when the breath is going, you have to be that hand for them to hold on to. I go to many funerals because my patients put it in writing that they would like me to attend."
While Palmer likes her job and feels it's important, she remains frustrated at the lack of time and resources. "There is a sense that what we do matters, but, because we don't have the time to put in it, these folks are angry. There are days where you feel sorry for them, sorry for yourself, and mad at the system. Honestly, I wish the powers that be agreed to put a little bit more in so that we could be there a little bit more for them."
OUR SENIORS, OURSELVES
The treatment of personal support workers and that of the residents they care for are two sides of the same coin. It's past due time for Canadians to think about the way we expect to be cared for when we can no longer care for ourselves. This is even more urgent because of our aging population. In 2005, 13 per cent of the population was over 65. In 2031, almost one quarter of the population is projected to be over 65.
The way that many Canadian seniors and their caregivers are currently treated is unacceptable. The rate of injury and violence that PSWs face is unconscionable. For residents, despite the hard work of their caregivers, long-term care centres can be extremely lonely and alienating, and the limited resources put towards restorative care means that they often physically deteriorate much more quickly than they would otherwise. Long-term care must be recognized as an essential health service and become a national priority.
Palmer describes the situation as "horrible." "I am very upset, because Canada waves this flag of human rights: 'I'm a First World country, everything is okay here.' It's not. It's rotten to the core. When you live here, you realize, there's a lot undercover. And in long-term care, it's not subtle at all."
Palmer believes that for-profit care is a problem. Employers can be brutal and, "as long as this type of care is being done for profit, it's not going to get any better. Government has really downloaded onto the private sector. For them it's a business."
She believes better government regulations are needed. "They have to put a number to how many patients one should care for and what is expected from you within that given time." And this needs to be enforced. With fewer patients to care for, she could do more with each: take a resident for a walk, talk to them about how they're doing. All health care, including long-term care, should be free and public and accessible to everyone, she says.
For Palmer, rank-and-file organizing is the key to improving working conditions, which is why she's a steward with her union. "I keep saying to my co-workers, 'Don't go behind a closed door and cry.' Many do that, they will go into the washroom and cry, or they will not come to work. Some say, 'I just can't make it because of what happened yesterday.' We have to stand together as a voice. We are the ones who are going to make changes. As long as we work here, no managers, no owners, are going to make those changes. And look at it: one day we are going to be old, if we don't die young. This is the way of the world. The system is not going to change if we don't act. They're not going to change it for us."
