"The conditions of work are the conditions of care."
Natalie Mehra, executive director, Ontario Health Coalition
As a nurse, Althea Quinn's instinct was to spend more time with the husband of the dying woman she was attending to during a home visit.
"It was obvious that she was going to die fairly soon. And the husband was [taking care of her] all by himself," she says. "So if I was in long-term care, I would have given a lot more time to that patient and that husband to make sure that [they were okay]."
But when she called the office to ask if she could stay longer, she was told to "go on to the next one."
"I felt it was hard-hearted. That was the purpose of having a nurse come in [to care for people]," she says. "And the stupid thing is I went to the next one, and it was the same circumstances. She was dying too. And it just seems the families were overwhelmed. They didn't know what to expect."
Quinn's anecdote isn't an aberration. Home-care workers are constrained by the logic of health-care policy designed by governments more concerned with managing costs than caring for people.
Government cost-cutting and privatizing services
Health care in Ontario is severely underfunded, a fact perhaps best exemplified by the glaring statistic of the province having the least hospital beds per capita in Canada. Low spending under successive Conservative and Liberal governments have led to decreasing hospital capacity and expanding long-term care wait lists.
Although home care has been marketed as a solution, funding has failed to keep pace with the pressures of an aging population and the downward pressure of inaccessible long-term care, which currently has a wait list of over 35,000 people.
Consequently, home care has been rationed, resulting in reductions of services for existing recipients, and wait lists for eligible patients.
Insufficient funding is exacerbated by the privatization of services, creating an insecure, overburdened and precarious workforce. The marriage of the two has produced stressful conditions for workers, patients and family members alike.
'Making sure people are treated with respect and dignity'
When Michelle Clermont decided to quit the software industry after 25 years, her teenage goal of being a child-care worker weighed on her mind. Having been thrust into caregiving to shield her little sister from the ravages of feuding parents, she was drawn to the vocation.
But noting her grandmother's poor experience in a long-term facility in Ontario, and the pattern of abuse in the sector, she opted for seniors' care.
"That was the biggest factor in making me lean towards becoming a PSW [personal support worker] for seniors," she says. "Because I was passionate about making sure people were treated with respect and dignity and not just a number in a system."
"If you ask the majority of home-care workers, they will say their number one reason for this job is the client," says Tali Zrehen, director of home and community care for the Service Employees International Union. "Who's in it for $14 an hour or $16.50?"
But as Zrehen points out, the working conditions and the ability to provide appropriate care are intrinsically bound.
"If you provide a higher quality of life for PSWs, if you provide them with a career, if you provide them stable hours, that will translate into better quality care for their clients, because they're going to get hours that are consistent [and visits by the same PSWs]," Zrehen says.
The need for stability and time to care
Due to high turnover rates and instability for workers, residents don't get the consistency in service they seek. For Merry-Anne Garvey, 58, who suffers from kidney lupus and heart disease, getting a last-minute call about her regular PSW being replaced is a source of stress.
"They will just call and say, 'Oh your worker can't come today.' I immediately panic and lose my mind when that happens. I just don't like having different people," she says.
Garvey's predicament is in part due to her unique situation of having a dialysis catheter, which in her experience isn't always dealt with properly by workers unaccustomed to helping her shower.
Her agitation about being visited by a new worker speaks to the importance of stability and relational care -- forming connections with caregivers who assist patients with intimate tasks.
Annette Gerard's 94-year-old mother, a dementia patient, is unable to easily articulate her needs due to aphasia (loss of speech) after a vascular stroke she suffered 12 years ago.
Caring for her requires trust and attunement to her needs, which is why her regular PSW is essential.
"There's not much communication left at all [with my mother]. We do not even have yes or no anymore. So it's really very intuitive," Gerard says. "Knowing her is very helpful to care for her."
But when a new PSW is sent in, it's a stressful experience for the client and their family members, and an unfair demand on the worker. The patient may resist being undressed and showered by a stranger, creating a risk of physical conflict and injury.
Even if workers can navigate the challenge smoothly, the additional effort and time creates another problem. The local health network assigns limited time for tasks. For instance, a client may be allotted an hour for a shower, which reduces flexibility for provider and recipient.
"We make do, but I mean we rush and a lot of times my workers' phone goes off because the hour is up and we're done," Garvey says, about being dressed and showered. "So I get finished up myself or get some support from my family."
But a task as simple as getting dressed is a challenge for patients who are not able-bodied. Add to that the arbitrary scheduling -- once a week Garvey has a 45-minute visit as opposed to the hour-long visits on other days.
Workers are not compensated for additional time they spend with patients. Even if they feel compelled to do so, their schedule may not permit them as they might have to race to another client.
On the other hand, as patients become "items" -- 45-minute shower person, 30-minute wound care patient, 15-minute toileting client -- workers are incentivized to rush.
"If you want to make more money, then you have to work faster," says Lucy Morton, regional vice president for the Ontario Public Service Employees Union. "The faster you work, the more patients you get paid for. So it's like putting you on the hamster wheel if you will."
The rush to get done and move on to "the next one" takes a toll on workers' health and finances. Katherine Edwards, who worked over a decade for St. Elizabeth Home Health and CBI Home Health until she got injured in August, speaks about the absurdity of being assigned 15 minutes to shower a dementia patient in a retirement home.
"If they've got dementia, and they wander, you have to look for them, right?," she says. "So it can take you 15 minutes to find them."
"A 15-minute visit turns into 45 minutes and then you have documentation on top of that."
Dyana Forshner-Juby, a PSW with CarePartners, decries the futility of short visits.
"We don't have the allotment to perform the care that we need to do," she says. "What do you do in 15 minutes? I park my car. I go up the stairs. I check-in, I turn around, I go down the stairs and I drive away."
Scheduling quirks propel workers into rushing between clients -- especially those in rural areas who drive long distances between homes -- and simultaneously enduring unpaid gaps in their schedule.
Edwards, who was getting paid $19.85 an hour, was compelled to work late into the evening despite being officially scheduled from 7 a.m. to 3 p.m. Her employer didn't penalize her for refusing shifts after-hours, but as a single mother paying tuition for her daughter's higher education, she had to take them.
Most days, Edwards says she would finish late at night.
The low wages are compounded by piecework. For a 15-minute visit a worker gets paid pro-rated wages. In the case of Edwards, that would be less than $5, even as she would potentially drive 30 minutes to get there. Like many other employers, St. Elizabeth and CBI Home Health compensate for mileage but don't pay hourly wages for travel.
Thus, even as the car is the most valuable asset for a home-care worker (although some also use public transit), the cost of gas and maintenance becomes onerous when workers can rack up 200 kilometres a day. Plus, as Forshner-Juby says, there is a safety component as well.
"Thank God, my husband's a mechanic, he can take care of my vehicle for me," she says. "But there are young girls out there that are driving heaps of junk that have no heating and bald tires, and they're potentially putting themselves in horrible risk."
Sabina, who wanted her last name withheld, says she went through three brand new cars in a decade of home visits. The costs are harsher on workers with less resources.
"We have workers that once their car's beaten down and broken and they can't get a new fuel pump or they can't get new tires. They're out of a job -- simple," Forshner-Juby says.
The emotional toll
In a society where women are socialized to care, and are left to a marketplace that revolves around the logic of keeping costs low and profits high, their ability to cater to the needs of an aging population is compromised.
The onus of being responsible for the care of a vulnerable population while bearing the risk and weight of failure, takes an emotional toll.
"Mentally, it's a very draining job," Sabina says. "You get attached to your client, and then you get frustrated because you know they need more care, and they aren't getting it."
"Most of us PSWs are the type that, if the client's having a bad day, it's hard not to take that with you."
One day, Sabina realized she had had enough. She quit.
"I was burnt out," she says, her voice heavy with dejection and weariness. "I sat in my car, and I started crying. And I couldn't stop."
Zaid Noorsumar is rabble's labour beat reporter for 2019, and is a journalist who has previously contributed to CBC, The Canadian Press, the Toronto Star and Rankandfile.ca. To contact Zaid with story leads, email zaid[at]rabble.ca.
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