“I’ll go from working here to living here.”

1. “I’ll go from working here to living here.” Rural personal care homes as workplaces Dr. Bonnie C. Hallman, Associate Professor Department of Environment and Geography, Clayton H. Riddell Faculty of Environment, Earth and Resources University of Manitoba

2. The Study • Manitoba portion of larger study conducted 2003-2005 • Collaboration with Centre for Families, Work and Wellbeing, University of Guelph, Ontario • Status of Women Canada Policy Research Fund • http://www.sfc-cfc.gc.ca • The Impact of Patient Classification Systems on Women Frontline Care Workers in Rural Nursing Homes Dr. B. Hallman, University of Manitoba

3. Project Context: Restructuring, Rurality and LTC Work • Reduction of many local government services • Smaller / closed hospitals, schools, banks, post offices • Rural labour markets drastically changed • Significant changes to agricultural and rural landscape as economy diversifies • International trade, loss of Crow Rate etc., • Services only expanding rural labour sector Dr. B. Hallman, University of Manitoba

4. Manitoba: Restructuring = Decentralization • mid-1990s reductions in CHST • Cut costs • Decision-making away from ‘big’ provincial bureaucracies • Greater accountability • Decentralized delivery and financing of health care delivery into 11 regional health authorities • Regional focus mediated by provincial and federal policy Dr. B. Hallman, University of Manitoba

5. PCH Residents • Only 5% of Manitobans aged 75-79 live in PCHs • 90% of those aged 90 or older do • 55%+ ‘old-old’ and Level 3 or 4 care • Average age of rural PCH residents: 84.3 Dr. B. Hallman, University of Manitoba

6. Manitoba Challenges in LTC • Small scattered communities • Tendency for seniors to remain in small, rural communities • Increasing (frail) elderly population • Lasting effects of healthcare restructuring / decentralization / regionalization Dr. B. Hallman, University of Manitoba

7. Rural Communities, Long-term Care and Women • Women are the majority of front-line workers in long-term care • Nurses, health care aides • LTC policy disproportionately affects women • As frontline and administrative employees and as clients / residents • Rural LTC facilities often are one of the few local sources of employment for rural women Dr. B. Hallman, University of Manitoba

8. Frontline Workers: Issues in a Rural Manitoba Context • Interviewed home care case coordinators /nurses (RHA and direct PCH contacts) – n=15 • Focus groups with health care aides (union contacts) – n=24 (4 groups) Dr. B. Hallman, University of Manitoba

9. Frontline Workers: Issues in a Rural Manitoba Context • Rural labour shortages = no time / too exhausted to reliably document accurately • Long distances + winter weather = high absenteeism Dr. B. Hallman, University of Manitoba

10. When you get up to (town name) there are people there for the paycheque. So, you can imagine what kind of care these people are getting. I mean that, this is not a job you should be doing if you don’t like it! And I think in your rural areas you’re going to find that a fair bit. And then you’re also stuck in the sense that, well, you don’t get…there aren’t enough people, there aren’t enough people doing this and … you’re scrambling and switching shifts, to cover the shifts so that three of us could be away [for their union meeting]. Yeah … and it’s just kind of an ongoing problem. And like ___ said, we’ve talked about this, we’ve got daughters that are 23 and there’s no way in hell we’d ever encourage them to go into health care. (HCA, Manitoba) Dr. B. Hallman, University of Manitoba

11. Frontline Workers: Issues in a Rural Manitoba Context • Lack of training = inaccurate documentation / undocumented care • Aging work force = high rates repetitive strain injury • Aging work force = special consideration re:computerization of documentation Dr. B. Hallman, University of Manitoba

12. I’ve worked construction and I’ve never been so tired as I have working in a nursing home…But working in a nursing home is very stressful…I’ve got to go home and have a nap and I’ve never done that and I’ve always worked two jobs! I’m just getting older…(laughs). I work one job now and it’s like, I get home and I [makes sleeping motion] for a couple of hours. It’s the stress. Emotionally, physically and mentally it is very stressful; very, very stressful. Especially when you have kids. We still have people that lift residents. One of my girls hurt herself; she still lifts people up. I do not lift anybody manually anymore … wait until they’ve been there 20 years and they can’t walk any more on certain days. Dr. B. Hallman, University of Manitoba

13. For the aides themselves…I mean I’ve done some education, but there are some that haven’t and they can’t handle that [dementia]. They slam the door or say ‘I’m not going in that room, I don’t even want to look at them!’, and they have to provide care to them. When you’re stressed out, you injure yourself a lot easier than you would if you’re … you’re tense, you’ll injure yourself a lot faster than you would We calculated it and it was three minutes per resident for 30 residents. That’s Hoyer [lifting with a device], wash, groom, the whole bit. Three minutes per resident, is what the average time is. That’s not including the baths we have to do, the four baths. You get ready in three minutes! Ha! Dr. B. Hallman, University of Manitoba

14. I think that using a computer will be a challenge for the older worker, but I also think … I’ve been in some homes where I’ve seen maybe three computers. One’s in the administration office, one’s in the DON’s [Director of Nurses] office, and one’s at the main desk. Dr. B. Hallman, University of Manitoba

15. Frontline Workers: Issues in a Rural Manitoba Context • Rural frontline workers know their residents = affect assessment consistency, impacts on workers • Delay between assessment and funding = inability to react to acuity level increases Dr. B. Hallman, University of Manitoba

16. When somebody does pass away you don’t even have time, or they won’t let you have time, to spend with that person if there’s nobody to be with them. It’s hard when they are dying and there’s no one there and you want to hold their hand … they’re grabbing for your hand and you can’t stay. That’s the hard part … and they die alone. I told one nurse ‘get lost’. I was staying. Nobody’s going to die alone when I’m there … but I mean it has happened that they’ve chased people out ‘get to work, we’ve got other people to get to.’ Well, it took us what, three years of heavy, heavy; we had all Level 4s. It took us a strike before we got an extra person! Dr. B. Hallman, University of Manitoba

17. When you hear Level 4 you know it is heavy as in physical work. Level 2 can be just as heavy only mentally…trying to prevent a mixed up person when they can’t leave, when they are looking for their parents, or they have to go look after the horses and they are crying. You have to tactfully, gently soothe them, redirect them. So it is a lot harder mentally on me. Sometimes you just want to go into another room and scream. About 5 years ago, instead of just 1,2,3, and 4…you could be a 2y, and that would be ‘with behaviour’. So that’s closer to a level 3…they wanted the government to fund behaviour as well, but it’s not being done. Dr. B. Hallman, University of Manitoba

18. Remember when we used to have time in the afternoon, say 2 o’clock, when we would get together to have a discussion about how bad or good things are going, or whatever? But you know, there is never enough time for that. It takes us until 2 o’clock or 2:30 to get everybody panned after lunch and laid down for his or her nap. Then we have these forms – the flow sheets – to fill out and it’s time to go home… Sometimes it’s just too busy there. Dr. B. Hallman, University of Manitoba

19. Conclusions • Rural communities are struggling to find ways to sustain themselves • Rural care homes can and do make positive contributions to the sustainability of rural communities • BUT • Using patient classification to determine funding has detrimental consequences for frontline workers in rural care homes • Set out 18 recommendations to ameliorate this situation Dr. B. Hallman, University of Manitoba