Prescriptive or interpretive regulation at the Frontlines of care work in the "three worlds" of Canada, Germany and Norway.
Daly, Tamara ; Struthers, Jim ; Muller, Beatrice 等
ABSTRACT
This paper examines the tension between macro level regulation and
the rule breaking and rule following that happens at the workplace
level. Using a comparative study of Canada, Norway, and Germany, the
paper documents how long-term residential care work is regulated and
organized differently depending on country, regional, and organizational
contexts. We ask where each jurisdiction's staffing regulations
fall on a prescription-interpretation continuum; we define prescription
as a regulatory tendency to identify what to do and when and how to do
it, and interpretation as a tendency to delineate what to do but not
when and how to do it. In examining frontline care workers'
strategies for accomplishing everyday social, health, and dining care
tasks we explore how a policy-level prescriptive or interpretive
regulatory approach affects the potential for promising practices to
emerge on the frontlines of care work. Overall, we note the following
associations: prescriptive regulatory environments tend to be
accompanied by a lower ratio of professional to non-professional staff,
a higher concentration of for-profit providers, a lower ratio of staff
to residents and a sharper division of labour. Interpretive regulatory
environments tend to have higher numbers of professionals relative to
non-professionals, more limited for-profit provision, a higher ratio of
staff to residents, and a more relational division of labour that
enables the work to be more fluid and responsive. The implication of a
prescriptive environment, such as is found in Ontario, Canada, is that
frontline care workers possess less autonomy to be creative in meeting
residents' needs, a tendency towards more task-oriented care and
less job autonomy. The paper reveals that what matters is the type of
regulation as well as the regulatory tendency towards controlling
frontline care workers decision-making and decision-latitude.
RESUME
Cet article examine la tension entre le reglement du niveau macro
et la rupture de la regle et la regle suivante qui se passe au niveau du
lieu de travail. En utilisant une etude comparative entre le Canada, la
Norvege et l'Allemagne, l'article expose a grands traits
comment le travail de soins a domicile a long terme est reglemente et
organise differemment selon le pays, les regions et les contextes
organisationnels. Nous demandons l'endroit ou la dotation en
personnel de chaque pays tombe dans un continuum
d'ordonnance-interpretation; nous definissons l'ordonnance
comme une tendance reglementaire pour identifier ce qu'il faut
faire et quand et comment le faire, et l'interpretation comme une
tendance a definir ce qu'il faut faire, mais pas quand et comment
le faire. En examinant les strategies des travailleurs de soins de
premiere ligne dans l'accomplissement de leurs taches quotidiennes
sociales et medicales, nous explorons la facon dont une approche
reglementaire prescriptive ou interpretative au niveau politique touche
le potentiel de pratiques prometteuses d'emerger sur le front du
travail de soins. Dans l'ensemble, nous notons les associations
suivantes : les environnements reglementaires normatifs ont tendance a
etre accompagnes d'une baisse du ratio du personnel professionnel
par rapport au personnel amateur, une concentration plus elevee de
prestataires a but lucratif, un ratio plus faible du personnel pour les
residents et une division plus aigue du travail. Les environnements
reglementaires d'interpretation ont tendance a avoir un plus grand
nombre de personnel professionnel par rapport au personnel amateur, une
disposition plus limitee a but lucratif, un ratio plus eleve de
personnel pour les residents, et une division plus relationnelle du
travail qui permet le travail a etre plus fluide et reactif.
L'implication d'un environnement normatif, comme on en trouve
en Ontario, au Canada, est que les travailleurs de premiere ligne
possedent moins d'autonomie a etre creatifs pour repondre aux
besoins des residents, une tendance vers plus de soins axes sur les
taches que sur l'autonomie de travail. L'article revele que ce
qui importe est le type de reglement ainsi que la tendance reglementaire
vers le controle des travailleurs de premiere ligne par la prise de
decision.
Introduction
A wall is more or less white than another wall we can see or
imagine. So, our subjectivity, with the wealth of comparisons it
implants in us, transforms us into tourists of ourselves, visitors of
the odd sights of everyday life. It removes the dull sense that anything
at all is obvious. Arlie Russell Hochschild (1)
LONG-TERM CARE (LTC) NURSING and personal care homes provide
specialized medical and social care to society's most vulnerable,
including younger but mostly older adults with multiple health ailments
and disabilities. These are complex organizations, (2) providing ever
more highly acute medical and social care, owned by for-profit,
non-profit, and public entities and governed by intersecting regulations
that structure tableside and bedside work. The sector's complexity
drives debate about its regulation; as Kieran Walshe argues,
"[n]ursing home regulation remains the constant subject of policy
attention...." (3)
In the context of this complexity, how states should regulate to
best guarantee good living conditions and care for residents while
maintaining good working conditions for staff are important
considerations and the focus of this paper. Who does what work, how it
is organized, and how many people are available to do it are arguably
the most important factors affecting residents' receipt of quality
social and health care, so it is particularly important to have the
right staffing regulations. (4)
Interestingly, despite the similarity of residents' needs and
of LTC work tasks, staffing is regulated and organized quite differently
depending on country, regional, and organizational contexts. This
variety in the face of similarity invites us to explore the regulatory
structures in LTC by investigating the nature and form of macro level
staffing regulations--which can be either highly prescriptive or more
interpretive--in connection with frontline work organization. We define
prescriptive regulation as a tendency to identify which staff should do
what work and when and how they should do it. Interpretative regulation
reflects a tendency to broadly define care but not which staff should do
it, nor when and how they should do it. The variety also allows us to
explore how frontline care workers react, resist, and respond to the
tensions between the regulatory context and the needs of the situation
that they encounter in their everyday work. Drawing on the conceptual
framework afforded by Gosta Esping-Andersen's three worlds of
welfare capitalism, we examine care work regulation and frontline work
organization with examples of music activities, medication dispersal,
and dining in liberal, conservative and social democratic regimes, in
Canada, Germany, and Norway respectively. (5)
This paper seeks to answer three questions. Where do each
jurisdiction's staffing regulations fall on the
prescription--interpretation continuum? What are frontline care
workers' strategies for accomplishing everyday social, health and
dining care tasks? Furthermore, in what ways does a policy-level
prescriptive or interpretive regulatory approach affect the potential
for promising practices to emerge on the frontlines of care work?
Following the literature review in section II, section III outlines the
study's methods. In section IV, we first describe the LTC
regulatory context in each of Ontario, Manitoba, and British Columbia,
Canada; Oslo and Bergen, Norway; and North-Rhine Westphalia, Germany,
and then present findings from the sites of our empirical data
collection. We use the examples of social (music activities), health
(medications dispersal), and dining (health and social care) to
highlight how regulatory structures effect how frontline workers'
respond to regulation--in reactive, resistive, and responsive ways--in
order to best care for residents. The final section analyses each
region's regulatory framework along a prescriptive-interpretive
axis and discusses the implications of these contexts for policy-makers
and frontline work organization.
Literature Review
LIKE PETER JACOBSON, we use regulation as a term inclusive of
government-level legislative and administrative oversight. (6) Specific
to the LTC sector, regulation has been described as interrelated policy
approaches that control quality and guard against abuses; standards to
make care practices consistent and to match outcomes to targets; and
market-based incentive schemes like performance-based measurement and
internal competition. (7) Both definitions of the term focus on
government roles but ignore social relations. Our notion is more
expansive, draws on feminist political economy (8) and includes the
range of norms, values, and ethics that structure and frame who does
what work, under what conditions, and with what consequences. As a
result, we define care work regulation as the range of laws, rules,
norms, ethics, values, and systems that structure care work and
workers' actions and activities. Given our broader definition, we
draw on several literatures focused on institutional health and social
care work at multiple levels of analysis. We consider overarching gender
norms and debates about ownership and profit in care; conceptual
frameworks addressing forms of government LTC regulation; and additional
layers of regulation emanating from professional ethics,
self-regulation, and accreditation.
Gender Norms
LTC houses a mostly female clientele in need of intimate social,
emotional, and medical care; and employs a mostly female workforce
(approximately 90 per cent) of healthcare professionals (e.g. nurses,
therapists, and social workers) and non-professionals (e.g. care aides,
administrators, and workers in areas like housekeeping, laundry, food
services, and social care). The ratio of professionals differs
jurisdictionally. In the literature, care work is understood as complex
but in practice it is treated as less skilled and less highly paid work
compared with other sectors. Early feminist scholars were vocal about
the gendered nature of care, (9) its status as skilled work in both its
paid and unpaid forms (10) and its position within formal production and
informal reproduction systems. (11) There is little debate that this
workspace is structured by overarching gender norms and expectations
about women's capacities and sense of duty to care. With its
feminized labour force there is the expectation that labour will be
"endlessly stretchable" and fill care gaps to address
residents' needs in the face of austere systems and familial care.
(12) LTC is thus a highly gendered home space and workplace regulated by
overarching gendered norms and expectations of women that are shared
across places but with obligations to provide familial care that are
place specific.
"Private" in LTC Regulation
In the context of the LTC regulation, "private" involves
delivery (i.e. facility ownership), payment (e.g. user fees), quality
(e.g. accreditation), and standards (e.g. licensing, professional ethics
and self-regulation). There are different levels of for-profit,
non-profit, and public sector delivery based on a jurisdiction's
historical context and social welfare approaches. (13) Even so, there
remains considerable debate about the impact of ownership on the quality
of residents' care. At an aggregate level, studies have shown that
commercial provision of care can have negative quality implications, on
balance showing higher quality in non-profit and public facilities on
important quality measures for residents' clinical outcomes. (14)
There remains a knowledge gap about the impact of ownership on the
quality of LTC working conditions. In contrast, there is little current
policy debate about user fees, because governments in all countries
differentiate between accommodations and care costs. User fees can be
dependent on the person's income level, which is a general feature
of institutional care.
Jacobson draws our attention to another aspect of the LTC
sector's regulatory complexity: a continuum exists between
regulations that "facilitate market forces"--such as private
accreditation and professional self-regulation --and ones that
"displace" or "substitute for the market" as with
government regulation. (15) Private regulation can provide overarching
regulatory frameworks. For instance, studies have shown how the quality
of LTC is associated with higher numbers of professionals providing it,
(16) although any relationship between the nature of regulation
(prescriptive / interpretive) and the ratio of professionals to
non-professionals on the frontlines is under-explored. Private
accreditation conducted by for-profit and non-profit organizations sets
standards for quality, skills and qualifications, and adds another
regulatory layer. While some studies have looked at the link between
accreditation and resident outcomes, (17) the role accreditation plays
in structuring frontline LTC work is under-explored.
Government Regulation, Organization Responses, and Frontline Care
Work
Policy-makers enact LTC sector regulations to set principles and
roles; to guard against abuse, neglect, and risks to residents and
workers; to control who does what work; and to delineate who pays for
what especially as this concerns allocations of public funds and
out-of-pocket user payments. According to Walshe, governments can choose
three regulatory paradigms: compliance, deterrence, and responsive
regulation, with new public management most closely resembling the
deterrence paradigm. (18) However, Walshe's singular focus on
governmental rules and organizational responses renders frontline
workers' agency invisible. Furthermore, the focus on rule
compliance assumes that care is a straightforward, linear process devoid
of complex social relations, an assumption categorically challenged in
feminist critiques. As Karen Davies argues, care work takes time and
requires flexibility; (19) thus, attending to the needs of the situation
may require non-compliance with some rules in order to provide good
care. This is a point underscored by the application of complex adaptive
systems theory to healthcare environments. (20)
Even considering the intersecting layers of regulation such as
gender norms, governments, professional ethics and accreditation shows
how the tension between rule making and rule following is mired in
obfuscation. Confronting this tension, Steven Lopez highlights frontline
work with his participant observations in a non-profit nursing home in
the United States, by noting that workers, managers and clients engage
in "mock routinization" and "institutionalized
rule-breaking" because of a "mismatch between time and tasks,
the development of new (informal) skills, with the institutionalization
of rule-breaking, negative effects on quality, the collaboration of
shop-level supervision, and workers' experience of managerial
irrationality." (21) His study reveals how complex and
tension-prone is the space between regulations and frontline work and
further challenges us to better understand how this space functions in
different jurisdictional and ownership arrangements. Following
presentation of the method, we document several government regulatory
approaches vis-a-vis frontline LTC work.
Method
THERE ARE LIMITS TO USING cross-national and even cross-regional
statistical staffing data because of the way data are collected and
defined, and because the data do not adequately make frontline work and
its constraints visible. These limits require us to gather primary data
that address how staffing is regulated, how regulations are interpreted,
and how work is managed. Data are drawn from an international and
comparative Social Sciences and Humanities Research Council funded study
of "promising practices" and a Canadian Institutes of Health
Research funded study of "healthy active aging" in LTC led by
Dr. Pat Armstrong. The project involves a team of 25 academic
researchers and double that number of graduate students. The authors of
this study are part of the "work organization" theme led by
Tamara Daly and Jim Struthers. (22) Ethics for the project were reviewed
and granted by the Office of Research Ethics at York University. The
data for this paper are drawn from content analyses of a cross-national
mapping of regulations, rules and funding arrangements specifically
related to staffing, as well as from observations recorded in field
notes during week-long rapid ethnographies (23) and key informant
interviews (n=291) conducted in 12 LTC facilities located in Bergen and
Oslo in Norway; Toronto, Ontario, Vancouver, British Columbia and
Winnipeg, Manitoba in Canada; and North-Rhine-Westphalia in Germany
between December 2012 and December 2014. The larger programme of
research includes 6 countries, 467 interviews, 21 different sites and
over 1,000 hours of work observations with complementary field notes.
Exemplary case sites (24) with "promising practices" in the
provision of residential long-term care were selected in each
jurisdiction following key informant interviews with policy-makers and
others knowledgeable about the sector. We conducted observations on open
and "locked" LTC units and public spaces starting at 7 am and
until midnight and later.
Long-term Residential Care in Context: Canada, Germany and Norway
A broad overview of each jurisdiction's long-term care
legislation, ownership composition, and payment schemes is presented
below.
Canada
LTC is an extended health service under the Canada Health Act, 1984
giving provinces considerable latitude to decide the terms of its public
funding and legislation, with some opting for capped budgets and others
including it as an insured service. Admittance to a facility is
provincially assessed on the basis of need and space availability. There
is a co-pay model, with residents responsible for a varying payment
depending on the province/territory. For-profit providers dominate in
some provinces, though they own at least one quarter of the homes in
most provinces. Many facilities are accredited voluntarily by either the
Commission on Accreditation of Rehabilitation Facilities International
or Accreditation Canada, of which both are non-profit organizations.
Additionally, health professional licensing is handled by each of the
provinces. There are provincial similarities in scope of practice, but
dissimilar or no staffing ratio standards.
In Ontario, the Long-Term Care Homes Act, 2007 merged municipal
(public) homes, charitable (non-profit) homes and (private commercial
and non-profit) nursing homes into the same regulatory framework. (25)
Beds at near full ( (97) per cent) occupancy are remunerated at full
capacity and receive per diem activity-based subsidies from the
provincial government using a case mix formula derived from the Minimum
Data Set Resident 2.0 (MDS-RAI) assessments. (26) Currently, there are
about 78,000 LTC licensed beds located across 643 homes, (27) with more
than 60 per cent owned or managed by commercial chain conglomerates.
(28) Ontario's local health integration networks--regional health
authorities--sign accountability agreements with individual homes.
Ontario has basic and preferred monthly accommodation fees (from
$1,731.62 for basic to $2,438.81 for private rooms in new facilities)
paid by the residents.
Standards for Manitoba's provincially funded "personal
care homes" are set out in the Personal Care Homes Standards
Regulation, 2005. (29) Of the 125 homes most are located in the urban
regions, and nearly 4 in 10 (37.9 per cent) are provincially run; over
one third (34.9 per cent) are private non-profits; and just under one
third are for-profits (27.2 per cent). Like Ontario, Manitoba's
regional health authorities hold responsibility for LTC. The MDS-RAI
assessment is used in the Winnipeg region, but only for planning
purposes and across Manitoba staffing levels are determined on a
flat-payment system. There are four levels of care, with the fourth
being the highest. To supplement the provincial government funding,
residents pay between $34 and $79 per day, depending on a person's
marital status and after tax income. (30) Staffing levels in Manitoba
are standardized so that all residents receive 3.6 paid hours of direct
care from nurses and care aides combined, regardless of the level of
care required by the resident. This amount excludes care provided by
those who perform laundry, cleaning, and dining care.
The Community Care and Assisted Living Act Residential Care
Regulation (2009) governs the 281 nursing homes in British Columbia.
(31) Nearly one quarter of the homes (24.5 per cent) are in the public
sector, one third are controlled by non-profit religious or lay
organizations, and the remaining 40 per cent are proprietary. (32) There
is a co-payment dependent on peoples' after-tax income with a
minimum user fee of less than $325 cad and a maximum of $2,932; fees
cannot exceed 80 per cent of a person's net income. (33)
Germany
As the fifth "pillar" of the social security system,
there is a universal, national, and mandatory system of "Soziale
Pflegeversicherung" or social long-term care insurance (LTCI) in
Germany. (34) Nearly the entire population of Germany has coverage with
the public health insurance and the long-term care insurance system.
Benefits also cover home-based services and cash payments to family
providing care. Persons insured by private health care insurances are
obliged to purchase equivalent coverage from private care insurance
funds (10.6 per cent in 2007). (35) Facilities are funded from the LTCI
(36) and residents' private co-payment. (37) Women
"choose" residential care more often than men, often after
outliving a partner, while men more often "choose" cash
payments while being cared for by partners, often wives. Before the
current system was introduced in 1995/96, long-term care provision
responsibility resided mainly with the family. (38) Arguably, the system
is still built on the foundation of family support. Reliance on informal
family care and market-based formal care help with the state's cost
containment imperative. While the system provides universal access for a
defined set of care services, the goal of the LTCI is to control rising
costs for individuals, and to enable people to age in place with family
supports. This insurance was accomplished by the state's creation
of a "new type of social rights," establishment of specific
funding, maintenance of a family care requirement, and bolstering
market-based options for purchasing care. (39) Most homes are run by
non-profits (welfare organizations/54 per cent) and for-profits (41 per
cent) with the remaining 618 homes run by the public, and mainly by
municipalities (5 per cent). (40)
There are three care levels in Germany--I, II, III plus an
additional recognition on hardship cases. Level I is reflecting the
lowest need and the smallest benefit reimbursement (1064 Euros) as well
as hardship cases reflecting the highest need and receiving the highest
benefit amounts (1995 Euros). (41) An individual needs to have basic
body care needs exceeding 45 minutes for level I; 120 minutes for level
II and more than 240 minutes for level III.
The German system is heavily reliant on professional standards to
guide structure, process, and outcome quality. For instance, the system
uses "national expert standards in nursing" developed by the
German Network for Quality Development in Nursing working with the
German Nursing Council. (42) The standards define the quality level of
professional care that users of both health and LTC services can expect
when being cared for by nurses and elder carers. In addition, Germany
accredits nursing homes. (43) In the past, quality assurance has been a
role played by "provider bodies" such as the lander (state)
level Medical Advisory Service (MAS) of the statutory Health Insurance
Funds Medizinische Dienste der Krankenversicherung (MDK). The MDK-MAS
conducts needs assessments for care requirements as well as for quality
assurance and publishes all audit results. The Health Insurance Funds
contract with LTC homes provided service, funding, and personnel
criterion are met. Each German lander (region) holds responsibility for
surveilling and monitoring LTC homes' compliance. In terms of
workforce accreditation and certification, LTC providers are required to
uphold provisions of a quality management system such as e-Qalin.
In 2013, just under one third (29 per cent) of LTCI beneficiaries
were in residential services). (44) Furthermore, those with the most
wealth opt for services in the home or institutions, while those with
less financial means opt for cash payments and are cared for by
relatives. Like Norway, there is "free choice" for users about
location of care provision (home, facility) and providers (non-profit,
public, and for-profit). (45) Gender, socio-economic position and
immigrant status all affect the role of family care, levels of
professional care, and additional paid care services. The system has
been criticized for its bias favouring functional impairment over
dementia and privileging Germans over migrants. (46)
Norway
Starting in 1988 with the passage of the municipal health care law,
local authorities (municipalities) gained responsibility for long-term
care along with primary health care and various types of housing and
care services. (47) This "multi-level government model" is
centred on local autonomy with integration between the central and local
government levels--a "typical" Nordic pattern. (48) Following
the act's passage, spaces in LTC were increasingly reserved for
older adults with extensive needs, and the average stay of residents
decreased, (49) all while home care, including 24 hour in-home nursing,
was expanded. By 2010, most (78 per cent) of people residing in the 997
nursing homes were aged 67 or older with extensive care needs; (50)
about 41,000 people resided in nursing homes, representing about 16 per
cent of those receiving long-term care services. (51) As in other
countries, the vast majority (85 per cent) of health and care staff is
female. Assessments for long-term care are conducted by the
municipalities for placement into both public and private non-profit and
for-profit providers. These providers compete because Norwegians have
what is understood as "free choice" to determine whether to go
into a public or private facility, reflecting a move within the country
towards consumerism even for state funded services. (52) There is
debate, however, with some arguing that the threshold for getting into
LTC is "too high," (53) Of those living in institutions, 10.8
per cent live in a privately owned non-profit or commercial facilities.
(54) There are more privately owned facilities in the major cities, with
nearly half in both Oslo (21 of 50 facilities = 42 per cent) and Bergen
(17 of 40 facilities = 42 per cent). (55) Six main commercial chain
firms provide services. (56) Municipalities have become incorporated,
mimicking for-profit organizations. National and local taxation funds
LTC and co-payments are set by the municipalities: 75 per cent of income
over NOK 6 600 up to a maximum basic amount of NOK 75 641 plus any
income that exceeds this up to the full cost of the place, with the
amount varying by municipality. The government does not take property
and capital assets into consideration. (57) The family provides as much
help as does the state when care occurs in private homes, but less so
when someone is in residential care. As Daatland and Veestra note
"[o]f parents with Activities of Daily Living needs (for personal
care) about two out of three are institutionalized." (58) The
Norwegian Center for External Quality Assurance in Primary Health Care
accredits nursing homes as well as primary care physician offices and
other health care institutions.
In summary, Ontario is the most privatized jurisdiction, while
Norway is the least. Private co-payments are required in all of the
places examined, although the algorithms and actual amounts vary. In all
instances, co-payment calculations are subject to some income dependent
modifications. The reliance and obligations of informal care providers
also varies jurisdictionally. German legislation is the most explicit
about the primacy of family responsibility, while Norway is the least
reliant on informal family care. Norway's system seems most
explicit about LTC being a right of citizenship, though the German
system is based on social rights founded on the principles of pooled
risk and shared responsibility in its codified LTCI scheme. Manitoba
retains the insurance model, but Ontario and British Columbia have
created separate, capped funding envelopes. Finally, all of the systems
are regionalized, however, this also translates into jurisdictional
differences. In Ontario, Manitoba, and British Columbia, the legislation
is provincial and funding disbursement is to a regional health
authority. In Germany the legislation is national but managed at the
level of the German lander. In Norway, the legislation places onus and
responsibility on the municipal level. Finally, all of the jurisdictions
have noncompulsory private (non-profit) accreditation.
Findings
This section presents findings of our jurisdictional care work
regulation review and provides examples of frontline care work drawn
from our ethnographic field studies in Canada, Germany, and Norway in
the areas of social care (music as activity), health care (medications
dispersal), and food (meals).
Core Work Regulation
We focus on five regulatory areas. First, staff qualification
regulations stipulate the certifications that are required to complete
different care functions. Table I compares the study's
jurisdictions.
Norwegian care aides receive the most training (Table I) with one
to three years of secondary and post-secondary qualifications, while
Canadian and German care aide training varies, but generally a six-month
course of instruction is completed at a public community college or a
private "career" college. In Germany, dementia care aids have
been recently introduced; they require much less training to practice.
Practical nurses in Canada are college trained like Norwegian and German
counterparts, while Canadian Registered Nurses (RNS) have university
degrees like their Norwegian counterparts. The highest trained German
occupation in nursing homes is the qualified care worker, who requires
three years of on-the-job training.
Table II presents comparative "staff mix" regulations.
Like the OECD, we found varying requirements for the ratio of
professional to non-professional staff. (59)
While minimum nursing staff numbers were required in Norway and
Canada, in Germany an impressive half of the staff must be qualified
care workers (either elderly care providers or nurses with three year
on-the job training). Compared with Canada there are higher numbers of
Norwegian nurses on the floor. In both European countries, we found more
qualified or professional staff in the homes. The reverse is true in
Canadian settings; care aides, with less formal training, far outnumber
nurses and provide the bulk of care work.
As shown in Table III, staffing intensity ratios calculate the
minimum staffing allotment overall, usually measured in hours per
resident per day inclusive of direct care staff.
Germany has regionally determined minimums tied to its care levels;
overall staffing levels are higher with more professional staff than in
Canada. According to the most recent representative survey in 2010 the
resident-staff ratio was 100 residents to 44.9 care workers. (60) The
Norwegian informal levels also far exceed levels practiced by Canadian
provinces. Manitoba also has a minimum number of paid hours, though
these are shared by professionals and non-professionals.
Table IV shows jurisdictional approaches to funding the LTC sector.
As Sutherland and colleagues argue, funding patterns can be
population-based, global, activity-based, pay-for-performance, or
bundled. (61) Population-based formulas--calculated with age, sex,
socio-economic and other health-related characteristics--are used to
allocate funds from central to regional governments. A variety of other
models are used to directly fund organizations.
The pattern of funding, whether global, directed or activity-based,
can determine an organization's flexibility with respect to their
staffing complement. Directed funding can challenge frontline staff if
there are time lags between when funding flows and when workloads have
already increased based on residents' increased needs, while global
funding better allows a facility to internally shift in response to
changes in need. As table IV shows, Ontario's activity-based
funding, which is an even more stringent form of directed funding,
allows the narrowest degree of freedom around staffing flexibility.
Regulations governing the division of labour determine who can do
what work, and whether work performed is more task-oriented (e.g. finish
each task according to a defined schedule) or relational (flexible in
response to what the resident needs at that time); and separated (e.g.
health care; social care; dietary care) or integrated (full scope of
care). Table V summarizes the potential for work integration between
care aides, nurses, and dietary workers in each site.
In care work, a task-oriented focus--for example being focused on
getting certain tasks like bathing completed to meet a pre-determined
schedule is in contrast with one that is relational--which more flexibly
adapts the order, frequency and duration of care to meet the
resident's needs.
Care Work Organization on the frontline
Below, we have drawn from our field notes and key informant
interviews to illustrate the ways in which social care activities
(music); medication dispersal (health care); and dining care (meals)
demonstrate a reactive, resistive, or responsive model of work
organization and the division of labour in different settings.
In Canada, nurses (RNS) and assistant nurses (RPNS / LPNS) were
responsible for supervision, documentation and regulated acts (e.g.
injections and drug dispensing), while care aides were responsible for a
range of body and care tasks differing depending on the province. In
general, most care aides engaged in washing, feeding, toileting, and,
when time permitted, listening, chatting, and comforting residents. In
the Canadian context, the work was more constrained and divided such
that care aides did body work and cleaning of some of the space,
including tables and beds. Sometimes they used computers to document,
but often they used paper and pen. Sometimes they put away laundry.
Recreation therapists were responsible for social care and their time
was usually shared with sixty or more residents. There were also dietary
workers who cooked and served meals, and cleaned kitchens, serveries,
and dishes. Canada tended to have hierarchical and task-oriented
workplaces. (62)
Outside of Canada, care aides' roles were much more expansive.
For instance, in Germany and Norway care aides had more decision
latitude and more varied work. They did the body work, cleared tables
and beds and put away laundry like their Canadian counterparts, however,
they also cooked, planned, baked, cleaned, took residents outside for
walks, and bought items at local stores for parties. Mostly this is
related to the approach Hausgemeinschaft and not a general pattern in
Germany. In Germany, assistive personnel also ensured residents consumed
medicines.
Social Care: Activities
Following the generally strict and hierarchical division of labour
in Ontario (63) specially qualified recreation therapists--with at least
college education--performed social care in scheduled increments.
Ontario workers complained that their work emphasized more counting than
caring. The work was highly prescribed, documented, standardized, and
audited. As one recreation therapist noted:
That's what the Ministry looks to when they come in when
we're audited. We write down what programs [residents] attend; what
needs we meet socially, emotionally, spiritually, physically, and then
... we do ... a care plan for them.... We do tick off the boxes on the
computer screen ... with respect to what programs they attend ... and
there's a psychosocial box that we have to fill in and an activity
section ... we have to fill in. (64)
In addition, because the "task" of social care was the
purview of the recreation therapists, and the schedule of social care
may interfere with tasks other workers needed to perform, this led to
staff conflicts. One worker's experience highlights this conflict:
There are times when I'm doing an activity and I really get
upset with staff because if somebody is sitting there listening to
music, they'll come and just take them out to give them their bath
or toilet them or whatever. You take them out and there's that
feeling of loss and confusion so they come back and they're not the
same. Some of them are agitated ... and I know if they were with the
doctor they wouldn't come in and take them from the doctor's
presence to toilet them or whatever, right? (65)
Furthermore, this worker's experience illustrates how, though
social care may be counted, it "does not count" in terms of
the hierarchy of tasks, with body work and medical work coming first and
little appreciation for how the social is an integral part of the care.
In this instance described above, workers appeared to be reacting to the
pressures to complete their own "tasks," with little attention
to residents' relational care needs.
Our observations and interviews in a very large Norwegian long-term
care facility revealed a different pattern of integration between health
and social care and a different level of staff empowerment for
responding to residents' needs for relational care. There, in a
32-resident secure unit within the larger facility, music therapy
informed almost every aspect of care delivered to cognitively impaired
residents over the past five years. Staff members worked together as a
team, in sharp contrast to the Ontario sites both in terms of the
teamwork and the integration of the social and medical care. To
implement the program, the Director of Music Therapy and her assistant
trained staff in how music programs that were individually tailored to
each resident could be successful in eliminating the need for
psychotropic or sedating medications to manage agitation, depression,
and aggression among residents with moderate to severe forms of
dementia. As she explained:
... the easiest way of telling it is that in the music in daily
activities as you call it, you use music as a stimulant in the patient
for getting them calmed down ... But as a music therapist [you are]
working out ways of communicating with ... the patient with music so you
are sort of reflecting with the person.... [fit's sort of
psychological processing and your goal is not to stimulate that person
with the music to get them to do what you want. It's more like what
is their meaning and you try to make meaning out of things speaking
together through music. So it's a different way of thinking.... So
when I meet somebody we do music together as a verb. We don't use
music as an object.... One of the main theories in music therapy is that
everybody is born with a basis to communicate. As a child ... you
already start to communicate. And this is a musical way of
communicating. So we all are really musical. But it's not a musical
way of being able to play scales or sing perfect. That you have to
learn. But what lies underneath [is] the music everybody knows ... and
that's why everybody gets moved by music. So I use this small thing
to communicate with the patient. (66)
All staff working with residents in this secure unit received
training about how to integrate singing, dancing, touch, and rhythm into
all phases of their daily interactions with them. The success of music
therapy on this floor has led to a dramatic reduction in the use of
mood-altering medications and has contributed greatly to staff being
satisfied about their work. These positive results have also led to the
gradual introduction of music therapy on other units. A nursing social
worker described its transformative impact on her job in this way:
I have been working a lot with music here and we see that makes
[residents] more relaxed. Maybe they can tell about their past. Maybe
they speak more. People that don't have any language anymore they
can suddenly sing a whole song from the memory and then they suddenly
started speaking more because of the music ... Before, maybe five, six
years ago I didn't sing at all. Never. Never sang because I
don't like my voice. But we started this project and I started
singing and I just thought that it doesn't matter if I have a bad
voice. It's not for me, it's for the patient. Now I sing all
day long. I dance and sing with my patients and if they're maybe
... if they have problems brushing their teeth I can start singing a
song I know they like and some manage. It's just moments that make
things easier for them just by using music, just by singing. It's
really, really interesting. (67)
In the German sites, half of the staff need to be qualified care
workers (elder carers or nurses). There are also care aides (dementia
carers) separately funded by the LTCI. One organization actively
resisted state funding level limitations; it increased the staffing
complement by adding large numbers of student apprentices. The costs of
the training of the apprentices (wages) are refunded not carried by the
facility. They also included a sizable number of "1-Euro
Jobbers" --who were remunerated at 1 [euro] per hour and
additionally funded through a labour market program aimed at job
re-training. As a result, we observed a much higher level of social
interaction in this facility. (68) Apprentices performed bodywork and
social care under the direction of the nursing staff, which then enabled
the nursing staff to work in a more direct way with residents. In our
observations, we noted that the large numbers of staff, apprentices and
1-Euro Jobbers available to provide care was the precondition for the
comprehensive social care that was provided on the units. In this site,
the facility resisted lower staffing allotments in favour of a model
that ensured there were plenty of people available to provide care, even
if they were precariously employed, by actively resisting the funding
constraints imposed by the legislation. As a result, the facility had
enough people available to provide care and did not lock its doors, even
on units with highly mobile people living with dementia. We also found
that there was plenty of smiles and every-day activities for residents
to be engaged in (meal preparation, cooking, cleaning, reading
newspapers, singing, sitting together, hand holding) that supplemented
the "formal" activity schedule (cafes, games). One
researcher's field notes recorded the interactions as follows:
When we arrive we see two apprentices sitting with one resident and
talking to each other but also to the resident. Other residents are
sitting around the table. The atmosphere feels calm and relaxed. All
residents are dressed nicely. One woman in a wheelchair makes sounds
(she did this as well on the other days). She seems a little agitated
especially if the young man (apprentice, I guess) takes his hand away
from her hand. She kisses and touches his hand. She seems very much
needing these contact/touches and I'm very impressed that I saw
various staff members touching her very kindly and allowing her to kiss
and touch their hand, arm. I ask the apprentices if they sit with the
residents ... every day or if they have other duties.... They say that
they are sitting there every day and that they are supposed to sit there
and that they don't have many other things to do during this time
of the day. (69) In this home, social care was imbued throughout the
care work. Workers of all qualifications engaged in social care, but the
capacity to do so was set within the organization's active
resistance to the constraints imposed by the German model that espoused
cost containment, even while it was more interpretive in privileging
professional standards and ethics. In addition, even though subject to
critique, the facility had more people available to care by employing
people subsidized by the state to get job re-training.
In summary, these examples from the three countries reveal
differences between the integration of social care with medical care and
bodywork, and the relative priority afforded to relational care. Each
also illustrates how workers and organizations operated in ways that
were reactive, responsive, or resistive to the pressures in order to
meet the needs of the situation. Social care was a clearly defined
episodic activity in the Ontario sites, while in the German one we
visited there were blurry boundaries between health and social care, and
in the Norway sites, social care was an integral part of health as an
important alternative to medication and also a way for care workers to
find meaning in their work.
Health Care: Medications
Medicine dispersal usually happens close to dining times. There are
some commonalities amongst the jurisdictions: medication dispersal
usually involves nurses taking out a medications cart, moving from
resident to resident, and often crushing and mixing tablets with soft
food. This is usually one person's responsibility per unit.
In the Canadian jurisdictions, giving medications is a regulated
act; thus, there are strict regulations that distinguish it from
bodywork such as washing, dressing, and toileting. Only nurses, usually
Licensed Practical Nurses (LPN), are permitted to perform medications
dispersal and to ensure medication consumption. We observed that while
medication rounds occurred, RNS' work involved computer- and
paper-work and addressing complex health needs. Meanwhile, if it was the
morning, care aides were getting people up by providing the vast
majority of body care and transport to the dining room for breakfast.
Like breakfast, lunch and dinner involved serving, feeding, and bussing
tables. In order for the LPNS to avoid being called upon to do frontline
care work such as moving residents requiring two people while dispensing
medicines, many organizations allowed signs on medicine carts that
indicated that no one was to talk to nurses while doing medications
work. Doling out medicines usually happened while residents were being
brought to the dining rooms and it was done in an assembly line fashion,
with nurses responsible for as many as 32 residents. Nurses stood over
residents who were usually sitting in a passive position at a dining
table waiting to be served their meal. In terms of work organization,
care aides complained about declining teamwork due to the nursing staff
no longer having the time to help with bodywork when care aides were
most pressed for time during the mornings. The lack of extra hands often
meant that care aides reacted by moving residents--even those who needed
two people--without a partner. Care aides argued that managers knew
about this but ignored their reactions because everyone knew that the
work could not be completed otherwise, like the "mock
routinization" described by Lopez. (70)
In one German home, medications were secured at night, but out in
the open in the Great Room during the day where residents and nurses
spent most of their time together, much as you might find in a
person's own home. When it was time to consume the medicines, the
nurse gave the medications to the resident, poured more water into the
residents' cup, and then walked away--but not out of the room--and
dispensed medicines to another resident. Care aides and apprentices
sitting at the table calmly ensured that the medicines were consumed,
sometimes with gentle words, other times by "consuming"
something themselves by drinking, thereby turning medicine time into an
opportunity for social connection with a resident with dementia. German
regulations allow the qualified care worker to use professional judgment
and this enabled the work to be seamless, natural and very
home-like--very different from the highly clinical encounters we
observed in the Canadian context. In this example, the qualified care
worker delegated only the role of watching the consumption of the
medicines, while she remained in the room but not standing over the
person. Each person providing care understood that the resident was to
take the medicines, but done in this way, the resident could take them
when ready as the care aide was there to spend time with the resident.
The German home was less hierarchical and the division of labour was
less rigidly enforced. This site followed a Hausgemeinschaften model
where eight to twelve residents live in one unit; thus there is a better
staffing ratio in a facility following this concept, but also because
the site where we observed trained a large number of apprentices who
provided extra sets of hands. German legislation is weighted in favour
of half of the staff being qualified care workers in terms of staffing
intensity and more dependent on their professional judgment compared
with the Canadian jurisdictions. Compared with other homes in Germany,
this site actively resisted the state imposed care gap due to austere
funding by having more people around to provide care. The
organization's actively resisted under-staffing by having more
"hands" available to provide care who would not be considered
full-time staff, and thus not subject to the rules about having half of
the staff as nurses, and allowing the type of social care that they
wished to provide to flourish. With the work more distributed, in
combination with more workers, there was more flexibility to resist
narrow job definitions, and to respond to residents' needs in a
timely and relational way, while still maintaining a complement of
nurses comparable to similar facilities.
In one Norwegian site, high staff to resident ratios allowed for
the work to be responsive to residents' needs. Medication dispersal
happened during quiet times, when residents were resting in their rooms.
The nurses were unhurried in the process and took time with each
resident. The process happened outside of the main space where dining
and socializing occurred unless a resident happened to be in that space.
The nurse chatted with the eight residents for whom s/he was
responsible, about one-quarter to one-fifth the number of residents that
nurses were responsible for in Canadian facilities.
Food: Meal Times
Congregate mealtimes are a common feature of residential care, but
there was tremendous variation when we compared mealtimes between
Canadian and European sites. While all of the sites were subject to
government's safe food handling regulations, Canadian regulations
are highly prescriptive with respect to who could cook and touch raw and
cooked food, with Ontario the most prescriptive with respect to how many
hours the dietary servers must work, and where the food preparation
takes place. Central kitchens prepared the food to be ready for a
certain time, which largely determined the work schedules of others such
as front line care workers who were not a part of meal production. Even
though some dietary workers set and cleared tables, it was usually care
aides who did so, and also brought residents to the dining space,
offered food choices, delivered the prepared food, helped residents with
eating and drinking, scraped the plates, and cleared the tables. The
autonomy and dignity of both workers and residents were compromised
because often there were between twenty and thirty people in a single
dining room. The regulatory goal was that each resident would be fed
without delay; however, the resident numbers were burdensome and
residents often waited for everyone to be brought to the space, for
medicines to be dispensed and for the food to be served.
Facilities had to interpret frontline work organization within the
confines of prescriptive dining regulations; this was often done by
requiring care aides to record the quantities of food and drink consumed
by each resident at each and every meal. With each care aide responsible
for between eight and twelve residents who usually did not sit together,
timely and accurate recording was a practical impossibility, and there
was a great deal of resistance that accompanied this job function. In
some places, care aides were required to enter information into computer
programs directly following the dining hour when they could otherwise be
engaging with residents. In other places, "tick-boxes" on
paper were filled in at the end of the shift. Care aides revealed that
they reacted to the constraints by estimating and sometimes copying the
previous day's input, raising serious questions as to the
reliability of the data and showing the extent to which this
documentation was less important than other tasks that competed for
their time. Facilities reacted to regulations about when residents
should eat by documenting residents' preferences in care plans. For
instance they only allowed someone to sleep-in and receive a later
continental breakfast if they could "care plan it."
While following European regulations for safe food handling, in
Germany and Norway food could be prepared freshly on the unit or
re-heated from food prepared in central kitchens. The unit stoves were
used at predictable though not fixed times in relation to the
residents' needs. The result was the smells of food wafted through
the air. We observed that the workers also engaged the residents in the
work. For instance, one care worker in Germany set the table while the
residents passed the cutlery. The residents' participation made
"activation" a normal part of the day and not a defined and
separate activity. The residents also hand-washed and put dishes in the
dishwasher. In this site, when potatoes were left from lunch, the
workers asked residents what should be done with them; they participated
in decisions about how the potatoes would be cooked later that night.
One of the residents who liked to clean up, collected the dirty dishes
from the table and was allowed to wash and put the dishes away. We
watched and the staff did not re-wash the dishes afterwards. Staff cut
apples and shared them at the table, while also eating a slice
themselves to stimulate the social nature of dining. Residents could
have wine or other alcohol at the table. Residents swept floors and
workers did not resweep. Residents cut and workers did not re-cut. For
supper on the dementia unit, a family member helped prepare potatoes and
an omelette. The food was soft, easy to chew and swallow, smelled
palatable, and included thin slices of cucumber. There was a single
plate of bread, cheese, and meat for the table, and people chose what
they wanted from it. Bottles of water were left on the table and
residents poured water for one another. This Hausgemeinschaften model
places emphasis on residents' involvement in housekeeping, keeping
a more home-like atmosphere, having smaller groups and the presence of
at least one care worker always in the common space.
Discussion and Conclusions
We found marked jurisdictional differences both in terms of
regulatory approaches and how care was provided on the frontlines. How
regulations structured frontline care work was evident when we compared
how activity, medication dispersal, and dining were performed in the
Canadian, German, and Norwegian jurisdictions. In this section, we
locate each jurisdictions' position on the
prescriptive--interpretive regulatory axis, discuss frontline reactive,
resistive, and responsive care work organization, and propose an
analytic framework that links the regulatory form to frontline work
organization.
Prescriptive and Interpretive Regulatory Axis
Prescriptive regulation identifies what should be done and which
staff should do it and delineates when and how they should do it. In
contrast, interpretative regulation is more open-ended; it identifies
that care should be provided but not which staff should do it, nor when
and how it should be done. Germany's legislation is focused on
delineating national, regional, local, and family responsibility. Care
is defined and care workers are expected to provide care that is
"in accordance with the generally recognized state medical and
nursing knowledge." (71) However, as our ethnographic study showed,
facilities can engage in rule bending to accomplish their care goals. In
Norway, the legislation is highly interpretive. As Mia Vabo and
colleagues argue, "eldercare is regulated not by special laws but
by general legislation. Care services are offered to all citizens in
need of care, regardless of age, income, family relations and so
on." (72) The Norwegian Act identifies that health services are a
municipal responsibility, but health professionals' responsibility
to carry the services out according to their professional standards
([section] 4-1). The European Acts we reviewed are similar in ascribing
agency to health professionals, and thus relying on professional
standards and ethics as a framework. The Canadian context is more
varied. The most minute care tasks are detailed in Ontario's
prescriptive legislation, including from how to handle continence care
and residents' weight changes to how often linens should be
laundered. In contrast, Manitoba's legislation is interpretive,
with broad categories of care work laid out and general guidelines
provided. For instance, soiled linen should be collected
"regularly;" surfaces cleaned "as often as
necessary;" meals offered "at reasonable intervals" in
each 24 hour period and nursing services "organized and available
to meet residents' nursing care needs, in accordance with
guidelines approved by the minister and consistent with professional
standards of practice." (73) However, on the issue of pharmacy and
medication management, the Manitoba legislation is quite prescriptive.
In British Columbia, the Act is more interpretive around care: staff
assist with activities of daily living (eating, mobility, dressing,
grooming, bathing, and personal hygiene), consistent with the
"health, safety and dignity of persons in care." It is more
prescriptive with respect to facility design elements and dining hours
but still remains more interpretive than Ontario in allowing for more
time during the morning rush and "brunch" on weekends and
holidays. Table VI summarizes these findings.
Overall, we noted the following associations: prescriptive
regulatory environments tend to be accompanied by a lower ratio of
professional to nonprofessional staff, a higher concentration of
for-profit providers, a lower ratio of staff to residents, and a sharper
division of labour. On the other hand, interpretive regulatory
environments tend to have higher numbers of professionals relative to
non-professionals, more limited for-profit provision, a higher relative
ratio of staff to residents, and a relational division of labour that
enables the care to be more fluid and responsive. In one US study, it
was found that higher numbers of nurses produced fewer
"deficiencies" in care. (74) With higher numbers of
professionals around to guard against deficiencies, a
jurisdiction's regulatory tendency towards interpretation might
reflect its reliance on professional ethics and frontline judgment as
its overarching regulatory benchmark.
Responses from the Frontline
As we found when considering the example of music therapy in
Ontario, highly prescriptive regulation seems to impact frontline care
workers' abilities to perform teamwork and integrate health and
social care. Geraldine Lee-Treweek argues that when we consider the care
and the worker separately, it is easier to identify the space for
resistance as an everyday strategy to control and "get
through" work. For example, private nursing homes' workers
controlled their work by making the care depersonalized, engaging in
non-compliance or selective adherence to tasks, and coming to their own
conclusions about residents' behaviours. (75) In the German site,
resistance was not an individual struggle; it was taken up by the
organization. Hiring many apprentices helped to provide more social care
overall, and it enhanced the working and living environment. Indeed, as
has been demonstrated aptly in other sectors, the adoption of new public
management involving heavy regulatory oversight and onerous reporting
requirements has significantly changed the university environment from a
collegium to a workplace. (76) How states choose to govern has
implications for the quality of the workplace.
Indeed, how care workers retain decision latitude within highly
prescriptive structures is demonstrated by several studies of frontline
care, all conducted within highly regulated systems. Rule breaking has
emerged in the literature as an important coping mechanism. For
instance, Canadian care aides' decisions when performing dementia
care were found to be discordant with organizational and legislative
rules, (77) which led aides to break rules in order to be able to
provide care. Furthermore, this occurred, on a case-by-case basis, with
supervisors' complicity. In some Canadian facilities, the only time
LPNS are on the floor is during the medication dispersal. They are
behind desks, filling in paperwork at other times. To allow nurses to
concentrate during medical dispersal, facilities have allowed the use of
do not disturb signs, which may in fact further weaken their connection
with non-professional staff and allow for rule-breaking. Similarly, in
the US, Lopez reports informal patterns of work depart significantly
from official procedures designed to protect the health and safety of
Long-term Care Facility workers and residents, underlining the
routinization of rule-breaking. Furthermore, with insufficient federal
funding, which limits facilities' ability to hire sufficient staff
to meet basic care standards, care aides (nursing aides) could not
complete work on time and thus engaged in a mock routinization of the
work that broke or bent important care rules and compromised quality of
care. (78) We noted that rules were broken and bent when workers needed
to actively react or resist in order to attend to the needs of the
situation. Similarly, Ryan DeForge and colleagues identify care
workers' "workarounds" as a way to address workplace
structures to show how reacting to mandated practices helps workers to
provide care. (79) Donna Baines notes that the context within which care
work occurs means that care workers toil on a "compulsion-coercion
continuum." This happens because care workers often perform unpaid
work to keep their jobs while at the same time feeling a compulsion to
do so because of a sense of duty, obligation and genuine care. (80)
By examining government regulation and the care planning processes
in LTC facilities, one study found a large time burden created by the
formal care planning process and documentation, observing that
"fear of citation" can lead facilities to write less specific
care plans. (81) Jennifer Black and colleagues reporting on LTC
dietitians surveyed in British Columbia found the majority (54 per cent)
perceived implementing new residential care regulations increased their
workload, thus suggesting they did comply with the regulations. (82) In
our study, Canadian facilities used care plans to document any
deviations from official rules, and documentation took up the majority
of LPN and RN time demonstrating that the nurses used care plans as a
means to depart from the official rules.
We found that the most highly privatized jurisdiction had the most
prescriptive regulation. Studies have shown higher quality is associated
with non-profit and public facilities. Public and non-profit facilities
more often increase the number of care workers as they fund the work
from other sources of funding. As one German site illustrated, having
apprentices available to supplement care is an active form of resistance
to conditions of under-funding, and provides a calmer and more
therapeutic environment in which to provide care. Also of note, the
European facilities we examined had smaller units and did not amalgamate
their dining spaces into larger ones. Instead the spaces were congregate
but intimate and more on the scale one would find in a large family
home.
Other studies have shown that even highly detailed regulations can
be interpreted in different ways. Regulation and external oversight can
be primary drivers of improvement initiatives in LTC, (83) although the
content and consequences of regulations are not always apparent to
frontline staff or administrators (84) and interpretations can vary. For
instance, one study that investigated in-house pureed food production in
an Ontario LTC found variation in how government guidelines were
interpreted. (85) In Germany and Norway, frontline workers had
responsibility for far fewer residents, and provided customized food
plates when residents were ready to eat.
Do more prescriptive rules, regulations and oversight of LTC
improve or diminish care? There can be serious problems with abuse,
deficiencies and violations (86) and regulations can be a guard against
these. But there is a downside to heavy and highly prescriptive
regulation. Julianne Payne and Jeffrey Leiter examine hospital and
nursing home management comparing Australia and the United States. They
found managers perceived increased regulation and reporting as obstacles
in the context of declining state support, market competition and
increased client demands. (87) Likewise, Nancy Foner argues that
bureaucratic rules associated with medical care complexity and state
regulation interfere with nursing home aides' abilities to provide
compassionate and supportive care. (88) In our study, we found that
highly prescribed rules led to work that was inflexible and incongruous.
In contrast, the flow of the day was calmer in the German and Norwegian
sites where there was less paperwork and more time to provide health and
social care.
Given that more prescriptive regulation tends to occur in
jurisdictions where care aides are in more regular contact with the
residents and far outnumber nursing staff, it is not surprising that
some studies conducted in similar jurisdictions have found that
formalization-"the degree to which rules and procedures are
followed by the organization and employees in carrying out different
activities"--was positively correlated with job satisfaction among
long term care staff. (89) Indeed, another found that certified nursing
aides and licensed vocational nurses in nursing homes accepted
regulatory oversight as important for providing good care. (90) It is
possible that, in the presence of less formal training and no
self-regulating body, care aides may like the clearly delineated job
roles that come with more prescriptive regulations; however, acceptance
is different than adherence, and as mentioned above there have been
plenty of studies that demonstrate the myriad workarounds that care
aides put in place in order to get the job done.
An important consideration may also be the extensive initial and
specialized training for care aides as is done in the European settings.
When considering training, Kihye Han and colleagues found that certified
nursing assistants in LTC were more satisfied with their jobs if they
worked in states with stricter regulation requiring additional initial
training hours. (91) Other scholarship suggests that staff do follow,
make an effort to follow, or should follow, rules and regulations in the
course of their work. Katherine McGilton and colleagues, for instance,
found charge nurses in LTC perceived a need to "balance competing
resident, family, staff, management, and regulation demands, while
completing all of their responsibilities." (92)
Lessons for Care Work Regulation & Frontline Care Workers
Our findings show how the regulatory approach to staffing and
administrative funding is highly prescriptive in Ontario while the
regulatory and funding orientation in Norway tends to be more
interpretive. German facilities also have some latitude to interpret
regulations. As a result, care work in Ontario tends to be very task
oriented with definite divisions of labour that hindered workers'
abilities to provide quality care. In other words, the prescriptive
regulations did not promote a high standard of relational care, nor did
they promote good working conditions. Instead, regulations promoted
reactive work organization. We found that resistive work organization
emerged within conditions of austerity when interpretive regulations
conceded to professional judgment and organizations then had flexibility
to provide care. Organizations also loosely interpreted rules around who
was to be included as staff so as to increase the number of bodies
without affecting the need to hire even more nurses than would be
considered standard. Finally, we found a more responsive model
accompanied regulation that was more interpretive, privileged
professional decision-making, and provided funding sufficient to meet
most residents' needs.
Baines and Daly argue that the forms of resistance that are
associated with feminized work are often overlooked because they are not
large scale, highly visible strategies. (93) However, care workers do
resist overbearing and punitive regulation in order to attend to the
needs of the situation. Thus, care workers who retained more decision
latitude and the opportunity to engage in more relational work geared to
better meet the timely needs of residents and co-workers experienced
more responsive work organization. The more interpretive regulations in
Norway yielded more responsive work organization and hold promise for
the provision of relational care that is supportive of workers' and
residents' needs. Sharmila Rudrappa elevates individual acts with
her concept of "radical care work," which describes her
findings of racialized, female workers going from being "passive
recipients (of normative gender ideologies) to active agents who
participated in making a more equitable world." (94) As a
consequence, it is important not only to look at common strategies for
resistance, but also to identify how the orientation of regulation
offers different spaces for resistance.
In some countries with growing private-for-profit sectors, there is
a desire to heavily regulate in order to better control the care
provided. What this analysis, however, shows is that the form and
content of regulation matters greatly for the ways that front line
workers can care, and that de-professionalizing this sector may
increases the need for prescriptive regulation that in turn hinders the
provision of good quality, flexible care.
Funding for this study was granted through a Social Sciences and
Humanities Research Council Major Collaborative Research Initiatives
Grant, "Reimagining Long-Term Residential Care: An International
Study of Promising Practices."
http://reLTC.apps01.yorku.ca/our-team (File# 412-2010-1004: Pat
Armstrong, Principal Investigator). Thank you to the site visit research
teams involved in the project and to Dr. Alison Jenkins Jayman and Ms.
Magali Rootham for assistance.
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http://www.ssb.no/pleie/tab-2011-07-08-01.html; Naess, Kvale Havig and
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in Norway," 577-596; Mia Vaba, "Caring for People or Caring
for Proxy Consumers?" European Societies 8, 3 (2006): 403-422.
(53.) Naess, Kvale Havig and Vabo, "Contested Spaces" 78.
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(Paris: OECD, 2011), 182,
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Unmapped Terrain: Comparing Care Work in Long-Term Residential Care for
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10.1111/j.l468-2397.2011.00806.x.
(63.) Daly and Szebehely, "Unheard Voices, Unmapped
Terrain," 139-148.
(64.) All interviews have been anonymized and the names of the
facilities have been changed. Recreation staff, interview by site visit
team member, Ontario B site, May 2013.
(65.) Recreation staff member, interview by site visit team member,
Ontario A site, December 2012.
(66.) Music therapist, interview by Norwegian site visit team
member, Norway site C, May 2014.
(67.) Nursing social worker, interview by Norwegian site visit team
member, Norway Site C, May 2014.
(68.) The flipside of these staffing arrangement are the precarious
working conditions of the 1 [euro] worker. This workfare program in
general is highly criticized in Germany.
(69.) Field note from Germany A site visit, April 2014.
(70.) Lopez, "Efficiency and the Fix Revisited," 225.
(71.) Germany, Social Code (SGB)--Eleventh Book (XI)--Social
Insurance (Article 1 of the Law Of 26 May 1994, I, P 1014). Section 11.
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(72.) Mia Vabo, Karen Christensen, Frode Fadnes Jacobsen and Hakon
Dalby Traetteberg, "Marketisation in Norwegian Eldercare:
Preconditions, Trends and Resistance," in Gabrielle Meagher and
Marta Szebehely, eds., Marketisation in Nordic Eldercare: A Research
Report on Legislation, Oversight, Extent and Consequences (Stockholm:
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(73.) Manitoba, Personal Care Homes Standards Regulation, Man Reg
30/2005, accessed 7 March 2015, http://canlii.ca/t/k8q4.
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Greene, and Mathy Mezey, "A Panel Data Analysis of the
Relationships of Nursing Home Staffing Levels and Standards to
Regulatory Deficiencies," Journal of Gerontology: Social Sciences
64B, 2 (2009): 269-278.
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Education and the New Managerialism (New York: Oxford University Press,
2007), 229.
(77.) Pia C. Kontos, Karen-Lee Miller, Gail J. Mitchell, and Cheryl
A. Cott, "Dementia Care at the Intersection of Regulation and
Reflexivity: A Critical Realist Perspective," The Journals of
Gerontology Series B: Psychological Sciences and Social Sciences 66B, 1
(April 2010): 119-128.
(78.) Steven H. Lopez, "Culture Change Management in Long-Term
Care: A Shop-Floor View," Politics and Society 34, 1 (March 2006):
55-80; Lopez, "Efficiency and the Fix Revisited," 225-247.
(79.) Ryan DeForge, Paula Van Wyk, Jodi Hall, and Alan Salmoni
"Afraid to Care; Unable to Care: A Critical Ethnography Within A
Long-Term Care Home," Journal of Aging Studies 25, 4 (December
2011): 415-426.
(80.) Donna Baines, "Caring for Nothing: Work Organization and
Unwaged Labour in Social Services," Work, Employment and Society
18, 2 (June 2004): 267-295.
(81.) Cathleen S. Colon-Emeric, Deborah Lekan-Rutledge, Queen
Utley-Smith, et al., "Connection, Regulation, and Care Plan
Innovation: A Case Study of Four Nursing Homes," Health Care
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(82.) Jennifer L. Black, Rebecca Dunham, and Tamar Kafka, "A
Study of Challenges and Opportunities: For Long-term Care Dietitians in
British Columbia," Canadian Journal of Dietetic Practice and
Research 74,3 (September 2013): 131-137.
(83.) Sarah Forbes-Thompson, Tona Leiker, and Michael R. Bleich,
"High-Performing and Low-Performing
Performing Nursing Homes: A View from Complexity Science,"
Health Care Management Review 32, 4 (2007): 341-351.
(84.) Black, Dunham, and Kafka, "A Study of Challenges and
Opportunities," 131-137; T. J. Legg, "Staff Development: The
Neglected Discipline," Nursing Homes Magazine 56, 3 (2007): 28-35;
Catherine E. DuBeau, Joseph G. Ouslander, and Mary H. Palmer,
"Knowledge and Attitudes of Nursing Home Staff and Surveyors about
the Revised Federal Guidance for Incontinence Care," The
Gerontologist 47, 4 (September 2007): 468-479.
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210-228.
(86.) Donna R. Lenhoff, "LTC Regulation and Enforcement: an
Overview from the Perspective of Residents and Their Families," The
Journal of Legal Medicine 26,1 (February 2007): 10-11; Nicholas Castle,
"Nursing Home Deficiency Citations for Abuse" Journal of
Applied Gerontology 30, 6 (December 2011): 719-743.
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Organizational Theory," Journal of Health Organization and
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in an American Nursing Home," Human Organization 54, 3 (Fall 1995):
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Staff: Bureaucracy Isn't Always Bad," Administration in Social
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(90.) Barbara Cherry, Alyce Ashcraft, and Donna Owen,
"Perceptions of Job Satisfaction and the Regulatory Environment
among Nurse Aides and Charge Nurses in Long-Term Care," Geriatric
Nursing 28, 3 (May 2007): 183-192.
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Meg Johantgen and Kyungsook Gartrell, "Associations between State
Regulations, Training Length, Perceived Quality and Job Satisfaction
among Certified Nursing Assistants: Cross-Sectional Secondary Data
Analysis," International Journal of Nursing Studies 51, 8 (January
2014): 1135-1141.
(92.) Katherine S. McGilton, Barbara Bowers, Barbara
McKenzie-Green, Veronique Boscart, and Maryanne Brown, "How do
Charge Nurses View Their Roles in Long-Term Care?" Journal of
Applied Gerontology 28, 5 (December 2009): 737.
(93.) Donna Baines and Tamara Daly, "Resisting Regulatory
Rigidities: Lessons from Front-Line Care Work," Studies in
Political Economy 95 (Spring 2015): 137-160.
(94.) Sharmila Rudrappa, "Radical Caring in an Ethnic Shelter:
South Asian American Women Workers at Apna Ghar, Chicago," Gender
and Society 18, 5 (October 2004): 599, doi: 10.1177/0891243204268131.
Tamara Daly, Jim Struthers, Beatrice Muller, Deanne Taylor, Monika
Goldmann, Malcolm Doupe, and Frode F. Jacobsen, "Prescriptive or
Interpretive Regulation at the Frontlines of Care Work in the
'Three Worlds' of Canada, Germany and Norway," Labour/Le
Travail 77 (Spring 2016): 37-71.
Table I: Care Staff Training/Qualifications
Registered Nurses
Ontario Registered Nurses require a Bachelor of
Nursing (BN or BScN). Self-regulated health
care professionals. (1) The scope of
practice is determined by individual
competence; requirements and policies of the
employer; needs of the client; and the
practice setting.2 The College of Nurses of
Ontario is the governing body.
Manitoba Registered Nurses require a Bachelor of
Nursing (BN or BScN). Self-regulated health
care professionals. (6) The scope of
practice is determined by individual
competence; requirements and policies of the
employer; needs of the client; and the
practice setting.7
British Columbia Registered Nurses require a Bachelor of
Nursing (BN or BScN). Self-regulated health
care professionals. (9) The scope of
practice is determined by individual
competence; requirements and policies of the
employer; needs of the client; and the
practice setting. (10)
North Rhine/Westphalia Qualified Care Workers (Schwesternhelfer/
in--Elder Carer/Geriatric Care Nurses) have
3 yrs. nursing school + job training + work
experience (about 2100 hours of theoretical
training and 2500 hours of practical
training, dependent on the state
regulations.) (14)
Oslo & Bergen Registered Nurses have 3 yrs. of education
from university colleges.
Practical Nurses
Ontario Registered Practical Nurses requires an
approved Ontario college diploma in
practical nursing. The College of Nurses of
Ontario is the governing body.
Manitoba Licensed Practical Nurses require a college
diploma governed by the College of Licensed
Practical Nurses of Manitoba. (8)
British Columbia Licensed Practical Nurses are governed by
the College of Licensed Practical Nurses
of BC. Self-regulated health care
professionals. (11) The programs are
stipulated through the Practical Nursing
Program Provincial Curriculum (July 2011)
The Health Professions Act Nurses (Licensed
Practical) Regulation.12
North Rhine/Westphalia Assistant Care Workers (Elder Care
Assistants/Nurse Assistants)/1 yr. nursing
school + work experience with between 700
and 750 hours of theoretical training and
850 to 900 hours of practical training.)
Oslo & Bergen Auxiliary Nurses with 3 yrs. of upper
secondary school-based education. (16)
Care Aides
Ontario Personal Support Worker can study at 3
separate program standards used (public
colleges in Ontario; private colleges in
Ontario; and district school boards in
Ontario. MIN: 324 hrs classroom + 290
clinical/practicum. (3, 4) Average program
length = 725 hrs. Workers are not
self-regulated but are registered with the
PSW Registry Ontario. (5)
Manitoba Health Care Aides do not have any province
wide curriculum but public colleges use
similar learning outcomes. The average
program length = 700 hrs. Workers are not
self-regulated or registered.
British Columbia Health Care Assistants can study at all
public colleges and most private
institutions follow the BC Ministry of
Advanced Education and Labour Market
Development curricula (2014) of MIN: 475
hrs classroom; 270 hrs clinical/practicum.
The average program length = 775 hrs.
Workers are not self-regulated but are
registered with the BC Care Aide &
Community Health Worker Registry. (13)
North Rhine/Westphalia Care Aides (Altenpflegehelfer/-helferinn)
work under the supervision of qualified care
workers Dementia Carer (Betreuunskrafte
([section]) 87b SGB XI) involves a five day
orientation internship + 3 modules of at
least 160 hrs. + 2 week internships. (15)
Oslo & Bergen Skilled Care Workers are under the Health
and Social Care Training Programme, which
involves completing lower secondary
education for 2-3 yrs. and it involves at
least 50 per cent theory. (17)
(1) Ontario, Ontario Regulated Health Professions Act, 1991 S.0.1991,
Chapter 18, accessed 23 March 2015, http://www.e-laws.gov.on.ca/html/
statutes/english/elaws_statutes_91r18_e.htm.
(2) Canadian Nurses Association (hereafter CNA), Framework for the
Practice of Registered Nurses in Canada (Ottawa: Canadian Nurses
Association, August 2007), 13, accessed 9 March 2015, https://
www.cna-aiic.ca/~/media/cna/page-content/pdf-en/framework-for-the-
pracice-of-registered-nurses-in-canada.pdf?la=en.
(3) OECD, "Help Wanted?: Providing and Paying for Long-Term Care,"
182, accessed 15 February 2015, http://www.oecd.org/els/health-
systems/help-wanted.htm.
(4) The Association of Canadian Community Colleges (hereafter ACCC)/
Canadian Association of Continuing Care Educators (hereafter CACCE),
Canadian Educational Standards for Personal Care Providers (ACCC/
CACCE, June 2012), 12-13, accessed 9 March 2015, http://
www.collegesinstitutes.ca/wp-content/uploads/2014/05/Reference-
Guide_Canadian-Educational-Standards-for-Personal-Care-Providers_
ACCC.pdf.
(5) PSW Registry Ontario, Ontario psw Registry, accessed26 February
2015, http://www.pswregistry.org/Pages/en/Default.aspx.
(6) Manitoba, S.M. 2009, c. 15 Bill 18,3rd Session, 39th Legislature,
The Regulated Health Professions Act (Assented to June 11,2009),
accessed 23 March 2015, http://web2.gov.mb.ca/laws/statutes/2009/
c01509e.php.
(7) CNA, Framework for the Practice of Registered Nurses in Canada,
13.
(8) Manitoba, C.C.5.M. c. L125 The Licensed Practical Nurses Act
(Assented to July 14,1999), accessed 23 March 2015,
http://web2.gov.mb.ca/laws/statutes/ccsm/M25e.php.
(9.) British Columbia, Health Professions Act [R5BC 1996] Chapter
183, accessed 3 March 2015, http://www.bclaws.ca/civix/document/id/
complete/statreg/96183_01.
(10.) CNA, Framework for the Practice of Registered Nurses in
Canada, 13.
(11.) British Columbia, Health Professions Act, Chapter 183.
(12.) British Columbia, B.C. Reg 283/2008 M243/2008 Oct 17,2008,
Health Professions Act Nurses (Licensed Practical), accessed 3 March
2015, http://www.bclaws.ca/EPLIbrarles/bclaws_new/document/ID/
freeside/283_2008.
(13.) British Columbia, BC Care Aide & Community Health Worker
Registry, accessed 26 February 2015, http://www.cachwr.bc.ca/
Home.aspx.
(14.) Charlene Harrington, Jacqueline Choinlere, Monika Goldmann, et
al., "Nursing Home Staffing Standards and Staffing Levels In Six
Countries," Nursing Scholarship 44,1 (2012): 94.
(15.) OECD, "Help Wanted?," 165.
(16.) Harrington, et al, "Nursing Home Staffing Standards and
Staffing Levels In Six Countries," 93.
(17.) OECD, "Help Wanted?," 165.
Table II: Staffing Mix Regulations
Canada
British
Ontario (1) Manitoba (2) Columbia (3)
Professional Director of Director of Director of
Staff Nursing (RN) Nursing (Nurse Nursing is not
Minimums from 4 hours for in charge of required. The
19 or fewer beds care): RN or legislation
ranging to 35 Registered stipulates that:
hours for 65 or Psychiatric [e]mployees on
more beds RN 24 Nurse full-time duty are
hours per day. with 60 or more sufficient in
beds; with numbers, training
additional and experience
responsibilities Food services
with fewer than manager must be
60 beds. in facilities
Registered >50.
Nurses in charge
of nursing
services.
Registered
Dietician
available for
consultation as
necessary.
Sufficient to
meet the needs
of residents.
Non- Personal Support Health Care Health Care
professional Workers: No Aides: No Assistants: No
Staff minimum number minimum number. minimum number.
Minimums Food Service
Workers: %
occupancy of the
home x 0.45 = #
food service
workers.
Germany Norway
North Rhine /
Westphalia (4) Oslo & Bergen (5)
Professional Nurses (Elder Carer/ Director of Nursing (RN)
Staff Nurse): must be 50% of and Charge Nurse is
Minimums all care staff + 24 hr informally required per
nurse staffing with home irrespective of
minimum of 1 nurse on size. Registered Nurse at
night shift. (6) ward level per 8 to 10
residents.
Non- Care Aides Skilled Care Workers: No
professional (Schwestern-helfer/in): formal staffing
Staff No minimum number. standards, though some
Minimums municipalities have
unofficial standards.
(1.) Ontario, Ontario Regulation 79/10 Long-Term Care Homes Act
(2007, S.0.2007, c. 8), accessed 22 February 2015,
http://www.e-laws.gov.on.ca/html/source/regs/english/2010/
elaws_src_regs_rl0079_e.htm#BK37.
(2.) Manitoba, Personal Care Homes Standards Regulation, Man Reg
30/2005, accessed 7 March 2015, http://canlii.ca/t/k8q4.
(3.) British Columbia, Community Care and Assisted Living Act (2009,
Reg 96/2009 O.C225/2009) Residential Care Regulation, accessed 22
February 2015, http://www.bciaws.ca/Recon/document/ID/freeside/
96_2009#division_d2e2506.
(4.) Germany, Social Code (SGB)-Eleventh Book (XI)-Social Insurance
(Article 1 of the Law Of 26 May 1994,1, P1014). Section 11. Rights
And Duties Of Care Facilities, accessed 2 February 2015,
http://www.gesetze-im-internet.de/sgb_11/_11.html.
(5.) Norway, Ministry of Health, Law on Municipal Health Care,
accessed 4 March 2015, https://lovdata.no/dokument/NL/lov/
2011-06-24-30.
(6.) Harrington, et al, "Nursing Home Staffing Standards and
Staffing Levels in Six Countries," 93.
Table III: Staffing Intensity Regulations
Canada
British
Ontario (1) Manitoba (2) Columbia (3)
Ratios/or/ Standards No minimum. No minimum, No minimum (in
hours per Based on but a general) but
resident Case Mix target: 3.6 newly
per day Index (CMI). paid hours constructed
(hprd) Non-profits per resident facilities: 2.8
and public per day hprd. "The act
institutions (funded) (6) stipulates
may that: the
supplement employees on
duty are
sufficient in
numbers,
training and
experience, and
organized in an
appropriate
staffing
pattern"
Germany Norway
North Rhine/Westphalia (4) Oslo & Bergen (5)
Ratios/or/ Minimum of 3.0 hprd. 1 FTE No minimum but Bergen
hours per for 4 residents (level I); ratio is 0.95 FTE direct
resident 1 FTE for 2.5 residents (RNs, licensed vocational
per day (Level II); 1 FTE for 1.8 nurses, and nursing
(hprd) residents (Level III) (7) assistants) and indirect
care workers (managers,
and housekeeping staff)
per resident. Informally,
there is a 4.2 to 5.1
hprd (8)
(1.) Ontario, Long-Term Care Homes Act.
(2.) Manitoba, Personal Care Homes Standards Regulation.
(3.) British Columbia, Community Care and Assisted Living Act.
(4.) Germany, Social Code (SGB)--Eleventh Book (XI).
(5.) Norway, Ministry of Health, Law on Municipal Health Care.
(6.) Office of the Auditor General of Manitoba, Report to the
Legislative Assembly--Audits of Government Operations (November
2009), 51, accessed 1 April 2015, www.oag.mb/ca.
(7.) Harrington, et al, "Nursing Home Staffing Standards and Staffing
Levels in Six Countries," 93.
(8.) Harrington, et al, "Nursing Home Staffing Standards and Staffing
Levels in Six Countries," 93.
Table IV: Funding Regulations Directly Affecting Staffing Levels
Canada
Ontario (1)
Flow of State LTC Funding Sub-national: province to health
National Sub-national regions to facilities.
Regional/Municipal Funding Capped in an envelope held
Capped envelope; Insurance; Block outside of the provincial
grant insurance scheme and then
transferred to Local Health
Integration Networks.
Facilities' Funding Activity-based funding +
Activity-based; Global legislated income-dependent fees
from resident per diems. Public
funding is based on facilities'
CMI, a composite of their
assessment scores measured
against other facilities. Funding
is relative to CMI of all
facilities. It is at least 1 year
for assessment changes to catch
up to funding. Based on resource
utilization groups care
dependencies tied to MDS-RAI[TM]
Assessments but unclear in terms
of $$ amounts + legislated, means
tested income from resident per
diems.
Canada
British Columbia (2, 3)
Flow of State LTC Funding Sub-national: province to health
National Sub-national regions to facilities.
Regional/Municipal Funding Block grants transferred yearly
Capped envelope; Insurance; Block to regional health authorities
grant and then dispersed to facilities.
Facilities' Funding Global: provincial funding +
Activity-based; Global legislated income-dependent fees
from resident per diems.
Canada
Manitoba (4,5)
Flow of State LTC Funding Sub-national: province to health
National Sub-national regions to facilities.
Regional/Municipal Funding Insurance with funds transferred
Capped envelope; Insurance; Block to Regional Health Authorities
grant using a population-based model.
Facilities' Funding Global funding with facilities'
Activity-based; Global budget determined yearly by
budget officer who recommends
budget to Minister, though
facilities can appeal +legislated
income-dependent fees from
resident per diems.
Germany
North Rhine/Westphalia (6)
Flow of State LTC Funding National: Central government to
National Sub-national lander to facilities.
Regional/Municipal Funding Insurance with facilities budgets
Capped envelope; Insurance; Block determined by nationally set
grant rates by care levels. It takes 5
weeks for care level changes.
Assessments are in the process of
being changed. (8)
Facilities' Funding Directed: Based on care
Activity-based; Global dependencies (Care 1, II, III,
IV) + legislated fees from
resident per diems.
Norway
Oslo & Bergen (7)
Flow of State LTC Funding National: central to municipal
National Sub-national governments to facilities.
Regional/Municipal Funding Block grants to municipalities
Capped envelope; Insurance; Block for health & social care with
grant facilities budgets set by
municipalities.
Facilities' Funding Global: local and national
Activity-based; Global taxation + legislated
income-dependent fees from
resident per diems.
(1.) Ontario, Long-Term Care Homes Act.
(2.) British Columbia, Community Care and Assisted Living Act.
(3.) British Columbia, Health Authorities Act, RSBC 1996 Chapter 180,
Queen's Printer, accessed 11 March 2015, http://www.bclaws.ca/civix/
document/id/complete/statreg/96180_01#section10.
(4.) Manitoba, Personal Care Homes Standards Regulation.
(5.) Manitoba, The Health Services Insurance Act, (C.C.S.M.c.H35)
Personal Care Services Insurance and Administration Regulation 52/93
Registered March 19, 1993.
(6.) Germany, Social Code (SGB)--Eleventh Book (XI).
(7.) Norway, Ministry of Health, Law on Municipal Health Care.
(8.) NBA (Neues Begutachtungsassessment zur Feststellung der
Pflegebedurftigkeit) is a new assessment tool to assess eligibility
and "dependency on nursing care." It has not yet been implemented.
According to Biischer and colleagues, assessments are conducted by
the Medical Board of the health care insurance--MDK Medizinischer
Dienst der Krankenversicherung--the official, independent consultancy
that employs doctors and nurses, is jointly financed by the national
level healthcare insurance, but is organized at the Lander (state)
level. It assesses individuals' eligibility for insurance benefits
for long-term care and controls and evaluates professional services
quality. Andreas Buscher, Klaus Wingenfeld, and Doris Schaeffer,
Determining Eligibility for Long-term Care--Lessons from Germany,
International Journal of Integrated Care, 11 (May 2011): 1-9,
accessed 27 March 2015, http://www.ijic.org/index.php/ijic/article/
view/584/1252.
Table V: Work Organization Observed at Sites in "Promising Practices"
Study
Canada
Ontario
Task Oriented/Relational Highly task oriented & strict
division of labour.
Health, Social and Dietary Care: Separated: minimum number of
Separated Mixed Integrated dietary staff is mandated. Work
generally involves delivering
food to unit, setting tables,
doling food onto plates and
washing dishes after the meal is
complete. Separate activities
with little or no time for care
aides to perform this work.
Germany
British Columbia
Task Oriented/Relational Task oriented & strict division
of labour.
Health, Social and Dietary Care: Separated: food service employees
Separated Mixed Integrated perform food delivery and
provision duties. Separate
activities coordinator, with care
aides having little or no time
for social care.
Norway
Manitoba
Task Oriented/Relational Task oriented with relational
elements.
Health, Social and Dietary Care: Mixed: workers perform a variety
Separated Mixed Integrated of duties that don't conform to
strict categories but there are
still divisions of labour between
professional and nonprofessional
staff.
North Rhine/Westphalia
Task Oriented/Relational Relational and team oriented
care.
Health, Social and Dietary Care: Integrated: Unit level care
Separated Mixed Integrated workers plan, organize and cook
the meals and assist residents
with eating, and perform social
care during the day in addition
to scheduled activities.
Oslo & Bergen
Task Oriented/Relational Relational and team oriented
care.
Health, Social and Dietary Care: Integrated: Unit level care
Separated Mixed Integrated workers plan, organize and cook
the meals and assist residents
with eating and perform social
care during the day in addition
to scheduled activities.
Table VI: Nature of Regulation
Canada
Ontario (1)
Prescriptive/Interpretive Prescriptive with respect to who does
what and how with every task from meal
hours to number of baths is prescribed
in detail in the legislation and
additional criterion are applied as part
of the compliance process.
Canada
British Columbia (2)
Prescriptive/Interpretive Interpretive with respect to what and
how tasks are done; Prescriptive, with
respect to dining hours.
Canada
Manitoba (3)
Prescriptive/Interpretive Interpretive with respect to who does
what and how it is done. For example,
the act calls for "at least three full
meals or equivalent are offered to each
resident at reasonable intervals in each
24-hour period" giving staff and
residents flexibility to plan and
execute their day. Prescriptive with
respect to medications.
Germany
North Rhine/Westphalia (4)
Prescriptive/Interpretive Interpretive with respect to how tasks
are done and Prescriptive with respect
to funding. Additional rules are set at
the regional level so that there is
variation within and between regions.
Norway
Oslo & Bergen (5)
Prescriptive/Interpretive Interpretive, and set at the municipal
level.
(1.) Ontario, Long-Term Care Homes Act
(2.) British Columbia, Community Care and Assisted Living Act.
(3.) Manitoba, Personal Care Homes Standards Regulation.
(4.) Germany, Social Code (SGB)--Eleventh Book (XL)
(5.) Norway, Ministry of Health, Law on Municipal Health Care.