The Cost And Value Of Care
Annaleese Jochems writes about life on the front lines of Aotearoa New Zealand's aging population, where aged care residents and those who care for them negotiate the right to care, love, and protection in an unstable new environment.
The pay equity settlement for Aotearoa New Zealand’s care workers, reached in April and in effect from this July was a historic and significant achievement the predominantly-women workers in the aged care, home support, and disability services sectors. But for many, the victory remains incomplete. Carers will now be salaried appropriately for the work they do: many who were working six and seven day weeks to provide for their families will have the freedom to reduce their hours, to spend more on fruit and veges, finally go to the dentist, pay off debt, and even save for holidays.
But some will see these benefits come at a cost to the elderly they care for. Even as they fought for their labour to be fairly compensated, carers have been communicating for years that in many homes they’re not adequately resourced to do their jobs properly, particularly in regards to time allocated, and their concerns remain unaccounted for in the updated funding model.
Funding for the settlement has been calculated on averages - average qualification levels and average staff-to-resident-ratios – which creates an incentive for homes to hire less qualified staff, alongside the incentive to roster them on for fewer hours. Also, few homes actually operate at full-occupancy, and the funding increase is only being paid per occupied bed, not in accordance with actual staffing levels. The result was reported in June as “a hollow victory”, which would leave many providers facing a shortfall.
District Health Boards and Aged Residential Care Providers have initiated a review of the aged residential care funding model in collaboration with the Ministry of Health following the settlement. However, the review is yet to begin and is not expected to be complete until June 2018.
The settlement, coupled with long-existing financial pressure on the sector, has already pushed several homes to close. As the minimum ratios of carers to residents are set extremely low, homes with higher ratios will be forced to foot a greater portion of the bill than larger, for-profit providers,who are likely to be able to stretch their staff further.
These calculations, and their consequences, matter to the everyday dignity and wellbeing of residents’ lives. Five minutes of a carer’s time can be the difference between a resident being left reassured, and left feeling anxious and unsettled. If that carer’s on the new highest wage of $23.50, that’s $1.95 of time. Two dollars could be the difference between someone being assisted to drink a full cup of tea, and having a few sips then being left to watch the rest of it go cold. Half that, $0.97, or two and half minutes, is time for a resident to communicate a desire to listen to some music, and for the carer to find the right CD and put it on. But if a carer goes on to spend an extra ten minutes with every resident they’re responsible for, and they’re responsible for ten residents (many are responsible for up to fourteen), that’s an extra fifty minutes that needs to come from somewhere.
I interviewed three carers, and all had clear and passionate ideas of what they’d like to do for residents but don’t have time to. One, Simone, said she wished she could, ‘Just have a conversation, put them in a wheelchair and take them for a walk outside, because not much of that happens... It’s all in their care plans, things they loved to do when they were able to. We want to give them quality of life.’
Another, Rosie, said the same. ‘I’d love to be able to sit and talk about their pasts and their lives, you know, do a bit of pampering.’ Marianne, an experienced carer, recalled that when she started care work twenty years ago, there was more time. Back then, she had time to bathe residents with arthritis rather than showering them upright. She agreed with Rosie and Simone. ‘One thing I find very hard is not being able to spend more time one on one with them.’
The desire to chat might seem sentimental or trivial, but conversation can be a key way for an elderly person to maintain or regain cognitive function, particularly after a stroke. To talk is to think, and many have family who live overseas, or who are busy, and so don’t receive many visits. Many, too, are grieving when they come into residential care. Often they’ve come straight from hospital after something sudden like a stroke or fall, and are mourning a loss of independence. They may have lost partners or children before coming in, or lose them while they’re in care.
Rosie talked to me about consoling residents who might be down or grieving. For her it’s part of the job, but she said that time pressures often made it hard to provide the sort of support she feels residents deserve or require.
Marianne saw a similar gap in essential care. ‘Because we don’t have time to talk to them one on one, I think they should have someone for that, whether it’s a counsellor or social worker.’
They’re doing important work, and they’re doing it quickly. If they forget to move a resident’s bell after transferring them from a bed to their chair that resident may not be able to call for help if they need it. Or, if they forget to apply a specific cream before putting a resident’s pad on that resident might be awake and itchy during the night. If a carers in a hurry they may miss things they know to check for, like bruising, skin tears, or pressure sores.
But the need for more time isn’t simply about social or cognitive engagement. Simone told me that where she works shortcuts are sometimes unavoidable, particularly when staffing is tight. ‘We would like to toilet residents more often, and not just put a pad on them and put them to bed. We can’t always do their teeth, but try to make sure they’re done at least once a day. That’s to cut down on time. Sometimes we don’t have an option. We’re relying on incontinence products, because if you can’t toilet them that’s what’s going to happen.’
She’s adamant that this isn’t good enough. ‘It makes you feel you’re not doing your job properly. You’re not able to do your job in the way you want to. It’s a feeling that residents are missing out on something. You put the blame on yourself, but it’s really not your fault. What’s fair here? It’s not fair on the caregiver who provides help, and it’s not fair on the resident.’
Over a third of caregivers in the AUT Work Research Institute’s NZ Aged Care Workforce Survey last year said they experienced physical abuse often or very often in their work, and 46% said they experienced verbal abuse often, very often, or all the time. Negotiating with difficult residents and tolerating challenging behaviour is part of a carer’s job, but if residents feel rushed, pressured or unheard, then challenging behaviour can’t be considered as being symptomatic only of dementia or mental illness.
Marianne told me she often feels herself situated in the midst of conflict between what she knows residents want, and what management expect from her. She agreed that challenging behaviours would be easier to address if she had more time with residents, but added that it would help to have more flexibility in her negotiations with them. ‘If there wasn’t pressure from above saying, it doesn’t matter what it takes, shower them.’
I asked May, a rest-home resident with dementia, how she felt carers should go about assisting residents. ‘Suggest and communicate. Speak to me as an equal. Don’t talk down to me.’ Her son told me that May had communicated more than once that while having her caring duties done she often felt like ‘a piece of meat.’
Showering can become a particular axis of conflict. People with dementia can find the process frightening, confusing, or just very unpleasant. They may not remember or know the carer sent to assist them, and may feel a loss of dignity in being showered by an effective stranger. Marianne added that, ‘Lots of old people don’t like water. They never used to shower in the old days, they used to bathe, or have a wash with a wash cloth. It’s frustrating because in training you’re told to respect their culture, but if their culture’s not showering we’re not respecting that if we force them to do it.’ She said that sometimes it’s about meeting the expectations of resident’s families, but often it’s about documentation, which is audited.
In training, carers are told that to physically restrain a resident constitutes abuse, but that not washing or showering them when they need it – if their pad is dirty – is neglect. They’re told that good negotiating skills, or leaving a resident and coming back later, or getting someone else to have a go at convincing the resident, should solve the problem, but none of those tactics are infallible, particularly under time pressure, and if they don’t work it’s unclear what’s ultimately available to the carer in way of support. Marianne said, ‘You’re being told one thing (in training), then you’re being told to do something else (on the floor), and then if the tables turn and they say again, don’t do it, you don’t even know where you are. You’ve received conflicting information.’
The things carers are expected to prioritise, and entered the industry to provide – listening, and respect – are not being adequately funded in many homes, and so both carers and residents are being subjected to unnecessary stress on at a systemic level.
Seven out of ten carers said in the AUT survey that they ‘found the job more stressful than they’d ever imagined it would be.’ They’re doing important work, and they’re doing it quickly. If they forget to move a resident’s bell after transferring them from a bed to their chair that resident may not be able to call for help if they need it. Or, if they forget to apply a specific cream before putting a resident’s pad on that resident might be awake and itchy during the night. If a carers in a hurry they may miss things they know to check for, like bruising, skin tears, or pressure sores.
Or it could be something simple, like forgetting to put a torch on the bedside table so the resident can use it to see at night when they can’t reach another light, or being too brisk and realising later that a resident had been trying to tell them something. Each of the three carers I interviewed said they thought about residents after going home, and worried they’d forgotten something.
(Since 2005) the elderly have been enabled to live in their own homes for longer, and consequently have more intense needs when they eventually do move into retirement homes. Marianne told me that her view, based on when she began working as a carer, is that a rest home resident now generally requires what would have nearly constituted hospital level care twenty years ago.
Simone explained, ‘If you work in this sector your heart has to be in it one hundred percent. We want to look after people who are vulnerable. That’s our aim, that’s our wish. We want to feel satisfied that we’ve given residents what we need to. You go home and think about what you might have missed. I often do.’
Grant Thornton’s Aged Residential Care Service Review, in September 2010, reported a variation of between eight and thirteen hours a week of caregiver time per resident between different facilities. It’s likely very little has changed since then, as the template contracts between District Health Boards and providers allow for homes with fifty residents to have only two caregivers on duty at a time, which equals only 6.7 hours of care a week.
No distinction is made in the contracts between ‘peak’ times of day when residents require a lot of assistance (in the mornings, say, or after dinner before bed) and quieter periods, so carers can find themselves showering multiple residents and settling them into bed well before dinner. The contracts do state that facilities must provide ‘sufficient staff to meet the health and personal care needs of all residents at all times,’ but DHBs depend on audits to determine if this condition is being met.
Unless a serious complaint has been made, organisations are informed in advance of audits, and so are enabled to make specific provisions for the days it’s conducted, rostering on extra staff and perhaps sweeping ongoing resourcing issues under the rug. And audit results are dependent on documentation, increasing the imperative for homes to focus on things which can be measured and ticked off at the expense of things which can’t.
The carers I interviewed cautioned against considering underfunding and understaffing to be new issues, or issues particular to the settlement. Marianne said, ‘The settlement hasn’t actually changed anything. We had all this crap before. That resident numbers are down, so when somebody rings in sick we might not have someone to replace them.’ She said she’d heard of people saying that carers should be doing more and providing better quality care now they’re being paid more, but argues that, ‘carers were providing good quality care before, when they were getting paid shit. They were being tasked with more than they should have been already, then.’
The Greens and Labour both called for more accountability in their 2010 review into New Zealand’s aged care sector, and after reinvestigating the sector this year they reaffirmed the need for reform. In 2013, the Ministry of Health began publishing the results of audits online, but outside of the standard roster of audits , it’s still unclear what’s being done to monitor the way taxpayer’s money is spent by aged-care organisations.
The two biggest residential care providers in New Zealand are Bupa Care Services, with sixty facilities and owned by Bupa UK, and Oceania Care group, with forty three and owned by Macquarie Group in Australia until it became publically listed on the NZX in May 2017. Non-profit facilities, which generally have higher staffing levels and weaker economies of scale, are under increased financial pressure now after the settlement.
Funding for care workers is based on the twelve-hour minimum recommended by Standards NZ in Indicators for Safe Aged-care and Dementia-care for Consumers, but those standards are only voluntary, and were published twelve years ago. In that time the elderly have been enabled to live in their own homes for longer, and consequently have more intense needs when they eventually do move into retirement homes. Marianne told me that her view, based on when she began working as a carer, is that a rest home resident now generally requires what would have nearly constituted hospital level care twenty years ago.
She also said that carers are often expected to look after residents requiring dementia-level care in facilities that aren’t specialised, and indicated that homes might be unwilling to acknowledge the progression of a resident’s needs if doing so may see them moved out of the facility, leaving an empty bed. She said that often management didn’t have an accurate idea of how things were on the floor and the amount of time some residents required.
Gregory seems to be a clear example of what she’s talking about - a resident requiring more supervision and assistance than he was provided with. His primary carer, a family member, had hoped that his moving into a rest home would be a relief for her, but when she visited him she ended up doing a lot the things she’d done for him at home anyway. His grandson, Tom, tells me that leaving could feel like abandoning him.
‘Sometimes it’s not just about allowing people to be happy. It’s about engaging them in the whole spectrum of their emotions.’ It’s not just a matter of spending time, she told me, it’s quality of time. What’s required is a cultural shift. A political change in what we value, and how we allocate our resources and attention.
They worried that Gregory wasn’t eating. Carers would drop his breakfast off in his room, then come back and collect the food cold and untouched and take it away. He wasn’t being reminded to eat, and would forget about it. He also needed to be reminded about his oxygen tubes, which came out when he scratched his nose. That level of supervision wasn’t available, so he often didn’t have them in. Gregory wasn’t happy going to the toilet in a pad, but it frequently took fifteen minutes for a carer to answer his bell, by which time it would be too late. Carers would then change his pad rather than assisting him to get to the toilet.
As his mobility declined, he lost access to the social activities he’d previously enjoyed. ‘There would be things coming on over the intercom, but no-one would pop in and check if he wanted to go.’ His social life meant a lot to him, and Tom believes this loss of access facilitated his further decline.
Josie, a rest-home resident and a retired aged-care educator, told me that, ‘The whole thing is being connected. Being connected to oneself, others, and the world.’ She talked about the need to engage residents in all their psychological complexity. ‘Sometimes it’s not just about allowing people to be happy. It’s about engaging them in the whole spectrum of their emotions.’ It’s not just a matter of spending time, she told me, it’s quality of time. She spoke passionately about the hard work she saw the staff and volunteer carers around her doing every day, particularly the recreational staff , but emphasised that a cultural shift is required; a political change in what we value, and how we allocate our resources and attention.
The equity settlement is a splendid beginning (pay rises for aged-care nurses and mental health workers would also be splendid beginnings). Care work has gone from a poorly paid job to a plausible career; an acknowledged vocation. Carers are hopeful that the settlement will attract young people to the sector, and men. The new, tiered system of pay will provide opportunity for less experienced and young carers to learn the job under less pressure, and for more experienced carers to receive recognition for their experience. ‘We now feel valued, encouraged, and positive about what we do. We love our job, we always have,’ Simone told me.
Rosie talked about her satisfaction at being there for residents when they need her. Marianne, too, said the positive feedback she got from residents meant a lot to her. ‘They might say thank you, or that you’ve been very understanding and you’ve helped them to do something they hadn’t been able to do before. Or they say thank you for spending that time with me. Or for doing something special for them, like tidying their drawers, or helping them write a letter, when you’ve got time to do that. Sew a button on their shirts.’
Carers deserve the opportunity to do their jobs to their own satisfaction, and to that of those they work with in every home, all of the time. ‘Sometimes it’s about challenging the powers that be,’ Marianne told me. ‘We’ve got to say, this isn’t right. If we want to provide quality care we’ve got to have time to provide that care.’
What comes up again and again is that residents often feel patronised, and reduced as people. ‘We need to think about what we mean by care,’ Josie said. ‘To me it means taking care of the whole person.’ To care for a whole person takes a community of people, hard work, love, and yes – money. Maybe it’s the last part that’s hardest to accept, but accepting it will help us with the rest.
Cover image: Albert Anker, Grandfather's Prayer, 1893
Names and identities of some interview subjects have been changed for their protection.