Long Term "Care"?
I worked in long term care in Manitoba for over a decade. Frankly, I don't think I will ever recover from the moral distress that I accumulated during that decade. I worked for a profit-based company, but, I don't think there is much difference in care regardless of the setting. When I left, I asked my employer if I would be able to write a book about my experiences and my employer said it was likely a good idea. The book I would be writing would be Why Culture Change Failed at One of Canada's Largest For Profit Companies. I have to confess every time I get started, I get triggered and have to stop. I know my health would be improved if I didn't have so many things stored in my long-term memory. The most obvious way working in that environment affected me is my weight. During my employment, I gained over 80 lbs. It hasn't been that long since leaving, but I have lost about 20 of those pounds, however, even sitting down now and writing this, I am having a hard time not getting a litre of ice cream.
It is also important for me to say that I also witnessed many examples of genuine care and compassion that genuinely inspired me and made it possible to keep coming back to work. However, upon reflection most of the examples that I witnessed happened when the staff involved were aware that they were witnessed.
The conditions in long term care may be shocking to the politicians, but the general public has known for a long while that something has been wrong. We used to call them Nursing homes. Now, we call them Personal Care Homes or Long Term Care Facilities. The change was meant to change the culture noting that personal care or attention was as important as Nursing tasks. Essentially, the model was focusing on person-centered care and that everyone would have their own care plan. It meant that instead of providing care for residents it would be providing care with residents. Change is hard under the best of circumstances but changing the culture in the long term care environment is a very tall order. It is a system that is bogged down with policies and procedures. There are so many policies and procedures that management actually believe that by creating a policy called "Person Centered Care" that it will magically change the system. Often when auditors from the respective health region come in, they spend their time reviewing the policy binders and the policies are right, they assume that what is in the policy is actually occurring. If they find deficits in the policies, they instruct the home to write new policies. Homes are given weeks notice when the auditors are coming and which files will be reviewed. Staff are coached as to how to respond. They ask to interview some cognitive residents and they are coached as well.
I remember the first time I experienced some distress. It was a small incident but indicative of the larger problem. I was standing next to a health care aide while we were receiving training on evacuation procedures in the event of a fire. She indicated she really liked getting training because it was an hour that she didn't have to do any resident care, but, the truth was that if there was ever a fire, she would be the first one out the door and wouldn't bother even trying to save a resident let alone the 10 under her care. As we have seen in Ontario and Quebec, this attitude seems quite rampant.
Speaking of fire training, each home in Manitoba must have three fire drills per month; one on each shift. Each drill is audited by management in the home. The person organizing the fire drills always seems to forget about this so often the drills are predictable and occur on the last day of the month. The staff give the time that is best for them for the drill to occur. Management will indicate that they will have the fire drill at alternating times to stimulate a real drill because fires can happen at any time. Ultimately, staff win because management need to have a positive relationship with staff. Their salary increases often depend on feedback from staff. Regardless, I know of instances where the audit occurred prior to the drill being conducted. The manager was just too busy to participate in the drill. Auditors from the province would note that it was impossible to have "perfect" drills all the time, so, home auditors would them start recording minor infractions that were easy to document fixes. There is always a way to find a short cut or to make things look good on paper.
When it comes right down to it, when deficiencies are found or when a family complains, the home has an easy answer. It blames the Province for not increasing staff levels or reducing funding. It simply is a blaming culture. The provincial government is usually the scapegoat and an easy target since they haven't adjusted staffing levels and are decreasing funding. However, within the home, the blaming culture continues. Management blames staff. Day shift blames evening shift. Evening shifts blames night shift. Night shift blames day shift. Even within the shift or the Unit, everyone blames someone else. It is not my fault. That wasn't my resident. It happened when I was on break. Blame. Blame. It also is a complicit culture. Once I didn't tattle on the health care aide who admitted she wouldn't attempt to save residents in a fire, I was complicit, so now she had something on me to file away. So, I could never report her because she would report me. It would go on and on.
Residents who had family members who were good "advocates" would receive better care. In most facilities, 70-80% of the population has some type of dementia. The 20-30% of the population cognitively intact received better care because they were capable of complaining of poor treatment. Even people with mild or early stages of dementia would be accused of making-up stories if they complained. Even the cognitively intact residents would rarely complain because they were worried about retaliation in the form of less attention from staff.
Sadly, I have witnessed a resident sit at their spot in the dining room for more than 8 hours. The wheelchair brakes would be locked when the resident was brought for breakfast and was just left there for the remaining meals. If staff were confronted with this information, they would back each other up that they had brought the resident back between meals for toileting and the resident would want to sit there in the dining room. Staff would also content that the brakes on the wheelchair were engaged by the resident.
Many family members would come in every day to ensure their loved one got the care they needed. The care was usually done by the loved one. When they would take a day off or go for a holiday, they would ensure another family member would take over or they would hire private care. It is important to realize that residents in Manitoba pay handsomely for their care in personal care homes. The rates are based on income so the theory is that everyone can pay for their care, however, some for profit homes make handsome profits on incidentals. One home hired an executive director whose experience was in the hospitality industry. She had some great ideas. Residents are required to supply their own toiletries. She would make it mandatory for residents to use the toiletries that the home would purchase and then raise the price by atleast 50%. charged to their trust account and then each transaction of the trust account would be subject to an administration fee. You would assume that a long term care facility would have a generator in case of a power failure. Generators cost a great deal of money and is not "seen" so for-profit homes don't see it as a priority. They would rather put the money into things that create an illusion of a home-like environment. The need for a generator in Manitoba should be obvious but it is seen as superfluous by corporations operating long term care facilities. In some respect, they are right. The only integral use of electricity is to operate oxygen concentrators and in the event of a power outage, there are portable tanks to be used. Some staff actually like it when the power is off. They can put residents in bed with extra blankets and cut down on their workload/interaction with them. They can claim that they only can provide emergency care because it is not safe for them to do otherwise. The kitchen staff have less work to do because they can use plastic cutlery and paper plates and basically only have to make sandwiches. Less work for everyone.
Oral care is an issue in most personal care homes. In fairness, providing oral care to residents is not pleasant. Often, they pocket food and their breathe is bad. So, it is just easier not to do it. If they are questioned, staff can say the family doesn't provide toothpaste or the right kind of toothbrushes. Family members would often bring me unopened tubes of toothpaste and toothbrushes with the date marked when it was brought in. I have seen instances of dentures being soaked together and the next day the family would report their parent wearing a set of dentures that were not theirs. Gums are frequently infected and that infection travels downward. In fairness to the system, there are so many systemic problems in the industry that it is pretty overwhelming trying to make changes.
I was able to facilitate some small victories. These were very time-consuming and the solution was just common sense. Being labeled "Refusing Care" or being "difficult" was difficult labels for residents to overcome. I remember discussing a man who had not had a bath since admission (5 weeks) and was starting to have an odour. It was recommended that the man be given a sedative prior to care (all care) in order to help with the cooperation. I always found this man very polite and reasonable so it didn't make sense to me that he was refusing his bath. I decided to talk to him. It turned out, his scheduled bath was at the same time his Priest came to give him communion. His faith was very important to him so he wasn't going to miss communion so he wasn't refusing his bath, he was refusing it at the time it was being offered. There is a schedule for baths, after all and each resident is assigned a bath time once a week. I asked staff if there was a way to change his bath time. No, that "bed" had a particular time and date for a bath and the schedule could not be changed because that is way it was always done. I had to find another resident who would be willing to swap bath times and days. It should have been common sense. It wasn't. Because it has always been done this way is one of the biggest obstacles to person-centered care.
Residents are often soiled or sit in urine even in non-pandemic times. It is never anyone's fault. The staff members can say that they are limited to one product per shift so blame management. Management blames the government for not funding them adequately. If the family brings in their own products, the staff can claim the resident refused to be changed. It is hard to dispute when the resident doesn't have the cognitive ability to be a good witness.
Each resident has to have documentation that they are receiving some sort of care or check every two hours. For their own safety, some residents have to be checked on more frequently. One morning a resident who required 15 minute checks found her way into my office shortly after breakfast. I was just curious to see how long it would take before someone came looking for her. I ended up bringing her a tray for lunch. After lunch, she napped in her chair until the next shift. I took her back to her unit and confirmed that someone had signed the sheet indicating 15 minute checks had been completed and I also noted that it had been reported that she had been toileted and had a medium bowel movement.
I saw a resident wearing the same clothes for five days in a row and each day, they were becoming more and more dirty with food stains. I was told the problem was he didn't have any clothes. I was also told he was resistant to care. I took him to his room. He didn't have a lot of clothes but he did have a change of clothes. His sheets were heavily soiled and when I asked for them to be changed. I was told that sheets were changed once a week on bath day. Again that is why things were done. Who wanted to do extra work that was not necessary like changing sheets. This occurs more common than anyone would want to admit.
Sadly, I have only scratched the surface of my memory. I have literally a decades worth of issues that I am trying to forget.
My heart goes out to residents in Manitoba who have been isolated from their families. I know some are having face-time visits and atleast that is something. My heart is going out to residents in Ontario and Quebec. My heart is also breaking for the military who found these horrific conditions. It is hard to unsee something or un-ring a bell. Atleast the two Premiers and the Prime Minister are going to try and affect change. I wish them the best. They have their work cut out for them. Let's hope they have heard of the phrase "trust but verify".
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