Lifting the ‘Violence Veil’: Examining Working Conditions in Long-term Care Facilities Using Iterative Mixed Methods

Prevalence and associated factors of sexual, psychological, and physical violence among physical therapists in their clinical role in Spain: a national web-based cross-sectional survey

OBJECTIVES

To determine the extent of career-long and 12-month exposure to sexual, physical, and psychological/verbal violence committed by patients or their companions among physical therapists in Spain. Additionally, to identify the factors associated with such exposure.

METHODS

This study employed an observational cross-sectional approach. Initially, a questionnaire was developed and validated using a convenience sample. Subsequently, it was distributed via email to all physical therapists registered in Spain in the first quarter of 2022. Individual risk models were created for each type of violence experienced within the past 12 months.

RESULTS

The prevalence of violence encountered by physical therapists throughout their careers was 47.9% for sexual violence, 42.7% for psychological/verbal abuse, and 17.6% for physical abuse. Lower values were observed within the last 12 months (13.4%, 15.8%, and 5.2%, respectively). Statistical risk modeling for each type of violence experienced in the past 12 months indicated that the common precipitating factor for all forms of violence was working with patients with cognitive impairment. Working part-time appeared to be a protective factor. Other factors, such as the practitioners' gender, practice setting, or clinic location showed variations among the diverse types of violence.

CONCLUSIONS

The exposure to type II workplace violence within the last 12 months among physical therapists in Spain (Europe) is not so high as in some other world regions. Various individual, clinical, and professional/organizational risk factors have been identified in connection with type II workplace violence. Further research is warranted to compare the violence experienced once the COVID pandemic has subsided.

Precarious work among personal support workers in the Greater Toronto Area: a respondent-driven sampling study

BACKGROUND

The COVID-19 pandemic has highlighted the role of personal support workers (PSWs) in health care, as well as their work conditions. Our study aimed to understand the characteristics of the PSW workforce, their work conditions and their job security, as well as to explore the health of PSWs and the impact of precarious employment on their health.

METHODS

Our community-based participatory action research focused on PSWs in the Greater Toronto Area. We administered an online, cross-sectional survey between June and December 2020 using respondent-driven sampling. Data on sociodemographics, employment precarity, worker empowerment and health status were collected. We assessed the association between precarious employment and health using multivariable logistic regression models.

RESULTS

We contacted 739 PSWs, and 664 consented to participate. Overall, 658 (99.1%) completed at least part of the survey. Using data adjusted for our sampling approach, the participants were predominantly Black (76.5%, 95% confidence interval [CI] 68.2%-84.9%), women (90.1%, 95% CI 85.1%-95.1%) and born outside of Canada (97.4%, 95% CI 94.9%-99.9%). Most worked in home care (43.9%, 95% CI 35.2%-52.5%) or long-term care (34.5%, 95% CI 27.4%-42.0%). Although most participants had at least some postsecondary education (unadjusted proportion = 83.4%, n = 529), more than half were considered low income (55.1%, 95% CI 46.3%-63.9%). Most participants were precariously employed (86.5%, 95% CI 80.7%-92.4%) and lacked paid sick days (89.5%, 95% CI 85.8%-93.3%) or extended health benefits (74.1%, 95% CI 66.8%-81.4%). Nearly half of the participants described their health as less than very good (46.7%, 95% CI 37.9%-55.5%). Employment precarity was significantly associated with higher risk of depression (odds ratio 1.02, 95% CI 1.01-1.03).

INTERPRETATION

Despite being key members of health care teams, most PSWs were precariously employed with low wages that keep them in poverty; the poor work conditions they faced could be detrimental to their physical and mental health. Equitable strategies are needed to provide decent work conditions for PSWs and to improve their health.

Factors associated with residents’ responsive behaviours towards staff in long-term care homes: A systematic review

Background and Objectives

When staff experience responsive behaviors from residents, this can lead to decreased quality of work-life and lower quality of care in long-term care homes. We synthesised research on factors associated with resident responsive behaviours directed towards care staff and characteristics of interventions to reduce the behaviours.

Research Design and Methods

We conducted a mixed-methods systematic review with quantitative and qualitative research. We searched 12 bibliographic databases and “grey” literature, using two keywords (long-term care, responsive behaviours) and their synonyms. Pairs of reviewers independently completed screening, data extraction, and risk of bias assessment. We developed a coding scheme using the ecological model as an organising structure and prepared narrative summaries for each factor.

Results

From 86 included studies (57 quantitative, 28 qualitative, 1 mixed methods), multiple factors emerged, such as staff training background (individual level); staff approaches to care (interpersonal level); leadership and staffing resources (institutional level); and racism and patriarchy (societal level). Quantitative and qualitative results each provided key insights, such as qualitative results pertaining to leadership responses to reports of behaviours, and quantitative findings on the impact of staff approaches to care on behaviours. Effects of interventions (n=14) to reduce the behaviours were inconclusive.

Discussion and Implications

We identified the need for enhanced understanding of the interrelationships among factors associated with resident responsive behaviours towards staff and processes leading to the behaviours. To address these gaps and to inform theory-based effective interventions for preventing or mitigating responsive behaviours, we suggest intervention studies with systematic process evaluations.

Racism, racialization, and health equity in Canadian residential long term care: A case study in Toronto

To date, most of the interdisciplinary scholarly literature pertaining to care work and labor studies of marginalized groups, such as women, visible minorities, and immigrants, has focused on emotional labor as well as concerns about high stress and high turnover. However, few mention racism and racialization. Using a single-case study research design of a long term care ("LTC") home in Toronto, Ontario, Canada, this paper contributes to our understanding of racism and racialization by analyzing participants' experiences of work. It documents how particular social determinants of health ("SDoH"), such as race and racialization, can manifest themselves in the lives of workers. Drawing on critical race theory and feminist political economy, this study examines the ways in which the participants discuss their experiences of care work, with closer attention to racism and racialization.

Sexual harassment from older residents at long-term care facilities: is it really part of the job?

OBJECTIVES

To explore the extent to which staff members in long-term care facilities (LTCF) have experienced situations of sexual harassment, how they commonly and ideally manage the situation, and how their work position influences their responses.

DESIGN

Cross-sectional quantitative study, using the vignette technique.

METHOD

A total of 2,196 staff-members who were currently working in Spanish LTCF participated in the study. Data were collected using a self-administered questionnaire. Questions regarding sexual harassment were analysed by a vignette that described a case of sexual harassment. Participants had to choose common and best practices for dealing with the case, and report the frequency with which they had experienced similar situations.

RESULTS

The results indicate that 29.9% of participants had experienced an episode of sexual harassment in a LTCF similar to the one presented in the vignette. Responses to the situation were diverse and there were significant differences between common and perceived best practices. Differences were also found depending on the work position of the participant (manager, technical staff or nursing assistant).

CONCLUSIONS

There is a need for a fuller recognition of the sexual needs of older people. However, the presence of inappropriate sexual behavior must also be acknowledged. The right of staff to work in an environment free of harassment must be respected. The need for explicit institutional guidelines and training opportunities is discussed.

Diet, physical activity, and emotional health: what works, what doesn't, and why we need integrated solutions for total worker health

Background

Current research advocates lifestyle factors to manage workers’ health issues, such as obesity, metabolic syndrome, and type II diabetes mellitus, among other things (World Health Organization (WHO) Obesity: preventing and managing the global epidemic, 2000; World Health Organization (WHO) Obesity and overweight, 2016), though little is known about employees’ lifestyle factors in high-stress, high turnover environments, such as in the long term care (LTC) sector.

Methods

Drawing on qualitative single-case study in Ontario, Canada, this paper investigates an under-researched area consisting of the health practices of health care workers from high-stress, high turnover environments. In particular, it identifies LTC worker’s mechanisms for maintaining physical, emotional, and social wellbeing.

Results

The findings suggest that while particular mechanisms were prevalent, such as through diet and exercise, they were often conducted in group settings or tied to emotional health, suggesting important social and mental health contexts to these behaviors. Furthermore, there were financial barriers that prevented workers from participating in these activities and achieving health benefits, suggesting that structurally, social determinants of health (SDoH), such as income and income distribution, are contextually important.

Conclusions

Accordingly, given that workplace health promotion and protection must be addressed at the individual, organizational, and structural levels, this study advocates integrated, total worker health (TWH) initiatives that consider social determinants of health approaches, recognizing the wider socio-economic impacts of workers’ health and wellbeing.

The "Violent Resident": A Critical Exploration of the Ethics of Resident-to-Resident Aggression

Resident-to-resident aggression is quite prevalent in long-term care settings. Within popular and empirical accounts, this form of aggression is most commonly attributed to the actions of an aberrant individual living with dementia characterized as the "violent resident." It is often a medical diagnosis of dementia that is highlighted as the ultimate cause of aggression. This neglects the fact that acts of aggression are influenced by broader structural conditions. This has ethical implications in that the emphasis on individual aberration informs public policy strategies for prevention with a focus on restricting the freedom of individuals using behavioural modification, drugs, or other restraints with the intent to protect others from harm. A more ethical approach requires attention to the structural conditions of long-term care that both foster aggression and constrain prevention efforts. To this end, we turn to a model of relational citizenship that offers a theory of embodied selfhood and relationality as essential to human dignity, thus entailing human rights protections. The application of an ethic based on this model offers a more holistic prevention strategy for resident-to-resident aggression by drawing attention to the critical need and obligation to promote human flourishing through system level efforts.

Problematizing Sexual Harassment in Residential Long-Term Care: The Need for a More Ethical Prevention Strategy

La promotion des droits sexuels dans les établissements de soins de longue durée est complexe sur le plan éthique, étant donné que ce milieu est à la fois une résidence et un lieu de travail. Bien que les données empiriques démontrent que le bien-être des soignants professionnels et des résidents sont inextricablement liés, les politiques publiques au Canada ne reconnaissent généralement pas cette relation et continuent de se concentrer isolément sur le bien-être des résidents ou des travailleurs. Les conséquences problématiques de cette situation sont particulièrement mises en évidence lorsque l'on considère les défis associés à la prévention du harcèlement sexuel envers les travailleurs, dans un contexte où l'on ne veut pas restreindre indûment la liberté d'expression sexuelle des résidents atteints de démence. Nous avons utilisé l'approche « Quel est le problème représenté ? » ("What's the Problem Represented to be?") de Carol Bacchi pour analyser de façon critique un plan d'action canadien récent visant à prévenir la violence et le harcèlement sexuels. Notre analyse suggère que cette approche de prévention du harcèlement sexuel n'est pas une politique publique prometteuse et pourrait même contribuer à augmenter le phénomène qu'elle vise à corriger. Il est donc urgent de concentrer les efforts de prévention sur les facteurs structurels de ce phénomène afin de soutenir les droits sexuels des soignants et des résidents.

Supporting sexual rights in residential long-term care is ethically complex. The well-being of care workers and residents is inextricably linked, and increasingly recognized empirically, yet public policy in Canada generally continues to exclusively focus on either the well-being of residents or workers. The consequences of this are particularly evident when we consider how to prevent sexual harassment towards workers without unjustly restricting the freedom of sexual expression for residents living with dementia. Employing Carol Bacchi’s “What’s the Problem Represented to be?” approach, we critically analysed a recent Canadian action plan to prevent sexual violence and harassment. Our analysis suggests that this policy is less than promising and may reproduce the very phenomenon it is intended to redress. The need to refocus prevention efforts on the structural factors implicated in this phenomenon is urgent if we are to support the sexual rights of both care workers and residents.

Breaking Point: Violence Against Long-Term Care Staff

Direct resident care in long-term care facilities is carried out predominantly by personal support workers and registered practical nurses, the majority of whom are women. They experience physical, verbal, and sexual violence from residents on a regular basis. To explore this widespread problem, fifty-six staff in seven communities in Ontario, Canada, were consulted. They identified such immediate causes of violence as resident fear, confusion, and agitation and such underlying causes as task-driven organization of work, understaffing, inappropriate resident placement, and inadequate time for relational care. They saw violence as symptomatic of an institution that undervalues both its staff and residents. They described how violence affects their own health and well-being-causing injuries, unaddressed emotional trauma, job dissatisfaction, and burnout. They outlined barriers to preventing violence, such as insufficient training and resources, systemic underfunding, lack of recognition of the severity and ubiquity of the phenomenon, and limited public awareness.

"That Is So Common Everyday . . . Everywhere You Go": Sexual Harassment of Workers in Assisted Living

In assisted living (AL) facilities, workers are intimately involved in the lives of residents. Existing research on AL demonstrates the imbalance of this environment, which is a personal home for the residents and a workplace for staff. Using observational and interview data collected from six AL facilities, this grounded theory project analyzes how AL staff define, understand, and negotiate sexual comments, joking, and physical touch. We developed a conceptual model to describe how such harassment was perceived, experienced by AL workers, and how they responded. Sexualized behavior or harassment was experienced by workers of every status. We found that words and actions were contextualized based on resident and worker characteristics and the behavior. Staff members refused to engage residents, redirected them, or reframed the words and gestures to get the job done. Reporting the incidents was less common. We conclude by discussing implications for policy and research.

Liminal and invisible long-term care labour: Precarity in the face of austerity

Using feminist political economy, this article argues that companions hired privately by families to care for residents in publicly funded long-term care facilities (nursing homes) are a liminal and invisible labour force. A care gap, created by public sector austerity, has resulted in insufficient staff to meet residents' health and social care needs. Families pay to fill this care gap in public funding with companion care, which limits demands on the state to collectively bear the costs of care for older adults. We assess companions' work in light of Vosko's (2015) and Rodgers and Rodgers' (1989) dimensions for precariousness. We discuss how to classify paid care work that overlaps with paid formal and unpaid informal care. Our findings illuminate how companions' labour is simultaneously autonomous and precarious; it fills a care gap and creates one, and can be relational compared with staffs' task-oriented work.

Liminality in Ontario's long-term care facilities: Private companions' care work in the space 'betwixt and between'

Nursing, personal care, food and cleaning are publicly funded in Ontario's long-term care facilities, but under-staffing usually renders all but the most basic of personal preferences superfluous. This individualization of responsibility for more personalized care has resulted in more families providing more care and opting to hire private, private companion care. With direct payment of companions becoming a growing but largely invisible facet of care, exploring companion's roles is important. Using a six site rapid ethnographic study in long-term care facilities (i.e. observations, documents and key informant interviews (n=167)), this paper argues that private companions occupy a liminal space between policy, family and market, and their role within institutions and in private homes may be the missing link in the care work chain in the sense that it can at once be classified as formal and informal and draws on their own and others paid and unpaid labour.