Not all regulations are the same

1. A Major Collaborative Research Initiative funded by the Social Sciences and Humanities Research Council of Canada The Paradox of Regulation Albert Banerjee, PhD CIHR Postdoctoral Research Fellow Pat Armstrong, PhD Distinguished Research Professor of Sociology Presentation at “ Do Regulations Make it Harder to Care?”, Toronto, Canada, May 28, 2013

2. Not all regulations are the same • Policy level regulations, set the conditions for care (e.g., ownership, funding levels, minimum staffing levels, required training, etc). • Local level regulations specify the process of care (e.g., a Resident’s Bill of Rights, Family councils, how and when and how feeding is to be done, etc.)

3. Distinguishing “relational” care • Relational care recognises that care is provided in and through relationships between people. • Furthermore, care is always situated, located within institutions processes and organizational practices. • Care - understood relationally - is always embedded, dynamic and as a result, often unpredictable.

4. Distinguishing approaches to accountability • A relational approach to accountability would expect that policy and institutions would be accountable to residents and those who immediately care for them. Such relational forms of accountability would involve ensuring adequate time to care, flexibility, communication, resources as well as the power to identify and resolve problems in a context appropriate and timely matter. • The auditing approach to accountability: Objectives, performance measurement, monitoring & reporting (Powers, 2000, The Audit Society, Second thoughts)

5. Individualizing problems • “We heard…seniors had missed their weekly bath due to staff shortages” (274). • “Staff who contacted us said they don’t always have time to assist with thorough daily oral hygiene” (275). • “Several of the residents require feeding at meal times…With only two aides available this is difficult” (278). • “Due to staffing levels, the residents are toileted at specific times only, so for my mother … if she needs to go to the bathroom outside of her times, she ends up going into the diaper as she cannot possibly hold on” (275). Source: BC Ombudsperson Report (2012), The Best of Care

6. The logic of the audit “It is surprising that neither the ministry nor the health authorities have established standards on acceptable response times to call bells. Technology enabling the measurement of call-bell response times is available, and some facilities are already using it. Without objective data, it is difficult to determine the extent of the problem. It would be useful for health authorities to collect objective data about actual response times and use it to support the development of appropriate standards and guidelines. Once this is done, compliance with these standards can be monitored” Source: BC Ombudsperson Report (2012), The Best of Care

7. The limits to Auditing Accountability • Increasing workload • Taking time away from care • Increasing paperwork • Supporting a culture of mistrust and marginalization • Decoupling power from residents care • Transforming carework . • Routinization & defensive work

8. Tensions with relational care “Gosh forbid I walk down the hall and give somebody a drink without checking the food and fluid binder! It creates all this dissociation from what the whole intent is, which is to give the residents what they would really enjoy having for their tea or anything else. It creates this whole disciplinary approach to documentation. .... So instead of sitting there for 20 minutes and having just a nice chat over tea, they’ve got to sit there doing the busy work of documenting...That’s part of the problem I have with the Act because I’m constrained by these things to not create what would be seen as a normal living circumstance for someone because you feel like you’re in a lab and people are, you know, everything you do, everything you do! has got to be written down.” -LTRC RN

9. Five Lessons • Lesson 1: Not all regulations are the same • Lesson 2: The conditions of work are the conditions of care • Lesson 3: Respond to problems with inadequate staffing by regulating minimum staffing levels • Lesson 4: Developing public and non-profit providers and approaches • Lesson 5: Policy level regulations are political

10. Solving the problem of call bell response times “It is surprising, therefore, that neither the ministry nor the health authorities have established standards on acceptable response times to call bells. Technology enabling the measurement of call-bell response times is available, and some facilities are already using it. Without objective data, it is difficult to determine the extent of the problem. It would be useful for health authorities to collect objective data about actual response times and use it to support the development of appropriate standards and guidelines. Once this is done, compliance with these standards can be monitored.” Cost to provide 3.36 direct care hours per day The Fraser Health Authority said it would need to invest an additional $79 million in staffing to achieve the guideline. The Interior Health Authority estimated that it would cost $39 million to achieve the guideline. The Northern Health Authority said it would require an additional $11.6 million to meet the guideline. The Vancouver Coastal Health Authority said that it would cost approximately $57 million. NB: No information was obtained from the Vancouver Island Health Authority. Technique vs. Politics Source: BC Ombudsperson Report (2012), The Best of Care

11. Thank-you! For more information or to offer feedback please contact: Albert Banerjee balbertb@yorku.ca