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Research/Quality Practices

2003 First Place 

Using Service Cues to Enhance the Client-Provider Relationship

by Lisa Browne 

Healthier Together:  A Strategic Health Plan for Newfoundland and Labrador outlines a five-year plan for the health system.  Traditionally, marketing in the health sector has emphasized health promotion.  Healthier Together continues in this direction but also touches on a number of issues that could be addressed through a comprehensive marketing plan, including gaps in the services offered, particularly mental health and long-term care, and distribution of services provided.[1]   While the plan is provincial in nature and will require strong direction and co-ordination from government, individual health boards and their employees can make use of various marketing concepts to enhance the system.  In particular, concentrating on service cues will increase the level of satisfaction with the exchange relationship between client and provider and lay the groundwork for further implementation of marketing concepts. 

A textbook definition of marketing—“the process of creating, distributing, promoting and pricing goods, services and ideas to facilitate satisfying exchange relationships in a dynamic environment”—emphasizes the concept of a satisfying exchange relationship.[2]  It is unlikely that either clients or providers would readily agree that their current health care relationship is satisfying given the existing multitude of challenges in the health sector.  

The client – provider relationship during a service encounter is particularly important in the health system.  In most cases, the client cannot judge the technical skill of a physiotherapist or a community health nurse, for example.  The client does, however, base a perception of quality on intangibles such as whether or not the health services provider showed concern or has answered the client’s questions fully.[3]  This is evidenced by the many documented complaints in health organizations that have some prevailing attitude as the focus of a complaint, such as “the doctor was rude”, “no one cared”, or “the nurse was mean”.  Similarly, an Emergency Room satisfaction survey that comments on the lack of cleanliness of a room without referring to the service provided reflects the difficulty those clients have with judging the health care service received. 

In addition to this difficulty in judging the actual service provided, the overwhelming majority of people who enter the health system do so with some degree of anxiety.  Whether it is to visit an acute care setting to have a diagnostic test, visit a sick friend, request assistance from a community health addictions counselor or even to go to work in the system, health settings are sources of stress.   

All of this points to the importance of service cues.  Service cues are things other than the service being provided that can help a client form the basis of an opinion about the service that is received.  And, it is service cues that can be controlled by all employees within the health sector.  No special knowledge is required, employees must simply be aware of how clients judge the service provided to them.

William M. Pride and others categorize service cues as tangibles, reliability, responsiveness, assurance and empathy.[4]   Their definitions of the service cues, when using health examples, produce the following chart:

Take, for example, the client who visits a family physician and because of excess weight and a strong family history of diabetes requests a referral to see a dietitian at a local hospital.  This in itself is positive, as the client is taking responsibility for her health.  However, the client is then provided with a requisition, told to travel to a local hospital to wait to give it to a receptionist who then informs the client that she will be notified of an appointment time at a later date.  The work of the client to take responsibility for her own health has increased quite a bit.  If that family physician had forwarded the requisition directly to the hospital, the client would have been less inconvenienced.  This sort of seamless care is consistent with the provincial government’s Framework for Primary Care Renewal which indicates that one “of the key components of primary health care enhancement is the collaboration of all health service providers to enable a team approach to care.  This should benefit patients, as they will have better access to streamlined, comprehensive care.”[5] 

Similarly, a patient asks for some assistance with lowering cholesterol and they are provided with a much-photocopied sheet of paper with a small font and excessive text.  This certainly does not send out a positive message and, for the 24% of the adult population who are at the lowest reading skill level and for the aging population, does not provide much assistance[6].  In this case, the information provided is a negative service cue.

While all health service providers can benefit from knowing about service cues, it is particularly important for front-line employees.  The people who answer the phones, work at reception areas and booking offices have in many cases first contact with clients.  When a client phones a Health and Community Services Board, looking for information on child protection, it is the receptionist who must ensure that the call is properly forwarded and the client reassured. 

For the receptionist in a family physician office who must call patients throughout the day and relay messages from their physician, this is a part of their day-to-day responsibilities that might be considered fairly mundane.  However, for the person in the waiting room, who hears that Mrs. Johnson needs to have her pap smear repeated, the privacy and confidentiality of that patient might be protected in a large city.  If you are the only Mrs. Johnson in a small community, it is not!  Again, this is a negative service cue and does not provide the client with any level of assurance in the system.

In the private sector, this focus on quality and the client would lead to increased client loyalty.  Does this equate to the health sector?  One could argue that increased loyalty to the health system or to a particular health service provider will lead to an increased responsibility for one’s health.  If, for example, the overweight client with the family history of diabetes mentioned above has a positive experience with the dietitian, the facility and the education materials provided, it is likely that the client will continue to return for follow-up visits as necessary.  If through this preventative and proactive measure the client manages to avoid or delay the onset of diabetes, the health system has saved thousands of dollars. 

But with health service workers concerned about their quality of life and health boards focused on stretching health resources, how important is concentrating on service cues?  The results of concentrating on the elements that allow clients to judge the benefits of health care in a way that they can provides enhanced client/family confidence in their health care, increased employee morale and community pride, improved recruitment and retention rates and increased donations.  In essence, it is a very doable individual and team focus on the client and quality.  It puts tangibles to the concept of quality itself—a term so overused that it has little real relevance these days.  And, it essentially is internal marketing:  putting the client first.  It is only once this internal emphasis on the client is ongoing can the health system develop an effective external marketing plan.

In a time when the challenges in the health system can seem insurmountable, an awareness of service cues can provide employees with a clear focus on how clients judge the level of service provided and more importantly, can provide them with clear ways to help increase satisfaction levels. 

Biography

Lisa Browne

Lisa Browne is Director of Communications  & Planning at the Peninsulas Health Care Corporation (PHCC).

She is the immediate past-president of the Clarenville Rotary Club and is a member of the Clarenville Regional Arts and Recreation Committee.  She co-hosts a local cable show, Our Town, about happenings and activities in the area.   Lisa has been a member of the Memorial University Board of Regents for the past four years and chairs the board’s Audit Committee. 

She has a Masters in Business Administration degree and a Bachelor of Arts (English) degree.

2003 Second Place

The TraveLling Health Show:

A Cancer Prevention Initiative

in Labrador

 by Andrea White

Executive Summary

Cancer is often perceived as a random and unpredictable disease.  However, it is estimated that about 80% of all cancers are caused by “behavioural” factors and are therefore under human control.

Two of the leading risk factors associated with cancer are tobacco smoke and diet.  Together, they are responsible for about two thirds of all new cancer cases.  Tobacco smoke is the major cause of 80 to 90 per cent of lung cancer cases.  It is also an important cause of bladder and breast cancer.  Diet associated cancers include colon, rectum, breast and stomach.  For example, high fat consumption is considered a risk factor for colon and possibly breast cancer.  Other well established risk factors include work related exposure, alcohol consumption, and radiation – including sunlight, drugs and viruses.[i]

This year, nearly 5000 young people in our province will smoke their first cigarette; 90% of those youth will become regular smokers by the age of 13 (of those adults who are regular smokers, 85% started before the age of 16[ii]).  Even more concerning are the rates of smoking within our aboriginal population.  Aboriginal Canadians have a 62% rate of smoking, twice that of non-aboriginal Canadians[iii].  In the Regional Health Survey done by the Labrador Inuit Health Commission in 1997, Labrador Inuit Association (LIA) members reported an even greater rate of smoking (65%) than the national aboriginal rate, with most members commonly starting to smoke around 16 years of age[iv].  In other Labrador communities, 26% of youth aged 12 to 15 smoke, and 48% of youth aged 16-18 years of age smoke.  Among communities, the rates of youth who smoke varied from 24% to 80%[v].

In a recent study within Labrador (not including the 5 LIA communities) only 11% of those adults surveyed reported eating the five or more servings of fruits and vegetables per day as recommended by Canada’s Food Guide.  27% of the adults surveyed reported eating foods high in fat three times a week or more[vi].

The most frequently diagnosed cancers continue to be lung, breast, and colorectal cancer in women and prostate, lung and colorectal cancers in men.[vii]  The number of new cases and deaths continue to rise as the population ages.[viii]      The Canadian Cancer Society recommends that women between the ages of 50 – 69 have a mammogram every two years, in combination with physical examination of the breasts by a trained health professional.[ix]

Prostate cancer is unique among cancers in that there is a slow growing type and an aggressive, fast growing type.  The prostate specific antigen (PSA) blood test can detect prostate cancer before symptoms appear, but it is not good at differentiating between the slow growing and fast growing types of cancer. [x]  Men over 50 should discuss with their doctor the potential benefits and risks of early detection using tests that are currently available.

Affecting both sexes is the human papilloma virus, a commonly sexually transmitted disease that is a major risk factor for cervical cancer[xi].  It is the most common yet the least understood sexually transmitted infection.  The majority of HPV infections produce no onset symptoms so the infected are not aware they have it, allowing for the individual risks of cervical cancer to be insidious.[xii]

Rationale:  

Through knowledge, residents of Labrador can reduce their risk of cancer.  Eating more fruits and vegetables and less fat, quitting smoking or, even better, not starting would have an impact.  Further protection from cancer can come through effective and easily performed local screening (for example, mammography screening to detect breast cancer and a PSA test to detect prostate cancer.  When carried out according to established guidelines, these tests detect cancer earlier, thus improving cancer survival rates.  These screening options are now available in Labrador for the first time, as is Human Papilloma Virus testing which provides very early detection of risk for cervical cancer.

Individuals can reduce their risk of cancer, but to do so they must be inspired to make lifestyle changes.  Providing information in a manner that reaches a wide array of age groups and that is community specific and tailored to each unique geographic and cultural setting is one method of personalizing the message and facilitating changes.  In this “instantaneous information age” the presentation of some facts can be confusing to the public and health professionals.  They need a venue where questions can be asked and answered, options explored and the latest information shared.  A “Travelling Health Show” is able to accomplish this and more.

Health Labrador Corporation, in partnership with the Labrador Inuit Health Commission, Innu Nation and the local branch of the Canadian Cancer Society embarked upon a three pronged education project, delivered via a “Travelling Health Show” aimed at Cancer prevention and the promotion of healthy lifestyle practices in Labrador.

The three focal deliverables of the project are:

1.                  School Module: School students are invited and encouraged to participate in and prepare an interactive message to be presented back to the school students in the community.

2.                  Community Health Fair Module: A panel presentation in each community addressing the risks of cancer, benefits of prevention and screening, and a question and answer period.  A simultaneous health exhibition is also displayed.

3.                  Health Care Providers Module: An information session providing details on screening availability, referral patterns, available resources and inter disciplinary service provision.

The project is primarily funded through contributions from the annual Air Labrador/Frontec Memorial Golf Tournament. $13,700 over three years was committed, and fund managers have indicated that additional monies are available for expanding the program.   

The provincial Strategic Social Plan also committed annual funding for community collaboration efforts. 

All of the partnering groups provide some in kind contributions from pamphlets to display boards, facilities and accommodation.  In addition to being collaborative, multisectoral and interdisciplinary, the community commitment to the Travelling Health Show is very high.

Area:

Health Labrador Corporation is an integrated board, providing both acute care and community health and social services to a geographic area greater than that of Great Britain, but with a population that barely reaches 30,000. 

The catchment area consists of thirteen communities, seven of which are very small, isolated and remote. Populations range from 250 to 10,000 people of Inuit, Innu, Metis and white settler cultures. To date, the coastal communities are accessed only by air, as there are no road connections. Travel by snowmobile in winter and boat in summer is possible, but impractical for health delivery. Often referred to as the land God gave to Cain, challenges include rugged geography and a harsh northern climate.

Process:

The intersectoral planning group decided that the Travelling Health Show would go to three communities per year, tailored to meet the specific cultural, educational, demographic and socio-economic levels of each community.

The actual “Show” team that goes into the community includes the regional Cancer Society coordinator, the diagnostic services team leader, the community dietician, the Regional Director of Public Health and either the Medical Officer of Health or a District Medical Officer.  Where schedules permit, the Labrador representative to the provincial Teen Tobacco Team and the Nurse Researcher from the IGA Hereditary Colon Cancer Research Project attend.  Local health participants include the Regional Nurses, Public Health nurses, Home Care nurse, a Community Health representative and Mental Health workers (where applicable

An interdisciplinary working committee made up of representatives from the partnering agencies is assembled to plan each  “Travelling Health Show”.

·        Who:  For each community, the “Show” team includes the regional Cancer Society coordinator, a regional health representative from Health Labrador Corporation’s laboratory or x-ray department, a fourth year BN program nursing student and either the Medical Officer of Health or a District Medical Officer.  Where schedules permit the Labrador representative to the provincial Teen Tobacco Team has been included, as has the Nurse Researcher from the IGA Hereditary Colon Cancer Research Project.  Local health participants include the Regional Nurses, Public Health nurses, Home Care nurse, Community Health Representatives and Mental Health workers (where applicable). 

·        When:  The winter months (after Christmas) are the optimal time for a presentation, as the BN nursing students are available, travel is less hindered by sudden weather changes, seasonal work has ended and community people are available.

·        Where:  The Travelling Health Show goes to each community in the HLC catchment area at a rate of three per year.  The “Show” is tailored to meet the specific needs of each Labrador community that is visited, and the presentation adapted to the culture, education level, and demographic and social-economic levels of each community.  There is ample opportunity for community members to view information displays and exchange information through panel presentations and question and answer sessions.

·        How:  A typical health display emphasizes a healthy quality of life for Labrador people, focusing on prevention-based activities, local screening programs and resources.  Represented in the health display component are the Canadian Cancer Society, the Teen Tobacco Team, the Women’s Wellness Project, Walk a Mile in his Shoes (prostate screening awareness), etc.

School Module

The project is three pronged; the first aspect of which is a  School Module in which students are invited to participate in age appropriate activities:

·        Primary grades participate in an interactive puppet show starring child puppets depicting each of Labrador’s cultural groups, and a script involving the local Public Health Nurse and the community nursing clinic.

·        A Jeopardy game with prevention clues was developed by 4th year Nursing students for the Elementary grades;

·        Junior high students take part in a scavenger hunt involving the community displays; and

·        Senior high students participate in the preparation of a message that is presented back to the junior high school students in the community. Each year, a $200 bursary is presented to the school that presents the message with most impact. Depending on community, the school “productions” are also be presented at the Community sessions to tie the initiatives together and provide local identity.

Community Health Module

The Community Health module consists of two parts:

·        A health exhibit is displayed at each venue, with poster presentation, interactive opportunities, and culturally appropriate literature which emphasizes a healthy quality of life for Labrador people focusing on prevention-based activities, local screening programs and local resources.

·        In the evening, a panel presentation with the health professionals,  provides a venue through which the risks of cancer, the benefits of prevention and screening, and a question and answer period are addressed.

Health Care Providers Module

From the beginning, it was our intention to provide an information session to health service providers in each community, as keeping health workers up to date is a challenge with coastal isolation, low staffing complements, expanded scope of practice and high turnover.

To facilitate the process and ensure that all health organizations in the region were presenting uniform messages, the Medical Officer of Health sent copies of the Canadian cancer screening guidelines to each physician in the organization, and organized a Grand Rounds session to discuss current practice. The physicians found the session to be of tremendous value, and scheduled follow up meetings to make the process continuous.  Although not a part of the original plan, this aspect of the project helped to regionalize the initiative, as well as making it truly interdisciplinary on all care delivery planes.

The Travelling Health Show provides an excellent opportunity to bring community health workers and regional resource people together for collaboration, problem solving and skills training related to screening and diagnostics. In addition there are always new developments in the areas of cancer treatment, pain management and palliative care. This initiative has increased confidence, resource sharing and efficient referrals.

Evaluation:

A summative evaluation is planned.  In each community that has hosted a Travelling Health Show, data will be collected to measure the success of the project.  Some indicators are:

1.      The number of PSA lab tests done.

2.      The number of mammograms done, the waitlist and a breakdown of age groups and community.

3.      The number of school students who enroll in smoking cessation projects such as “Kick the Nic”.

The cost benefit analysis for a region as vast and challenging as Labrador is overwhelming.  $20,000 over a three year period is not a significant amount of money for the coverage and impact offered.  Moreover, as with most health prevention and promotion projects, the greatest benefit of this endeavour will be realized in the long term, as learning is internalized and lifestyle changes occur. 

Conclusion

Health Labrador Corporation has realized an additional benefit from the structure of the  ‘Travelling Road Show’.  The arrangement has proven to be so effective and efficient that administrators are planning for the first regional management road show, in which the Senior Administrators and Regional Managers will visit communities ‘en masse’.

We also recognize that there is a qualitative aspect to this initiative that is difficult to capture.  The high level of satisfaction of the “Show” members and communities, and the fun and personal empowerment of all that participate cannot be quantified, but will long have an effect on health promotion efforts in Labrador. 

2003 Third Place  

Disability Management in Health Care - Flavour of the Week or Strategic Organizational Program?

 by Maureen Meaney

Disability management, absence management, early and safe return to work, attendance support - all these terms are used to describe an organization’s efforts to reduce lost time due to illness and injury of its employees.  These programs are touted as being able to help employers deal with rising costs associated with lost time as well as increasing legislative pressures.  Disability management associations and consultants push them as “best practice solutions” or “the right thing to do”.  But do they work or are they just the “flavour of the week”? Not unlike other organizational initiatives, perhaps the success of the programs is all in the implementation strategy.  One health organization in Newfoundland and Labrador has shown that through a strategic focus and a bit of perseverance, success is possible.

Lost time related to absence and disability has had an increasingly significant impact on the Canadian economy.   According to the 2002 Statistics Canada Report, the days lost per workers for illness, disability and personal and family responsibilities has risen from 8.0 days in 1999 to 9.0 days in 2002.  This same report indicates that, in the Canadian health industry, that same statistic has climbed from 12.6 days lost per worker to 13.4 days lost per worker.[i]  The Newfoundland and Labrador health system experience has been all the more unsettling.  In 1999, the health boards in this province posted average sick leave days lost per worker of 15.84 days.  This figure had climbed to 17.23 days by the end of 2001.[ii]  Add to this high work-related injury rates and it’s easy to see why health organizations are concerned. 

There are many reasons reported for the increasing absence and injury rates both nationally and provincially – aging workforce, stress, illness, increased workload, job satisfaction, and competing demands of work and family, however few organizations have taken a hard look at solutions to the problem. The Health Care Corporation of St. John’s (HCCSJ) is one employer that has taken a strategic approach to solving this growing problem.

The recent history of the HCCSJ should sound familiar to other health boards in Canada – restructuring, layoffs, job actions, and financial restraint.  Despite the challenges associated with managing in this type of environment, the HCCSJ decided that it needed to place priority on developing programs aimed at supporting employees and lower absence levels related to work and non-work related injury and illness. 

Prior to the establishment of the Health Care Corporation of St. John’s, each of the former employers made efforts toward the management of workers’ compensation claims with varying degrees of success.  Each employer had a stand-alone Occupational Health Service and there were some programs in place for back injury prevention.  Few formal policies or processes were in place to support employees who were off work as a result of a non-occupational illness or injury. 

In 1996, the HCCSJ developed its Employee Wellness Model to begin to build linkages between the programs and resources dedicated to employee health and safety.  The five components of the Employee Wellness Model are: Injury Prevention/Occupational Health and Safety, Disability Management, Health Monitoring and Surveillance, Employee and Family Assistance and Health Promotion. 

While the model was helpful in creating ties amongst the human resources and clinical professionals working in the area, they still worked in silos.  They all reported independently to the Director of Human Resources.  In 1998, the Manager of Employee Wellness was put in place to lead the implementation of the Disability/Attendance Management initiatives and to bring the multi-disciplinary team of health and human resources professionals together with common goals, strengthened linkages and a team focus. 

With this, the team turned its attention to developing an integrated, disability management approach for occupational and non-occupational illness and injuries.  This approach includes proactive claims management, clinical recovery management and return to work support. 

The remainder of this article highlights some of the key factors that made the HCCSJ’s program a success.

1.      A strategic approach is taken to solving the problem and people are held accountable for results.

With limited financial resources and stretched human resources, it was important for the organization to carefully select its priorities.  The program had to be consistent with the organization’s direction and priorities in order to have the commitment it required from the board and senior management.  In its first five-year strategic plan, the HCCSJ identified attendance management and occupational health and safety as key strategic objectives and made it the mandate of the organization to support the resulting goals.  Each program and department was given accountability for helping carrying out these objectives. 

Managers were provided with training with respect to their role in the program and specific accountability mechanisms were put in place to have them report on their progress.  In the past year, a series of meetings were held with the top ten departments with the highest sick leave and workers’ compensation statistics to set expectations for improvement as well as to offer support.

2.      Key indicators track and measure outcomes of the program.

The HCCSJ identified early on in the process that many long-standing employee health and safety initiatives were not have the desired impact.  Early on in the process, the employee wellness team developed objective indicators to measure the outcomes of new and current programs.  Those initiatives that demonstrated that they added value to the organization were supported with additional resources.  Initiatives that didn’t deliver were put on the back burner or cut out altogether. Adopting philosophies of “what gets measured, gets done” and “you can’t fix what you don’t measure”, systems were developed to capture the following information:

These indicators are tracked and trended on a monthly, quarterly and annual basis and the information is shared widely with managers and employees to create awareness of the extent of the problem and the progress being made.

A database was also established to track and trend work-related incidents (lost-time, medical aid and report only).  This information has allowed the employee wellness team, managers and occupational health and safety committees to identify and respond to safety concerns in a timelier manner.  It also helps pinpoint “hotspots” that require longer-term attention.

3.      The input of union representatives was sought and acted upon along the way.

The HCCSJ tried to steer clear of the “abuse model” that is occasionally adopted to deal with absence problems.  Having found a great deal of distrust between union and management at the outset of the implementation, the HCCSJ realized that it was imperative to involve union representatives by gathering feedback and acting on their input where possible.  The Corporate Wellness Advisory Committee was one forum that provided the unions with a voice in the process.  The committee put labour and management representatives on an equal footing and allowed them to share in the success and failures of the program.  Unions maintained their autonomy to contest portions of the program that they felt they couldn’t support, however this was done outside the mandate of the committee.

In the past year, the HCCSJ has employed a NAPE Return to Work Coordinator who works directly within the employee wellness team.  This position was supported by both the HCCSJ and NAPE as a pilot.  The position has allowed NAPE and the HCCSJ to build a common understanding of return to work and accommodations for both occupational and non-occupational lost time cases. To date the pilot has been a tremendous success both qualitatively and financially. 

4.      Disability Management efforts are truly integrated into the larger employee wellness model

Through the employee wellness model, all employee wellness team members focus on the preventative and reactive sides of disability management.  This included the recent move of the Safety Officer position from Facilities Management into Employee Wellness.  Integrating occupational health and safety and return to work under the same umbrella helps the team understand that, while return to work options are very important, prevention is a critical factor in bringing down lost time rates.  It was felt that this would get lost if the focus was strictly on getting people back to work.  Employee wellness team members are able to move beyond the micro-organizational factors and to consider the global safety implications of returning an employee to the workplace without having addressed the problem that caused the injury in the first place.

5.      Early intervention and return to work represent the foundation of the disability management program.

 Research and industry experience support that the longer the employee is absent, the less likely it is that he or she will ever return to work.[iii]  The HCCSJ implemented several key strategies to build early intervention into their program.

 While the process was not without its bumps and bruises along the way, the HCCSJ’s program has achieved outstanding results.  The organization’s sick leave rate has dropped by 8-½ % since 1999/2000 and the workers’ compensation lost time rate has dropped by 22-½ %.  WHSCC claims durations have been cut in half leading to the HCCSJ receiving a discount on its WHSCC assessment rates two years in a row.  This success has filtered much-needed dollars back into a financially strained health care system and has allowed for further investment in programs to support employees. The organization has also been recognized by the National Institute for Disability Management and Research with an Award of Excellence. 

Along with the successes of the program come a number of lessons learned along the way:

2003 Honourable Mention

Can Newfoundland and Labrador Sustain its Informal Caregiving System?

by Trudy Read

Informal Caregiving: Families that Provide Care

Newfoundland and Labrador families traditionally have emerged from extended family structures within mainly rural communities. As in other Eastern Canadian provinces, families have depended primarily on spousal and adult children’s support for management of health, and acute and chronic illnesses (Parsons, 1997; Wuest, 1998). Attention to family caregiving arose with the escalation of situations in which the impaired or chronically ill elderly were taken care of by family members at home (Brody, 1990). Many families in Canada have expressed a wish to care for their relatives, regarding caregiving as rewarding, worthwhile work. However, the actual experiences of caregiving can exact a toll on informal caregivers, despite these positive aspects. With shorter hospital admissions and the resultant pressure on community-based care, families are expected to assume major responsibility for care of its members at home (Boland & Sims, 1996; Faison, Faria & Frank, 1999; Langille, MacLellan, & Berrigan, 1998; Rutman, 1996). The rather slippery notion of ‘community care’ or informal care tends to mean unpaid care provided by family members (Aronson, 1991).  

It is well known that family caregivers are at risk for physical, social, and financial burdens as a result of the intense work they do (Davies, Reimer, & Martens, 1994). Family caregivers are also at risk for their own health deterioration from fatigue, exhaustion, and burnout, sometimes compounding underlying health problems (Davis, Cowley, & Ryland, 1996). Even though caregivers value their caregiving roles, there is frequently associated physical and emotional sacrifice, and often, loss of income (Pincombe & Tooth, 1996). Compounding the challenges of caring for loved ones is that most provinces, including Newfoundland and Labrador, provide little or no job protection for those taking leave to provide care, and no province provides income security (Canadian Palliative Care Association, 2001). What is often challenging in this province is that many extended family members may be living away, creating further stress on the traditional family structure. A Canadian health system which emphasizes treatment of acute conditions greatly impacts the degree of caregiving expected by unpaid, non-professional caregivers (Ferrell & Borneman, 1999). In Newfoundland and Labrador, there is an urgent need to prepare professional caregivers for future health care needs of the population.

Significance of the Problem

During the last century, public health and clinical medicine have given people the opportunity to live longer and more productive lives, despite progressive illness (The SUPPORT Principal Investigators, 1995). Demographic trends in Canada show a steady increase in an elderly population with a concomitant rise in chronic illnesses (Deachman,1995; Statistics Canada, 2003a). The population of Canada in the age group 65 years of age and older is increasing at a rapid pace. At the turn of the twentieth century, the average life expectancy in Canada was 59 years; in 1990-1992, the average life expectancy was 77-78 years (Statistics Canada, 2003b). As people age, they often develop chronic conditions, with cancer, heart, cerebrovascular, and pulmonary diseases as the leading causes of death (Statistics Canada, 2003a). In 2001, the National Cancer Institute of Canada estimated there would be 65,300 deaths from cancer alone. In Canada, there were 217,688 deaths in 1997-1998; and, in 2001-2002, there were 231,232 deaths. In Newfoundland and Labrador, death rates increased from 4,340 in 1997-1998 to 4,420 in 2001-2002 (Statistics Canada, 2003c). Additionally, in 1996, seniors accounted for more than a third of Canadians living alone, and 71% of them were widows. Forty-eight % of those 85 and over lived by themselves in 1996; as seniors get older, their likelihood of living alone increases significantly. Women over 65 were more than twice as likely to live alone as men, explained by the fact that women, for the large part, outlive men (Statistics Canada, 1997). The General Social Survey in 1996 reported that well over half (59%) of widows living by themselves had at least one adult child who lived within 10 kilometres. There was a strong relationship between kin and living arrangements among surveyed Canadians (Statistics Canada, 1999). Interestingly, among the provinces, Newfoundland and Labrador had the lowest proportion of one-person households with less than 18% of men and women who lived alone. Furthermore, about 51% of all young Newfoundland and Labrador adults aged 20 to 29 were living in the parental home during the last census time. Also, this province had the lowest proportion (28%) of women over 85 who lived alone in Canada (Statistics Canada, 2001a). With an aging population and with more seniors cared for by families in Canada, the demand for care of the elderly will increase both at the community and institutional levels.

With Canada’s aging population and consequent chronic illnesses, the demand for informal caregiving is increasing. Economic changes in Canada and in Newfoundland and Labrador, and the recent closure of the Newfoundland and Labrador cod fishery, have resulted in many adult children working and living many kilometres away from their aging parents. The population of the province dropped from 551,792 in 1996 to 512,930 in 2001, a -7.0% change (Statistics Canada, 2003d). Demographic accounts of population change in 1996-2001 in the province indicated that the greatest decline in population occurred when young people aged 20-34 left the island, a -21% reduction in persons. On the other hand, the population of older citizens between the ages of 65 to over 90 years increased at a rate of 6.3% over the same time period.  As well, 30 to 44 year olds left the province at a rate of -10.8%, thus decreasing the potential caregiver age group as the older population was increasing (Statistics Canada, 2001b). For the aging parent, this “out migration” has resulted in seniors experiencing the loss of family support as they age and acquire chronic conditions. Women who potentially could have cared for ailing parents may be many miles away, thus diminishing the supply of informal caregivers available to parents facing chronic illness (Langille, MacLellan, & Berrigan, 1998).  Population projections for Newfoundland and Labrador over the next 10 years indicate that women aged 40-49 will decrease from 45,361 in 2003 to 39,280 in 2013, a -13.4% change in population. At the same time the number of male and female seniors 65 and over is projected to increase from 65,627 in 2003 to 86,325 in 2013, a 24% increase in the aging population over the next decade (Government of Newfoundland and Labrador, 2002).

What is challenging for families in this province is the declining supply of informal caregivers as our population is aging. Fiscal and economic restructuring of health and social services from institutional care to community-based care has not resulted in funding to back the rhetoric which claims care at home is best for all involved (Frederick & Fast, 1999). Finally, “The rise in the number of older people, the fall in the birth rate, and the rise in the gainful employment of women mean that it is impossible to return to some mythical golden age of community care” (Hall, 1990, pp. 139-140).

Implications

Both families and health professionals implement the emotional and physical work of caregiving. Formal caregivers need to develop an awareness of the impact of informal caregiving on individuals and their families. The needs of informal caregivers in Newfoundland and Labrador must be considered in program planning and health and social policy. Although family caregivers do their best under current health and social systems, there are ways government and health professionals can provide support to informal caregivers to improve outcomes for all. It is imperative that health boards and stakeholder organizations develop policies and offer support to reduce costs for all involved.

Traditional family caregiving in Newfoundland and Labrador is threatened by such trends as an aging population and the movement of adult children away from the island. It is crucial that existing health and community services programs do not inadvertently increase the care expectations of those left behind to provide informal care. Can Newfoundland and Labrador sustain its informal caregiving system? The answer to this question will emerge as future consumer demands impact the health system. To conclude, Canadians Frederick and Fast (1999) add support to the author’s comments:

Women (from the 1996 General Social Survey) who spent the most time helping seniors were primary caregivers who cared for dying relatives, lived with them, and were emotionally close to them. For both men and women, longer hours of care resulted in greater emotional and psychological burden and greater personal consequences . . . The current trend to community-based care, combined with the diminishing availability of informal caregivers, increases the risk of burnout for caregivers. Paradoxically, caregiver burnout may lead to the very outcome that everyone is trying to avoid: a greater need for institutionalization (pp. 29-30).

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Biography

Trudy Read 

Trudy Read is a Community Health Nurse employed by Health and Community Services Western in Deer Lake, NL. She graduated from the Halifax Infirmary in 1984 (RN), Memorial University of NL in 1998 (Bachelor of Nursing), and the University of New Brunswick in 2003 (Master of Nursing). Trudy has practiced nursing in Nova Scotia and Northern and Western NL. Her graduate thesis study involved informal caregiving, entitled, “Daughters Caring for Dying, Elderly Parents: A Process of Relinquishing.” Trudy enjoys spending time with her immediate family and, extended family that, like her, have returned to Newfoundland and Labrador, contrary to the trend of “out” migration.