Introduction
Nursing homes play a critical role in Canada’s health care system, providing personal, supportive, and medical care to residents who are unable to live independently. More than 200,000 residents live in 2,136 nursing homes across Canada (Statistics Canada, 2011). As Canada’s population ages, the number of older adults living in nursing homes is increasing, and residents are older, sicker, and require higher levels of care than ever before (Doupe et al., Reference Doupe, John, Chateau, Strang, Smele and Bozat-Emre2012; Manitoba Nurses Union, 2006). In recent years, Canadian nursing homes have become increasingly dependent on immigrant health care aides (Statistics Canada, 2008). Immigrant women represent almost one quarter of Canada’s health care aide labour force, and they make up 18.4 per cent of the total nursing home workforce (Statistics Canada, 2008).Footnote 1
Filipino women are particularly concentrated among health care aides in the Canadian health care system (Statistics Canada, 2008). Although they make up less than 1 per cent of the Canadian labour force, Filipino women represent 4.8 per cent of the health care aide workforce (Statistics Canada, 2008). Given the high prevalence of immigrant women, effective human resource planning requires an understanding of the demand for immigrant health care aides as well as of the factors that motivate them to enter the workforce. However, until recently, relatively little research has been done on immigrant health care aides and the essential role they play in the health care system.
The study in this article has addressed that gap in our understanding by examining the high concentration of Filipino health care aides employed in nursing homes in Winnipeg, Manitoba, from the perspectives of health care aides and health policy stakeholders. The study sought to answer the following questions: (1) What factors influence Filipino immigrant women to enter the health care aide labour force? (2) What is the relationship between the Filipino community and the labour market for health care aides? (3) What are the employment experiences of these health care aides? and (4) What can we learn from examining these issues about how long-term care is managed in Canadian nursing homes? To address these questions, I examined health care aides’ migration and employment experiences by means of in-depth interviews. Furthermore, through semi-structured interviews with health policy stakeholders, I analyzed the policy context of long-term care to identify policies and practices that impact the health care aide workforce.
Globalization of Care Work
Although the literature on health care aides is comparatively limited, the research can be situated within the broad framework of global migration and care workers. The Philippines has the world’s largest organized labour-exporting program; approximately 10 million Filipino migrants work in 197 countries around the world (Philippine Overseas Employment Administration [POEA], 2008). More than half of these migrants are women (POEA). The migration of Filipino women in particular has been described as “the widest flow of contemporary migration in the world today” (Parrenas, Reference Parrenas2008, p. 4), yet the labour market participation of Filipino women is relatively narrow, with millions of Filipino women concentrated in the care sectors of high-income countries (Parrenas).
Ehrenreich and Hochschild (Reference Ehrenreich and Hochschild2002) used the term “globalization of women’s work” to describe the rising numbers of migrant women performing care work in high-income countries (p.12). Research within this framework has focused primarily on nurses (Ball, Reference Ball2004; Bourgeault & Wrede, Reference Bourgeault and Wrede2008; Choy, Reference Choy2003; Stasiulis & Bakan, Reference Stasiulis and Bakan2005) and domestic workers (Ehrenreich & Hochschild, Reference Ehrenreich and Hochschild2002; Bakan & Stasiulis, Reference Bakan, Stasiulis, Bakan and Stasiulis1995; Lindio-McGovern, Reference Lindio-McGovern2003; Parrenas, Reference Parrenas2001; Pratt, Reference Pratt1999, Reference Pratt2008); comparatively few studies have investigated immigrant health care aides (Bourgeault, Atanackovic, Rashid, & Parpia, Reference Bourgeault, Atanackovic, Rashid and Parpia2010; Brown & Braun, Reference Brown and Braun2008; Spencer, Martin, Bougeault, & O’Shea, Reference Spencer, Martin, Bourgeault and O’Shea2010).
With an aging population worldwide, however, attention in this field has shifted from a focus on child care and domestic service to the provision of elder care (Anderson, Reference Anderson2007). Immigrant care workers play a significant and growing role in long-term care systems in Canada and elsewhere (Armstrong, Armstrong, & Scott-Dixon, Reference Armstrong, Armstrong and Scott-Dixon2008; Colombo, Llena-Nozal, Mercier, & Tjadens, Reference Colombo, Llena-Nozal, Mercier and Tjadens2011; Redfoot & Houser, Reference Redfoot and Houser2005). A small but growing body of work is considering the relationships between immigrant care workers and care recipients in long-term care. Research in this area has identified prejudices and discrimination towards care workers (Doyle & Timonen, Reference Doyle and Timonen2009), and it has also identified the impact of linguistic and cultural barriers on care relationships (Bourgeault et al., Reference Bourgeault, Atanackovic, Rashid and Parpia2010; Walsh & Shutes, Reference Walsh and Shutes2013). Although Filipino nursing home workers were included in these studies, they were part of larger samples comprising care workers from different occupations, different sectors of the long-term care system, and various countries of origin.
In fact, much of the literature on the globalization of care work uses the term care work to refer to a range of occupations traditionally associated with women’s work (e.g., nurses, health care aides, child care providers, live-in caregivers, and domestic workers). These occupations are gendered and often filled by immigrant women from developing countries (Ehrenreich & Hochschild, Reference Ehrenreich and Hochschild2002). Important distinctions, however, characterize these occupations. In Manitoba, the majority of health care aides in the nursing home workforce are employed in unionized positions providing frontline care to residents with complex health conditions. The aides’ occupational status and working conditions differ significantly from those of nurses, home care workers, and domestic workers. Furthermore, their migration pathways differ. In Canada, nurses and live-in caregivers may be recruited internationally, but health care aides are not. Given their different labour markets, employment conditions, and migration pathways, my intention is for this study to add to the literature by examining the intersections between Filipino women’s migration to Manitoba and the nursing home labour market.
Care Work and Migrant Social Networks
Although the literature on global migration patterns provides a necessary macro focus, it does not explain how migrant care workers secure and organize employment in the destination country. Social network theory offers a useful perspective on how these processes unfold, shape, and are shaped by, labour markets. Recent empirical research on immigrant caregivers in the United Kingdom, Ireland, Canada, and the United States indicates that immigrant care workers use informal networks to secure employment in older adult care. Specifically, Spencer et al. (Reference Spencer, Martin, Bourgeault and O’Shea2010) found that recruitment agencies do not play a significant role in the migration or employment of direct care workers, such as health care aides. Rather, informal (word of mouth) networks direct immigrants to seek work in long-term care. Employers also utilize informal social networks, relying on referrals to recruit new employees (Spencer et al., Reference Spencer, Martin, Bourgeault and O’Shea2010).
Migrant social networks refer to a set of social ties linking migrants and non-migrants in origin and destination communities “through the bonds of kinship, friendship, and shared community origin” (Massey, Reference Massey1988, p. 396). According to migrant social network theory, labour migration occurs within the context of social relations, whereby migrants “draw upon obligations implicit in relationships such as kinship and friendship to gain access to employment and assistance at the point of destination” (Massey et al., Reference Massey, Arango, Hugo, Kouaouci, Pellegrino and Taylor1993, p. 449). In addition to linking people, social networks connect “immigrants and the institutions that sustain them” (Waldinger & Lichter, Reference Waldinger and Lichter2003, p. 3). The social networks that span immigrant communities can direct immigrants into occupational niches, predominantly low-status jobs that native-born workers are reluctant to fill. Because migrants tend to follow their family and friends, they make use of these social connections when searching for employment. These social ties convey information about the job market, providing social supports and referrals that ultimately impact the social organization of labour (Waldinger & Lichter).
In contrast to the macro-level perspectives of the literature on globalization and care work, social network theory offers a micro-level approach focused on informal organization among immigrants (Portes, Reference Portes2007). Although the two theoretical perspectives approach their subject through different analytical lenses, they are not necessarily contradictory. Massey et al. (Reference Massey, Arango, Hugo, Kouaouci, Pellegrino and Taylor1993) asserted that the complexity of contemporary migration “requires a sophisticated theory that incorporates a variety of perspectives, levels and assumptions” (p. 432). The two complementary perspectives provide insight into the prevalence of Filipino health care aides from different analytical levels – the global processes facilitating this movement and the social networks linking immigrants to occupational niches.
Context of the Study
Nursing homes provide basic services, supportive care, and professional nursing care to residents who are unable to live on their own. Health care aides represent the largest group of workers in nursing homes and the fastest growing sector of the nursing workforce (Pyper, Reference Pyper2004). As already indicated, Filipino women are significantly over-represented among health care aides in Canada (Statistics Canada, 2008). Filipino women are particularly concentrated within the health care aide workforce of Winnipeg, a mid-sized city and the capital of the province of Manitoba. According to 2006 Statistics Canada census data, almost one half (45%) of all health aides working in Winnipeg were born abroad, and 20.1 per cent of health care aides are Canadians of Filipino origin (Statistics Canada, 2008).
Winnipeg is home to Canada’s oldest Filipino community and has the highest proportion of Filipinos of all Canadian cities (Statistics Canada, 2007). The Filipino population in Winnipeg reached 37,000 in 2006, accounting for approximately 5.9 per cent of the city’s population (Statistics Canada). In 2011, the Philippines represented the largest source country of immigrants to Manitoba, the majority of whom applied as economic immigrants (Manitoba Labour and Immigration, 2012). Other Filipinos have immigrated to Canada as family class or refugee class immigrants, or through temporary foreign work programs such as the Live-in Caregiver Program. The large Filipino population and substantial health care sector make Winnipeg an ideal location for a study of Filipino health care aides.
Methods
Qualitative interviews were conducted with Filipino health care aides working in nursing homes and with health policy stakeholders. In-depth interviews with Filipino health care aides explored their decisions to migrate, their settlement experiences in Winnipeg, and their work experiences as health care aides. Semi-structured interviews were conducted with health policy stakeholders to examine long-term care policies and management practices that have an impact on the health care aide labour force.
Ethical approval was obtained from the Health Research Ethics Board at the University of Manitoba. Permission to recruit health care aides was obtained from the Winnipeg Regional Health Authority and participating institutions. Recruitment took place over a one-year period, from June 2009 to July 2010. All participants signed written informed consent forms prior to participating in interviews.
Health Care Aides
Filipino immigrant women working as health care aides in nursing homes were recruited by means of snowball sampling as well as by advertisements posted in three Winnipeg nursing homes. The study sample consisted of seven female health care aides, born in the Philippines, currently working in a Winnipeg nursing home. The sample included health care aides with different lengths of residence in Canada in order to capture the experiences of Filipino health care aides over time and shed light on the changing structure of the long-term care labour force in Winnipeg.
The recruitment of health care aides for this study presented several challenges. Several participants chose not to provide referrals for potential candidates, explaining that their co-workers have multiple jobs and family responsibilities. The reluctance of women who hold multiple jobs to participate in this study may have introduced a sample bias favoring women with regular, full-time employment. Five of the seven participants held full-time positions, and they had each worked as health care aides for 10 years or more.
An in-depth, semi-structured interview lasting approximately two hours was conducted with each health care aide. The interviews were conducted in English. In addition, a short questionnaire was administered at the start of the interview to obtain basic demographic characteristics, employment history, and migration dates. Five of the seven interviews were recorded and subsequently transcribed. Two health care aides chose not to have the interviews recorded, so notes were taken during these interviews instead.
The interview guide was a modified version of the questionnaire developed and pilot-tested across four countries by Spencer et al. (Reference Spencer, Martin, Bourgeault and O’Shea2010) for an international study of migrant care workers. For the present study, participants were asked questions about their migration histories including their reasons for leaving the Philippines, the circumstances surrounding their decision to migrate, and why they chose to immigrate to Canada. Next, they were asked a series of open-ended questions about their employment history. These questions traced their education and work history from the Philippines to Canada and explored their reasons for becoming health care aides and taking up employment in nursing homes. The last section of the interview centered on their experiences as health care aides and included questions about their work life, training, and job satisfaction.
Health Policy Stakeholders
A purposive sampling approach was used to select health policy stakeholders. This strategy involved identifying administrators and managers of the health care aide labour force and contacting them directly to request an interview. Potential volunteers were identified through websites for nursing homes and through government bodies and unions representing health care workers. Seven interviews were conducted with policy stakeholders, including two administrators of long-term care who worked for regional health authorities in the province of Manitoba, two managers of nursing homes, one union representative, and two representatives from the Department of Labour and Immigration. Six of the seven interviews were conducted in person. One administrator chose to have the interview conducted over the phone. Each interview lasted between 30 and 45 minutes, was recorded, and subsequently was transcribed. Stakeholders were asked about the policies that impact the nursing home workforce, recruitment and hiring practices, and the factors contributing to the high concentration of Filipino health care aides in Winnipeg.
Interview transcripts, field notes, and questionnaire responses were analyzed using QSR International’s NVivo 8 software. A preliminary coding scheme was developed and cross-referenced with the literature on immigrant care workers, Philippine migration, and nursing home work in Canada. Transcripts and interview field notes were read and re-read to identify themes in health care aides’ and health policy stakeholders’ responses. This process generated a preliminary list of themes for each participant group. The key themes that emerged from the health care aide and health policy interviews were compared to determine similarities and differences. Once the coding scheme was finalized, the transcripts and field notes were coded using NVivo 8 software. To ensure confidentiality, code numbers were used in place of participants’ names, preceded by (HCA) for health care aides or (HP) for health policy stakeholders.
To strengthen the validity of the research findings, the study employed data triangulation which refers to the use of multiple data sources in a single study (Creswell, Reference Creswell2009; Patton, Reference Patton2002). Data collected from interviews with health care aides were compared and contrasted with the findings from interviews with health policy stakeholders. This process revealed connections between the migration and employment experiences of Filipino health care aides and the policy context of nursing homes in Manitoba. Cross-referencing interviews with health care aides and health policy stakeholders also illuminated discrepancies between both data sources. Although small sample size limits the generalizability of the results, the comparative approach provided an in-depth analysis of the concentration of Filipino health care aides from multiple perspectives.
Findings
Study Population
The health care aides in this study immigrated to Canada over a period of 40 years, between 1969 and 2009. Six out of the seven health care aides were Canadian citizens, and one had landed immigrant status. Most (five out of seven) were sponsored by their relatives and immigrated through a family reunification program; three were sponsored by a relative who worked in Winnipeg’s garment industry. One participant came to Canada through the live-in caregiver program to work for a family member. Their ages ranged from 40 to over 60. Six of the health care aides were married; and six had children, all of whom were living in Canada.
The women came from different regions of the Philippines with various levels of education. Three had attained university degrees, two had some university, and two identified their health care aide certificate as their highest level of education. None of the aides came to Canada with the intention to work as health care aides; they each decided to work in long-term care after arriving in Canada. In fact, no one had previous older adult care work experience or training in the Philippines. Their experience working in nursing homes in Canada ranged from four months to 35 years. They worked in for-profit and not-for-profit facilities; several worked in multiple facilities and different sectors of long-term care.
Poverty, Unemployment, and Underemployment in the Philippines
Health care aides (identified here as HCA-01 through HCA-07) cited poverty, unemployment, and underemployment as their primary reasons for emigrating from the Philippines. Although they had diverse educational backgrounds, each aide struggled to provide for themselves and their families. Some of the aides grew up on farms in rural Philippines and described the challenges of poverty and unemployment:
To live [in] the Philippines, we were nine in that family, nine children. My eldest sister was the one who came here first. My dad was a farmer and my mom was a housewife. So imagine nine children: the way of living back home – there [are] lots of people but [a] lack of jobs. Even though you want to work, there [are] no jobs. (HCA-03)
Those who were able to obtain jobs in the Philippines endured poor working conditions, long hours, low wages, and job insecurity. For example, HCA-05 worked as a teacher, and her husband was an electrician. Their combined salary was not enough to support their family:
I was professional and my husband had a good job too, but it was really hard … That’s the frustrating thing: even though you have a degree, most of the professionals don’t have a job. I have a good job, but the salary that we are earning is not enough … So that’s why most of the professionals – they go in different countries to have a better future, for greener pastures.
Whether they lived on farms in rural areas or worked as professionals in large cities, each health care aide felt that migration was their only option to secure sufficient income for themselves and their families.
Migration and Social Networks
Although poverty and unemployment propelled their migration, transnational connections among Filipinos provided the opportunity and resources to move abroad. HCA-01, who had the earliest date of entry to Canada, was the only participant who did not have a familial connection to Manitoba before she immigrated. The other six health care aides had at least one relative who preceded them to Canada. Consequently, most of them were sponsored by their relatives and immigrated through a family reunification program.
Health care aides’ migration patterns suggest that women’s migration can be instrumental for subsequent family migration. Six of the seven health care aides had sponsored multiple family members to immigrate to Canada. The only participant in the study who had not sponsored any relatives was the most recent arrival to the country. Having been in Canada for less than a year, she had already begun the process to sponsor her four sisters.
Barriers in the Labour Market
All of the health care aides immigrated to Canada in search of work to support themselves and their families. Some of them were single women, responsible for sending remittances to their families abroad. Others had children of their own to support. The high cost of immigrating put additional financial pressure on recent arrivals. They came in search of employment, but many of the health care aides encountered multiple barriers in the labour market including accreditation, language requirements, and job insecurity. The barriers they faced as immigrant women shaped their decisions to work in nursing homes.
Three out of seven health care aides had university degrees from the Philippines, but none of them were able to work in their chosen field in Manitoba. HCA-05 moved to Canada along with her husband and her children in 2004. A school teacher in the Philippines, she described her experience looking for work in Canada:
I tried to apply what I learned in the Philippines, but wherever I go, they are looking for certificates from here. So, how can I [have a Canadian certificate] if I just came here? So, to make it short, they didn’t recognize my paper. I was miserable. It’s really hard.
Speaking English as a second language created additional barriers for health care aides seeking employment. For example, HCA-04 was an accountant in the Philippines. Her written work was conducted in English, but she felt that her oral English skills prevented her from working as an accountant in Manitoba.
As immigrant women, participants faced challenges in the labour market including accreditation and language barriers. As mothers and daughters, they had a responsibility to financially support their families in Canada and abroad. These two factors – financial need and limited opportunities for work – formed the context for their decisions to work as health care aides.
Employment and Social Networks
In light of the barriers they faced in the labour market, health care aides drew on their social networks to obtain information about the job market. Each participant had a family member or friend working in long-term care who influenced her decision to work as a health care aide. Among health care aides with the earliest dates of entry to Canada, their social connections to long-term care workers were non-familial, consisting of friends and acquaintances. Health care aides with later dates of entry to Canada arrived with established ties to nursing home workers; some were sponsored by relatives in Canada who worked in long-term care, and others had multiple family members working as health care aides. Social connections provided information about the job and educational programs, encouragement and, in some cases, referrals for positions in nursing homes. These social networks acted as pathways linking migrants to employment opportunities in long-term care.
The simultaneous recruitment in the late 1960s of Filipino nurses and garment workers to Canada resulted in social connections between both groups within a small community of mostly female immigrants. HCA-01, who was recruited to work in Winnipeg’s garment industry in 1969, learned about employment opportunities in nursing homes through a nurse from Philippine community in Winnipeg. She recounted how she and other Filipino garment workers learned about job openings in nursing homes after completing two-year contracts with garment factories:
I had a friend that I asked her, where do you work? She says to me that, “I’m working in a nursing home.” That friend of me is a nurse from the Philippines but she first came [to Canada] from United States. It’s because [there were] only a few Filipinos [here] at that time, we most[ly] know each other. I [asked] her: “how to get in?” She said you can just go there and apply and they will interview you … To be as a health care aide at that time, they [were] not forcing us to have a certificate.
Interviews with Filipino health care aides indicated that the formation of the Filipino health care aide labour force in Winnipeg traced back to the social connections between Filipino garment workers and nurses beginning in the late 1960s. Over time, migration to Winnipeg accelerated, and the networks among Filipino women working in nursing homes expanded.
In the 1990s, nursing homes began to require certification for health care aides. Health care aides who arrived since that time described how family members and relatives encouraged them to take the health care aide training program:
Some friends, and then my aunt also, who is a [registered nurse] … said, “health care aide [position] is better for you, for security reasons and it is in demand.” So from there, I decided to take a health care aide course, [which was being offered] for only four and a half months. (HCA-06)
The first [relative who encouraged me] is my sister-in-law. And then after my sister-in-law, I made a decision; I can be a health care aide too. And then here comes another, my sister-in-law, and she’s a health care aide now too. (HCA-05)
HCA-04 was the most recent arrival in the study sample. When she arrived in Winnipeg in 2009, she came with established social connections to nursing home workers: her sponsor was a health care aide and HCA-04 had several relatives and friends from the Philippines working in Winnipeg’s nursing homes. Thirty-five years after HCA-01 first learned about a job opportunity in a nursing home through a friend who was a nurse, social networks among Filipino health care aides have expanded considerably.
Employers and Social Networks
Employers (identified here as HP-01 through HP-07) also use social networks. According to health care aides and managers, referral-based hiring is common within Winnipeg’s nursing homes. As a result, nursing homes often employ extended family networks. A long-term care administrator commented on the extent of social networks within long-term care facilities:
There’s a lot of networking. In fact, in most personal care homes it’s amazing the number of relations that are working together, because they know the place, they know the people. (HP-01)
When asked about the prevalence of social networks within the nursing home workforce, health policy stakeholders tended to emphasize the role of health care aides, rather than employers. For example, a director of a nursing home commented:
People go where – well, their friends say: “I’m working down the street, why don’t you come?” So they come where the friends are because they’re comfortable. (HP-05)
Referral-based hiring offers several advantages for employers. Referrals reduce the costs and risks of hiring new staff, in part because the employee has a stake in the performance of the new recruit, especially if it is a family member (Waldinger & Lichter, Reference Waldinger and Lichter2003). Using employees’ informal networks to bring forth new recruits also allows employers to avoid the cost of recruitment strategies, and they do not have to increase wages or improve working conditions to attract Canadian-born workers. None of the health policy stakeholders acknowledged the benefits of this recruitment strategy for employers or long-term care institutions. In fact, they tended to focus on the role of health care aides in perpetuating this practice. Nevertheless, health care aides and health policy stakeholders identified informal social networks as a significant factor contributing to the high concentration of Filipino health care aides.
Incentives
In addition to facilitating migration, social networks link Filipino immigrants with employment opportunities in long-term care by providing employment information. Health care aides identified four key incentives conveyed by family members or friends that influenced their decision to work as aides: (1) jobs are in demand; (2) the training period is relatively short; (3) jobs are secure; and (4) wages are relatively high. For example, HCA-02 commented:
It is a stable job, even though it is hard. There are no layoffs, [and] it’s always in demand because people are aging.
Job security was a priority for most of the health care aides, especially for those who had endured layoffs in the Philippines and elsewhere in Winnipeg. The collapse of Winnipeg’s garment industry in the 1990s left thousands of Filipino immigrants, mostly women, out of work. The economic impact was so profound that it influenced health care aides’ choice of work, whether or not they had ever worked in a factory.
Working in a hospital, in a facility, it’s a secure job, there’s no layoffs or [anything]. If you go to a company or something, sometimes they have layoffs because they’re going bankrupt or something. So what am I going to do? But if you are working in a facility, in a hospital or nursing home – those are forever … If you go to a sewing factory and they close [you can lose your job] . With this kind of job it’s security. (HCA-06)
For some of the health care aides, particularly those who hoped to move into other areas of work, the opportunity to improve their English skills and gain experience working with people provided additional incentives to work as health care aides. Flexible hours were also an attractive feature, as it allowed women to balance work and family life.
The incentives identified by health care aides reflect their earlier experiences in the labour market: unemployment, job insecurity, low wages, and lack of recognition for their education. Compared to their previous employment, health care aides felt that working in nursing homes was more secure and higher paying. They valued the short training time because it allowed them to enter the workforce quickly and provide financial support to their families in Canada and abroad.
Long-Term Care Policy Context
Interviews with health care aides and health policy stakeholders identified several aspects of the long-term care policy context that shape the composition of the workforce and contribute to the high concentration of Filipino health care aides in Winnipeg’s nursing homes. The lack of formal education requirements for health care aides and the absence of regulations for certification programs enabled Filipino social networks to expand in the workforce. For-profit vocational schools may also contribute to the high proportion of Filipino health care aides by maintaining lenient admissions criteria and promoting health care aide work as a continuously open job market (Novek, Reference Novek2011).
Health Care Aide Training Programs
Until the 1990s, there were no formal requirements for health care aides. With no education or language requirements, the three health care aides who entered the workforce during that period used personal referrals to obtain work. For example, HCA-03 described obtaining her first job in a nursing home:
[At] that time you [didn’t] even have to have a certificate. You didn’t even have to have experience. You just know somebody in there and they train you.
HCA-03’s comment illustrates the connection between the lack of formal training requirements and referral-based hiring practices. The move to require certification for health care aides in the 1990s may have restricted access to jobs, but training programs were and are unregulated. There are no standardized qualifications for health care aides entering or graduating from educational programs. Whereas some public institutions adopted standardized admissions criteria, many for-profit schools have not, which facilitates access for immigrant students.
Managers of nursing homes were particularly concerned with the lack of standards and the absence of a common curriculum for health care aides. They have argued that standards are necessary to reduce discrepancies between educational institutions and to ensure that health care aides are qualified for an increasingly complex workload. For example, a long-term care administrator commented:
Health care aides: it used to be that they didn’t have to be certified. Now they need to have a health care aide certificate. There aren’t any regulations at this point in time relative to having to have an approval process; there isn’t a competency assessment. What we’re finding is that there are some very good programs and there are some not-so-good programs. Therefore, when a health care aide is arriving [in Canada], there’s a huge continuum of skill and knowledge they are bringing to the job. You need to know which programs are good, which are not, which are acceptable. (HP-01)
On the other hand, another administrator cautioned that regulations could create recruitment problems. HP-03 was concerned that regulations would restrict the pool of potential health care aides, leading to a shortage of workers:
Well, it’s been debated for quite some time … Would it be beneficial? Certainly, anytime you introduce consistent standards there is a benefit to doing that. But there is also a price to pay for that. So if you start elevating a standard – not that that is bad, but you start getting more restrictive on who can go in. So the trade-off is always “we need health care aides, they are the bulk of our workforce. If we restrict entry into programs, do we have fewer people that go into the programs?” So what’s more important: a consistent standard of care or having enough hands to get the job done?
HP-03’s comment illustrates the tension between formal requirements and the supply of immigrant labour. It also suggests that Manitoba’s reluctance to regulate health care aide training programs is part of a strategy designed to maintain a steady supply of low-skilled workers. The lack of regulations for health care aide training programs is based on the perception of a shortage of workers, but there is no system in place to record the number of health care aides or to estimate staffing needs.
Job Demand
Just as health care aides tended to view their work as secure and in-demand, administrators, managers, and the union representative espoused the idea of a shortage of health care aides. However, some health care aides and managers challenged the notion of a shortage. HCA-06 argued that there are many unemployed and underemployed health care aides looking for work: “I know they said that it’s a shortage, but there are lots of people who really want a job.” One manager agreed that facilities experience shortages, but proposed that it is primarily a recruitment and retention problem due to low wages and the lack of full-time positions. According to both health care aides and managers, new workers can expect to work in casual positions for several years until they have garnered the seniority to secure a regular part-time position.
Another manager and a union representative further argued that the abundance of casual and part-time positions creates scheduling conflicts that lead to chronic understaffing. According to HP-02, facilities intentionally keep their workforce underemployed to maintain a flexible labour force:
It’s in the best interest of the organization to have part-time staff to fill in their hours. So you almost create a need in your staff to pick up extra hours, which again, only serves the organization.
Despite the abundance of training programs and the proliferation of casual work, the notion of a health care aide shortage has persisted. The high proportion of immigrant health care aides has shaped policy stakeholders’ perceptions of the labour market: the growing concentration of immigrant women has often been viewed as an indication of a labour shortage and used as a rationale for avoiding regulations and increasing staffing. In contrast, some health care aides and managers argued that there is a large pool of underemployed health care aides unable to attain regular employment.
Work Life: Stressful yet Rewarding
Health care aides described their work as stressful and demanding but also rewarding. They identified several factors that contribute to the physical and emotional stress of their job including casual and part-time work arrangements, nursing home resident health, and staffing levels. Health policy stakeholders saw casual employment as necessary but problematic because it leads to scheduling problems and chronic understaffing. Health care aides described casual employment as unreliable and inadequate, and preferred full-time and regular arrangements. For example, HCA-07 worked for seven years before she was able to obtain a full-time position. She described how she coped with part-time work:
Before I was only [part-time] when I started. Sometimes there’s no [shifts to pick up] whatsoever, I do agency too just to combine. I [gained] experience from agency too; I did home care for a year.
Health care aides expressed concern about the increasing burden of illness and challenging behaviours among nursing home residents. Residents are increasingly more likely to have dementia and immobility, and to require total assistance for activities of daily living. For health care aides, this has resulted in a heavier workload, injury, and burnout:
Before, the work was easier, now health care aides have a heavier workload. In the past, residents needed care, but they were still independent; health care aides would just give [them] assistance. (HCA-02)
Health care aides were particularly concerned with aggressive and violent behavior among residents. All of the health care aides had encountered violence in the workplace:
Sometimes they pull your hair, they kick you, they spit on you, they throw food on you, anything that they can … If it’s like that, we report it to the nurse, and to our supervisor, and then they say, “you leave them”. But, OK, leave them for now: then you have to come back again later, and they’re [still] like that later, so what are you going to do? (HCA-03)
Six out of seven health care aides felt that the ratio of aides to residents is inadequate and should be increased in order to support an increasingly demanding workload. With heavy workloads and chronic understaffing, health care aides often have to ration care. Participants gave accounts of situations where they were unable to respond to residents’ needs or where they provided inadequate care due to time and staff constraints. When sharing these stories, health care aides often became emotional:
If you work midnight, you have to get everyone up at five in the morning and put them to the chair. That’s inhumane! Because they have a quota to get them up to help the day staff. If you have extra staff to do that you don’t need to wake them up at five in the morning. (HCA-06)
Sometimes there are three people who put their light on [at the same time]; everybody needs to go to the washroom. What are you going to do? And sometimes you can’t leave them alone, you have to wait. So what happens to the [other] two? They end up doing it in their chair. Sometimes they still have this [their mind], eh. And they are so embarrassed that they did it in the chair. (HCA-03)
Rewarding Work
Though the work is stressful and demanding, it is also highly rewarding. Health care aides regarded their work as essential caregiving provided to people who require high levels of care. They emphasized the clinical and interpersonal skills they employed when working with residents. For example, several participants described monitoring residents’ health conditions, including sores, rashes, weight loss, and respiratory problems. They also highlighted the specialized interpersonal skills they applied when working with residents who exhibited challenging behaviours associated with dementia:
When I make the resident happy. I love – … let’s say when they lost weight and when I help them gain weight, or let’s say they have sores and I help them. Some of them, when they come from the hospital, they have lots of sores, then they improve. It’s a gift … it’s priceless, you know, the feeling. (HCA-03)
It depends; there’s a time that they’re really bad, and there’s a time that they’re good. So you re-approach them. They don’t know what they are doing, and if you talk to them they calm down. It depends how you talk to them, [how] you approach them. You have to have the experience, really, because some of them really are violent. (HCA-01)
The rewarding aspects of their work were often explained within the context of Filipino culture. Health care aides commonly compared residents to their parents, and referred to feeling “at home” in nursing homes. They drew on Filipino cultural ideals of love and caregiving to impart value and meaning to their work:
For us, we look after our parents, if you just think about your parents; you will be a good health care aide. I see residents as parents. (HCA-02)
As a daughter it’s naturally you have to help your parents: no matter what, you have to help them. It’s a part of our culture. (HCA-07)
Although financial incentives drew them into the field, health care aides valued the non-economic aspects of their work, regarding it as essential caregiving. They valued their relationships with residents and families, and felt that they made a positive impact on residents’ quality of life.
Discussion
Theoretical work on globalization and care work suggests that contemporary female migration patterns are shaped by global inequalities that direct migrant women from low-income countries into the care sectors of high-income countries (Brown & Braun, Reference Brown and Braun2008; Ehrenreich & Hochschild, Reference Ehrenreich and Hochschild2002; Lindio-McGovern, Reference Lindio-McGovern2003; Parrenas, Reference Parrenas2001, Reference Parrenas2008; Stasiulis and Bakan, Reference Stasiulis and Bakan2005). The women in this study were part of a global movement of female labour. In their home country, all participants were unable to earn sufficient income to support themselves or their families. On the other hand, experiences of poverty in the Philippines did not directly lead to health care aide work in Canada. Unlike many Filipino nurses and live-in caregivers, the women in this study were not recruited from overseas to work as health care aides, nor did they come to Canada with the intention to work in older adult care. Rather, their decisions to work in long-term care grew out of their experiences as immigrants and were mediated by social networks encountered in Canada.
Once in Canada, health care aides encountered multiple barriers in the labour market. Their high school and post-secondary credentials from the Philippines were not recognized in Winnipeg, and language barriers posed an additional disadvantage. In pursuit of employment, health care aides turned to their friends and family members to gain advice on the labour market and to obtain referrals for job openings. These social networks acted as pathways linking Filipino immigrants with employment opportunities in nursing homes. In addition to providing referrals, social networks communicated incentives about health care aide work that attracted Filipino immigrants to the occupation. They furnished a key part of the connection between female migration from the Philippines and Winnipeg’s long-term care labour market.
According to social network theory, migrant social networks tend to expand once in place (Massey et al., Reference Massey, Arango, Hugo, Kouaouci, Pellegrino and Taylor1993). The migration histories of health care aides compiled in this study support this hypothesis. Health care aides with the earliest dates of entry to Canada were introduced to nursing home workers through friends and acquaintances they met in Winnipeg. Health care aides with later dates of entry to Canada arrived with established ties to nursing home workers. For example, when HCA-04 arrived in 2009, she had multiple family members and friends from the Philippines working as health care aides in Winnipeg’s nursing homes. Shortly after she immigrated to Winnipeg, HCA-04 was encouraged by her cousin, who was working as a health care aide in a nursing home, to enroll in a health care aide certification program.
The use of informal networks among health care aides and nursing home employers is consistent with findings from an international study of immigrant care workers in Canada, Ireland, the United Kingdom, and the United States (Spencer et al., Reference Spencer, Martin, Bourgeault and O’Shea2010). The four country study found that foreign-born direct care staff often use referrals from friends and family to obtain employment. Employers also take advantage of informal networks among immigrant care workers to recruit new employees. The study described here applied social network theory to build on those findings by situating social networks within the context of Filipino women’s migration and settlement experiences, along with the nursing home policies and employment conditions that promote and sustain social networks in the workforce.
The migration histories of Filipino health care aides suggest that the origins of Winnipeg’s Filipino health care aide workforce trace back to the formation of the Filipino community in Winnipeg. The simultaneous recruitment of nurses and garment workers from the Philippines resulted in social connections between both groups in a relatively small community. After learning about job opportunities from Filipino nurses working in nursing homes, garment workers began to take up work as health care aides. Over time, migration to Winnipeg accelerated and the networks of Filipino women working in nursing homes expanded.
This study also identified several aspects of the long-term care policy that sustain the supply of immigrant labour and promote the expansion of Filipino social networks in the workforce. Until the 1990s, there were no formal requirements for health care aides. This enabled Filipino women without recognized education credentials and with varying degrees of fluency to enter the workforce. Facilities began to require certification in the 1990s, but certification programs still lack regulations. Although some programs require up to a year of training, others are only four months in duration, a much more accessible option for immigrants eager to enter the workforce. On one hand, the lack of regulations facilitates the entry of immigrant women into the long-term care labour force. On the other hand, it contributes to the low-skill categorization of health care aides and may force a disproportionate number of immigrant health care aides to pay higher tuition fees at for-profit schools compared to Canadian-born students.
Although their migration and employment decisions were primarily based on financial need, once employed as health care aides, the women in this study developed an appreciation for the non-economic aspects of their work. They viewed their work as critical caregiving to residents with complex health conditions and highlighted the skills, work ethic, and compassion that their job demands. Many of them referred to Filipino cultural ideals of love and caregiving to explain the meaning and value of their work. By doing so, health care aides minimized the stigma of working in nursing homes, and emphasized the personal and cultural value of their work.
Given the small sample size, the results of this study should be interpreted with caution. As already noted, the recruitment of health care aides presented several challenges and may have introduced a sample bias favoring women with regular, full-time employment. On the other hand, in-depth interviews provided rich illustrations of issues identified in the literature on immigrant care workers. The themes that emerged from interviews with health care aides corresponded to findings in related research projects and also identified topics for future research.
Conclusion
Canadian nursing homes have become increasingly dependent on immigrant health care aides, yet our understanding of their role in the long-term care system and the factors that contribute to their employment remains limited. Few studies have looked at immigrant health care aides and even fewer have addressed Filipino health care aides working in nursing homes. The study described here has addressed this gap in the literature by exploring the high concentration of Filipino health care aides in nursing homes from the aides’ perspectives as well as that of policy stakeholders. By doing so, the study has shed light on the various connections between Philippine migration to Manitoba, the nursing home labour market, and the policy context impacting the labour force.
The findings from this study indicate that the health care aide labour market depends on the international migration of women and the social networks that support immigrant employment. The make-up of the labour force is also shaped by management strategies and labour market accommodations that respond to and reinforce these social networks. For example, the lack of formal requirements for health care aide certification programs enables immigrant women without recognized high school diplomas or with minimum English language facility to enter the occupation. For-profit schools have responded to this market, providing accessible training programs and targeting immigrant women in their marketing campaigns.
The nursing homes’ current recruitment strategy relies on lenient admissions criteria and social networks among health care aides to draw care workers into the labour market. Although this strategy reduces costs to employers and enables immigrant workers to enter the workforce, the approach has several potential drawbacks. First, over-reliance on migrant social networks may leave the labour market vulnerable to changes in migration patterns as well as the changing employment preferences of Filipino immigrants in Winnipeg. For example, recent increases in tuition fees and the proliferation of casual work may cause health care aides to reconsider recommending the training program to friends and relatives.
Furthermore, this strategy is based on the notion of a shortage of workers, a notion that may be something of an illusion. There is no system in place to keep track of the number of health care aides, and there are no publicly available studies estimating future staffing needs in Manitoba. In fact, several managers and health care aides challenged the notion of a shortage of workers, arguing that recruitment and staffing problems stem from a shortage of full-time positions rather than a shortage of workers. Without a system in place to facilitate evidence-based assessments of staffing needs or a plan to attract and retain qualified employees, the current human resource strategy may not be sustainable.
Perhaps even more critical, the absence of minimum criteria for health care aide certification impacts the skill levels of health care aides entering the workforce. Manitoba’s current regulatory environment has no system in place to ensure consistency across training programs, or to implement changes to curriculums to reflect advances in the field and changing care needs. This impacts the quality of care available within nursing homes as well as the status of health care aides in Manitoba. Thus, the lack of standards for health care aides increases the potential pool of labour and the scope of social networks in the workforce, but it also impedes the quality and safety of nursing home care.
As the population ages, the health care aide labour force will need to be strengthened and expanded. The long-term care system will require qualified health care aides to provide increasingly complex care. Given the growing demand for immigrant health care aides, human resource planning must take into account the relationship between the international migration of women and the health care aide labour market. This research presents a first foray into this field by exploring the context of Filipino women’s migration and employment in nursing homes. It also examines the long-term care policies and practices that have facilitated the movement of immigrant women into the health care aide labour force. Effective workforce planning will require much more research into the role that health care aides play in long-term care, the relationship between women’s migration and long-term care policies, and how these factors affect the quality of care.
