Having a Say in Patient Care: Factors Associated with High and Low Voice among Home Care Workers

OBJECTIVES

To identify factors associated with high and low "voice"-or level of input in patient care decisions-among home care workers (HCWs), an often marginalized workforce that provides care in the home to older adults and those with chronic conditions.

DESIGN

We conducted a secondary analysis of data from a cross-sectional survey assessing experiences of HCWs in caring for adults with heart failure. The survey measured HCWs' voice using a validated, 5-item instrument.

SETTING AND PARTICIPANTS

The survey was conducted virtually from June 2020 to July 2021 in partnership with the 1199 Service Employees International Union (1199SEIU) Training and Employment Funds, a union labor management fund. English- or Spanish-speaking HCWs employed by a certified or licensed home care agency in New York, NY, were eligible.

METHODS

HCW voice was the main outcome of interest, which we assessed by tertiles (low, medium, and high, with medium as the referent group). Using multinominal logistic regression, we calculated odds ratios (ORs) and 95% CIs for the relationship between participant characteristics and low and high levels of voice.

RESULTS

The 261 HCWs had a mean age of 48.4 years (SD 11.9), 96.6% were female, and 44.2% identified as Hispanic. A total of 38.7% had low voice, 37.9% had medium voice, and 23.4% had high voice. In the adjusted model, factors associated with low voice included Spanish as a primary language (OR 3.71, P = .001), depersonalization-related burnout (OR 1.14, P = .04), and knowing which doctor to call (OR 0.19, P < .001). Factors associated with high voice included Spanish as a primary language (OR 2.61, P = .04) and job satisfaction (OR 1.22, P = .001).

CONCLUSIONS AND IMPLICATIONS

Organizational factors such as team communication practices-including among non-English speakers-may play an important role in HCW voice. Improving HCW voice may help retain HCWs in the workforce, but future research is needed to evaluate this.

"I'll fill in the gaps": perspectives of HHAs on promoting aging in place for older adults with low incomes

Older adults with low incomes experience disproportionate rates of cognitive and functional impairment and an elevated risk of nursing home admission. Home health aides (HHAs) may have insight into how to optimize aging in place for this population, yet little is known about HHAs' perspectives on this topic. We conducted 6 focus groups with 21 English-speaking and 10 Spanish-speaking HHAs in Pennsylvania and New Jersey. Transcripts were analyzed using qualitative thematic analysis, and three themes emerged. First, HHAs described the uniqueness of their role within multidisciplinary care teams. Second, HHAs shared concrete interventions they employ to help their clients improve their function at home. Third, HHAs discussed barriers they face when helping clients age in place. Our findings suggest that HHAs have important insights into improving aging in place for older adults with low incomes and that their perspectives should be incorporated into care planning and intervention delivery.

"We want to hear your problems and fix them": A case study of pandemic support calls for home health aides

Home health aides and home care agencies, who operate in a high work stress environment under normal conditions, were placed under extraordinary demands during the COVID-19 pandemic. In this paper, we examine the unfolding effort at one agency in New York City to offer phone-based support calls to aides. We used a qualitative, single case study design involving semi-structured interviews with call staff and agency leaders (n = 9) and analysis of one year of thematic notes from the calls. We found that the calls resulted in multidirectional communication between agency staff and aides, an increased sense of empathy among staff, and a greater integration of aides into the agency's overall infrastructure. We explore how these calls might contribute to aide retention, worker voice, and mental health. We note the facilitators and barriers to implementing this type of job-based support to help other agencies that may be considering similar models.

Prevalence and Predictors of Home Health Care Workers' General, Physical, and Mental Health: Findings From the 2014‒2018 Behavioral Risk Factor Surveillance System

Objectives. To determine the prevalence and predictors of US home health care workers' (HHWs') self-reported general, physical, and mental health. Methods. Using the 2014-2018 Behavioral Risk Factor Surveillance System, we analyzed the characteristics and health of 2987 HHWs (weighted n = 659 000) compared with 2 similar low-wage worker groups (health care aides and health care support workers, not working in the home). We conducted multivariable logistic regression to determine which characteristics predicted HHWs' health. Results. Overall, 26.6% of HHWs had fair or poor general health, 14.1% had poor physical health, and 20.9% had poor mental health; the prevalence of each outcome was significantly higher than that of the comparison groups. Among HHWs, certain factors, such as low household income, an inability to see a doctor because of cost, and a history of depression, were associated with all 3 aspects of suboptimal health. Conclusions. HHWs had worse general, physical, and mental health compared with low-wage workers not in home health. Public Health Implications. Increased attention to the health of HHWs by public health experts and policymakers is warranted. In addition, targeted interventions appropriate to their specific health needs may be required. (Am J Public Health. 2021;111(12):2239-2250. https://doi.org/10.2105/AJPH.2021.306512).

Home care aides' attitudes to training on oral health care

This study investigated home care aides' (HCAs) oral health care experience, knowledge, and their intention to receive professional training, to explain and predict factors of their intention to receive such training. This cross-sectional study collected data through a structured questionnaire. HCAs affiliated with home care agencies in Taichung, Taiwan were recruited through purposive sampling. A total of 487 questionnaires were distributed from September to December 2015 with 280 valid responses collected (57.4%).This study predicted the factors of HCAs' intention to receive oral health care training through a decision tree analysis. The decision tree model classified the respondents with an accuracy of 77.5%. The optimal predictor variable was oral health care knowledge (χ2 = 66.662, p < 0.0001). Among the low-scoring respondents on oral health care knowledge, 76.4% were classified in the "uninterested" group, whereas 84.8% of the high scorers were classified in the "interested" group. The second best predictor variable was whether oral health care is part of the job responsibility (χ2 = 7.979, p = 0.007). Among those who answered Yes, 92.9% were in the interested group, as were 76.5% of those who answered No. It is recommended to add "disease and oral care-related content" and "safety protection, assessment, and usage of oral care tools during practical oral care process" to the oral healthcare training course content for HCAs in order to improve HCAs' oral healthcare knowledge and oral care skills. These research findings are valuable and may be taken into account in the future development of the in-service educational training of oral healthcare for HCAs.

Home Care Aide Safety Concerns and Job Challenges During the COVID-19 Pandemic

Home care aides are on the frontlines providing care to vulnerable individuals in their homes during the COVID-19 pandemic yet are often excluded from policies to protect health care workers. The goal of this study was to examine experiences of agency-employed home care aides during the COVID-19 pandemic and to identify ways to mitigate concerns. We used an innovative journaling approach with thirty-seven aides as well as in-depth interviews with fifteen aides and leadership representatives from nine home health agencies in New York and Michigan. Workers described a range of concerns around workplace safety including uncertainty around whether a client had COVID-19, inadequate access to personal protective equipment and safe transportation, as well as fundamental changes to interactions with clients. Agencies also faced challenges acquiring personal protective equipment for their aides. This research points to needed resources to support home care aides and home health agencies both during a public health crisis and in the future.

Characteristics and Work Life Quality of Nursing Home Care Aides in Canada

This cross-sectional study describes care aides’ characteristics and quality of work life in Western Canadian nursing homes.

Heart Failure Training and Job Satisfaction: A Survey of Home Care Workers Caring for Adults with Heart Failure in New York City

Background

Home care workers (HCWs), who include home health aides and personal care attendants, frequently care for adults with heart failure (HF). Despite substantial involvement in HF care, prior qualitative studies have found that HCWs lack training and confidence, which creates challenges for this workforce and potentially for patient care. Herein, we quantified the prevalence of HF training among HCWs and determined its association with job satisfaction.

Methods

We conducted a cross-sectional survey of agency-employed HCWs caring for HF patients across New York, NY from 2018-2019. HF training was assessed with, "Have you received prior HF training?" Job satisfaction was assessed with, "How satisfied are you with your job?" The association between HF training and job satisfaction was determined with robust poisson regression.

Results

323 HCWs from 23 agencies participated; their median age was 50 years (IQR: 37,58), 94% were women, 44% were non-Hispanic Black, 23% were Hispanic, 78% completed ≥ high school education, and 72% were foreign-born. They had been caregiving for a median of 8.5 years (IQR: 4,15) and 73% had cared for 1-5 HF patients. Two-thirds received none/a little HF training and 82% felt satisfied with their job. In a fully adjusted model, HCWs with some/a lot of HF training had 14% higher job satisfaction than those with none/a little HF training (aPR 1.14; 95% CI 1.03-1.27).

Conclusions

The majority of HCWs have not received HF training. HF training was associated with higher job satisfaction, suggesting that HF training programs may improve HCWs' experience caring for this patient population.

They are Essential Workers Now, and Should Continue to Be: Social Workers and Home Health Care Workers during COVID-19 and Beyond

During COVID-19, social workers can ensure safe and quality care for older adults through advocacy and support of home health care workers.

The Role of Empowerment in Home Care Work

The home care industry experiences similar problems with the recruitment and retention of direct care workers (DCWs) as those faced by institutions, and it is important to identify strategies to help retain and grow this important workforce. The empowerment of DCWs has been shown to be an effective strategy for increasing job satisfaction and decreasing turnover in nursing homes but has not been studied in home care. Using Kanter's organizational theory of empowerment, including structural empowerment (structure of opportunity, access to resources, access to information, and access to support) and psychological empowerment (meaning, competence, self-determination or autonomy, and impact) this study examined whether home care workers (HCWs) feel empowered in carrying out their jobs. An exploratory, qualitative study of 12 HCWs, recruited from two states in the United States, found high levels of both structural and psychological empowerment among research participants, as well as a number of disempowering aspects of their job. Findings suggest ways to support elements of the work that HCWs find empowering and decrease elements that contribute to job dissatisfaction and turnover.

"That's not my job": A mixed methods study of challenging client behaviors, boundaries, and home care aide occupational safety and health

INTRODUCTION

Home care (HC) aide is among the fastest-growing jobs. Aides often work in long-term care relationships with elders or people with disabilities in clients' homes, assisting with daily activities. The purpose of this mixed-methods paper is to elucidate aides' experiences around the boundary-challenging behaviors of clients asking for services beyond aides' job duties and to identify possible interventions.

METHODS

A cross-sectional survey of HC aides in Massachusetts (n = 1249) provided quantitative data. Post-survey qualitative data were collected from nine HC aide focus groups (n = 70) and seven in-depth interviews with HC industry and labor representatives.

RESULTS

Quantitatively, aides who reported often being asked to do tasks outside their job duties were more likely to report abuse (prevalence ratio [PR] = 1.93; 95%CI: 1.47-2.52 for verbal, PR = 1.81; 95%CI: 1.13-2.91 for physical/sexual) and pain/injury with lost work time or medical care (PR = 1.58; 95%CI: 1.11-2.25). They were also less likely to want to remain in their job (PR = 0.94; 95%CI: 0.89-1.00) or recommend it to others (PR = 0.94; 95%CI: 0.90-0.98). Qualitative data showed that clients' requests for tasks beyond job duties were frequent and can lead to injuries, abuse, and psychosocial stress. Yet, requests often reflected genuine need. Helping clients stay at home, compassion, and feeling appreciated contributed to job satisfaction; therefore, aides can feel conflicted about refusing requests.

CONCLUSION

Client task requests outside HC services are a complex problem. Employer support, training, care plans, and feeling part of a care team can help aides navigate professional boundaries while delivering high quality care.

Care workers under pressure - A comparison of the work situation in Swedish home care 2005 and 2015

As in many Western countries, eldercare services in Sweden have changed dramatically over recent decades. Population ageing, ageing-in-place policies, pressures to contain costs and organisational reforms linked to New Public Management are challenging public home care. There is, however, limited knowledge about how the job content and working conditions have changed in the Swedish home care across this period. This article aims to analyse and compare the work situation in the Swedish home care in 2005 and 2015. The analysis is based on the international Nordcare survey and draws on the subsample of respondents working in Swedish home care 2005 and 2015 (n = 371). The data were analysed with bivariate and multivariate methods. The results suggest that, overall, the work situation of home-care workers was worse in 2015 compared to 2005. For example, those surveyed in 2015 reported meeting a larger number of clients per day, receiving less support from their supervisors, and having less time to discuss difficult situations with colleagues and considerably less scope to affect the planning of their daily work. Care workers in 2015 were also more mentally exhausted than those surveyed in 2005. In addition, the workers in 2015 experienced an accumulation of work-related problems. Deteriorating working conditions could be related to cutbacks and organisational reforms, and evidence suggests that home-care workers are paying a high price for ageing-in-place policies. Improvements of the work situation in home care are necessary not only to ensure the quality of care for older people, but also to ensure workers' well-being and to recruit and retain care workers, and thus, to meet the future needs for home care in an ageing society.

Broadening the scope of live-in migrant care research: How care networks shape the experience of precarious work

Live-in migrant care work is increasing across welfare states. In the context of ageing populations and changing healthcare systems, live-in care enables ageing in place without overburdening family caregivers. However, research has shown that live-in care often puts migrant care workers and their recipients in precarious positions. While the outcome of precarious work has gained attention, it is not self-evident. Based on interviews with migrant care workers in the Netherlands, as well as formal and informal caregivers, and the staff of intermediary organisations, this study shows that besides client conditions, the interactions of actors in the care network shape the circumstances and experience of migrant live-in care work. The findings suggest that managing the care networks to which migrant care workers belong makes it possible to mitigate the associated precariousness.

[Feelings of difficulty experienced by home healthcare support workers in collaborative practice with medical professionals: Scale development]

Objective　Healthcare support workers play an important role in team healthcare. The objective of this study was to develop scales for measuring feelings of difficulty among home healthcare support workers when in collaborative practice with medical professionals.Methods　Scale drafts consisting of 10 questions were developed by an expert panel, using qualitative data from previous studies. We conducted a questionnaire survey of 220 healthcare workers in a certain city using the developed scales, and reliability and validity of the scale were examined.Results　An exploratory and confirmatory factor analysis was conducted, after which two factor structures and six questions were selected. The factors were "feelings of disrespect from medical professionals" and "communication barriers between home healthcare support workers and medical professionals". Cronbach's coefficient alpha was 0.77-0.81 for the scale and its two subscales, which demonstrated good internal consistency. Correlation coefficients between the scale and the face-to-face cooperative confidence questionnaire (FFCCQ) and interdisciplinary collaborative practice scales (ICPS) were estimated to examine the criterion-related validity. As a consequence, the score of the scale had a significant negative correlation with FFCCQ and ICPS (r=-0.36--0.42). The two subscales also had negative correlations with FFCCQ and ICPS (r=-0.17--0.42).Conclusion　The scales we developed were reliable and valid for measuring home healthcare support workers' feelings of difficulty in collaborative practice with medical professionals.

Effectiveness of the Labour Inspection Authority's regulatory tools for work environment and employee health: study protocol for a cluster-randomised controlled trial among Norwegian home-care workers

INTRODUCTION

There is a need to evaluate whether, and to what degree, labour inspections or other regulatory tools have the desired effects on psychosocial, organisational and mechanical work environment, and employee health. The Norwegian Labour Inspection Authority (NLIA) uses different tools and strategies to enforce compliance with occupational safety and health (OSH) legislation. The aim of the present study is to evaluate the effects of labour inspections and other regulatory tools employed by the NLIA. The home-care service is one of the fastest growing occupations and a prioritised area for the NLIA, hence the present study will investigate regulatory tools in this sector.

METHODS AND ANALYSIS

The research project has been designed as a longitudinal, cluster-randomised, controlled trial and will be conducted among Norwegian home-care workers. The objective of the research project is to evaluate the effects of the NLIA's regulatory tools (inspection and guidance) on: (1) compliance with OSH legislation and regulation; (2) psychosocial, organisational and mechanical work environment; (3) employee health in terms of musculoskeletal and mental health complaints; and (4) sickness absence. Public home-care services have been randomised to three intervention groups and one control group. Home-care services in the intervention groups will receive one of three intervention activities from the NLIA: (1) inspection from the Labour Inspection Authority; (2) guidance through an online interactive risk-assessment tool; and (3) guidance on psychosocial, organisational and mechanical work environment through workshops. The interventions will be performed at the organisational level (home-care service), and the effects of the interventions on the working environment and health complaints will be measured at the individual level (home-care employees).

ETHICS AND DISSEMINATION

This project has been approved by the Regional Committees for Medical and Health Research Ethics (REC) in Norway (REC South East) (2018/2003/REK sør-øst C), the Norwegian Center for Research Data (566128), and will be conducted in accordance with the World Medical Association Declaration of Helsinki. The results will be reported in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03855163.

Perceived Discrimination and Stigma in the Context of the Long-Term Care Insurance Law from the Perspectives of Arabs and the Jews in the North of Israel

The Long-Term Care Insurance Law provides support to older Israelis who wish to remain in their home. The present study evaluated the experience of perceived discrimination and stigma in the context of the law among Arab older adults, their family members, and their paid home care workers. For triangulation purposes, we interviewed 15 National Insurance Institute workers (NII; responsible for implementing the law; 47% Arab), 31 older adults (81% Arab), 31 family members (87% Arab), and six paid home care workers (83% Arab) in the north of Israel. Respondents were queried about their home care experience and their encounter with the NII. Thematic analysis was conducted. Four main themes emerged: (a) a strong sense of perceived discrimination among Arab interviewees, (b) reports suggesting the internalization of stigma and the adoption of negative views regarding the Arab population by some Arab respondents, (c) implicit stigma manifested in claims concerning the Arab population (primarily) as "cheating" the system, and (d) the negation of discrimination of Arabs as reported by Jewish interviewees and NII workers. The findings show that a sense of perceived discrimination is common and colors the experience of service seeking among Arabs. On the other hand, the Jewish interviewees in this study completely negated any discrimination or stigma directed toward Arabs. The findings point to the importance of group affiliation (e.g., minority vs. majority) in interpreting the existence of discrimination. The findings likely have major implications for both service providers and policy-makers and legislators.

Psychometric properties of the Korean version of the Copenhagen Burnout Inventory in Korean homecare workers for older adults

BACKGROUND

Despite the increasing number of homecare workers, a reliable and valid tool with which to measure burnout among Korean homecare workers is still lacking. The aim of this study was to examine the reliability and construct validity of the Korean version of the Copenhagen Burnout Inventory (CBI-K).

METHODS

The study population consisted of 465 homecare workers. Data were collected in 2016 through a self-administered questionnaire including the three subscales of the CBI-K, the Center for Epidemiologic Studies Depression Scale (CESD-10), a measure of work-life conflict, and questions about respondents' sociodemographic characteristics.

RESULTS

The confirmatory factor analyses results showed that the model fit indices of the refined three-factor model, in which the PB, WRB, and CRB subscales each contained six items, were acceptable (CFI = 0.924, SRMR = 0.049, RMSEA = 0.091). Furthermore, based on the results for construct reliability, discriminant validity of the refined three-factor model and job characteristics of homecare workers, we proposed that an abbreviated two-factor scale using the PB and CRB subscales could be used, with appropriate model fit indices (CFI = 0.950, SRMR = 0.047, RMSEA = 0.084). Each of the PB, WRB, and CRB subscales of CBI-K were associated with depressive symptoms even after controlling for covariates.

CONCLUSIONS

The CBI-K has adequate reliability and validity for use with homecare workers. To increase its practicality, we suggest a refined form comprising only PB and CRB subscales can be used rather than a three-factor model.

Improving Long-Term Care by Finally Respecting Home-Care Aides

The American system of long-term care is disorganized and expensive. Obtaining care for a loved one is a confusing and difficult journey. When it comes to paying for that care, a bit over half who receive care are supported at least partially by insurance, and those with no insurance pay entirely out of pocket. The costs are exorbitant. What makes the system function is reliance on unpaid family members, who care for their loved ones often at considerable cost to themselves. As the baby boom generation ages, this creaky system will become increasingly dysfunctional, and a likely shortage of caregivers will be at the heart of the difficulties. The supply of unpaid family caregivers will become limited, as the ratio of people in the category of ages forty-five to sixty-four compared to those who are eighty and older shrinks from just above seven to one in 2010 to just above four to one in 2030. Paid caregivers will be needed to take up the slack, yet they are poorly paid, work under very difficult conditions, and receive little respect from the health care system. In this essay, I discuss the circumstances facing these paid home-care workers and a possible path forward, illustrating the current problems by drawing on interviews I conducted for a book-length study published in 2017.

Between older adults' needs and the law: The Israeli Long Term Care Insurance Law from the Perspectives of Service Users and Providers

The Israeli Long Term Care Insurance Law (LTCIL) was one of the first long term care insurances in the world to support older adults and their family members and allow them to stay in their homes for as long as possible. The present study aimed to evaluate the perspectives of older adults, their family members and home care workers regarding the LTCIL. Views of workers of the National Insurance Institute (NII), which is directly responsible for the enactment of the law, are also integrated. Interviews were conducted between June 2016 and June 2017. Thematic qualitative analysis is based on interviews with 15 NII workers, 31 older adults, 31 family members, and 6 paid home care workers. The present study stresses the tension between the LTCIL and older adults' perceived rights and needs. It also demonstrates how even though the NII workers are engaged with various stakeholders, they often lack direct contact with older adults, their family members and paid home care workers: those most directly influenced by the LTCIL. Policy considerations are discussed.

Musculoskeletal Pain and Interest in Meditation and Yoga in Home Health Aides: Evidence From the Home Health Occupations Musculoskeletal Examinations (HHOME) Study

Home healthcare aides (HHAs) are a growing U.S. workforce highly susceptible to workplace stressors and musculoskeletal pain. In the present study we: 1) examine the association of musculoskeletal pain to life satisfaction and emotional exhaustion; and 2) characterize interest in meditation and yoga in a sample of HHAs. A nonprobabilistic sample of HHAs employed at home healthcare agencies in Florida, Massachusetts, and Oregon (n = 285 total) completed a self-administered questionnaire with standard survey measures on musculoskeletal pain location, duration, and severity; life satisfaction; emotional exhaustion; and interest in meditation techniques and yoga. Among HHAs responding, 48.4% reported pain in the last 7 days and 46.6% reported pain in the last 3 months. Home healthcare aides who reported current pain and chronic pain had a significant (P < .05) decrease in satisfaction with life score and a significant increase in emotional exhaustion score. The majority of HHAs reported an interest in learning about the benefits (65.6%) and practice (66.4%) of meditation and a willingness to participate in a yoga class (59.2%) or stress management meeting (59.1%). The HHAs reported both acute and chronic musculoskeletal pain that was correlated with lower life satisfaction and greater emotional exhaustion. More efforts are needed to reduce the sources of injury and emotional exhaustion.

Home Health Aides' Perceptions of Quality Care: Goals, Challenges, and Implications for a Rapidly Changing Industry

Home care payment models, quality measures, and care plans are based on physical tasks workers perform, ignoring relational care that supports clients' cognitive, emotional, and social well-being. As states seek to rein in costs and improve the efficiency and quality of care, they will need to consider how to measure and support relational care. In four focus groups ( n = 27) of unionized, agency-based New York City home health aides, workers reported aide-client relationships were a cornerstone of high-quality care, and building them required communication, respect, and going the extra mile. Since much of this care was invisible outside the worker-client relationship, aides received little supervisory support and felt excluded from the formal care team. Aligning payment models with quality requires understanding the full scope of services aides provide and a quality work environment that offers support and supervision, engages aides in patient care, and gives them a voice in policy decisions.

Burnout After Patient Death: Challenges for Direct Care Workers

CONTEXT

Direct care workers in long-term care can develop close relationships with their patients and subsequently experience significant grief after patient death. Consequences of this experience for employment outcomes have received little attention.

OBJECTIVES

To investigate staff, institutional, patient, and grief factors as predictors of burnout dimensions among direct care workers who had experienced recent patient death; determine which specific aspects of these factors are of particular importance; and establish grief as an independent predictor of burnout dimensions.

METHODS

Participants were 140 certified nursing assistants and 80 homecare workers who recently experienced patient death. Data collection involved comprehensive semistructured in-person interviews. Standardized assessments and structured questions addressed staff, patient, and institutional characteristics, grief symptoms and grief avoidance, as well as burnout dimensions (depersonalization, emotional exhaustion, and personal accomplishment).

RESULTS

Hierarchical regressions revealed that grief factors accounted for unique variance in depersonalization, over and above staff, patient, and institutional factors. Supervisor support and caregiving benefits were consistently associated with higher levels on burnout dimensions. In contrast, coworker support was associated with a higher likelihood of depersonalization and emotional exhaustion.

CONCLUSION

Findings suggest that grief over patient death plays an overlooked role in direct care worker burnout. High supervisor support and caregiving benefits may have protective effects with respect to burnout, whereas high coworker support may constitute a reflection of burnout.

Building Health Promotion into the Job of Home Care Aides: Transformation of the Workplace Health Environment

Home care aides (HCAs), predominantly women, constitute one of the fastest growing occupations in the United States. HCAs work in clients’ homes that lack typical workplace resources and benefits. This mixed-methods study examined how HCAs’ work environment was transformed by a pilot workplace health promotion program that targeted clients as well as workers. The intervention started with training HCAs to deliver a gentle physical activity program to their older clients in a Medicaid-funded home care program. Older HCAs aged 50+ reported increased time doing the types of physical activity that they delivered to their clients (stretching or strengthening exercise) (p = 0.027). Almost all (98%) HCAs were satisfied with the program. These quantitative results were corroborated by qualitative data from open-ended survey questions and focus groups. HCAs described how they exercised with clients and how the psychosocial work environment changed with the program. Building physical activity into HCAs’ job is feasible and can effectively promote HCAs’ health, especially among older HCAs.

Latent classes of caregiver relationships with patients: Workplace violence implications

The bonds and relationships that direct care workers in the home setting (DCWHs) develop with their elderly or disabled home care patients may put them at risk for patient violence. This study used a data-driven approach, latent class analysis, to identify distinct underlying patterns of DCWH-patient relationships and then assessed how DCWH-patient class membership was associated with patient violence. This study analyzed survey data obtained from 964 DCWHs working in two not-for-profit home care agencies. Four classes of DCWH-patient relationships emerged: Non-familial (40% of the sample), Overly Concerned (14%); Boundary-keeping (22%), and Overly Involved (24%). DCWHs in the Overly Involved class were more likely to experience physical violence from their patients relative to those in the Non-familial class (probability = 0.11 vs. 0.04, p = 0.01). Building a positive relationship with boundaries between caregivers and patients may have a potential to reduce patient violence toward the caregivers and ultimately improve the quality of care.

Complexity of occupational exposures for home health-care workers: nurses vs. home health aides

AIM

To identify occupational exposures for home health-care nurses and aides.

BACKGROUND

Home health-care workers' occupational injury rates in the USA are higher than the national average, yet research on causative exposures and hazards is limited.

METHODS

Participants were interviewed about annual frequency of occupational exposures and hazards. Exposure and hazard means were compared between home health-care nurses and aides using a Wilcoxon two-sample test.

RESULTS

A majority of the sample was over 40 years old and obese, potentially increasing injury risks. Home health-care nurses performed more clinical tasks, increasing exposure to blood-borne pathogens. Home health-care aides performed more physical tasks with risk for occupational musculoskeletal injuries. They also dispensed oral medications and anti-cancer medications, and were exposed to drug residue at a frequency comparable to home health-care nurses. Both groups were exposed to occupational second-hand smoke.

CONCLUSIONS

Establishing employee safety-related policies, promoting healthy lifestyle among staff, and making engineered tools readily available to staff can assist in decreasing exposures and hazards.

IMPLICATIONS FOR NURSING MANAGEMENT

Implications for nursing management include implementation of health-promotion programmes, strategies to reduce exposure to second-hand smoke, ensuring access to and education on assistive and safety devices, and education for all staff on protection against drug residue.

Rehabilitative bodywork: cleaning up the dirty work of homecare

Care work for elderly people has been characterised as dirty work, owing to its proximity to the (dys)functions and discharges of aged bodies and the notions of disease, decay and death associated with the idea of old age. However, a wave of reform programmes in Danish municipalities promoting rehabilitative care practices aiming to empower, train and activate elderly citizens provides opportunities for homecare workers to renegotiate their status and reconstruct their work and occupational identities with a cleaner and more optimistic image. Drawing on ethnographic fieldwork in two Danish homecare units, this article analyses how rehabilitative care practices, drawing on a narrative of the third age, provide an optimistic and anti-ageist framing of homecare work that informs the development of new occupational identities for care workers as coaches rather than carers in relation to citizens. Furthermore, rehabilitation efforts change the bodywork of care, rendering it more distanced and physically passive, and rehabilitation efforts also involve extensive motivational work aiming to help citizens to see themselves as capable, resourceful and self-reliant. However, while rehabilitation efforts become a new resource in care workers' taint management; they also entail potentially negative consequences in terms of responsibilising and disciplinary approaches to elderly citizens.

Linguistic Stereotyping in Older Adults' Perceptions of Health Care Aides

The cultural and linguistic diversity of the U.S. health care provider workforce is expanding. Diversity among health care personnel such as paraprofessional health care assistants (HCAs)-many of whom are immigrants-means that intimate, high-stakes cross-cultural and cross-linguistic contact characterizes many health interactions. In particular, nonmainstream HCAs may face negative patient expectations because of patients' language stereotypes. In other contexts, reverse linguistic stereotyping has been shown to result in negative speaker evaluations and even reduced listening comprehension quite independently of the actual language performance of the speaker. The present study extends the language and attitude paradigm to older adults' perceptions of HCAs. Listeners heard the identical speaker of Standard American English as they watched interactions between an HCA and an older patient. Ethnolinguistic identities-either an Anglo native speaker of English or a Mexican nonnative speaker-were ascribed to HCAs by means of fabricated personnel files. Dependent variables included measures of perceived HCA language proficiency, personal characteristics, and professional competence, as well as listeners' comprehension of a health message delivered by the putative HCA. For most of these outcomes, moderate effect sizes were found such that the HCA with an ascribed Anglo identity-relative to the Mexican guise-was judged more proficient in English, socially superior, interpersonally more attractive, more dynamic, and a more satisfactory home health aide. No difference in listening comprehension emerged, but the Anglo guise tended to engender a more compliant listening mind set. Results of this study can inform both provider-directed and patient-directed efforts to improve health care services for members of all linguistic and cultural groups.

The COMmunity of Practice And Safety Support (COMPASS) Total Worker Health™ study among home care workers: study protocol for a randomized controlled trial

BACKGROUND

Home care workers are a high-risk group for injury and illness. Their unique work structure presents challenges to delivering a program to enhance their health and safety. No randomized controlled trials have assessed the impact of a Total Worker Health™ program designed for their needs.

METHODS/DESIGN

The COMPASS (COMmunity of Practice And Safety Support) study is a cluster randomized trial being implemented among Oregon's unionized home care workers. Partnering with the Oregon Home Care Commission allowed recruiting 10 pairs of home care worker groups with 8 participants per group (n = 160) for balanced randomization of groups to intervention and control conditions. Physiologic and survey evaluation of all participants will be at enrollment, 6 months and 12 months. Primary outcomes are to increase health promoting (for example, healthy nutrition and regular physical activity) and health protecting (that is, safety) behaviors. In addition to assessing outcomes adjusted for the hierarchical design, mediation analyses will be used to deconstruct and confirm the program's theoretical underpinnings and intervention processes. Intervention groups will participate in a series of monthly 2-hour meetings designed as ritualized, scripted peer-led sessions to increase knowledge, practice skills and build support for healthy actions. Self-monitoring and individual and team level goals are included to augment change. Because generalizability, reach and achieving dissemination are priorities, following initial wave findings, a second wave of COMPASS groups will be recruited and enrolled with tailoring of the program to align with existing Home Care Commission educational offerings. Outcomes, process and mediation of those tailored groups will be compared with the original wave's findings.

DISCUSSION

The COMPASS trial will assess a novel program to enhance the safety and health of a vulnerable, rapidly expanding group of isolated caregivers, whose critical work allows independent living of frail seniors and the disabled.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02113371, first registered 11 March 2014.

Psychosocial work characteristics of personal care and service occupations: a process for developing meaningful measures for a multiethnic workforce

BACKGROUND AND OBJECTIVES

Despite their rapid increase in number, workers in personal care and service occupations are underrepresented in research on psychosocial work characteristics and occupational health. Some of the research challenges stem from the high proportion of immigrants in these occupations. Language barriers, low literacy, and cultural differences as well as their nontraditional work setting (i.e., providing service for one person in his/her home) make generic questionnaire measures inadequate for capturing salient aspects of personal care and service work. This study presents strategies for (1) identifying psychosocial work characteristics of home care workers that may affect their occupational safety and health and (2) creating survey measures that overcome barriers posed by language, low literacy, and cultural differences.

DESIGN AND RESULTS

We pursued these aims in four phases: (Phase 1) Six focus groups to identify the psychosocial work characteristics affecting the home care workers' occupational safety and health; (Phase 2) Selection of questionnaire items (i.e., questions or statements to assess the target construct) and first round of cognitive interviews (n = 30) to refine the items in an iterative process; (Phase 3) Item revision and second round of cognitive interviews (n = 11); (Phase 4) Quantitative pilot test to ensure the scales' reliability and validity across three language groups (English, Spanish, and Chinese; total n = 404). Analysis of the data from each phase informed the nature of subsequent phases. This iterative process ensured that survey measures not only met the reliability and validity criteria across groups, but were also meaningful to home care workers.

CONCLUSION

This complex process is necessary when conducting research with nontraditional and multilingual worker populations.

How to recruit caring and compassionate HCAs

Heathcare organisations are faced with the challenge of recruiting staff who have caring and compassionate values so need to ensure these can be identified at interview. We piloted multiple mini-interviews as a possible solution to recruiting healthcare assistants. This article outlines how these were implemented and highlights some of the pitfalls of using this approach. Although the work has not been evaluated formally we decided to share our early experiences of using this approach so others can learn from our practice.

Understanding significant processes during work environment interventions to alleviate time pressure and associated sick leave of home care workers--a case study

BACKGROUND

Ergonomic and work stress interventions rarely show long-term positive effect. The municipality participating in this study received orders from the Norwegian Labour Inspectorate due to an identified unhealthy level of time pressure, and responded by effectuating several work environment interventions. The study aim is to identify critical factors in the interaction between work environment interventions and independent rationalization measures in order to understand a potential negative interfering effect from concurrent rationalizations on a comprehensive work environment intervention.

METHODS

The study, using a historic prospective mixed-method design, comprised 6 home care units in a municipality in Norway (138 respondents, response rate 76.2%; 17 informants). The study included quantitative estimations, register data of sick leave, a time line of significant events and changes, and qualitative descriptions of employee appraisals of their work situation gathered through semi-structured interviews and open survey responses.

RESULTS

The work environment interventions were in general regarded as positive by the home care workers. However, all units were simultaneously subjected to substantial contextual instability, involving new work programs, new technology, restructurings, unit mergers, and management replacements, perceived by the home care workers to be major sources of stress. Findings suggest that concurrent changes induced through rationalization resulted in negative exposure effects that negated positive work environment intervention effects, causing an overall deteriorated work situation for the home care workers.

CONCLUSIONS

Establishment and active utilization of communication channels from workers to managers are recommended in order to increase awareness of putative harmful and interruptive effects of rationalization measures.

The evolving role of health care aides in the long-term care and home and community care sectors in Canada

Health Care Aides (HCAs) provide up to 80% of the direct care to older Canadians living in long-term care facilities, or in their homes. They are an understudied workforce, and calls for health human resources strategies relating to these workers are, we feel, precipitous. First, we need a better understanding of the nature and scope of their work, and of the factors that shape it. Here, we discuss the evolving role of HCAs and the factors that impact how and where they work. The work of HCAs includes role-required behaviors, an increasing array of delegated acts, and extra-role behaviors like emotional support. Role boundaries, particularly instances where some workers over-invest in care beyond expected levels, are identified as one of the biggest concerns among employers of HCAs in the current cost-containment environment. A number of factors significantly impact what these workers do and where they work, including market-level differences, job mobility, and work structure. In Canada, entry into this 'profession' is increasingly constrained to the Home and Community Care sector, while market-level and work structure differences constrain job mobility to transitions of only the most experienced workers, to the long-term care sector. We note that this is in direct opposition to recent policy initiatives designed to encourage aging at home. Work structure influences what these workers do, and how they work; many HCAs work for three or four different agencies in order to sustain themselves and their families. Expectations with regard to HCA preparation have changed over the past decade in Canada, and training is emerging as a high priority health human resource issue. An increasing emphasis on improving quality of care and measuring performance, and on integrated team-based care delivery, has considerable implications for worker training. New models of care delivery foreshadow a need for management and leadership expertise--these workers have not historically been prepared for leadership roles. We conclude with a brief discussion of the next steps necessary to generating evidence necessary to informing a health human resource strategy relating to the provision of care to older Canadians.

Using the associative imagery technique in qualitative health research: the experiences of homecare workers and consumers

The associative imagery technique is a qualitative tool with which researchers use carefully selected photographs or images to trigger participants' responses to explain difficult behavioral and social concepts. In this article, we describe the development and implementation of the associative imagery method in focus groups to understand the complex relationships between homecare workers and their clients as part of a larger health and safety intervention project conducted by the National Institute for Occupational Safety and Health. A total of 116 homecare workers and clients were recruited for the study. We found that participants used images mainly in two ways. First, the images served to remind participants of specific persons, events, and/or objects. Second, the images facilitated recollections and reflections that allowed participants to metaphorically describe their experiences, feelings, and emotions. Both usages of imagery generated comments that answered the research question in a more relevant, descriptive, and vivid way.

An overview of home health aides: United States, 2007

OBJECTIVES

This report presents national estimates of home health aides providing assistance in activities of daily living (ADLs) and employed by agencies providing home health and hospice care in 2007. Data are presented on demographics, training, work environment, pay and benefits, use of public benefits, and injuries.

METHODS

Estimates are based on data collected in the 2007 National Home Health Aide Survey. Estimates are derived from data collected during telephone interviews with home health aides providing assistance with ADLs and employed by agencies providing home health and hospice care.

RESULTS

In the United States in 2007, 160,700 home health and hospice aides provided ADL assistance and were employed by agencies providing home health and hospice care. Most home health aides were female; approximately one-half were white and one-third black. Approximately one-half of aides were at least 35 years old. Two-thirds had an annual family income of less than $40,000. More than 80% received initial training to become a home health aide and more than 90% received continuing education classes in the previous 2 years. Almost three-quarters of aides would definitely become a home health aide again, and slightly more than one-half of aides would definitely take their current job again. The average hourly pay was $10.88 per hour. Almost three-quarters of aides reported that they were offered health insurance by their employers, but almost 19% of aides had no health insurance coverage from any source. More than 1 in 10 aides had had at least one work-related injury in the previous 12 months.

CONCLUSIONS

The picture that emerges from this analysis is of a financially vulnerable workforce, but one in which the majority of aides are satisfied with their jobs. The findings may be useful in informing initiatives to train, recruit, and retain these direct care workers.

Attitudes of different professionals toward the well-being of older adults living at home

OBJECTIVES

Negative attitudes in society toward working in eldercare constitute a challenge to educators and care providers. The purpose of this study was to explore, describe, and compare the attitudes of different professional groups toward factors that are important for the well-being of older adults.

METHODS

A randomized sample of 210 respondents that included registered nurses (RNs), registered occupational therapists (OTRs), personal benefit advisors (PBAs), and home help assistants (HHAs) was collected from social service agencies in 10 Swedish municipalities. A scale was developed in a six-step process to measure attitudes toward factors influencing elder well-being, and the final 22-item Likert-type scale was called the "Staff Attitudes toward the Well-being of Older Adults" scale.

RESULTS

Thirty-three percent of staff responded with positive attitudes toward working with elders, and the remaining were uncertain or negative. The attitudes of RNs, OTRs, and PBAs were significantly more positive than those of HHAs.

DISCUSSION

The scale is practical for use in different professional groups with the aim of exploring existing attitudes, identifying areas with a low degree of prevailing positive attitudes and differences between groups, and evaluating whether attitudes change after staff training.

Pandemic-related ability and willingness in home healthcare workers

OBJECTIVE

To assess pandemic-related attitudes and behavioral intentions of home healthcare workers (HHCWs).

DESIGN

Cross-sectional survey.

SETTING

New York City.

PARTICIPANTS

A convenience sample of 384 HHCWs.

MAIN OUTCOME VARIABLES

Ability and willingness to report to work during a pandemic influenza outbreak.

RESULTS

A large proportion of HHCWs reported that they would be either unable or unwilling (or both) to provide care to their current (83 percent) or new (91 percent) patients during a pandemic. Ability was significantly associated with not having children living at home, having alternatives to mass transportation, not having a spouse/partner employed as a first responder or healthcare worker, and having longer tenure (ie, six or more years) in homecare. During an outbreak, 43 percent of HHCWs said they would be willing to take care of current patients and only 27 percent were willing to take care of new patients. Willingness to care for both current and new patients was inversely associated with fear for personal safety (p < 0.01). Provision of key elements of a respiratory protection program was associated with decreased fear (p < 0.05). Most participants (86 percent) had not received any work-based, pandemic-related training, and only 5 percent reported that their employer had an influenza pandemic plan.

CONCLUSIONS

Given that a large majority of the participating HHCWs would either be unable or unwilling to report to duty during a pandemic, potential shortfalls in this workforce may occur. To counter this, organizations should focus on strategies targeting intervenable barriers to ability and to willingness (ie, the provision of a vaccine and respiratory protection programs).

Personal assistants’ conceptions of their cooperation in the rehabilitation of disabled persons

Personal assistants assist persons with severe disability in the performance of their daily activities. The law that covers the right to personal assistance is intended to strengthen the disabled individual's position as a member of society. The aim of the study was to describe personal assistants' conceptions of their cooperation in the rehabilitation of disabled persons. A qualitative method with a phenomenographic approach was used. Six personal assistants were interviewed. Strategic selection of the participants was carried out in order to obtain as wide a variation in conceptions as possible. The results showed that, apart from the factors related to the assistants, factors related to the disabled persons and the environment were of major significance for rehabilitation. The conceptions generated by the study were presented in the form of main categories and subcategories. Four main categories were developed: the meaning of will; the professional role; to consider ability; and awareness of the environment.

Enhanced care assistant training to address the workforce crisis in home care: changes related to job satisfaction and career commitment

Changes in job satisfaction and career commitment were observed as a consequence of a geriatric case management training program focusing on skills development among personal care attendants in home care. A comparison of pretraining and posttraining scores uncovered a statistically significant increase in Intrinsic Job Satisfaction scores for participants 18-39 years of age, whereas levels declined among the group of middle aged participants and no change was observed among participants age 52 and older. On the other hand, a statistically significant decline in Extrinsic Job Satisfaction was documented over all participants, but this was found to be primarily due to declines among participants 40-51 years of age. When contacted 6-12 months after the training series had concluded participants indicated that the training substantially increased the likelihood that they would stay in their current jobs and improved their job satisfaction to some extent. A comparison of pretraining and posttraining scores among participants providing follow-up data revealed a statistically significant improvement in levels of Career Resilience. These results are discussed as they relate to similar training models and national data sets, and recommendations are offered for targeting future educational programs designed to address the long-term care workforce shortage.

Level of Empowerment and Health Knowledge of Home Support Workers Providing Care for Frail Elderly

The purpose of this study was to assess the profile of home support workers (HSWs) caring for the frail elderly and to determine the perceived empowerment levels and general health knowledge of these support workers. Background, work-profile, empowerment level and health knowledge related to seniors of 64 HSWs were assessed using questionnaires. Findings revealed the majority of workers to be middleaged women, and their health knowledge scores were low. Empowerment levels were moderate as was formal power. Findings demonstrate the need to revise the curriculum of HSWs to include health topics, as well as the need for continued education and strategies to enhance empowerment levels.

Can't they get anything better? Home support workers call for change

A descriptive exploratory study examined the demographic characteristics and working conditions of home support workers in one Canadian province. Four hundred and sixty-three workers, a response rate of 43.5%, completed the Home Support Worker Survey, an instrument designed for the purposes of the study. Workers identified a need for changes to their working conditions including better wages, improved benefits, and a modified work schedule. Since these workers are the largest segment of formal care providers and the mainstay of formal support services for chronically ill seniors, attention to their issues is critical to the sustainability of the home care industry.

Abuse and violence during home care work as predictor of worker depression

OBJECTIVES

Home care workers provide care without the normal protections afforded in the hospital. This study describes the prevalence of abuse and violence experienced by home care workers and its relationship to workers' depression.

METHODS

A two-wave telephone survey (N=1,643) was conducted to assess the prevalence of abuse and prevalence/incidence of workers' depression.

RESULTS

Abuse was significant for elevated odds for depression, with a dose effect. Violence was highly associated with depression.

CONCLUSIONS

Preventive and early intervention measures should be taken to reduce mental health consequences of abuse and violence among home care workers.

Elder abuse--a family experience

Abuse happens every day to elderly and disabled individuals either through ignorance or design. Protecting your patient or loved one requires you to be suspicious of everyone who has access to the patient, even other family members. It is the most difficult and demanding task you will ever undertake. Our story is a long and emotional one, If you wish to read an account of our experiences, please visit my Web site at www.iannarino.us/elderabuse.

Restructuring of the Québec health network and its effects on the profession of home health aides and their occupational health and safety

The Québec health sector is facing profound macroeconomic and macro-organizational changes. This article addresses the impact of these changes on the work of home health aides (HHAs) and their occupational health and safety (OHS). The study was carried out in the home care services of four local community service centers (CLSCs) with different organizational characteristics. It is based on an analysis by triangulation of 66 individual and group interviews, 11 work days, and 35 multidisciplinary or professional meetings observed, as well as administrative documents. HHAs are experiencing an erosion of their job because the relational and emotional components of their work are disappearing. This results in an increase in musculoskeletal and psychological health problems. This study also shows that managers' decisions can reduce or increase the HHAs' work constraints. Stability in the clientele served and the possibility of organizing their routes are good examples of positive impacts.

Is it racism? Skepticism and resistance towards ethnic minority care workers among older care recipients

The study investigates the occurrence and character of skepticism and resistance towards ethnic minority care workers among older care recipients in a municipality in Sweden. Twelve representatives of caregiver organizations were interviewed about their experience of this phenomenon. Three additional interviews were conducted with ethnic minority care workers. Representatives described the problem as rare and mostly occurring as language difficulties or as a temporary problem characterized as a fear of the unknown among some care recipients. They tended to apply a pragmatic or pathologizing approach when talking about causes of and solutions to the problem. These approaches enabled care providers to comply with "potential racism" without challenging an official ideology of anti-racism. In contrast, staff of foreign descent described the problem as more frequent and severe, particularly for short-term employees who experience many first-time encounters with care recipients.