Finding dignity in dirty work: the constraints and rewards of low-wage home care labour

The ageing of the population in the US and elsewhere raises important questions about who will provide long-term care for elderly and disabled people. Current projections indicate that home care workers--most of whom are unskilled, untrained and underpaid--will increasingly absorb responsibility for care. While research to date confirms the demanding aspects of the work and the need for improved working conditions, little is known about how home care workers themselves experience and negotiate their labour on a daily basis. This paper attempts to address this gap by examining how home care workers assign meaning to their 'dirty work'. Qualitative interviews suggest that home care workers have a conflicted, often contradictory, relationship to their labour. Workers identify constraints that compromise their ability to do a good job or to experience their work as meaningful, but they also report several rewards that come from caring for dependent adults. I suggest workers draw dignity from these rewards, especially workers who enter home care after fleeing an alienating service job, within or outside the healthcare industry.     

Managing the body work of home care

Body work is a key element of home healthcare. Recent restructuring of health and social care services means the home is increasingly a key site of long-term care. While there is a growing literature on the social dynamics between care recipients and their family caregivers, less is known about the formal work dynamic between paid care workers and care recipients and family caregivers. Drawing on interview data from an Ontario-based study of long-term home care, we explore how body work is negotiated through the embodied practices of care in the home and through care relationships associated with home care. In particular we focus on how the practices of intimate body care (such as bathing, toileting, and catheter management) show the diverse dynamics of care work through which caregivers, care recipients and homespace are constituted. We argue that the practices of care are shaped by a complex interweaving of regulatory mechanisms associated with home care along with the physical and affective dimensions of intimate body work. In turn this suggests the need for new ways of understanding body work in contemporary landscapes of care.     

Home care is where the heart is: the role of interpersonal relationships in paraprofessional home care

While the provision of an adequate floor of wages and benefits for paraprofessional workers in the home care component of our long-term care system is desirable, efforts to provide it are curtailed by cost constraints. As a result, other factors which encourage the retention of an adequate home care workforce are all-important. Findings from a study of a representative sample of 487 paraprofessional home care workers in New York City indicate that the ability to develop close interpersonal relationships with home care clients and their families is one of the most attractive and rewarding aspects of the work. It is suggested that agencies focus on their roles in providing an optimum environment for the development of such relationships.     

Support workers in intermediate care

Despite the proliferation of support worker roles in the UK, little is known about their actual numbers, employment conditions or levels of training. Intermediate care services appear to be an important employer of support workers, but the diversity of intermediate care services makes the task of understanding support worker roles even more complex. This paper presents data from 33 services which were involved in an NHS Modernisation Agency's Changing Workforce Programme project, the Accelerated Development Programme for Support Workers in Intermediate Care in England. Within this project, the main employers of support workers were primary care trusts and/or social services. Participating intermediate care teams were involved in admission avoidance, assisted discharge and reablement, or combinations of these services, and the majority of care was provided in the patient's own home. The 33 services employed 794 support workers and 368 professionally qualified staff. The mean ratio of professionally qualified staff to support workers was 0.95 (range = 0-4.9, SD = 1.05). Support worker roles included multidisciplinary working, meeting rehabilitation needs, providing personal care and enablement. Team leaders included nurses, social workers, physiotherapists, professional managers, home carers and support workers. The most commonly reported sources of support worker training were National Vocational Qualifications and in-house training. In 80% of the services, at least half of the support workers had a qualification. Three models of supervision emerged across the services: the allocation of a mentor; team supervision; and formal and informal line management. These findings illustrate the diversity of employment of support workers in intermediate care. The variations in training, supervision and skill mix have implications for clinical governance and support worker regulation. The employment of support worker staff jointly across health and social care raises cross-boundary issues around employment contracts and pay.     

Team-based care: Views from community health center staff

ABSTRACT

Community health centers (CHC) provide quality care for vulnerable patients, and a potentially contributing factor to this quality is the integration of a patient-centered medical home (PCMH). PCMH relies on a team-based approach, a principle in which social workers are trained and research examines in primary care environments. Less is known about team-based care in CHCs. An exploratory qualitative study with 14 CHC staff was conducted to examine the current state of team-based care and secondarily, to examine the role of social workers. Content analysis revealed four themes central to team-based care. Implications for CHCs and social workers are discussed.     

Home health care workers' attitudes toward the elderly

This study examined home health care workers' attitudes toward the elderly and their elderly clients. Data were collected from a convenience sample of 106 home health care workers in South Central Florida in October 1994, using the Attitudes Toward the Elderly Questionnaire (ATE). Estimated internal consistency reliability of the scale was .60, using Cronbach's alpha. Findings suggest that home health care workers have positive attitudes toward the elderly, their elderly clients, and provide a reasonable level of service for them. Also, findings suggest that overall the attitudes and perceptions among urban and rural home health care workers are similar.     

Job characteristics and problems related to home care services for the elderly. A comparison among employment categories in Sapporo

OBJECTIVE: The aims of this study were to describe job characteristics for daytime and shift workers in home care services for the elderly and to clarify health care in the work setting, social support, and job satisfaction and possibilities. METHODS: A self-reported questionnaire was given to 433 home care workers, both full time and part time (more than 15 hours), at 35 institutions that provide home care services to residents of Sapporo (return rate; 80.2%). The following issues were investigated: job content (physical care, assistance with housework, and advice), specialty, job satisfaction, possibilities, job training, health care and social support. The results were compared among employed types: full-time and part-time daytime and shift workers using the t-test or the Fisher's test. RESULTS: The participants demonstrated high dissatisfaction with wages, physical uneasiness themselves and limited social support from their supervisors. Especially full-time workers were dissatisfied with the payment, whereas part-time workers complained about insufficient attention to the prevention of lumbago. It was found that part-time daytime workers were given insufficient on-job-training and education for prevention of infection, and that full-time shift workers greatly wished to leave the employment. However, the home care workers were satisfied with their job itself and expected to continue their work. Furthermore, half of the part-time workers hoped to work full time. CONCLUSIONS: Health management and educational training for part-time workers may be necessary to improve the quality of care services and protection of health. Promotion of full time employment and reconsideration of working condition might be necessary to provide sufficient home care services.     

Risks to home care workers: Professional perspectives

Care at home is fundamental to community care policy, but the simultaneous growth of health and safety regulation has implications for home care services because of the duty of employers towards home care workers. This grounded theory study set in Northern Ireland used data from 19 focus groups and nine semi-structured interviews with a range of health and social services professionals and managers to explore perspectives on planning long term care for older people. Home care workers faced a wide range of hazards in the homes of clients, who themselves were faced with adapting their living habits due to their changing health and care needs and ‘risks.’ Creative approaches were used to ensure the health and safety of home care workers and simultaneously to meet the choices of clients. Staff experienced feelings of conflict when they judged it necessary to impose their way of providing home care and thus impose their values on clients to create a safe working environment. There was variation between and within organizations in terms of the staff focus on client needs or on their employer responsibility towards home care workers. The planning of home care services must take account of both the choices of clients and the hazards facing home care staff.     

Knowing the diagnosis and counselling the relatives of a person with dementia: the perspective of home nurses and home care workers in Belgium

Home nurses and home care workers share the care for a person with dementia with family caregivers, and are confronted with their needs for medical and service-related information, for advice on how to cope with the behaviour changes, and for emotional support. The first objective of the present study was to describe some of the conditions for effective counselling, such as the perception that knowing the diagnosis has positive consequences for the formal caregivers. A second objective was to describe the formal caregivers' counselling practice, and ascertain its relationship with the psychological variables of attitudes, self-efficacy and subjective norm. A postal questionnaire was sent to 287 home nurses and 1259 home care workers in a defined region of Belgium; the questionnaire was returned by 169 home nurses (58.9% response) and 665 home care workers (52.8% response). The Theory of Planned Behaviour was the organising framework which underpinned the development of the instruments. Only the 168 home nurses and 601 home care workers reporting experience with caregiving to people with dementia were included in the analysis. Formal caregivers indicated that knowing the diagnosis was important, but it could facilitate or hinder caregiving. They were able to describe behavioural characteristics which are indicative of dementia, but only in a limited way, and their strategies to uncover the diagnosis were also limited. Formal caregivers reported that they supported family members emotionally, advised about communication with the person with dementia and informed family caregivers about services. However, providing family caregivers with information about dementia lagged behind these forms of support. In general, nurses scored higher than home care workers. Multiple linear regression analysis was used to investigate the relationships between self-reported practice and the concepts of the model. In both professions, attitudes and self-efficacy were found to be strong independent predictors, and the implications for practice are discussed.     

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.     

Working conditions in home care: a survey of Washington state's home care workers

Home care services make it possible for millions of older Americans to continue living in the community. Such services may enhance the recipients' quality of life while providing essential respite to family caregivers. But while there has been increasing recognition of the burden borne by the predominantly female family caregivers, there has been less attention to the plight of the home care workforce. With the growth of the home care industry, the burden of care has to some extent shifted from one category of female caregivers to another. This paper, based on a survey of 16 agencies and 1,900 workers, examines the employment conditions of home care workers in Washington state. The study reveals a pattern of harsh working conditions, low wages, and few benefits. The findings raise questions about the ethics and efficacy of government policies that are based on the exploitation of home care workers.     

Food provision for older people receiving home care from the perspectives of home‐care workers

Malnutrition is a significant cause of morbidity and mortality, particularly among older people. Attention has focused on the inadequacies of food provision in institutions, yet the majority suffering from malnutrition live in the community. The aim of this study was to explore barriers and facilitators to food provision for older people receiving home care. It was a qualitative exploratory study using semi‐structured interviews with nine home‐care workers in June 2013 employed by independent agencies in a large city in northern England. Data were analysed thematically, based on the principles of grounded theory. Findings showed that significant time pressures limited home‐care workers in their ability to socially engage with service users at mealtimes, or provide them with anything other than ready meals. Enabling choice was considered more important than providing a healthy diet, but choice was limited by food availability and reliance on families for shopping. Despite their knowledge of service users and their central role in providing food, home‐care workers received little nutritional training and were not involved by healthcare professionals in the management of malnutrition. Despite the rhetoric of individual choice and importance of social engagement and nutrition for health and well‐being, nutritional care has been significantly compromised by cuts to social care budgets. The potential role for home‐care workers in promoting good nutrition in older people is undervalued and undermined by the lack of recognition, training and time dedicated to food‐related care. This has led to a situation whereby good quality food and enjoyable mealtimes are denied to many older people on the basis that they are unaffordable luxuries rather than an integral component of fundamental care.     

Challenges for Japanese rural home care workers in interprofessional collaboration: a qualitative study

Among medical professionals, the role of home care workers is crucial in the care of patients in their homes. In Japan, however, research on the difficulties home care workers face while working in rural zones is limited. Using thematic analysis, a qualitative study was conducted with 57 home care workers in a rural area of Japan. Findings revealed the difficulties they experienced regarding the medical problems of their patients and in their relationships with other professionals. The old customs of rural medicine and the system of long-term care insurance strongly influence relationships among multiprofessionals, leading to conflict and hierarchy.     

The interests of three stakeholders in independent personal care for disabled elders

There is concern throughout developed countries about how sufficient services can be mounted in this century to care for all older, disabled persons who want to remain at home. With declining availability of family care and high turnover among paid workers, cost, care supply, and quality dilemmas abound. Therefore, how can home care be improved? One suggestion is to revise the care "contract" by simply eliminating the costly bureaucratic and controlling dimensions of agency oversight and management. In consumer-directed or self-managed care, independent workers are hired directly by consumers or their family members. Consumers spend their own private money or government provides authorization for them to "hire" their own workers. Such arrangements may be more responsive to the needs of consumers, more directly accountable to them, and less costly for both individuals and government. This article examines 41 cases of consumer-directed care in Milwaukee. Extended interviews with three "stakeholders" in care--the disabled, older client, the family caregiver, and the personal assistant--were conducted, including both private pay and government subsidized arrangements. This analysis identifies some essential, but disparate interests of the three partners in care.     

Intention to Leave the Job Among Live-In Foreign Home Care Workers in Israel

In Israel, almost all around-the-clock home care services are provided by foreign workers. Despite the fact that these workers are considered temporary, the Israeli government has acknowledged the need for consistency in care and now allows workers to stay in the country for as long as their care recipient is alive. Nonetheless, there have been increasing concerns about the tendency of foreign home care workers to view Israel as a temporary station on their way to more attractive destinations, such as Canada or England. Using the job rewards and concerns model, this article evaluates determinants of foreign home care workers' intentions to leave their job. This study was a cross-sectional analysis of 178 Filipino home care workers in Israel. Only 15 workers (8.4%) reported that they would be likely or very likely to leave their job within the next 3 months. The final model suggested that negative experiences within the home/work environment as well as within Israeli society at large contribute to depression and posttraumatic stress symptoms. However, caring for an older adult with dementia was the only predictor of intention to leave the job. The majority of workers do not report an intention to leave their job. Nonetheless, greater supervision of this caregiving arrangement in an attempt to protect the rights of foreign home care workers within the home/work environment is an important step, which has to be followed up by attitudinal changes within society at large. Specific training in dementia care is also warranted.     

Task shifting in the provision of home and social care in Ontario,Canada: implications for quality of care

Growing healthcare costs have caused home‐care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home‐care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home‐care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010–2011. Using a purposive sampling strategy, semi‐structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home‐care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G‐tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust‐based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.     

Navigating the field of temporally framed care in the Danish home care sector

The organisational and temporal framing of elderly care in Europe has changed in the wake of new public management reforms and standardised care services, the strict measurement of time and work schedules have become central aspects of care work. The article investigates the crafting of care in this framing: how care workers approach the services specified in their rotas and navigate between needs, demands and opportunities in the daily performance of duties. Applying feminist theory on time and anthropological theory on social navigation, it examines the practice of home care work in two Danish municipalities. Data are derived predominantly from participant observation. The article identifies two overarching temporal dilemmas in different home care situations: one where process time prevails over clock time and another where the care workers balance the two. Focusing on how care workers respond to these dilemmas in practice, the article identifies various navigation tactics, including leaving time outside, individualised routinisation, working on different paths simultaneously and postponing tasks. By assessing care workers' performance in the temporal framing of work and focusing on care workers' mediation between different time logics, this study provides an in‐depth perspective on the broader feminist literature on the dilemmas of care.     

Job stress and job dissatisfaction of home care workers in the context of health care restructuring.

Changes in the social organization of home care work due to health care restructuring have affected the job stress and job dissatisfaction of home care workers. This article reports the results of a survey of 892 employees from three nonprofit home care agencies in a medium-sized city in Ontario, Canada. Survey results are complemented by data from 16 focus groups with 99 employees. For the purposes of this study, home care workers include both office workers (managers, supervisors, coordinators, office support staff, and case managers) and visiting workers (nurses, therapists, and visiting homemakers). Focus group participants indicated that health care restructuring has resulted in organizational change, budget cuts, heavier workloads, job insecurity, loss of organizational support, loss of peer support, and loss of time to provide emotional laboring, or the "caring" aspects of home care work. Analyses of survey data show that organizational change, fear of job loss, heavy workloads, and lack of organizational and peer support lead to increased job stress and decreased levels of job satisfaction.     

Social work services in home health care: challenges for the new prospective payment system era

The implementation of the Prospective Payment System (PPS) provides a unique opportunity for social workers to be better integrated into home health care. To do so, it is important for social workers to define their roles and eliminate any barriers to providing social workers services, which may improve patient outcomes. Two focus groups with home health nurses (n = 10) and social workers (n = 8) were conducted in a large urban home health agency to define social work roles and identify barriers to providing social work services. This paper categorizes the barriers to providing social work services into informational, systems/organizational, and inter-professional barriers and presents possible solutions to these barriers as home health agencies strive to provide care under PPS.