Organizational Considerations for Supporting the Safety of Home Support Workers: Results From a Scoping Review

Abstract

As the population ages, and more people are living at home with chronic conditions, there is an increasing need for home support workers (HSWs). Safety is a central concern for HSWs, and contributes to the recruitment and retention of HSWs and ultimately to a sustainable home care sector. This article reports on a scoping review that was conducted to assess the state of the literature related to the safety of HSWs. Studies were selected that address the central phenomenon and that were conducted from 2000 to 2015. One hundred twenty-six studies were included in the synthesis of findings. This article outlines two of the four major findings, those related to safety factors associated with home care organizations: (1) injury prevention initiatives and (2) human resource planning. The findings have important implications for developing strategies to address safety concerns for HSWs.

Keywords

home support workers health care aides safety injury prevention management human resources

Introduction

There are increasing demands for home care in Western countries, particularly among older people and those with chronic health conditions. There are expectations that the number of older people will increase in Western countries, and with the increased numbers will come increasing needs for home care services. This trend has already been observed in several member countries of the Organisation for Economic Co-Operation and Development (OECD),¹ and is above and beyond the home care needs of other age groups. In Canada, home care services increased by 55% from 2008 to 2011,² and have continued to increase since then. Currently, approximately 8% of Canadians receive home care, and many thousands more require care but have not received it.³ Along with an increasing proportion of older people, these changes have been attributed to a move to provide more care in home settings rather than in health care settings, and increases in the number of people living with chronic conditions.^2,4 Public policy priorities have changed significantly in the past 10 years to reflect the importance of home care services such as increased access, a broader range of services, and the integration of home care services with other support services.²

Home support services are the most common type of home care services provided and include personal care, meal preparation, and assistance with household chores.^5,6 Home support services are generally provided by unregulated care providers. We chose to use the term home support workers (HSWs) to describe this role, but terms such as personal support workers, health care aides, community care aides, and others are also commonly used.⁷ We focused on home support service providers, rather than the complete gamut of home care providers because they tend to be underrepresented in the home care literature. This is especially true in the Canadian context, as the Canadian Homecare Association does not have statistics on HSW injuries, nor does Statistics Canada. In terms of the search and the literature available, this underrepresentation meant reviewing articles where HSWs were not the only group studied or reported on. The training of HSWs varies greatly across and within jurisdictions, ranging from certification programs to on-the-job training.⁶ As the demand for home care grows, there has been a concomitant increase in demand for HSWs. For example, in the United States, the number of HSWs is expected to increase by 26% from 2014 to 2024.⁸ Most HSWs are female, earn low wages, and are susceptible to injury on the job.¹

The nature of home support work often means there are safety concerns for HSWs. Safety in home care can be threatened by physical strain, increased stress, or incidences of violence. Home support work, which frequently includes manual handling of clients, increases the risks of musculoskeletal disorders (MSD) such as back pain and shoulder problems.^9,10 Furthermore, home care services have unique risks due to the nature of the home setting. Providing care in private homes means that HSWs have little control of their work environment: The physical environment can be hazardous, routines vary depending on client needs, there are fewer supports and resources available to HSWs than in health care settings, and unpredictable factors can readily affect how HSWs provide care. These characteristics all contribute to the safety of HSWs.¹⁰

Ensuring the safety of HSWs is important to safeguarding the sustainability of home support services. HSWs’ experiences of safety are related to their desire and ability to remain in the job.¹¹ The retention of experienced HSWs is vital to ensuring the quality of home care support and in sustaining an adequate workforce. The recruitment of new, qualified HSWs is also necessary to address the increasing demands for home support care. HSWs’ job satisfaction is also related to their perceptions of safety,¹² which is further related to quality service provision. There has been a high degree of job turnover among HSWs related to poor working conditions and job insecurity.^6,13 Policy makers and administrators in the home support sector need to attend to safety concerns to support an adequate HSW workforce.

The aim of this article is to describe the evidence related to HSWs’ safety, and specifically to discuss the body of knowledge related to how organizational factors can contribute to perceptions and experiences of safety for HSWs.

Methods

This scoping review was conducted to evaluate the state of the literature on safety for HSWs. Scoping reviews provide a systematic means to search the literature, identify relevant studies, and summarize the body of knowledge.¹⁴ They are characterized by their breadth on a topic and not depth and quality of included studies.¹⁴ The search was conducted through four databases (MEDLINE, CINAHL, EMBASE, and Scopus) and included studies from 2000 to 2015. No limits were put on the location of the study, language, or method. Data were extracted using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. The analysis of findings followed interpretive descriptive methods,¹⁵ and sought to provide findings that would be relevant to practitioners in home care practice and policy. A full description of the search methods has been submitted elsewhere.¹⁶ The research question guiding the scoping review was “What is the evidence related to HSWs’ safety?”

The nature of scoping reviews, including an inclusive search strategy and broad research questions,¹⁴ means there can be copious data, and diverse and far-reaching findings. That was the case with this review, and we chose to report the findings according to two major themes: (1) factors associated with HSWs’ experiences and (2) organizational factors affecting safety. The findings from the first theme are part of another paper submitted elsewhere.

Findings

The search of the literature resulted in the identification of 126 studies that were included in the review. The majority of articles selected were from the United States (64), Canada (20), and Sweden (14), with less than six articles each from The Netherlands, Denmark, Finland, France, Germany, Northern Ireland, Japan, Norway, or including multiple countries. Articles reporting various methods were included, such as randomized controlled trials, prevalence studies of back and musculoskeletal injuries, explorations of the HSW lived experiences, and overview articles (e.g., nature of HSW role, literature reviews).

The findings reported in this article concern the evidence related to organizational considerations for addressing safety issues in home support work, namely, (1) injury prevention initiatives and (2) human resource planning.

Injury Prevention Initiatives

There is very little literature examining noninstitutional care settings and staff safety.¹⁷ This scoping review yielded 23 studies involving interventions or randomized control trials related to injury prevention for HSWs. From the review, we found literature related to three types of initiatives that comprise this pattern: lumbar support interventions, safety interventions, and exercise interventions. The findings also suggest there are unique challenges to implementing interventions with HSWs; this finding is discussed in the section “Challenges for interventional studies with HSWs.”

Lumbar support interventions

In the studies of lumbar support interventions, researchers gave lumbar supports to HSWs with the aim of preventing MSDs and reducing costs through lost time and using the health care system. Roelofs et al¹⁸ reported some savings in health care costs and a reduction in the number of days suffering from low back pain. However, researchers could not recommend lumbar support use because the study did not include a control group, there was no random sampling, and there was high attrition.¹⁸ In the study by Jellema and colleagues, a majority of participants agreed that the lumbar support helped their back during lifting and wanted to use the support after the study.¹⁹ They also found that disability due to low back pain decreased. These researchers recommended caution in an overestimation of the clinical effect because of potential measurement bias in self-reported outcomes.¹⁹ The results support the need for large, randomized control trials for lumbar support interventions to recommend their use among HSWs.

Safety interventions

Several studies reported the implementation of a safety program or evaluated a program already in place. Johnsson et al evaluated a training program on patient handling and moving skills.²⁰ Although transfer skills were improved, they found that there was no significant decrease in musculoskeletal problems and job strain after 6 months of the training program. However, there was improved work technique. Olson and colleagues conducted a pilot study that showed promise where HSWs met monthly in teams for education and social support.²¹ Topics covered included communicating for hazard correction, using tools to ease strain and prevent injury, functional fitness, and healthy postures. The researchers found that safety compliance increased and participants made more specific safety changes and adopted new tools for lifts and transfers. However, this was a pilot project and the results were not considered generalizable to other groups of HSWs.

Amuwo et al created an intervention that consisted of a 1-day educational session utilizing peer educators to increase awareness about the risks for occupational exposure to blood and body fluids among HSWs, and a follow-up session introducing materials to facilitate communication with clients about safe sharps disposal.²² After education on blood and body fluids, the intervention group increased use of proper sharps containers. This study is an example of a successful intervention on a very specific issue.

Gershon and colleagues developed a safety checklist for workers to identify unsafe conditions, including fire and fall hazards, unsanitary conditions, and problems with medication management.²³ Workers found the checklist easy to use, and patients approved of the inspections. However, the 20-minute completion time was not feasible for most HSWs. Czuba et al implemented an effective pilot project to control HSWs’ daily exposure to higher needs patients. HSWs viewed this intervention favorably and reported feeling less fatigue.²⁴ The authors suggest that because it is not always feasible to incorporate patient handling equipment in homes, it makes more sense to implement workload control. Workload control means trying to balance the number of heavy physical care clients across HSW workloads. These studies produced mixed results or positive results from pilot studies that have not been replicated in larger research projects.

Exercise and rehabilitative interventions

The goal with these types of interventions is to keep workers injury-free for a longer period of time. Longitudinal studies that included exercises and training seemed more effective in helping workers. Pohjonen and Ranta’s work is an example of an effective intervention.²⁵ Over a 9-month period, HSWs engaged in supervised exercise 1 hour twice a week, and they were also given orientations on physical fitness and physically demanding jobs. Following baseline assessments and follow-up at 1 and 5 years, findings revealed that the intervention improved physical fitness and also prevented an early decline in work ability. This was a small sample of 50 HSWs and a rare study in this review, as HSWs were studied over 5 years.

Landstad et al conducted an 8-month intervention with HSWs which included a 2-week stay at an orthopedic rehabilitation center that provided training equipment, and found some improvement in MSDs after the intervention, suggesting that preventive and early rehabilitative programs can be useful.²⁶ This was a government program on improving working life. Participants often had more than one musculoskeletal pain condition, and examinations revealed that some participants improved in relation to some conditions but deteriorated in others. There were few studies in this subcategory, which suggests more intervention work needs to be done.

Challenges for interventional studies with HSWs

Almost all studies related to interventions reported limitations when designing and implementing interventions for HSWs. Jensen and colleagues reported issues when implementing interventions for HSWs, due to high turnover rate and difficulty to observe the intervention in private homes due to ethical concerns.²⁷ Johnsson and colleagues explained the costs involved in observing participants over a long period of time.²⁰ On average, intervention studies had a number of limitations, including small sample sizes that often render results that are not statistically significant.^18,19,28 This research suggests that there is much to be done regarding interventions to improve HSWs’ health and safety.

Human Resources Planning

Human resources and management play an important role in the way HSWs do their job, for example, the time of visit, location, type of work, and the workload, all affect safety and well-being. Pohjonen found that ability to control one’s work, time pressure, and management predicted work ability.²⁹ Ejaz et al reported that job-related stress is linked to scheduling changes, training, pay, and benefits.³⁰ Managers can also play a part in improving work conditions, reducing injuries through affecting policies around hiring, scheduling, training, wages, and equipment. Denton and colleagues found that being paid a fair wage with benefits, organizational and peer support, and control over work led to better health for HSWs.³¹ The effect of human resources planning on injuries is reported under the headings: “Restructuring and budget cuts” create time constraints and heavy workloads, “Management attitudes toward HSWs,” and “Lack of communication.”

Restructuring and budget cuts

Health care restructuring may compress HSWs’ time with clients through increased workloads, shorter visits, and split shifts, and can also lead to less organizational support. Denton et al³¹ found that health care restructuring in the form of budget cutbacks, organizational change, and declining organizational support to HSWs led to job stress for HSWs. HSWs’ tasks have intensified; clients require a higher level of clinical care than they did in the past, and are required to perform basic nursing tasks such as changing wound dressings and transferring/lifting paralyzed clients, sometimes with little information on the clients’ condition, as regular face-to-face meetings with supervisors are not part of their work schedules.³²

Storch et al noted that the impact of staff shortage was a serious challenge, leading to lack of proper preparation for home support work and inappropriate hiring or the amount and type of work HSWs are required to do with their training.³³ Staff shortages also created delayed assessments and delays in delegation of tasks. The work is also more clinically complex than it was previously. Martin-Matthews and Sims-Gould interviewed both HSWs and employers and found that managers recognized that clients’ needs were increasingly medically complex; the turnaround time from hospital to home was faster, as one said “We are an emergency system where once we were not,”^{34(p. 72)} and the current system did not always reflect clients’ needs: “We need a system that can provide for true needs not just tasks.”^{34(p. 72)} Another consequence of the rapid change and growth in the home care sector is the perception by workers of a decrease in organizational and peer support. At the supervisory level, as organizational support decreased, workload increased.³¹ One visiting homemaker said, “They’re more worried about getting their work finished, than what happens to you.”^{31(p. 342)} Home support work occurs within a context of unpredictability related to scheduling, time constraints, variability of client need, and changing work environments.

In their study of the restructuring of the Quebec health care system, Cloutier and colleagues explored how budget cuts affected HSWs.³⁵ They found that HSWs’ workload increased, and one-third of HSWs missed work during the 3 years preceding the study; the absences were primarily related to musculoskeletal problems. HSWs with a heavy workload, defined as six or more cases per day, had a higher exposure to postural constraints, and tried to avoid changes in positions as much as possible, such as going from a kneeling to a standing position, which can be physically demanding.³⁵ The authors reported that HSWs were feeling more fatigue and discomfort and more often experiencing increased workloads. However, different management policies eased the distribution of postural load by allowing HSWs to change the order of their daily visits, which positively affected their physical and emotional recovery during a work shift.³⁵ The study also found that due to intensification of the work required, HSWs have less time for their clients, could not give them the same level of attention, and were forced to make choices in the services they provided: “Today I will wash your hair; tomorrow I will change your bed.”^{35(p. 88)} Sims-Gould and Martin-Matthews also found that HSWs felt time pressures: They felt torn between the need to complete tasks while also striving to personalize care:

. . . the only thing that I don’t like [about] working with the elderly people . . . [is] the time. The time is—especially if I know that . . . this person really needs more help and yet you are catching and trying to accomplish everything for one hour, you know, or 45 minutes. I hate to leave clients or a patient that I work with—if I did not finish my job. I feel like I didn’t do my job well. So that’s the thing that I [am] not really happy with. Time and pressure.^{5(p. 103)}

HSWs’ visits can be compressed, and their workday can also be fragmented.

Casualization and working split shifts often means the HSWs see clients in the morning and evening, have less time to spend with them, and will often shorten their breaks and lunches to meet caring obligations, which can add to stress: “My hours look okay on the computer, about 25 hours a week, but the actual day, the human part is crazy.”^{32(p. 96)} HSWs noted feeling rushed, and 60% in one study noted that they “sometimes” or “never” had enough time to carry out their work, which made them rush through their visits and feel stressed about their jobs.³⁶ In addition, they were not satisfied with scheduling, not getting enough time off and/or working irregular or antisocial hours.^36,37

Management attitudes toward HSWs

There was a small set of papers that examined the managers’ perspective of HSWs and their labor. Despite how important formal leadership is to HSWs, if HSWs believed they received little support from their supervisors, their risk of workplace injuries increased.³⁸ In the study by Fleming and Taylor, 27% of HSWs “sometimes” or “never” felt supported by supervisors in emergencies, and felt isolated and ignored.³⁶ Interviewing female managers for home care organizations, Whitaker found that managers viewed the crisis of an HSW labor shortage not as a problem of working conditions, but as a problem of workers, applying a framework of gender, class, and race that privileged traditional conceptions of feminine self-sacrifice, and denigrated workers who did not live up to this ideal.³⁹ These female managers reproduce a work culture that legitimizes a wage penalty for care work. One manager remarked, “It’s no secret, we’re not choosing from the cream of the crop,”^{39(p. 22)} because they did not display a traditional feminine work ethic, and compared care workers with fast food and retail workers. A worker in the study by Stacey^{40(p. 839)} echoed this sentiment: “We’re Maids Plus, you know? Maids plus companion, maids plus nurse, maids plus family.” One HSW remarked, “There is an unspoken prejudice that we do not have the brains to learn anything new.”^{41(p. 403)} HSWs also did not feel respected by their managers:

Nobody’ll listen to you . . . you’re just the aides. I get so tired of being thought of as incompetent and stupid and don’t know anything. But I think it’s always been that way. And I think it will continue to be that way. We’re the ones that know the patients, and everything. But it’s the power trip, the control trip . . . I could care less. I do what I do, you know?^{40(p. 839)}

Managers’ attitudes toward HSWs negatively affect HSWs.

However, there is also evidence that managers are concerned about HSWs’ well-being. Taylor and Donnelly interviewed managers and other professionals and found that they worked hard to protect HSWs while ensuring clients were receiving proper care.⁴² One home care manager said, “You [as client] haven’t got an ultimate right to have everything your own way if you put somebody else [the home care worker] at risk.”^{42(p. 248)} Managers’ attitudes and the effect of these attitudes on HSWs’ health and safety is a topic that needs further investigation.

Lack of communication

Within the pattern of human resources planning, a lack of communication or miscommunication between mangers and HSWs was recurrent, and led to safety issues for both HSWs and their clients. The lack of communication was described as stressful by HSWs:

Never really knowing what was going on. That caused me a lot of stress. I am a planner. I have things set-up and that’s the way I expect them to go and things were never the way they said they were going to go. And, it just kind of had me in a tailspin, stressed out.^{43(p. 675)}

A sense of stress and burnout was also created when HSWs received no support from the agency, for example, when managers supported clients rather than HSWs when there were conflicts between clients and HSWs.⁴³ Ashley et al, in a study of HSWs’ perception of the job, noted HSWs’ frustration with supervisors: “My greatest frustration comes from my involvement with the agency, especially my supervisors. [My supervisor] seldom returns my calls in a timely manner if at all.”^{41(p. 403)}

Craven et al noted that organizational policies can either reduce severity of safety concerns or exacerbate them.⁴⁴ For example, engaged supervisors can easily speak with workers to assess, prevent, or improve safety concerns: “You have the option, like, if you don’t feel physically prepared, then you can say no and you can—it’s valid for them.”^{44(p. 529)} However, lack of communication between supervisor and worker can lead to safety issues. One worker revealed a situation where she was not informed about a client’s highly communicable disease for nearly a week: “I don’t want to transfer it to other clients and my family, . . . It’s all about the agency. They have to be responsible, [and] tell us right away.”^{44(p. 530)} Sometimes, HSWs are given virtually no information on a client:

HSWs do not receive enough information about new clients, sometimes don’t even know their age, and when care plans are out of date, this creates tensions between client and HSW, being told a person is in a wheelchair but is found walking and not using a wheelchair; not knowing if a person is just out of hospital.^{33(p. 87)}

Managers have the authority to increase or decrease safety for HSWs.

Some researchers found there was a lack of information among both managers and HSWs. Fazzone et al⁴⁵ found that workers were not often aware of safety policies and felt that policies were not easy to access. In addition, staff agreed that high-level administrators, those who made financial and policy decisions, had little, if any, knowledge of personal safety issues of staff.⁴⁵ HSWs often have limited control of tasks and scheduling and little impact with respect to agency policy.⁴⁶ For example, one HSW in a focus group said,

Many the time I worked with the client, who, you see changes, they need more care, they need more help, and you report it and report it and report it and you know like you feel there’s nothing being done.^{46(p. 13)}

Stevenson and colleagues found that HSWs appeared to have a high tolerance for risk and were not always sure about what an acceptable range of risk might be, which places them in vulnerable and potentially unsafe situations:

One day when it snowed, I had my husband drive me up the mountain to Mrs. [name] house as I knew she would not be able to manage her meds without me. It wasn’t a great idea as we had our kids in the car as there was no school, but what could you do, you can’t leave her on her own.^{28(p. 22)}

It is evident that lack of communication between managers and HSWs can create safety issues for both clients and workers.

Implications

This scoping review has important implications for home care policy and research, as well as the education of HSWs. The safety of HSWs ought to be a significant concern for policy makers. Safety is an important factor that contributes to the satisfaction of HSWs and contributes to their willingness to remain in the role. In a context where there is an aging population and increasing needs to provide health care in the community, sustained involvement of HSWs is essential to the viability of the home care sector in the future. Sims-Gould and Martin-Matthews suggest that social, organizational, spatial, and temporal domains all contribute to the experiences of HSWs.⁵ This review has begun to describe the role of home care organizations in affecting these domains to support positive safety experiences for HSWs.

There are also important implications for the design, implementation, and evaluation of interventions to support HSWs. The limitations of interventional research with HSWs reported in the literature suggest that home care is a particularly challenging place for developing and implementing innovations. This is especially true for implementing interventions across organizations, regions, or sectors, because complex policies, and standards, guide the delivery of home support services. Furthermore, the nature of home care work, being delivered in private homes and with clients with complex medical circumstances, means that it is difficult to ensure control and consistency to make generalizations about interventions. The findings suggest that organizational level interventions regarding controllable work characteristics, such as regular hours, communication strategies, and management styles, may be particularly well suited to this environment.

The education of HSWs can also support their safety in providing home care. The education of HSWs is far from standardized and varies greatly across jurisdictions.⁶ However, there are opportunities for individual organizations to provide education that can contribute to decreasing accidents in home care. Interventional studies, while having some limitations, did suggest that educational programs can reduce the prevalence and severity of musculoskeletal injuries among HSWs. Furthermore, educating HSWs in the identification of unsafe work environments, along with managerial support for reporting such conditions, can increase opportunities to address unsafe situations and increase the safety of HSWs. HSWs are very rarely in leadership or management roles, with such positions traditionally being held by more educated health care professionals. Berta et al⁶ suggest increasing management training for HSWs as a way to increase the inclusion of HSWs in defining organizational culture.

Summary

This article reports on findings of a scoping review aimed to better understand the state of the evidence about supporting the safety of HSWs. Through the review, we found that there is a small but important body of knowledge related to organizational factors that contribute to safety, which we have reported here. The evidence does show some important considerations regarding implementing safety initiatives and how relationships with management affect the experiences of safety for HSWs. Interventions to prevent injuries and increase awareness of safety issues among HSWs have shown promise, yet there are still questions about the effectiveness and generalizability of interventions across organizations and regions. Formal leadership in home care is important to the safety experience of HSWs, and there is some consensus about key factors influencing positive organizational characteristics that support the safety of HSWs such as regular working hours, availability of leadership, and strong communication strategies.

Footnotes

Acknowledgements

The authors gratefully acknowledge financial support from the Workers’ Compensation Board of Nova Scotia to complete this review.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received financial support from the Workers’ Compensation Board of Nova Scotia for the research.

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