At the centre of caring for the person-centred whole lies the personal support worker
By Jane Teasdale
There is a long-developing crisis in home and community care. Last year, the Ontario Personal Support Workers Association (OPSWA), reported that personal support workers (PSWs) are leaving their careers because of dissatisfaction and burnout. In a 2018 survey of OPSWA members, 79 per cent reported being unhappy with their job; staffing issues, pay scales, unsafe working environments, and long and unpredictable hours were just some of the issues raised. A recent Home Care Ontario report reiterated these issues, noting that service providers were struggling to attract and retain qualified PSWs.1
PSWs are leaving
According to Home Care Ontario, of the 8,000 new PSWs who graduated last year, only 4,000 remained at the end of the year. A 2018 report from the Waterloo Local Health Integration Network noted that many PSW graduates fail to enter the profession.2 And a 2010 Canadian Research Network for Care in the Community report noted that while 7,000 new PSWs were entering the industry annually, 9,000 were leaving for other employment opportunities, creating a deficit of workers.3 This 2010 report also noted that the four highest-ranked reasons for considering leaving the field were pay, unsatisfactory working conditions, scheduling and hours (45 per cent cited too few hours). Conversely, factors that were likely to make PSWs stay were good relationships with clients and their families, immediate supervisors and co-workers, satisfactory working conditions and respectful workplaces. The same report noted data from 2000, estimating turnover rates in personal support work at two to three times the rate for other health care workers.
Furthermore, PSWs in Canada have been found to be seven times more likely to experience violence in the workplace than those in Scandinavian countries. The reason stated was differences in workloads in institutional care.
Consequences of this loss
PSWs operate at the centre of institutional, home and community care. While anyone can “keep an eye” on a person and do light house-keeping, providing personal support is a different matter and requires training to care for patients with complex and often serious illnesses. The loss of PSWs leaves the door open for their roles to be taken up by less skilled workers in the largely unregulated home care marketplace.
Another consequence is the loss of expertise and knowledge. Knowing how to look after a person, how to communicate at a meaningful level and how to interpret personal preferences and needs is a learned skillset. This is especially the case when looking after people at the end of life and those living with dementia and other challenging health issues. A good PSW requires years of on-the-job experience and further training, in addition to the basic educational qualifications.
Pay and conditions
Hourly pay is clearly an issue, but it might not be the central one. Higher hourly wage rates are found in hospitals and long-term care homes, whereas lower rates are paid in home care—and it is in these settings that we find the highest workloads and the most recorded instances of abuse. The hours in home care settings can often be long and the role is heavily task orientated. As shown by research, higher workloads are stressful and impact job satisfaction by hampering a worker’s ability to deliver safe and effective care.
Pay scales tend to reflect the type and intensity of work. Along with higher wages, the complexity of the care and rates of burnout also tend to be higher in institutional settings, for several reasons. Social and emotional needs, which define us as human beings, are often ignored for both those in care and PSWs. A good part of the crisis is a crisis of personhood. In institutional settings, a PSW can be looking after 10–15 people in the day and more during a night shift. Within the private delivery of community home care, however, it is usually one on one. On the other hand, the delivery of contracted public health care can still be arduous, as community PSWs have to move from client to client across a wide area.
The research suggests that working conditions are overwhelmingly important. If the caregiver has a problem, for example, how responsive is the home care company they are working for and is there accessible on-the-job support? How does the company address its caregivers’ social and emotional needs and job satisfaction, and provide flexibility when needed for personal or other reasons? Are the care workers considered an integral part of the team? Again, the workplace and the workloads of the organization are relevant in terms of its ability to deliver job satisfaction. The recent Home Care Ontario report pointed to many scheduling and care-related issues with public health contracted care.1 Sadly, this suggests that the issues are systemic and often out of the hands of care providers.
Wages in the institutional and contracted public health markets are paid for centrally, but tight budgets are forcing high person-to-staff ratios in institutions, and shorter visits and longer waiting lists in the contracted care arena. On the private home care side, wages are restricted by the ability of the market to pay. Many of those delivering home and community care are working on narrow margins. Research into the contracted care model shows similarly tight margins, with profitability running at little more than two per cent according to a 2014 Accenture report.5 From what we see, there is minimal leeway in many areas to raise hourly wages without additional government support.
The other major problem is available hours. If you cannot get the hours you require then your hourly rate may be academic. Many shifts are short and are not economically viable. With most people requiring care at similar times during the day, it is also difficult to stagger shifts for PSWs. In today’s world, with high rental and property costs, short shifts and uncertain hours are not going to keep workers satisfied, let alone keep them in the industry. Moreover, where the opportunities exist for longer hours—for example, the poorly staffed/high workload institutional setting—the risks of burnout are higher, given the tasks required.
Additional trends are compounding these issues. The development of a private “underground” marketplace for caregivers, as Home Care Ontario calls it, means that much care is being provided off the record for cash, without oversight, proper care assessment or accountability in care planning.
Home care is much more than the intermediation of health care workers. Many of those we look after have complex health issues that require special attention and monitoring. Awareness of local community resources and supports is also an important element of home care provision, as is properly addressing the social and emotional needs of the individual. Many of those who depend on care are also vulnerable to financial and other forms of abuse. In the home and the community, oversight by a client services team, with the necessary skillsets to identify and address issues, is arguably even more important than in the hospital setting.
Finally, those who contract privately likely do so without providing payroll benefits such as vacation pay and payments to Canada Pensions, as well as other Employment Standards Act requirements and occupational health and safety standards.
The problem is clearly much more than hourly wage rates. Social, emotional and work–life balance issues, as well as greater certainty and dependability of career earnings and opportunities for advancement, are clearly important. However, when we look at the overall health care system, we see systemic issues and a resultant inability to address the person fully. The gaps in addressing the needs of each individual are becoming better understood, but the failure extends well beyond to impact both families6 and health care workers.
What seems clear from all the research and trends in health care is that without a change in the way we address the holistic, community and work–life balance needs of health care workers, the crisis is likely to be exacerbated. Merely increasing hourly rates for contracted public health care may not be a clear solution.
Better organization and collaboration throughout the system and assistance from community volunteers, in non-direct care areas, should allow for better scheduling of PSWs and more efficient use of scarce resources. It may also result in better visibility and social support for PSWs and other health care workers in general. We might also need to adjust care provision to reflect affordability generally.7 Canada’s system of universal health care does not presently extend to those in our communities with complex care needs and a low income and wealth. The issue is a complex one—the solution is likewise.
Jane Teasdale is the business development director and principal of Mosaic Home Care & Community Resource Centres.