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Work 40 (2011) 21–28 21 DOI 10.3233/WOR-2011-1203 IOS Press

Key issues in human resource planning for home support workers in Canada

Janice M. Keefea,b,c,∗, Lucy Knightd, Anne Martin-Matthewse and Jacques Légaréf aDepartment of Family Studies and Gerontology and Nova Scotia Centre on Aging, Mount Saint Vincent University, Halifax, Nova Scotia, Canada bMount Saint Vincent University, Halifax, Nova Scotia, Canada cNova Scotia Centre on Aging, Mount Saint Vincent University, Halifax, Nova Scotia, Canada dMaritime Data Centre for Aging Research and Policy Analysis, Mount Saint Vincent University, Halifax, Nova Scotia, Canada eDepartment of Sociology, University of British Columbia, Vancouver, BC, Canada f Département de démographie, Université de Montréal, Montreal, QC, Canada

Received 7 December 2009

Accepted 22 February 2010

Abstract. Objective: This paper is a synthesis of research on recruitment and retention challenges for home support workers (HSWs) in Canada. Participants: Home support workers (HSWs) provide needed support with personal care and daily activities to older persons living in the community. Methods: Literature (peer reviewed, government, and non-government documents) published in the past decade was collected from systematic data base searches between January and September 2009, and yielded over 100 references relevant to home care human resources for older Canadians. Results: Four key human resource issues affecting HSWs were identified: compensation, education and training, quality assurance, and working conditions. To increase the workforce and retain skilled employees, employers can tailor their marketing strategies to specific groups, make improvements in work environment, and learn about what workers value and what attracts them to home support work. Conclusions: Understanding these HR issues for HSWs will improve recruitment and retention strategies for this workforce by helping agencies to target their limited resources. Given the projected increase in demand for these workers, preparations need to begin now and consider long-term strategies involving multiple policy areas, such as health and social care, employment, education, and immigration.

Keywords: Home care, recruitment and retention, compensation, working conditions

1. Introduction

Recruitment and retention of home support work- ers (HSWs) is of increasing interest to home support agencies, governments, and national organizations in Canada and other developed countries. HSWs provide paid, non-professional services such as personal care,

∗Address for correspondence: Janice M. Keefe, Mount Saint Vin- cent University, 166 Bedford Highway, Halifax, Nova Scotia B3M 2J6, Canada. Tel.: +1 902 457 6466; Fax: +1 902 457 6226; E-mail: [email protected].

housework, and meal preparation to individuals with demonstrated need in their homes, and are the largest occupational group in home care. It is estimated that 1.2 million people in Canada use home care services annually [11], the majority of whom are aged 65 and older. The demand for these services is expected to in- crease in the next twenty-five years, as the baby boomer cohort (1946–1964 in Canada) moves into later adult- hood and experiences increased life expectancy [40]. Also contributing to the demand for workers is home care policy that emphasizes “aging in place,” reflecting older adults’ desires to remain in their own homes and

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communities for as long as possible [12,28,44]. Ad- ditional factors include the decreased supply of formal caregivers due to pressures on health and social service systems to contain costs, the difficulty attracting people to long- term care work [26], and the high percentage of HSWs nearing retirement age [31]. These issues are not unique to Canada. Recruitment and retention are also priority issues in home care in most U.S. states [62] and growing demand in the long-term care workforce has been noted in other developed countries including the United Kingdom, Australia, Denmark, and others [26].

Family and friends remain the greatest contributors to meeting home support needs in Canada and the Unit- ed States [12,35]. However, research has called in- to question the capacity of family and friends to con- tinue providing this care at the levels required [39]. Reasons include fewer adult children available to pro- vide support; more women working outside the home; adult children who are less likely to live geographical- ly proximate to aging parents; and increasing divorce rates [39].

These challenges point to a need to address recruit- ment and retention of HSWs. Furthermore, home sup- port services are considered paramount to preventing health decline in the older population [58] and may be cost saving. Research in Canada has indicated that home care for older people can be cost effective when compared to institutional care and acute care [30]. Hol- lander et al. [30] argue that there is a strong case to push for policies that support the integration of home care and support into a broader integrated system of care in which they can substitute for facility and acute care.

Many jurisdictions in Canada are already facing shortages or anticipating shortages of HSWs [8,38]. The province of Alberta, for example, is projected to need an additional 5,000 Health Care Aides (who work in private homes and institutions) by 2016 [1]. How- ever, health human resources planning has tended to focus on strategies to meet the demand for doctors and nurses [59], despite wide consensus in the literature that recruitment and retention of adequate staffing is also a key problem facing home care [8,15,39]. The purpose of this literature review is to identify human re- source issues for HSWs,1 to inform long-term recruit- ment and retention strategies. In Canada, home care is

1We use the term “home support worker” because we are inter- ested in the non-professional front-line workers who work in clients’ homes. There is no common term used for this workforce in Canada. In the United States, these workers form a large part of the Direct Care workforce.

under provincial jurisdiction, with some services fund- ed (wholly or in part) by provincial governments and others available only privately. HSWs may work with- in provincial, publicly funded homecare systems; for contracted or private organizations; or autonomously, providing care privately to individuals. Whatever the context, common issues characterize this work: com- pensation, education and training, quality assurance, and working conditions. A discussion of agency-level initiatives to address human resource challenges fol- lows.

2. Method

This literature review is the first phase of research to examine human resources strategies to attract HSWs to meet future projected chronic care needs of older persons in Canada. Literature (peer reviewed, govern- ment, and non-government documents) published in the past decade was collected from a number of sources between January and September 2009, and yielded over 100 references relevant to home care human resources for older Canadians. Sources included: Ageline elec- tronic database, Google Scholar, websites of provincial governments, national and provincial organizations in home and community care, and literature referred to the project by its investigators and stakeholders. Literature was primarily written in English language and Cana- dian in scope, although some references are included that focus on research from the United States and other member states of the Organization for Economic Co- operation and Development (OECD), which were of interest to the project’s objective of identifying key hu- man resources issues for HSWs. Key words used to identify relevant literature included: recruitment, reten- tion, home support worker (and similar titles), human resources, compensation, education, training, quality, and working conditions/work environment.

3. Findings

3.1. Key human resources issues

Academic research on HSWs in Canada and the United States has tended to focus on conditions of their work [54,65], including: working in clients’ homes [18], stress [21,23], occupational health and safety [67], implications of agency type and/or provin- cial service delivery model [4,5,19,22,42,58], rela-

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tionship issues [44], and education and training [34]; and the resultant impacts on job satisfaction, well- being, and intent to remain in the occupation. Gov- ernment and organization reports commonly focus on HSW shortages within broader discussions of home and community care or health human resources [7,13, 59]. Specific topics include: defining scopes of prac- tice/competencies/curriculum of workers [50,57], ad- dressing challenges such as rural and remote home care delivery [9], HSWs as unregulated workers [10,28,56], and the role of HSWs on health care teams [51]. Some reports have focused exclusively on home and contin- uing care human resources [31,32,36]. Efforts to im- prove recruitment and retention of HSWs will need to address current challenges in four distinct yet over- lapping areas: compensation, education and training, quality assurance, and working conditions. These key areas are used as an organizational tool to synthesize the literature review.

3.1.1. Compensation Compensation issues include low wages, lack of

wage parity with counterparts in institutional settings and/or HSWs in other jurisdictions [31], and limited benefits. All of these may act as disincentives for en- tering the occupation [31]. Other compensation issues include whether employees receive paid breaks, are paid to attend meetings and for preparation time [31], and whether or not they are compensated for time and mileage during travel between clients [32].

HSW wage rates vary considerably across Cana- da [53]. In some provinces, HSWs receive lower pay than their counterparts in hospitals and long-term care facilities, despite completing a common curriculum. Several factors have been identified as contributing to this discrepancy in the province of Ontario. These include: legislation privileging the hospital over the home as a care setting; higher rates of unionization among hospital-based workers; devaluing of personal support; and the interest of other health professionals in maintaining the medical-social division between set- tings [43]. Reasons for wage discrepancies in other provinces are not readily available, but may be assumed to be related to many of these factors.

Benefits also vary across Canada, in terms of what is provided and the limits of these provisions. The Canadian Home Care Human Resources Study [31] found that approximately one-third of HSWs received paid sick leave, a similar percentage had a pension plan, and less than 40 percent were eligible for job-protected maternity leave. In some cases, HSWs who do not

receive paid sick time may go to work sick, putting their clients at risk in the process [55].

Many HSWs are employed on a casual basis and must work within “windows” of availability, meaning that they may be asked to be available for eight hours but paid to only work for four hours [46]. In addi- tion to being disruptive to workers’ home lives, limited hours limit income. Workers in the province of New Brunswick have expressed that without regular or guar- anteed hours of employment in home care, a second job is often necessary to achieve an adequate income [55]. The resultant job insecurity has been linked to turnover intention [66].

Unionization of HSWs in home care has been report- ed by previous research to increase wages and bene- fits while positively addressing working conditions [55, 66], which may increase retention. However, other re- search reports that unionization may have the poten- tial for negative side-effects, such as cuts to services, loss of contracts [37], and restrictions to scheduling options [38]. Union membership varies in Canada.

Similar to Canada, home care in the United States is characterized by low wages and limited benefits [26, 60]. A particular issue for the U.S. is lack of access to health benefits and health insurance for workers due to part-time and irregular work hours [35,62].

3.1.2. Education and training Most jurisdictions in Canada now require formal

training to become a HSW, usually completed at the college level. Program entry requirements vary from province to province, as do course lengths (although not usually more than one year), curriculum content, cost, and availability of financial aide. A lack of nation- al training standards creates difficulty in transferring skills between jurisdictions and raises concerns about inadequate training to meet the changing demands of the work [31]. Despite attempts to require formal train- ing, at least two provinces in Canada report that many of their HSWs do not have formal training [1,32]. On-the- job training, high costs for formal education programs, and the number of older workers with prior learning may explain this reality. Conversely, some HSWs are highly educated. A study in the province of British Columbia found some workers had university degrees (including graduate degrees) [58].

Scope of practice concerns the tasks that may be per- formed by a HSW given his or her training and skills. The increasing acuity of clients in home care and ad- vances in in-home technology are also affecting worker skill requirements [8,28,37,58]. However, training in- consistencies mean that all HSWs may not be equipped with the most up-to-date skills [32,33].

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3.1.3. Quality assurance Quality assurance refers to the maintenance of high

standards within home care programs, high standards for worker performance, and ensuring continuity of care for the client. Essential to maintaining these stan- dards is clear accountability [37]. Home care involves a diversity of occupational groups and services contribut- ing to uncertainties about who should be delivering which services and in what manner [31]. Given a grow- ing emphasis on health care teams and the role of un- regulated workers within these teams [56], addressing these uncertainties about roles and scope of practice is particularly salient. HSWs in Canada are not regulated by any professional or governmental regulatory body. This raises several issues for quality assurance, among them: confusion among agencies, workers, and other health team members as to the HSW’s role; and differ- ing job titles and scopes of practice across jurisdictions and between privately and publicly hired workers.

Provider registries are a less rigorous form of regu- lation that may lend more legitimacy to an occupation by tracking its membership. With no central registries, data collection on HSWs in Canada is difficult, limiting planning [56]. Registries would need to be mandatory and address credential and competency equivalencies, since not all HSWs receive the same training [28]. Giv- en the wide variability within and between provincial home support systems, a national registry is unlikely in the near future, but may be a goal for provinces to work towards through development of their own.

Continuity of care is a major concern in quality as- surance, particularly from a client’s perspective. Three types of continuity need to be considered: 1) informa- tional continuity ensuring that discreet care events are recorded and information is available to all health care providers of a client; 2) management continuity ensur- ing timely delivery of services; and 3) relational con- tinuity ensuring consistent and ongoing relationships between client and caregiver [27,58]. Continuity of care has been linked to retaining workers and improved quality of care, since workers really get to know their clients’ needs over time [42]. However, casualization (characterized by irregular and unpredictable hours and employment insecurity) has been found to negatively impact quality of care, continuity of care, and reten- tion of HSWs in the Canadian provinces of Ontario and British Columbia [58,66].

3.1.4. Working conditions Working conditions of HSWs are characterised by

both positive and negative aspects. Key issues include

workloads (too much or too little work), high levels of stress, safety concerns, job insecurity, and feeling undervalued [21,25,55,60,67]. Central to this discus- sion is scheduling. In some jurisdictions, workers are expected to be on-call or to work in split shifts, which is both disruptive to their daily lives and income limit- ing. Scheduling also affects clients, particularly when multiple workers are assigned to deliver home care ser- vices. In such cases, clients must adjust to each new worker and orient them to the tasks that they need to provide [46,58]. These issues are closely linked to job insecurity, a significant predictor of worker turnover [4, 22,65].

Safety issues include occupational injury, aggressive clients or family members, discrimination, racism, and unsafe conditions in the client’s home (including clean- liness, smoking, and pets) [45]. Poor working condi- tions can also impact workers’ physical health and have been linked to musculoskeletal disorders [67].

Ethno-cultural diversity between client and caregiv- er is common in home care in Canada and the United States, where foreign-born and/or visible minority in- dividuals are a large and growing segment of the formal caregiver population [26,47,60]. Harassment, discrim- ination and racism have been experienced by visible minority HSWs, particularly women [46,54,58]. Cau- casian HSWs have reported not being welcomed by visible-minority clients [47], and a study in the province of Quebec found that Haitian HSWs may experience discrimination from Haitian clients, due to issues of so- cial class [48]. However, ethno-cultural diversity does not necessarily lead to negative worker-client relation- ships. Studies have revealed that many HSWs derive satisfaction and benefits from these relationships [47, 48].

Many provinces face acute recruitment and reten- tion challenges in their rural and remote areas. Lim- ited amenities, social isolation and long distances be- tween clients are disincentives to attracting workers to these regions. A scan of rural and remote home care programs in Alberta, Ontario, and Newfoundland and Labrador found that programs are challenged by a lack of human resources [9]. Saskatchewan and British Columbia have also experienced challenges in this area [29,38].

HSWs have expressed feeling undervalued by other health care professionals and the public. For many, value is closely tied to remuneration. HSWs have re- ported that they feel they deserve more recognition and respect, and a greater role in health care planning for clients [55,60]. In some areas, home support work

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is not well understood and is equated with tradition- al “women’s work” [32]. This negative public image may contribute to HSWs leaving the occupation [61]. Opportunities for engagement with peers and as part of a health care team can help address feelings of low value [38]. HSWs also derive value from relationships with clients [60].

Despite the challenges of working in home care, HSWs express relatively high levels of job satisfaction, with older workers reporting greater job satisfaction than younger workers [17,22,24]. Type of agency may also be linked to job satisfaction. A survey of formal workers reported that HSWs’ satisfaction levels with salaries were higher in for-profit agencies than not-for- profit agencies [31]. A study in Quebec revealed that the workers prefer jobs in the public system, where wages are higher, workers are unionized, and job secu- rity and training are perceived to be better than working for private agencies [48].

4. Discussion

Despite the challenges for recruitment and retention identified above, opportunities exist to mitigate the ef- fects of future HSW shortages. This literature review supports the development of strategies at public policy and agency levels. Strategies must focus on increas- ing the workforce, making better use of existing work- ers’ time and skills, and retaining workers by making improvements in each of the four key areas. Howev- er, Mittal et al. [52] caution that “drivers of turnover are different than drivers of retention, and strategies aimed at reducing turnover should not be assumed to en- hance retention” (p. 630). Implementation challenges might include organization of home care service de- livery and governance, and resources available for hu- man resource planning. Agency-level strategies are discussed below. Evidence from this literature review suggests that a mix of strategies is most beneficial [26].

Reports from agency-led strategies suggest having a single person responsible for recruitment who acts as the contact person for new staff and providing opportu- nities for potential staff to “try out” the job [63]. Oth- er options include staff referrals; information sessions; word of mouth; marketing to non-traditional worker pools such as men, youth, and experienced workers not currently employed or employed elsewhere [2,3,26, 59]; and offering apprenticeships or traineeships [3]. Employers need to maximize opportunities to work co- operatively with other providers, as well as utilize in-

novative technological advances in social networking tools in their recruitment efforts [37,59]. There is ev- idence that fostering a good work environment is cru- cial to both attracting new workers and retaining those already employed. Attractive wages and benefits are important [49], particularly in recruiting workers to the job. Other factors include promoting a manageable work and family life balance; positive quality of work life; enjoyable, satisfying, and motivating job; ongoing training and development opportunities and support; and ample staffing for time off [59]. It is noted that those factors associated with relationship and advocacy for the client, as well as being called “to serve”, act more as pull factors to retain workers, while others, such as work-family conflict and difficulty of the job, are push factors creating turnover [52].

Evidence points to the value of employers imple- menting predictable scheduling and/or full-time hours to support worker retention [14,20,65]. Organizational and peer support are also important [16,65], including supporting HSWs’ relationships with clients through stable work assignments, thoughtful matching, partic- ipation in care planning, and training that broadens HSWs scope of practice [65]. Opportunities for up- ward mobility, such as developing a career ladder with- in the job, are suggested as other practical strategies to increase retention [6].

Employers can best target recruitment campaigns by understanding what workers value and what attracts them to home support in the first place. For exam- ple, younger workers are attracted to opportunities for career advancement [64]. A recent U.S. study found that “stayers” assign more meaning to their care work than do “leavers” [52]. Those who derive satisfaction from the emotional and caring nature of home support are apt to be more satisfied [21] and to remain in their jobs [52]. However, research evidence as to the per- sonal characteristics of “stayers” is limited.

At a more macro level, assessing the effects of con- textual issues and trends in home and community care on human resource planning is needed. These trends include: economic forces, including recessionary cy- cles affecting people’s earnings, as well as employment and retirement income; demographic trends, including fewer youth entering the labour force and more older people in need of care; and policy directions, includ- ing a shift towards increasing acute home care services and reducing publically funded home support services. Many of these trends are also being experienced in oth- er developed countries [26]. Solutions, though, must take into account context-specificity. In Canada, since

26 J.M. Keefe et al. / Key issues in human resource planning for home support workers in Canada

home care is under provincial jurisdiction and systems vary considerably from province-to-province, the rele- vancy of key issues and feasibility of strategies will be context-specific.

Attention is needed to assess the competition across health and social care sectors for the limited supply of workers. Public policy that promotes care in the com- munity must extend beyond delaying institutionaliza- tion to encompass strategies for enhancing the human resources to provide such care. Wage parity across sec- tors of home care and facility-based care is one example in Canada that demonstrates a disconnection between goals of the state to increase home care and the prac- tice of the marketplace to pay workers higher wages in facility-based care.

Human resource issues will be seen differently de- pending on the vantage point – employer, worker, or client [46]. In order to improve worker recruitment and retention, this literature review has provided evidence of these issues from the worker’s perspective. Agencies can use this evidence to be strategic in where they com- mit their limited resources. In Canada, planners would benefit from evaluations of specific recruitment and re- tention projects; however, to date such evaluations are scarce. In the U.S., recent evaluation of the “Better Jobs, Better Care” program is coming to light [23] and holds promise to assist with evidence-based decisions. In the absence of evaluation, employers need to use benchmarking indicators to track success of their own efforts.

5. Conclusion

A number of demographic and societal factors point to an increased demand for HSWs now and in the com- ing decades. Given the projected increase in demand for these workers, preparations need to begin now and consider long-term strategies. Agencies need to exam- ine their strengths and weaknesses within the four key areas of compensation, education and training, quality assurance, and working conditions. Until the negative aspects of working as a HSW are addressed, recruit- ment and retention will continue to be a challenge [38]. Furthermore, limited budgets to implement effective strategies, and limitations imposed by collective agree- ments in some jurisdictions, will constrain efforts.

Any discussion of human resource strategies for HSWs must recognize the intersection of multiple pol- icy areas, health and social care, employment, educa- tion and even immigration (in terms of the use of im-

migrant workers). Further research is needed to inves- tigate the way in which policies within these sectors work together or in silos to improve the lives of old- er people in need of home care support. Overlapping with this policy framework is consideration of the role of government, the marketplace, the voluntary sector and family/friend caregivers, and assumptions of their continued role to meet the future needs of older people requiring assistance.

Acknowledgements

We gratefully acknowledge the support of our fund- ing agency, Health Canada; our project partner, the Canadian Home Care Association; and project staff, students, and trainees, especially Rachel MacDougall and Joanie Sims-Gould, for their assistance with this literature review.

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