Introduction
“Building relationships … we do that just by the nature of our work. It’s very intimate work and I know some of my clients probably better than their children do, because you deal with them on such an intimate basis.” (55-year-old female home support worker)
Home care – the delivery of health and social services to individuals living in the community – stands at the forefront of current debates on health care in Canada. Home care costs have doubled over the past decade, from $1.6 billion to $3.4 billion (Canadian Institute for Health Information, 2007). In this same time period, the number of home care recipients has increased by 24 per cent (Statistics Canada, 2006). It is estimated that 1.2 million people in Canada use home care services annually (Carrière, Reference Carrière2006). Undeniably, the most rapidly expanding sector of Canada’s health care system is in the demand for home care (Canadian Institute for Health Information).
Home care involves a wide variety of workers with different levels of training and qualifications. They include nurses, care managers, social workers, physiotherapists, occupational therapists, and home support workers. Most home care workers provide services known as “home support”, typically defined as non-professional services involving personal assistance with daily activities, such as bathing, dressing, grooming, and light household tasks. These employees are variously known across Canada as home support workers, personal support workers, community health workers, community health care aides, home helpers, and homemakers (Martin-Matthews, Reference Martin-Matthews2007; Mahmood & Martin-Matthews, Reference Mahmood, Martin-Matthews, Martin-Matthews and Phillips2008). In 2001, an estimated 32,000 home support workers provided 70–80 per cent of the home care needs for Canadian home care recipients. This included both personal care (bathing, toileting, grooming, etc.) and work related to instrumental needs (e.g., food preparation, cleaning, laundry, etc.) (The Home Care Sector Study Corporation, 2003). This study examines the provision of home support services to elderly clients from the perspective of 118 home support workers currently employed in British Columbia (BC).
Key Issues in Home Support
To date, the majority of studies on home support services have focused on the organizational aspects of home care service delivery with emphasis on working conditions and the associated stress and strain involved in providing care. A number of recent studies underscore poor pay, lack of benefits, inconsistent work hours, and limited opportunities for advancement as key issues for home support workers (Denton, Zeytinoglu, Davies, & Hunter, Reference Denton, Zeytinoglu, Davies and Hunter2006; Fleming & Taylor, Reference Fleming and Taylor2007; Martin-Matthews & Sims-Gould, Reference Martin-Matthews and Sims-Gould2008; Sharman, Tigar McLaren, Cohen, & Ostry, Reference Sharman, Tigar McLaren, Cohen and Ostry2008; Yamada, 2002). These same factors have been found to impact job satisfaction with resultant negative effects on both recruitment and retention of home care workers (Denton, Zeytinoglu, Kusch, & Davies, Reference Denton, Zeytinoglu, Kusch and Davies2007; Denton et al., Reference Denton, Zeytinoglu, Davies and Hunter2006; Feldman, Reference Feldman1993; Nugent, Reference Nugent2007).
Other key issues for home support workers include heavy workloads, high levels of stress, occupational injury among workers, job insecurity, and feeling devalued (Denton, Zeytinoglu, Davies, & Lian, Reference Denton, Zeytinoglu, Davies and Lian2002; Fleming & Taylor, Reference Fleming and Taylor2007; Nugent, Reference Nugent2007; Stacey, Reference Stacey2005; Zeytinoglu, Denton, Webb, & Lian, Reference Zeytinoglu, Denton, Webb and Lian2000). Denton et al. (Reference Denton, Zeytinoglu, Davies and Lian2002) discussed the lack of agency support regarding worker safety and showed how this contributes to increased job stress and decreased job satisfaction. Zeytinoglu et al. (Reference Zeytinoglu, Denton, Webb and Lian2000) demonstrated that poor working conditions in home care contribute to increases in musculoskeletal disorders among home care workers. A number of studies have highlighted job insecurity as a key issue and consider it a significant predictor of worker turnover (Aronson, Denton, & Zeytinoglu, Reference Aronson, Denton and Zeytinoglu2004; Denton et al., Reference Denton, Zeytinoglu, Kusch and Davies2007;. Insecurity in the workplace contributes to worries of unemployment (Delp, 2006) and increased levels of stress (Denton et. al., 2002). A final key issue for home support workers is the expressed feeling that their job is undervalued by other health care professionals and that they deserve better recognition and respect and a greater role in health care planning for clients (Nugent; Stacey).
Despite poor pay, lack of benefits, inconsistent work hours, limited opportunities for advancement, heavy workloads, high levels of stress and occupational injury, job insecurity, and feeling devalued, home support workers express relatively high levels of job satisfaction, with older home care workers reporting greater job satisfaction than younger workers (Delp, 2006; Denton et al., Reference Denton, Zeytinoglu, Kusch and Davies2007; Feldman, Sapienza, & Kane, Reference Feldman, Sapienza and Kane1990). Home support workers also find ways to personalize their work activities (Aronson & Neysmith, Reference Aronson and Neysmith1996) and find dignity and reward in their caring labour (Stacey, Reference Stacey2005) despite the well-documented shortcomings of working in home support.
The present study is based on the premise that home care work is undertaken at the nexus of the public sphere of work and employment and the private sphere of home and personal life (Martin-Matthews, Reference Martin-Matthews2007). Home care workers not only must operate within the framework of organizational and bureaucratic structures and regulations, they also must interpret (and interact with) the rules and resources of the socio-spatial and temporal context of the home care environments. These home care environments are embedded within larger socio-economic, cultural, and political contexts. Thus, the rules and resources of the larger socio-spatial environment also influence the types of activities that can take place within the home when health and social care is provided there (Angus, Kontos, Dyck, McKeever & Poland, Reference Angus, Kontos, Dyck, McKeever and Poland2005; Giddens, Reference Giddens1984; Mahmood, Reference Mahmood2002).
Mahmood and Martin-Matthews (Reference Mahmood, Martin-Matthews, Martin-Matthews and Phillips2008) have posited that the interactions and negotiations central to home care work are framed by organizational, social, spatial, and temporal domains. Although these domains are not explicitly developed in their conceptual model, the extant literature in home care suggests a number of ways in which these domains may be characterized.
The organizational domain frames much of the “work” of home care. Home care workers are guided by the practices and procedures, and rules and regulations of home care agencies operating in the public sphere (themselves informed by municipal, provincial, and federal national policies and practices). When workers, guided by these procedures and policies, enter the private sphere of the home, there are specific types of tensions that necessitate the negotiation of boundary management between home and work.
The social domain is highly relevant to the conduct of home support work insofar as home support workers, who bring the public domain of work in to the private home of their clients, must manage the interfaces between expectations of home and paid work. Home care agency policies typically prescribe strong boundaries between paid work and home life. Analysis of the social domain advances the understanding of the strategies used by home support workers in managing these interfaces and interactions with clients and others.
The spatial domain is important because space is not a neutral backdrop. Bounded spaces actively influence the behaviour of people within them (Ardener, Reference Ardener and Ardener1993). In the provision of home care, health care activities from the public sector move into private residential space. The home is then not just a place of residence; it is also a work setting for staff providing care. Particular characteristics of the home space may potentially impact the service provided (and received) and aspects of the worker–client relationship.
The temporal domain is reflected in the way in which service is delivered in the form of time-bound tasks provided at regular or irregular intervals. In an earlier study of home support workers in Ontario, Martin-Matthews (Reference Martin-Matthews2007) also found that temporal issues arise in home care service provision outside of “paid” hours.
Using elements of the model developed by Mahmood and Martin-Matthews (Reference Mahmood, Martin-Matthews, Martin-Matthews and Phillips2008) as a conceptual guide, this article has two objectives:
To determine the salient issues in delivery of service from the perspective of home support workers who provide care to community-dwelling elderly clients; and
To examine the strategies employed by home support workers in addressing these issues and in completing the assigned tasks.
Methodology
Study Context
The present qualitative article is part of a larger mixed-methods study (Tashakkori & Teddlie, Reference Tashakkori and Teddlie2003) aimed at understanding the key issues in the delivery and receipt of home support services from the perspective of home support workers, elderly clients, and family members. The study stemmed from a prior research study about home support conducted a decade ago by one of the authors (Martin-Matthews & Wakefield, Reference Martin-Matthews and Wakefield1992). Based on the many changes in home and community care, the research team aimed to study the current context and experiences of home support.
Following a comprehensive literature review, a pilot study was conducted with 32 home support workers over a three-month period. The pilot study assisted the research team to establish connections with home support agencies and also resulted in the refinement of an interview guide.
Setting and Recruitment
Upon receiving ethical approval from the University of British Columbia behavioural research ethics board, data were collected from March 2007 to October 2007 in the Lower Mainland of BC. Selection of participants was limited to English-speaking home support workers, employed by home care agencies, who provide primarily “non-professional” services (e.g., non-medical services) to clients over the age of 65. Two methods of recruitment were applied to ensure access to home support workers employed across various agencies. First, three home care agencies were purposively selected as participating agencies to represent the spectrum of contracted agencies (two private and one not-for-profit) serving a mixture of both urban and rural clients. Second, participants were also randomly selected from a list of workers represented by the BC Government Employees Union (BCGEU local 403).
Letters were mailed to agency managers or supervisors asking for their assistance in recruiting home support workers. Notices were placed in employee mailboxes or with pay stubs, and posted in the common areas of the three agency offices. Two of the agencies also used their voice messaging systems to remind employees to check their mailboxes regarding study information. Ideally, we would have liked to send our introduction letter directly from our research team to workers instead of going through the agencies. However, the behavioural research ethics board would not allow us to do this. We had anticipated that by going through the agencies, workers would be cautious to speak to us for fear of agency reprisal, even though we assured anonymity and confidentiality. Throughout the course of our interviews, this was confirmed by a number of our participants who indicated that their co-workers were concerned about participating for fear that their employer would find out.
In the end, we sent out hundreds of letters across three agencies and were contacted by 3 to 11 per cent of respondents depending on the agency. Where we could use a voice mail blast to workers after they received their letter, we found our response rate to be higher. As a result of our low agency response rates, we also recruited through BCGEU. Participants were contacted by a union staff member who provided a brief description of the study, and asked for their consent to be contacted by the project manager. Those who consented were contacted by the project manager who further explained the study. The response rate through the union recruitment process proved to be better at 52 per cent consistent with other studies on home support workers (see Stone & Dawson, Reference Stone and Dawson2008). Removing the agency from the equation proved to be a much better approach. Interviews were scheduled with interested home support workers at a time and location convenient for them. In all, 118 home support workers were interviewed: 84 (71%) were recruited through the agency method, and 35 (29%) were recruited through the union. All of the home support workers we interviewed were unionized.
Data Collection
Data for the study were generated through in-depth semi-structured interviews (see Table 1 for sample questions). The interview instrument was derived from an earlier pilot study (Martin-Matthews & Sims-Gould, Reference Martin-Matthews and Sims-Gould2008); several questions were modified, added, or deleted based on feedback and results from the pilot study. Face-to-face interviews were digitally recorded using a handheld recorder. Interviews were then downloaded into research computers and saved using ID numbers and pseudonyms for easy reference. Transcripts were uploaded into the qualitative software database, NVivo 8. A casebook was created in NVivo 8. Although most interviews were conducted face-to-face, telephone interviews were conducted in order to meet the needs or preferences of respondents. Interviews were approximately 60 to 90 minutes in length. They were taped and transcribed verbatim.
Table 1: Sample interview questions
Sample
As expected, the majority of home support workers interviewed were female (93%), and the remaining 7 per cent of the sample was male. Workers ranged in age from 27 to 65 years of age, with a mean age of 50 years (SD = 8 years). All of the workers interviewed were unionized. Reflecting the growing international trend linking immigrant labour to home support work (Stacey, Reference Stacey2005), over two thirds (69%) of the workers we interviewed were born outside Canada. However, almost three quarters of these immigrants had lived in Canada for more than 10 years.
Most participants were employed full-time (61%), with the others either part-time (10%) or casual workers (29%). Duration of employment ranged from 0.5 years to 29 years (M = 12, SD = 7). Our sample was a very experienced workforce, with close to 60 per cent having worked in home support for more than 10 years, and just over 10 per cent having worked for more than 20 years in this sector. The workers had an average caseload of 4.2 clients per day (SD = 1.5), although this ranged from a minimum of one to a maximum of nine clients per day.
Analysis
The conceptual model developed by Mahmood and Martin-Matthews (Reference Mahmood, Martin-Matthews, Martin-Matthews and Phillips2008) guided the analysis by serving as an overarching framework for organizing the themes in the data. Using organizational, social, spatial, and temporal domains as broad categories, three members of the research team independently read and reread the completed interviews in sets of five. Each analyst identified broad themes located within the four overarching domain categories. Over a two-month period, five team analysis meetings took place in which the research team discussed themes in terms of issues and strategies identified by home support workers. At the research meetings, each team member presented their themes, provided examples from the transcripts, and discussed how and why these were either issues or strategies identified by home support workers. After the third meeting, the team agreed that no new themes were being identified in the transcripts. At this time, we determined saturation had occurred. We continued coding the data, but the focus of the meetings shifted to refining the previously identified themes and expanding the elements included in each of the four overarching categories.
Strategies for establishing rigor in this study included engaging in peer debriefing with the research team (via team meetings and smaller focused discussion about the developing themes), memo writing throughout the analysis process, and a recording of decisions made throughout data collection and analysis (i.e., an audit trail). In addition, the findings were presented at a conference with home support managers, home support workers, and researchers in the area of home support in attendance. Individuals involved in these processes felt the themes reflected their experiences in home support.
Results
What’s stressful is to go into a placement for one time … I’ve met some wonderful people that I only had one time. (57-year-old female home support worker)
The findings of our study were framed categorically within the four domains of home support: organizational, spatial, temporal, and social (Mahmood & Martin-Matthews, Reference Mahmood, Martin-Matthews, Martin-Matthews and Phillips2008). Results highlighted both the concerns and stresses – the salient issues – related to working in home support and the strategies used by workers to both personalize and find reward in their caring labour.
Organizational Domain
Salient Issues
Home support workers discussed the Care Plan or organizational tools that drive their work, and they lamented the compression of time and the rigidity of task assignments imposed by agency mandates and schedules. Workers also discussed the mechanisms for reporting organizational concerns to agency supervisors.
The Care Plan that outlines the work of each worker for every client was discussed at length in many interviews. Workers had varying reactions to the Care Plans. Although they often disliked being mandated to complete a set of assigned tasks, at the same time they often relied on the Care Plan to protect them from demanding clients who asked them to complete tasks outside the plan. For example, in the following excerpts, one worker lamented the inflexibility of the Care Plan (and described working outside it), while the other illustrated how workers use the plan to protect themselves.
One thing I do for her – her English is not the greatest; she saves her correspondence for me – one thing I did for her was that she had a medical plan, and it covered a lot of her prescriptions, and she never used it … so I got the medical plan in place, and I’ve saved her thousands of dollars over the years. You know, we don’t want her to have a heart attack over the stupid paperwork and stressed out about finding somebody to do it and everything. So I do it. But my office doesn’t know. (58-year-old female home support worker)
Like washing windows: no, I’m sorry. Washing floors: no, I’m sorry. Or, you know, stuff like that, no … that’s it. And you just tell them, “No, I’m sorry.” Or, “This is not in our Care Plan.” And the thing is if we do it and then it gets back [to the agency], then we’re in trouble. (59-year-old female home support worker)
Home support workers also discussed the process for reporting concerns, how they draw on the organizational tool (Care Plan) to protect them, and they also mentioned the pros and cons of notifying a supervisor and the resultant discomfort in doing this.
If it’s ongoing then I bring it to my supervisor, yeah. But then there’s pressure there, too. Because then the client knows that you’ve reported it. So it’s a little bit awkward. (39-year-old female home support worker)
We’re supposed to report it and it gets resolved. [but] … I know, like, if there are safety concerns, they don’t really want to talk about it because they want to keep the hours. There’s a lot of pressure to just keep quiet to get work, yeah. (39-year-old female home support worker)
Many workers also discussed the organizational reality of home support before and after changes to the health care system, which for many clients resulted in the cutback of services (BC Ministry of Health, 2001; Khouri, 2003; Sharman et al., Reference Sharman, Tigar McLaren, Cohen and Ostry2008). Despite the demonstrated cost-effectiveness of home care, in BC, and throughout much of Canada, there have been substantial reductions in the provision of home support services coinciding with a shift from a provincial system of care to regionalization (Konkin, Howe, & Soles, Reference Konkin, Howe and Soles2004). In BC, in 2001, a new health care delivery structure was established consisting of 16 health service delivery areas with five health authorities to govern, plan, and coordinate services regionally (BC Ministry of Health; Khouri). At this same time, the criteria for allocation of home support services changed. For many individuals, this meant a streamlining or reduction of services. Workers who had been employed in home support before and after the streamlining of services discussed how they had to modify the organizationally driven Care Plan. These home support workers adapted the Care Plan (i.e., bent the rules) to meet their client’s expectations and ultimately have found ways to squeeze in the lost services in their visits.
Because all the house cleaning is pretty well out of the system, right? But some people still do have it. Now, probably in the last few years anybody that comes into the system is mainly just [for] medical or, you know, necessity stuff: bath, shower, clean out the bathroom and that’s it …. So, it’s really gone down. Yeah, big change. That hurt a lot … of people when that came by. Yeah, it’s a worrisome thing. So, some of them in the system [clients] that I’ve had for a long, long time still have their needs. It just depends on their needs, but otherwise, a lot of them just cut out [non-medical services], for shower and that’s it. [But] we still – I still – do [non-medical services] for clients, too, now. (54-year-old female home support worker)
Spatial Domain
Salient Issues
Working in the private space of clients’ homes is a unique aspect of the home support workers’ job (Martin-Matthews, Reference Martin-Matthews2007; Martin-Matthews & Sims-Gould, Reference Martin-Matthews and Sims-Gould2008; Sharman et al., Reference Sharman, Tigar McLaren, Cohen and Ostry2008). While many workers indicated that they enjoy being in different homes with different people, other workers commented that having family members around can sometimes create an uncomfortable situation.
Ahhh, sometimes, not very often, and those are the times I really prefer them not to be there ’cause they’re very critical. They know best, you know, and you just kinda learn to turn the hearing aid off and just go about your business, and you get it done and you get out. (56-year-old female home support worker)
Similarly, another worker commented on a relatively common scenario wherein clients’ habits conflict with workers’ values and preferences. Issues related to elderly clients’ smoking, presence of pets, cleanliness, and clutter all came up repeatedly in the interviews. For example, one worker stated:
Smoking clients, yeah. I have problems with a smoking client. I still can’t ask people to not smoke in their homes when I’m there which I know we’re supposed to. (39-year-old female home support worker)
Workers also commented on the physical environment of clients’ living spaces. They discussed how workers sometimes have to assist clients with tasks outside of the assigned tasks because of the specific characteristics of the household environment. They also commented on how the physical environment can compromise their own safety.
I take out the garbage, because she’s kind of slow. It’s hard for her to go up and down the stairs. She’s on the top floor of her house. Take out the recycling. Once in a while we’ll hang up a few clothes downstairs in the laundry room or on the line. (58-year-old female home support worker)
… sometimes it snows, they can’t go and put salt. And sometimes they don’t leave the lights out at nighttime. So when you’re leaving it’s completely pitch dark and there’s no way you can feel safe … you’re going into the area and it’s dark and you don’t know what’s got – who’s behind you or anything. (55-year-old female home support worker)
Strategies
In terms of strategies, home support workers discussed the ways in which they work within clients’ homes to respect their personal space. These include such strategies such as not commenting on client behaviours (e.g., smoking), and remaining silent and working quickly when clients are critical or unwelcoming. Other strategies for managing the private sphere of clients’ home involved decisions to not ask questions and taking cues from the space of a client’s home. For example, one worker stated:
They’re very protective when it comes to their private lives. Some would not divulge or tell you about the family and we don’t ask unless they tell, especially if a client just had his wife die … those tragic things you don’t want to talk about. Or even if I see a picture in there and I just don’t ask because who knows, if the wife just died or something. So it would just aggravate the condition. (51-year-old male home support worker)
Temporal Domain
Salient Issues
Like the organizational and spatial domains of home support, the temporal aspects were described both in terms of the stresses and strains and the strategies employed to offset these stresses. Workers discussed compression of time to provide care, the reallocation of tasks when you have a “little extra time” and the time required traveling between clients’ homes as being issues.
Compression of time came up again and again in the interviews with home support workers. Workers expressed feeling torn between the need to complete assigned tasks and the need to get to the next client, while at the same time striving to personalize care. For example, workers commented on the need to “put a little [extra effort]” into your work while also acknowledging the compression of time.
Especially people that can’t do anything, you know. But, I think you have to put a little into it. You just don’t go in there and rush, rush, rush and go … that’s my hardest part about the job, yeah. (54-year-old female home support worker)
Another worker commented on the pressure of time.
… 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. (55-year-old female home support worker)
Another very common issue for home support workers was the compression of time related to travel to work and between jobs.
It’s pretty tight ’cause most of the time we have ten minutes’ traveling time. We go there late ten minutes and we have to go out ten minutes earlier because we have another client. Especially, like I started like nine to ten and then I have ten to eleven and I have eleven to twelve and [then] I have thirty minutes or a one-hour break. Then one to two and two to three. I mean doing all these tasks is just too tough to do [everything]. (55-year-old female home support worker)
The intersection of time and space issues (particular unfamiliar space) also impacts the work experience.
There’s the specific time and the location of the job. We don’t know: sometimes if it is the first time [I go] to the place and it’s too far, it really stresses me. Because you are looking for the address, especially at night or early morning and you don’t know. And you are in like in the highway or in the bush, you are more prone to accident. Because you are looking – that’s stressful, yeah. (52-year-old female home support worker)
Strategies
Workers also talked about how they use little bits of “extra time”. The extra time is referred to as the time left over when they have hurried to get something done, dropped a task, or accommodated a client’s wishes by juggling tasks on the Care Plan.
She asks me, “Would you please help me for the ironing?” I said, “That’s okay. I do,” yeah, because I have more time. (42-year-old female home support worker)
Social Domain
Salient Issues
Much of the content of the home support worker interviews centered on the social component of being a home support worker. Workers consistently discussed their relationships with clients, particularly the social aspect of their work both in the literal sense, like a visit or being social, and also social in terms of the relationship dynamics and negotiation of the provision of tasks.
For example, one worker described her role as being a visitor, “company” for her elderly client, stating:
And I think a lot of them like the company … because a lot of them don’t have any people coming in to socialize or sit down and have a cup of coffee with … we’re not supposed to take any coffee or have a snack or whatever, … and I go, “Oh, don’t listen to them [the agency]. I’ll have a coffee anyway.” … what’s the harm? (54-year-old female home support worker)
Another worker similarly stated (as if in a mock conversation with a client):
I’m going to have my lunch … you want to join me?” “Oh, I’m not hungry,”… “Well, why don’t you sit down and have a tea,” and then. I make some tea and then, “Okay, I can make sandwich here. Do you want to make some sandwich for yourself?” And so I make a sandwich for her. (52-year-old female home support worker)
This comment is consistent with those of many of the workers, who indicated that their clients were lonely and relied on them for social companionship. While workers recognized such needs, their perceptions were also balanced by their concern, not wanting clients to get too dependent on the social companionship of home support. The following worker described the tension for workers in providing more social care and companionship while maintaining a professional distance or balance.
Sometimes they want to form friendships with you. I mean it’s all right to be friendly with them. But you don’t want them to feel that they are emotionally dependent upon you … It’s learning to have a balance and sometimes that’s – that can be difficult to do. (50-year-old female home support worker)
Strategies
Workers discussed how social relationships between clients and workers can influence how care is negotiated. For example, one worker described how knowing someone’s personal family circumstance (through a social relationship) can influence the extent to which workers go above and beyond their description of duties or how they may work to personalize care. If workers feel that they have a relationship with a client, they will bend the rules, providing assistance outside of what is technically assigned.
… to see somebody, especially if they’re on their own and they have no family, they love that. Most of them are appreciative of what you do. You say “What do you need?” “Well, I need a toilet paper roll changed.” “Fine, I’ll go do it.” “But that’s not your job.” “Whatever.” Sometimes you have to take it on your own to do stupid little things, you know. (56-year-old female home support worker)
This worker similarly stated that when you know somebody, you can alter how (and what) type of care you provide.
… when they’re not feeling well, you don’t force them to have a shower. You don’t force them to wash their hair, you just kind of [say], “What would you like for lunch?” “I want a piece of cake and ice cream.” “Okay. How about a couple of pieces of toast first?” (56-year-old female home support worker)
Workers also emphasized how clients were involved in their own care and how they also exercised social control over the provision of care. A number of workers discussed how they managed clients’ expectations and wishes, balancing the need to get a job done while recognizing the autonomy of the elderly client. Receiving assistance was not easy for clients, and workers repeatedly acknowledged this.
I always tell them, “assist.” I don’t tell them, “I’m here to help,” because it’s kind of, “Who are you to help? I’m more experienced than you are. I’m older, right?” That’s their kind of defense. (51-year-old male home support worker)
Well, a lot of them, if they first start with home support, I get this [attitude] that, “Oh, I’m – I don’t, you know, I’m so independent. I don’t really like help” – it’s hard for them to accept us. But I always tell them, I say, “Well, you know, think of it like this: you’re giving us work.” So, you know, it kind of makes them feel a little better about doing something for us, right? Yeah, you have to make them feel like they’re doing you a favour. (61-year-old female home support worker)
Building rapport for the purposes of providing care in a personalized and meaningful way was described by many workers as being important for client approval but also for their own job satisfaction. Making a client “happy” was repeatedly described in terms of worker satisfaction – “if they are happy, I am happy”. For example:
… they would tell me their preferences: that’s how I make it easy for them to do it their way. … basically as long as they tell me what they want, … as long as I can make them happy, my job is easy. (45-year-old male home support worker)
You have to build the rapport first before they can say, “Okay now this girl is okay, so I will let her in and invade my privacy.” … So it’s very important … building a rapport, building a working relationship with each client of ours because everybody is different. (55-year-old female home support worker)
Workers also discussed how they recognized the humanity in their clients and often used touching or other personalizing forms of care to show their respect and affection for their clients. Workers spoke at great length emphasizing how important this was to their elderly clients.
You know, having that human touch in there, the human contact. … I mean, I say “touch” because a lot of them say, “Oh, you’re not wearing gloves.” Like, if I know the client, and she has no open cuts or anything, I don’t feel I need to wear a pair of gloves. We’re supposed to. But when you know the patient and you’ve been there and she’s got nothing, and they love that human touch. That’s why I use the word “touch.” Bu it’s having the, you know, the contact, the outside contact, because, you well know, they suffer. A lot of them suffer from loneliness … (57-year-old female home support worker)
Similarly, another worker spoke about the attention required by her elderly clients and her desire to give them that attention.
… these clients, … they need attention, that’s the most care. So if you … show them you are caring, they really, really say, “Thank you, thank you.” They are very happy. Yeah, as long as you show them your compassion. They need that and then their protection. The way you say, they are wanted, that you really care for them. You go there … to look after them and that makes them happy. (57-year-old female home support worker)
Discussion and Conclusions
These findings illustrate the utility of framing the analysis of the work lives of home support workers employed in terms of organizational, spatial, temporal, and social domains. Not only did the home support workers describe salient features of their work in terms of each domain, they also identified strategies employed to deal with routines and challenges in their work, and thereby highlighted the complexity of the issues that fall within these domains.
In our examination of home support work to elderly clients, we have cast a lens on an organizational setting in which workers deliver bureaucratically determined services through direct contact with clients, an environment described by Dill (Reference Dill, Gubrium and Sankar1990: 248) wherein “… work is oriented toward maximizing the amount of autonomy and individual discretion they exercise. It is grounded as well in the competing demands of concerns for clients and organizational objectives”. Our data emphasize two aspects of the organizational domain: the prominence of Care Plans in defining the tasks to be completed for the client (and within what time frame) and the changing nature of these plans over time, especially within the context of the far-ranging re-organization of home care services within BC in recent years (Hollander & Prince, Reference Hollander and Prince2008; Sharman et al., Reference Sharman, Tigar McLaren, Cohen and Ostry2008). Although the lack of fit between what elderly home care users want and what home care workers provide has been well documented (Dalley, Reference Dalley, Warnes, Warren and Nolan2000; Sharman et al.), our data identify the ways in which this lack is frequently managed by workers through strategies that involve the temporal and social domains, as discussed next.
Our analysis of the spatial domain focused on two elements: (1) the provision of health and social care in the context of the elderly home care client’s private space; and (2) the physical environment of clients’ homes, with attendant safety concerns. The workers’ accounts of their experiences reinforced Twigg’s (Reference Twigg, Warnes, Warren and Nolan2000: 128) observation that “the setting of treatment, care and support is significant” and the recognition that with home care come changes in the household. It is important to acknowledge, therefore, that by the time home support workers enter the private space of the home, it may likely have already been altered in fundamental ways that render it no longer as “homey” and “personal” as it was before. Nevertheless, the space must be negotiated and managed by home support workers, and privacy respected; workers discussed a number of strategies for doing so, including “taking cues” from the space and working (even if outside the Care Plan) to make the space a safe work environment. These strategies for managing the spatial domain also involve the social domain. The response to the challenges and constraints of each of the three organizational, temporal, and spatial domains is often social. This gives the social domain additional significance because it provides the context within which strategies for addressing issues within the other domains are enacted.
Our analysis of the temporal domain focused on several issues, including the compressed time in which to provide care; issues of time management, tempo, and pacing as workers gave priority to some tasks and/or eliminated others in order to either finish the work “on time” or to “do the extras” that (in their view) enhanced clients’ quality of life and well-being (but may not have been in the Care Plan). Intervals of time were also important to workers as they managed travel time and distance to and from clients’ homes. Because this sample of home support workers had an unexpectedly long period of employment in this sector, temporal issues also featured in their accounts, as they noted changes over time in organizational features of home care in BC.
In the course of their caring work, home support workers addressed the multiple and contested meanings of time (Phillips, Reference Phillips2007), the unpredictability of time, and the multiple and various ways in which time and the needs of the client may clash with the units of a worker’s set time (Phillips; Twigg, Reference Twigg, Warnes, Warren and Nolan2000). Throughout our interviews, workers spoke repeatedly of the “commodification” (Phillips) and allocation of time in the Care Plan, and how that contrasted with the client in terms of what was needed at what time and for what interval. As Phillips, Twigg, and others have noted, the temporal and social domains are inextricably linked in home care. Because “home care concerns close interpersonal activity … and the relationship is crucial”, the temporal domain is especially relevant in framing the home care experience, as care often has to be provided in a fast and efficient manner and can be perceived as “cold and distant”. The kind of “personalized” care that many workers desire to provide may therefore have “a different tempo” than that prescribed by the care agency.
We have already alluded to the particular complexity within the social domain, wherein issues of visiting and being social are relevant, as are a host of issues relevant to the dynamics of the relationship between workers, clients, agencies, and family members (Martin-Matthews, Reference Martin-Matthews2007; Sharman et al., Reference Sharman, Tigar McLaren, Cohen and Ostry2008). The accounts of many of the workers underscored their recognition that “providing ways for ill persons to feel good about themselves” (Corbin & Strauss, Reference Corbin, Strauss, Gubrium and Sankar1990: 61) is an important aspect of their work. But also, as we have already noted, it is in the social domain that workers undertake strategies to address issues and negotiate problems and tensions in the organizational, spatial, and temporal domains.
Home support workers spoke at great length about the importance of the building and negotiation of relationships with their clients, emphasizing how the quality of the relationship between worker and client drove both service delivery and worker satisfaction. For example, while home support workers lamented the compression of time and the rigidity of task assignments imposed by agency mandates and schedules, they simultaneously emphasized the rewards of working with older clients. Workers repeatedly noted how the interpersonal aspects of working in home support, reflecting the social domain, override the negative aspects of the job, most frequently manifested in the organizational and temporal aspects of the work.
Overlapping Domains
Already we have noted the relationships between and amongst the organizational, spatial, temporal, and social domains. The observations of the home support workers suggest that in home care, “arrangements … are interlocking, are interdependent, and in a fragile and complex equilibrium” (Corbin & Strauss, Reference Corbin, Strauss, Gubrium and Sankar1990: 68). In the extant literature, as in our own data, there are many examples of these intersections. For example, when Dill (Reference Dill, Gubrium and Sankar1990: 248) observed that “a primary aim for the worker … is that of processing the client as expeditiously and autonomously as possible. In the course of such processing, formal organizational rules and client-centered goals can become subverted”, she at once illustrated the intersection of the organizational (rules), social (client goals), and temporal (expeditiously) domains.
Home support workers are required to navigate tricky terrain, providing service within a set of guidelines, within tight time frames – all in the private space of someone’s home. Workers use their interpersonal skills and social knowledge of their clients’ needs and preferences to find methods of personalizing their caring labour. This is where the challenges of interlocking and interdependent factors in a fragile equilibrium become apparent. In the quote that appears just before this Discussion section, the worker described a scenario that reflected not only a social and personal relationship between worker and client, but also one framed by organizational and temporal constraints. Despite the change in the space and locale of care, the worker determined it was her responsibility to “be there” for her client.
In conclusion, research has demonstrated that most older people prefer to receive home-based health and social care in their homes from home care workers rather than from other health professionals, including nurses (Twigg, Reference Twigg, Warnes, Warren and Nolan2000). Data from our study of 118 home support workers in BC, Canada, have demonstrated the extent to which the delivery of home support involves not just the completion of a set of assigned tasks on a Care Plan, but rather the negotiation of a relationship between worker and client, framed within the context of organizational, spatial, temporal, and social factors. Within the organizational domain of home support, workers both disliked the rigidity of Care Plans and appreciated the protection that they can afford workers with demanding clients. In the spatial domain, workers observed that working in the private space of a client’s home allowed for more personal social interactions but also could create challenging situations (e.g., when a client smokes) that workers in institutional settings typically do not confront. In the temporal domain, workers discussed the compression of time and how this creates stress for workers, balanced by discussions of how workers adjusted their tasks when they have a “little extra time”. While workers identified these as salient concerns, they simultaneously employed strategies in negotiating and undertaking their work. These strategies typically fall outside the skill set for which workers are trained and often require them to extend beyond the specifics of the Care Plan. The personal attributes of sensitivity, social skills, ingenuity, patience, judgment, and ability to problem solve enable time-pressed and task-regulated workers to do the job they feel needs to be done for their clients. We have characterized these as operating within the social domain of care work, and they are truly at the core of home support.
