Seven years ago, when her daughter, Kiesha, was six years old, Tammy Embrey was in a devastating accident. She was outside her home, helping load Kiesha’s wheelchair on to her school bus, when the family pickup truck rolled out of the driveway and pinned Embrey between the truck and the bus. Embrey suffered multiple fractures—including seven in her pelvis—and spent five months in hospital. When she came home, she needed more help to care for Kiesha, who was born with numerous disabilities and is both non-mobile and non-verbal.
The local CCAC increased the family’s access to home care, with personal support workers coming in more than 16 hours a week. On a daily basis, Kiesha’s PSWs change her, bathe her, play with her and read to her. They’ve been trained to use special equipment installed in the home, including a ceiling track that runs between the kitchen and the living room and allows Kiesha to walk in a Jolly Jumper-like sling. Of the four workers who come to the Embreys’ home in Port Colborne, Ontario, two have been with the family for more than six years. “We’re very, very lucky,” says Embrey.
PSWs help patients with the essential activities of daily life—dressing, bathing, going to the bathroom. Sometimes they are delegated to assist with more complex tasks, such as administering medication or suctioning tracheostomies. They do what no one else in the health care system has time to do, and without them the system would not function. They are also very much the front line of caring for the province’s most vulnerable people—seniors who have severe dementia, for example, and children who have very complex developmental issues. They work in nursing homes, in the community, privately for families, and, increasingly, in acute care hospitals. While no official count has been taken since 2011, it is estimated that there are upwards of 100,000 PSWs working in Ontario. And the need for PSWs increases steadily as the population ages, living longer with more complex needs.
Despite the essential work PSWs perform, there’s a lack of data about them. What percentage are formally trained? How many work in institutions versus the community? Questions such as these were meant to be addressed by a provincial registry that was created in 2012, when Healthy Debate first wrote about the PSW sector in Ontario. At that time, the government had just changed the Long-Term Care Homes Act to include mandatory educational requirements for PSWs working in provincially funded nursing homes. But there was concern that no similar standard existed for PSWs working in home care. And there were other concerns: about understaffing of PSWs in nursing homes, about the level of nursing supervision available to PSWs in long-term care, and also about their income and job security.
Six years later, Healthy Debate revisits the PSW landscape, from training and workload to compensation.
What is the minimum training for a PSW?
In 2014, the Ministry of Training, Colleges and Universities (now known as the Ministry of Advanced Education and Skills Development) laid out a set of 14 vocational standards for PSW programs which include a demonstrated ability to work with clients experiencing dementia and with patients receiving palliative care.
Programs offered by community colleges must all meet these standards and are accredited by the ministry. These programs run for eight months (one academic year), comprise more than 700 hours, and cost about $4,000 to attend. Programs offered by career colleges tend not to be accredited by the ministry, instead following a curriculum provided by the National Association of Career Colleges, which is “based upon” ministry standards. These programs run six-to-eight months in length, comprise more than 600 hours, and cost anywhere from $3,000 to $14,000. The third educational stream for PSWs in Ontario is through municipal boards of education, which adhere to the MTCU’s 14 standards and comprise a minimum of 600 hours (most range between 650 and 800, according to Anita Plunkett, one of two PSW co-chairs with Ontario’s Continuing Education School Board Administrators). They cost somewhere between $1,000 and $2,000.
While long-term care homes require that PSWs meet the standards of and complete one of these curricula and complete a minimum of 600 hours of training, there is no such requirement for PSWs working in home care or privately for families. This means the PSW workforce in the community is “very much a mix,” says Veronique Boscart, the Schlegel/CIHR Industrial Research Chair for College in Seniors Care at Conestoga College. “Some are certified through a college, some come through a private career college, and others don’t have a standardized training.”
What does the PSW registry do?
The PSW registry established in 2012 was meant to determine how many PSWs were working in the province, where they were working and what their training was. It was also supposed to offer a measure of reassurance to families that their parents, children or partners were being cared for by trained, competent workers, as the public could look up PSWs by name on the registry.
But the government shut this registry down in 2016 when an audit revealed that it was not able to adequately track information on the roughly 30,000 PSWs who were registered. “The public and the employers thought that the people on the list were safe to hire, and there really wasn’t any information on them available,” says Boscart. “Which is a little scary.” She points out that it’s very common practice for PSWs to go from one employer to another, especially in home care. “If a PSW provides care and it’s not going well, we have no way of trying to figure out where that PSW is going to work tomorrow.”
In the provincial budget of 2017, the Ministry of Health and Long-Term Care announced that it would create a new PSW registry, and in September it announced that this registry would be run by the Michener Institute, a post-secondary institution in health sciences education in Toronto. Michener launched a registry website in January and is currently collecting data from PSWs who are working for a “registered employer” and have completed a community or career college program in 2016 or later. Registering will be mandatory for all PSWs by 2019, and the registry intends to verify their credentials. The website recently posted a code of ethics, a set of roles and responsibilities, and a complaints process, suggesting that registered PSWs will be held accountable to these professional standards. But how, exactly? If somebody breaks the code of ethics, “will [the registry] then have the power to actually withhold somebody from the registry and say this person has not met the professional criteria to be a PSW?” says Boscart. “This is not clear right now.”
Rather than a registry, the sector needs a regulating body, says Laura Bulmer, registered nurse and professor in the PSW program at George Brown College’s Sally Horsfall Eaton School of Nursing in Toronto. “Having this many workers, and dealing with the population they’re dealing with, there’s no doubt in my mind that they should be regulated. They have to keep up their skills, be life-long learners, and maybe a license. And if you do not follow certain guidelines, ethics, scope of practice and standards, then [there should be disciplinary action and possibly] your license gets removed.”
Miranda Ferrier, president and founder of the Ontario Personal Support Workers Association, agrees. “A registry is not going to fix the issues of standardization of education, recognition, oversight and accountability,” she says. Ferrier has for years been lobbying the government to give OPSWA the mandate to govern PSWs. OPSWA currently has 31,000 members who pay a $150 fee annually, and this covers a background check, a criminal record check, verification of schooling, liability insurance and whistleblower protection. “We really believe that in order to speak for a profession, you need to be of that profession,” says Ferrier.
Are PSWs spread too thin?
A recent episode of CBC’s Marketplace told the disturbing story of a long-term care resident who died after being attacked by a fellow resident who was suffering from severe dementia. The program suggested that the low staff-to-resident ratios in long-term care might be a factor leading to negative outcomes for residents.
In fact, says Boscart, nursing homes do have regulated ratios. The numbers are not as simple as “X number of PSWs per resident”; instead, they are carefully calibrated to reflect the acuity of resident needs. “There are mandatory assessments [known as resident assessment instruments, or RAIs] done on every resident in long-term care every three months,” she says. Based on these assessments, nursing homes calculate resource allocation. “It’s not a body count, it’s how much work is needed,” says Boscart. She explains that RAIs are also done at admission and anytime something goes wrong, like a fall or a sudden decline. Then the assessments are used to calculate quality indicators for specific long-term care facilities, and these results are posted publicly by CIHI for all to see. “Nursing homes are the most regulated environment in Canadian health care,” says Boscart.
Still, she says, it can be very difficult to find staff to hire, and some nursing homes do not always meet the requirement for staffing. “We don’t have enough nurses, we don’t have enough PSWs, we don’t have enough practical nurses to provide care to older people. We don’t have enough people trained. There is money for those people, there are positions for those people. We just need to find them.”
Are PSWs paid enough?
When she greets a new crop of students, Bulmer, professor at George Brown, always has a “reality chat” with them, telling them not to expect to pay off their OSAP loans too soon after entering the workforce. “I don’t think a lot of people realize how little PSWs get paid,” she says. “They’re very much like daycare workers.”
That said, PSWs do better in long-term care. They may start just a little above minimum wage, says Boscart, but she says workers who stay in one setting for several years can make up to $25 and even $30 an hour. In institutional settings, PSWs may also be unionized and part of benefit plans, and they are also able to do shift work, which brings additional compensation.
Home care compensation, on the other hand, is considerably less lucrative, “known to be hovering around minimum wage,” says Boscart. (In January, minimum wage in Ontario jumped from $11.60 an hour to $14; Bulmer says it’s yet to be seen how this will affect home care.) The other issue with compensation in home care is that many agencies do not pay their PSWs for travel from one care recipient to another, says Boscart. “Most PSWs probably don’t have money to buy a car, [so] we’re talking about a group of employees that goes by bus from one house to another,” she says. “If you’re only paid for the number of care hours you provide, that’s about half of the time you put in.”
Tammy Embrey, mom of Kiesha, doesn’t know how much the PSWs who come to her home are paid, but she’s confident that it isn’t enough. “They go way above and beyond,” she says.
That’s what we would all want for our family members receiving care from PSWs. And more and more of them—and us—will, over time. There’s a lot at stake for Ontarians when it comes to the training, monitoring and compensation of personal support workers. And there are still plenty of challenges ahead.
Correction: A previous version of this article incorrectly reported that school board PSW programs follow a curriculum set out the Ontario Community Support Association which comprises less than 600 hours. The article also previously reported that the cost of school board programs range from $500 to $1,500.