Imagine you are called in to work. All you are given is a name and address and you are told to be there at 6 p.m. You drive to the location, knock on the door, and walk into an unfamiliar home, alone.
This is a common experience for home care providers, a sector of mostly female personal support workers, or PSWs, who are at the front line of caring for older adults and people living at home with chronic or temporary illness. And it can be quite frightening. Debbie Jensen, a PSW working for RNS Health Care Services, has experienced multiple incidents of violence in her six years in home care, including being trapped in a room by a client’s father. “We should know [if there are] other people in the house, and their history of violence and mental health issues, before we walk in,” she says. “And we don’t.”
Workers in the category “assisted occupations in support of health services,” which includes PSWs, have the highest-risk jobs in Ontario, according to WSIB data compiled in a report by the Ontario PSW Association (OPSWA), especially women aged 35 to 44. That surpasses both manufacturing and transportation services. In 2017, workers in this category accounted for 16 times the number of lost hours of police officers and firefighters.
Meanwhile, Canada is witnessing an ever-increasing demand for home care, and there is a huge potential for savings by transferring care from hospitals and long-term care facilities to the home. “Home is where people want to live, receive care, and hopefully die,” explains Sue VanderBent, a social worker and CEO of Home Care Ontario, a home care providers’ association.
But as Ontario focuses on clearing patients out of hospital hallways and sending them home to manage their illnesses, are we turning a blind eye to the violence that’s happening against those who step in to care for them?
What we know about workplace violence in home care
Ontario has more than 100,000 personal support workers; the majority are female. PSWs comprise up to two-thirds of the home care workforce and are usually paid by the hour of care provided.
Personal support work is an unregulated job with no unions and limited labour standards. Few workers report instances of abuse or safety concerns to their employers because losing a client often means a cut in pay, says Miranda Ferrier, president of OPSWA with many years of experience in home care herself. “As an unregulated profession, PSWs are having the hardest time reporting and keeping themselves safe,” she explains.
Home care providers typically work on their own, with no peers or infrastructure to turn to should they feel unsafe while doing their job. The Ontario Health Care Health and Safety Committee, created under section 21 of the Occupational Health and Safety Act (OHSA), has been working on improving workplace safety in health care, but has mostly focused on institutional settings. And strategies designed for hospitals and long-term care homes do not translate well to the home care setting, says VanderBent. “Home care is still the afterthought,” she notes. “We have to have unique ways in our world to protect our workers and our clients.”
Currently, it is up to each home care agency to protect its employees. Both the agencies and the soon-to-be former Local Health Integration Networks (LHINs) are meant to ensure that homes where care is provided comply with the minimum OHSA standards, but Ferrier says these are not enough to protect home care workers from violence and abuse.
Mark Nesbitt, spokesperson for the Ministry of Health and Long-Term Care, says in a written statement that “employers have the ultimate responsibility to eliminate violence at work.” In addition to complying with OHSA standards, he adds, they must provide workers with information about a person with a history of violence if the worker can be expected to encounter that person in the course of their work.
Publicly funded home care agencies receive referrals through the LHINs, which begin with a call from a case coordinator offering basic information: “older adult, hip fracture surgery, discharged home from hospital, needs help with personal care, could you send a PSW today?” Ferrier estimates that 90 percent of the time when a PSW walks into a new client’s home, they don’t have information beyond this. If a client requires urgent care, she says, agencies feel pressed to send someone even without a complete picture of the client’s health status or the possible risks for the worker. It is often the PSW who has to assess her own safety and protect herself once she walks into a home during this first visit.
Once an agency accepts a client, the LHIN sends them a full report later that day, sometimes after a worker has already gone out. But information for this report is collected from the client, often at an acute care facility prior to discharge or over the phone, and is usually insufficient to assess risks for workplace violence, says Nicole Lewis, workplace and safety adviser to Home Care Ontario.
Once the full report is received, home care agencies are able to conduct an assessment on paper and flag any potential risks for workplace violence. Then, registered nurses employed by the agencies have up to two weeks to do an in-person assessment, develop a client’s care plan and conduct workplace health and safety checks. In the interim, PSWs and other professionals keep providing care. Ideally, says Jensen, these home assessments would be conducted by the LHIN or the agency prior to sending PSWs or other home care providers.
Violence is a risk with new clients, but also with clients experiencing behavioural changes. Three years ago, says Ferrier, a PSW providing care for a regular client with agitated dementia was punched in the face and hit in the head with an ironing board. No one else was home; his wife was out doing groceries. When the worker was able to make it upstairs to the kitchen where her cellphone was, she tried to call her supervisor at work. The client caught up to her and attacked her again. Luckily, his wife arrived back home and was able calm the man down.
Nesbitt explains that “if a staff member experiences any form of abuse and/or assault or neglect, the police should be contacted immediately.” If a PSW is in danger, Ferrier says, she should step out of the home immediately and call 911, not her supervisor. “But most workers do not know this,” she says.
Most agencies do not allow PSWs to carry their phones into a client’s bathroom or bedroom—where most personal care happens—to protect the client’s privacy, says Jensen. She thinks that if a client is known to be aggressive, the PSW should be allowed to have her phone or some form of communication with her. And many PSWs do choose to carry their phone at all times in order to keep themselves safe, says Ferrier.
There is also the problem of lack of coordination with the health care system. There are currently no mechanisms to facilitate an agency learning of changes in a client’s health status in a timely manner, which may increase the risk of violence for workers. For instance, if a woman discloses to a family doctor that her father, who has dementia, has started acting aggressively and recently hit her, home care agencies providing regular care to this man do not have direct access to this information, says VanderBent.
Also, multiple agencies often provide home care to a given a client, but do not exchange information with each other. For instance, one agency may provide physiotherapy services while another provides personal support workers and nurses. For publicly funded services, incident reports go directly to the LHIN, whose case coordinator investigates, and, if necessary, shares the information with other agencies. This process can delay access to critical information for PSWs, nurses and any other professionals providing care, says Lewis.
There is a major retention issue with PSWs in Ontario, which particularly affects home care. PSWs are transitioning to the long-term care sector in search of a safer environment with better institutional support and more stable pay and schedule, says Ferrier. According to the OPSWA report, the Statistics Canada vacancy rate for workers employed in the Personal Services Field, which includes PSWs, rose from 3.4 percent in 2017 to 4.8 percent in 2018. It is the highest vacancy rate in any field across Canada.
What can be done to reduce the risk of workplace violence for home care providers?
At the provincial level, the Ontario Health Care Health and Safety Committee has been working to translate tools designed for hospital settings into home care, says Lewis. The Public Services Health and Safety Association, a non-profit organization funded by the Ministry of Labour, recently developed a community care violence assessment tool which provides home care agencies and their personnel with an online instrument to assess, prevent and address violence. The tool is intended for pre-visit assessments of the home and tackles such issues as environmental conditions, communications and access, the presence of animals or weapons, and clients’ cognitive ability and challenging behaviours. It asks questions such as, “Are there any uneven surfaces that might impede a quick exit?” and “Are there unsecured firearms/weapons in the home?”
“As PSWs, we are trained to be observant and cautious,” says Jensen. “Other than that, it is pretty much learning on your own.” Crisis Prevention Intervention training, or CPI, is not mandatory for PSWs, but Jensen thinks it should be.
Laura Bulmer, registered nurse and professor in the PSW program at George Brown College, has been advocating for the inclusion of CPI in the PSW certificate. Currently, PSWs wanting to receive CPI training take it at an additional cost and on the weekends. “PSWs in home care are at a high risk for violence and receive lots of verbal abuse, like racial, sexist and homophobic slurs,” says Bulmer. “But they are hesitant to report. There is a need for additional training and continued support.”
OPSWA has been looking for a tech partner to develop a “panic button” device, similar to those worn by older adults on a necklace or bracelet. This could allow workers to connect directly with emergency services and send their GPS coordinates if the need arises.
Ontario’s health care changes present an opportunity for home care, says VanderBent. The dismantling of the LHINs and the creation of a centralized health care agency could speed information transfer and formalize procedures. Nesbitt explains that the Ontario Health Teams, which will soon replace the LHINs, will be a new way of organizing and delivering services in local communities. The teams, supported by the Ministry and Ontario Health, will be responsible for safe, high-quality, effective home care in partnership with service provider organizations. “Through a team-based approach,” says Nesbitt, “the Ministry hopes to improve connections in the system and promote safe, high-quality, effective care.”
Workplace safety should be everyone’s priority, says VanderBent. Because, “if it is unsafe for staff, it is unsafe for patients too.”
Astrid Escrig-Pinol is a freelance journalist and PhD candidate at the Dalla Lana School of Public Health, University of Toronto. She is currently pursuing a Certificate in Health Impact, offered jointly through the Munk School of Global Affairs and Public Policy, the School of Medicine and Dalla Lana.