For many, working in health care is a calling. In home care, workers know that their work helps people stay in their homes and live as well as possible for as long as possible. Homecare workers often form strong and meaningful bonds with the clients and families they care for, often over long periods.
Unfortunately, the less discussed experience of homecare work is the violence and harassment providers can experience. Exposure to harassment and violence erodes workers’ physical and mental health, decreases job satisfaction and performance, and drives people out of health care.
While rates are not available for home care, we know that surveys of health-care workers typically find that more than 60 per cent have experienced some form of violence or harassment in the past year – even when working in institutional settings where these behaviours are witnessed by other staff. In home and community care, the work literally happens behind closed doors in the client’s home environment, with no coworkers present to provide support. Cognitive impairment, which is common among homecare clients, increases the likelihood of “responsive behaviours” – a term that obscures the severity of some incidents.
A long-standing notion that harassment and violence are “just part of the job” feeds a culture of under-reporting throughout health care, especially when the behaviour is attributed to a client’s medical condition.
It’s time for change. But how can employers address incidents that they don’t know about or understand? To make the work safer, we must start by increasing reporting rates.
Research tells us that homecare workers who hesitate to report harassment or violence have these considerations in mind:
- Compassion for clients – care providers understand that clients with cognitive impairment may not mean the things they say and do. Providers tend to tolerate incidents that are attributable to a client’s medical condition.
- A culture of self-sacrifice – health-care workers know they see people in their most trying times, and want to do whatever it takes to help.
- A sense of fatalism – that harassment and violence is unavoidable in health care.
- Not wanting to make waves – many homecare workers are racialized, women or newer immigrants with lower socio-economic status who may find it difficult to advocate for their own safety.
- Loss of control – reporting an incident sets in motion a process that the worker cannot control.
- Fear of the outcome – reporting an incident may lead to no longer caring for that client. That may mean losing hours and income, and the next client may be no better.
- Or fear of no outcome – the belief that nothing will change, and that the time, effort and disruption of reporting will be in vain.
Employers can use these insights to address issues and increase reporting rates as a first step to reducing the burden on health-care workers.
Leaders must subvert the notion that some degree of harassment and violence is normal and tolerable. We must address the real and perceived risks of reporting and give workers more control over what happens after a report is filed. And we can inspire people to report incidents by showing that these reports can help both their coworkers and their clients.
VHA Home HealthCare (VHA) has tested a simple, four-part intervention to shape behaviour by addressing motivation, ability, role perceptions and situational factors. Developed by an interprofessional team of client and family caregiver advisors, it focuses on caregiver education, pre-visit screening and the reporting process, underpinned by clarified and updated policies.
Recognizing that some health-care workers are reluctant to report abuse out of compassion for the client or a sense that they can manage it on their own, the education emphasizes how reporting can help others. A care provider can support coworkers by documenting how they manage a particular client’s behaviours so that the next person knows what to do. We found that people are more likely to file a report when they think it will help someone else. Reporting can also help clients; sometimes, the behaviour is rooted in an unmet need that the care plan could address.
Pre-visit screening identifies risk factors and lets workers know what to expect when they enter a home for the first time.
The reporting process itself has been designed to be simple and quick, because workers usually submit the report in their personal time. It starts with a simple yes/no at the end of every visit: did an incident occur?
If the answer is yes, the reporting process lets workers decide whether a supervisor should follow up. This alleviates fears that the client will be removed from the provider’s schedule if that is not the provider’s preference. And while employers have a legal obligation to follow-up on reported incidents of harassment or violence, it is also important to recognize that overly vigorous follow-up deters reporting. When the worker has requested no follow-up, leaders can gently acknowledge the incident and offer support without initiating actions the worker cannot control.
The pilot to test this intervention involved more than 60 personal support workers (PSWs) serving 410 clients with more than 55,000 care visits over 32 weeks. During this period, incidents were reported by 21 per cent of PSWs. Follow-up was requested in only 41 per cent of these cases; half of the reports included client-specific strategies to manage the challenging behaviours.
After the trial period, 91 per cent of PSWs involved felt satisfied with the process. Although many reported greater comfort sharing their concerns, some still chose not to report. Their reasons included confidence in their ability to manage the incident, compassion for the client’s medical condition and a desire to prevent further conflict with the client.
Leaders felt they had greater insight into what was happening, a better understanding of how PSWs manage incidents, and appreciated the opportunity to address unmet client needs. Responding effectively required collaboration from supervisors, schedulers and interprofessional colleagues to find appropriate solutions in each case to best support both PSWs and clients.
VHA has expanded the program to all of its Personal Support teams, with some tweaks based on the experience of those involved. For those who would like additional information or may wish to adopt a similar approach, a recent Ontario Community Support Association webinar describes the intervention in detail and a peer-reviewed paper on our pilot study appeared recently in the journal Workplace Health & Safety.
PSWs understand their work to be physically and emotionally challenging. But it doesn’t have to be dangerous. Health-care employers can and must intervene.