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Purpose: This chapter problematizes the philosophical origins of direct funding models in a normative conception of independence that ignores and obscures the fundamentally relational nature of care work.

Approach: The study adopts a reflexive ethnographic methodological approach. In-depth, semistructured interviews were conducted with 19 participants variously involved with direct-funded attendant services (disabled “self-managers,” “attendant” employees, other members of self-managers’ support networks, and program staff). Additional data sources included the author's reflexive journaling and publicly available policy and program materials. The present analysis interrogated the impact of systemic constraints (i.e., limited funding) on the organization and management of attendant services.

Findings: The data illuminate how systemic constraints draw the interests of self-managers and attendants into tension, despite the affective relationality of the work they do together. The findings present four strategies self-managers adopt to maximize support hours, including: splitting shifts, strategic hiring, dynamic resource management, and supplementing remuneration. These findings suggest it is not vulnerability to each other that represents an ongoing concern for self-managers and attendants, so much as exploitation by a system that capitalizes on the oppression of both groups.

Implication/ Value: Disabled people and care workers have been and continue to be constructed as opposing interest groups. However, there is great potential in disabled people and care workers joining a united front to lobby for their common, often interrelated interests. Direct funding models are an important evolution of support services, but where they fail to attend to the relational nature of care work, we must continue to pursue more inclusive solutions.

Over 3 million intermittently employed and socially disadvantaged workers receive low wages and limited benefits in diverse long-term care settings and employment arrangements as they try to become a positively valued unified occupation: “direct care workers.” Before this occurs, these workers must overcome negative definitions imposed by three powerful institutions: professional guilds, employers, and states. Care workers’ legitimacy is challenged as nursing labels them “unlicensed, assistive personnel,” defining them in terms of their task relationship to nurses rather than their social relationship to clients. Care workers’ identity is obscured as corporate rationalization nullifies their unique contributions with task unbundling, part-time work, short staffing, and turnover undermining bonding with colleagues and clients. State regulation impedes care workers’ integration, segmenting similar workers under different regulatory regimes, defining workers negatively rather than by their educational attainments and competencies. Overcoming this triple negation will require not just cultural change, but also real structural changes, and can occur only through concerted actions involving coalitions. Labor market intermediaries, public authorities, labor unions, workforce investment boards, philanthropic organizations, and government interagency groups are among those supporting direct care workers’ advancement by strategically coordinating licensing, purchasing, and developing the workforce. Recent federal policy changes and health reform legislation have enhanced recognition of this occupation and are providing new resources for its development.

This chapter explores variation in direct care workers’ health risks within institutional and home-based settings, according to the demographic composition of workers and the gendered, raced, and citizenship-based expressions of their work roles.

This quantitative intersectional study draws on two nationwide datasets from the US National Center for Long-term Care Statistics, a division of the Centers for Disease Control and Prevention, the National Nursing Assistant Study (NNAS), and National Home Health Aide Survey (NHHAS).

Workplace context was the strongest predictor of workers’ health risks and working conditions. Physical injuries affected more than half of facility-based workers annually compared to less than 10% of home-based workers. Facility-based workers are more likely to report insufficient time for tasks, lower job satisfaction, and less respect and appreciation from patients. Home-based workers may be more likely to experience emotional distress, be offered fewer benefits, but experience fewer injuries, due to the better relative health of their patients and having more time for client care. Women reported more injuries and more time pressure than men across racial and citizenship groups within the same work setting.

There are limitations to the NHHAS and NNAS public-release data file data. We are unable to fully capture citizenship, some racial/ethnic categories, workers over age 65, supervisory workers, facilities with fewer than three residents, and facilities not certified with Medicare or Medicaid. The exclusion of these questions, workers, and contexts is a weakness of the present study.

Analyses draw on data from the first nationally representative sample surveys of home health aides and nursing assistants in the United States. Direct care workers are an important population to capture through intersectional research since care work is done predominantly by multiracial women and immigrants. This research also underscores the importance of workplace contexts in shaping the labor performed and the workers’ experiences.

This paper examines job satisfaction and participation in decision making in three home health aide facilities with different organizational structures (worker-owned for-profit, for-profit with no participation or ownership by workers, and nonprofit).

More than 600 surveys were completed by home health aides across the three facilities. The author also engaged in participant observation during training sessions and other meetings and conducted a small number of interviews with caregivers and agency management.

Home health aides at the worker-owned, participative decision making organization were significantly more satisfied with their jobs than those at the other agencies. Results for the other agencies were not significantly distinguishable from one another.

This study involved respondents from one of each type of business. A study across several of each type of organization would allow more focus on the effects of the structural characteristics of the organizations.

In the United States, the work that home health aides perform provides a valuable service to society. On behalf of caregivers and those for whom they provide care, conditions of the work need improvement. If participative democratic workplaces provide better outcomes, they should receive more attention from lawmakers, the business community, and researchers.

This research highlights the working conditions of the people (primarily women) who perform this work. The poor compensation received is a reminder of inequality in opportunity for some workers and of the value placed on this type of caring labor.

This research is unique in its focus on work environment and outcomes in home health care across nonprofit, for-profit, and worker-owned for-profit organizations. The findings of different job satisfaction outcomes from the others in the worker-owned organization and similar outcomes in the nonprofit and conventional for-profit organizations are also unique.

The COVID-19 pandemic stressed the health care sector's longstanding pain points, including the poor quality of frontline work and the staffing challenges that result from it. This has renewed interest in technology-centered approaches to achieving not only the “Triple Aim” of reducing costs while raising access and quality but also the “Quadruple Aim” of doing so without further squeezing wages and abrading job quality for frontline workers.

How can we leverage technology toward the achievement of the Quadruple Aim? I view this as a “grand challenge” for health care managers and policymakers. Those looking for guidance will find that most analyses of the workforce impact of technological change consider broad classes of technology such as computers or robots outside of any particular industry context. Further, they typically predict changes in work or labor market outcomes will come about at some ill-defined point in the medium to long run. This decontextualization and detemporization proves markedly problematic in the health care sector: the nonmarket, institutional factors driving technology adoption and implementation loom especially large in frontline care delivery, and managers and policymakers understandably must consider a well-defined, near-term, i.e., 5–10-year, time horizon.

This study is predicated on interviews with hospital and home health agency administrators, union representatives, health care information technology (IT) experts and consultants, and technology developers. I detail the near-term drivers and anticipated workforce impact of technological changes in frontline care delivery. With my emergent prescriptions for managers and policymakers, I hope to guide sectoral actors in using technology to address the “grand challenge” inherent to achieving the Quadruple Aim.

Deinstitutionalization has impacts also on direct care workers and their work. The purpose of this paper is to analyse the attitudes of direct care workers towards the closure of the institution, and these attitudes’ relation to workers’ occupational identity.

Data were collected by postal questionnaire before the closure of the institution. The respondents consisted of two groups: direct care workers of the institution (n=93) and direct care workers of community-based residential units run by the same organization (n=117).

The results clearly show that direct care workers in the institution, as a group, were against the closure of the institution. This is quite understandable, because the closure will irrevocably affect their work and also private life. Although this opposing is evident, there was also variance in the attitudes within this group: some were more willing to accept the change, some were more against it. Those opposing the closure seemed to be more reluctant in adopting the new kind of identity as supporters of the self-determination of their clients and also they felt more insecure about their own competence.

In deinstitutionalization research a staff perspective has not been very common. To successfully accomplish the change process it is important to take into account also the staff and how they experience the change. It would be far more beneficial to have staff promoting change than resisting it.

Following a recent government initiated change to a consumer-directed care model across the Australian community aged care sector, the purpose of this paper is to explore frontline home support workers’ perceptions of relational changes with clients in power and subordination within the triadic relationship between employer, employee and client.

Contextual interviews were held with managers (n=4), coordinators (n=10) and semi-structured face-to-face interviews with support workers (n=17) in three organizations. Interview transcripts were analyzed.

Some workers did not perceive a power change in their relationships with clients. Others perceived minimal change but were concerned about the incoming client generation (baby boomers) that were more aware of their rights. Others felt subordinated to the client, perceived a loss of control or that felt treated like an employee of the client. Consistent with the philosophy of consumer-directed care, senior staff encouraged clients to treat workers in this way.

Further research is recommended on worker and client perceptions of relationships within the context of a consumer or client focused model.

A clear and realistic understanding of the locus of power within a triadic relationship by all actors is important for positive workplace outcomes.

The increasing ageing population makes it essential that workers’ relationships with clients and with their organization are unambiguous.

This study makes a contribution to theories about change and power transfer in the implementation of consumer-directed care through the perceptions of support workers. Examination of power and subordination transfer through the perceptions of the actors of rather than through the prism of organizational policy deepens the understanding of frontline service work and relationships.

Different organisations have developed policies and programmes to prevent workplace injuries and facilitate return to work. Few multiple workplace studies have examined workers’ perceptions of these policies and programmes. The purpose of this paper is to compare workers’ perception and experience of workplace policies and practices on injury prevention, people-oriented work culture, and return to work.

This study recruited 118 workers from three healthcare facilities through an online and paper survey.

Work-related musculoskeletal injury was experienced by 46 per cent of the workers, with low back injuries being most prevalent. There were significant differences in perception of policies and practices for injury prevention among occupational groups, and between workers who have had previous workplace injury experience and those without past injury.

Selection bias is possible because of voluntary participation. A larger sample could give stronger statistical power.

The perception of workplace policies can vary depending on workers’ occupational and injury status. Organisational managers need to pay attention to the diversity among workers when designing and implementing injury prevention and return to work policies.

Risks for workplace injuries are related to multiple factors, including workplace policies and practices on health and safety. Workers’ understanding and response to the policies, programmes, and practices can determine injury outcomes.

No previous study has reported on workers’ perceptions of workplace policies and practices for injury prevention and return in Manitoba healthcare sector.

The purpose of this study is to evaluate a conflict management training that used a communication competence perspective. This addresses whether the training had an impact on role conflict, conflict resolution skills, horizontal violence, burnout, turnover intention and perceptions of consumers. It also assessed staff perceptions of the training.

A mixed-method analysis was used using survey data from multiple time points along with focus group interviews.

The program decreased role conflict, horizontal violence and burnout among direct-care workers, whereas feelings of safety and perceptions of workers’ ability to protect themselves and others in aggressive situations increased. Furthermore, staff felt the training was useful and increased feelings of safety and empowerment at the study.

These findings suggest that conflict management training may need additional refresher sessions. Administrative planning is also needed to ensure training of all staff is trained in an adequate timeframe.

These results, although positive, are somewhat time bound. Therefore, the content of training and knowledge dissemination of conflict management training need additional research to ensure best practices.

Hospitals within the United States consistently have injury rates that are over twice the national employee injury rate. Hospital safety studies typically investigate care providers rather than support service employees. Compounding the lack of evidence for this understudied population is the scant evidence that is available to examine the relationship of support service employees’ perceptions of safety and work-related injuries. To examine this phenomenon, the purpose of this study was to investigate support service employees’ perceptions of safety leadership and social support as well as the relationship of safety perception to levels of reported injuries.

A nonexperimental survey was conducted with the data collected from hospital support service employees (n=1,272) and examined: (1) relationships between safety leadership (supervisor and organization) and individual and unit safety perceptions; (2) the moderating effect of social support (supervisor and coworker) on individual and unit safety perceptions; and (3) the relationship of safety perception to reported injury rates. The survey items in this study were based on the items from the AHRQ Patient Safety Culture Survey and the U.S. National Health Care Surveys.

Safety leadership (supervisor and organization) was found to be positively related to individual safety perceptions and unit safety grade as was supervisor and coworker support. Coworker support was found to positively moderate the following relationships: supervisor safety leadership and safety perceptions, supervisor safety leadership and unit safety grade, and senior management safety leadership and safety perceptions. Positive employee safety perceptions were found to have a significant relationship with lower reported injury rates.

These findings suggest that safety leadership from supervisors and senior management as well as coworker support has positive implications for support service employees’ perceptions of safety, which, in turn, are negatively related to lower odds of reporting injuries.