"It's More than Just Needing money": The Value of Supporting Networks of Care.

It is well established in research, practice, and policy that unpaid caregivers (family and friends of people with care needs) experience stress in their role. Supports that have been put in place by policy planners and program developers to support caregivers may not be accessed by caregivers at all or may do little to reduce their stress. Accessing personal resources (education, finances), in addition to social resources (individual connections) and societal resources (community supports) are critical in fostering resilience in caregivers (helping them adapt to stress and adversity). Social capital theorists argue that creating connections at various levels can improve access to resources. This research, through qualitative interviews (n = 21), identifies the different levels of resources required to address the needs of caregivers. Our findings indicate that interventions that focus on access to personal-level resources (education, funding) are important, but are on their own insufficient. Of more importance were interventions that work to improve relationships between formal providers and families; access to interdisciplinary teams; cross-sectoral collaborations; and inter-organization relationships, highlighting that a system that works together is likely to improve caregivers' access to resources.

The influence of autonomy on personal support workers' job satisfaction, capacity to care, and intention to stay.

Using survey data collected in Ontario, Canada, we explore the impacts of autonomy on community-based Personal Support Workers' intrinsic job satisfaction, capacity to care for and about clients, and intention to continue working in home care. Autonomy was measured as "freedom to decide how to do your job" and "working on your own." Findings show that freedom to do your job and working on your own are both positively associated with job satisfaction and capacity to care, and indirectly increase intention to stay through their relationships with job satisfaction and capacity to care. We suggest that policies should allow personal support workers to make decisions about how to do their job within the care plans provided, to facilitate retention of this highly needed workforce.

Health and safety matters! Associations between organizational practices and personal support workers' life and work stress in Ontario, Canada.

BACKGROUND: The home and community care sector is one of the fastest growing sectors globally and most prominently in mature industrialized countries. Personal support workers (PSWs) are the largest occupational group in the sector. This paper focuses on the emotional health of PSWs working in the home and community care sector in Ontario, Canada. The purpose of this paper is to present evidence on the associations between PSWs' life and work stress and organizational practices of full-time and guaranteed hours, and PSWs' perceptions of support at work and preference for hours. METHODS: Data come from our 2015 survey of 1543 PSWs. Dependent variables are life and work stress. Independent variables are: objective organizational practices of full-time and guaranteed hours, and subjective organizational practices of perceived support at work, and preferred hours of work. Descriptive statistics, correlations and ordinary least square regression analyses with collinearity tests are conducted. RESULTS: Organizational practices of employing PSWs in full-time or guaranteed hours are not associated with their life and work stress. However, those who perceive support from their organizations are also the ones reporting lower life and work stress. In addition, those PSWs perceiving support from their supervisor report lower work stress. PSWs would like to work in their preferred hours, and those who prefer to work more hours report lower life and work stress, and conversely, those who prefer to work less hours report life and work stress. CONCLUSION: For PSWs in home and community care, perceived support from their organizations and supervisors, and employment in preferred hours are important factors related to their life and work stress.

Primary care physicians' perspectives on facilitating older patients' access to community support services: Qualitative case study.

OBJECTIVE: To understand how family physicians facilitate older patients' access to community support services (CSSs) and to identify similarities and differences across primary health care (PHC) models. DESIGN: Qualitative, multiple-case study design using semistructured interviews. SETTING: Four models of PHC delivery, specifically 2 family health teams (FHTs), 4 non-FHTs family health organizations, 4 fee-for-service practices, and 2 community health centres in urban Ontario. PARTICIPANTS: Purposeful sampling of 23 family physicians in solo and small and large group practices within the 4 models of PHC. METHODS: A multiple-case study approach was used. Semistructured interviews were conducted and data were analyzed using within- and cross-case analysis. Case study tactics to ensure study rigour included memos and an audit trail, investigator triangulation, and the use of multiple, rather than single, case studies. MAIN FINDINGS: Three main themes were identified: consulting and communicating with the health care team to create linkages; linking patients and families to CSSs; and relying on out-of-date resources and ineffective search strategies for information on CSSs. All participants worked with their team members; however, those in FHTs and community health centres generally had a broader range of health care providers available to assist them. Physicians relied on home-care case managers to help make linkages to CSSs. Physicians recommended the development of an easily searchable, online database containing available CSSs. CONCLUSION: This study shows the importance of interprofessional teamwork in primary care settings to facilitate linkages of older patients to CSSs. The study also provides insight into the strategies physicians use to link older persons to CSSs and their recommendations for change. This understanding can be used to develop resources and approaches to better support physicians in making appropriate linkages to CSSs.

The CHAP-EMS health promotion program: a qualitative study on participants' views of the role of paramedics.

BACKGROUND: Expanded roles for paramedics, commonly termed community paramedicine, are becoming increasingly common. Paramedics working in community paramedicine roles represent a distinct departure away from the traditional emergency paradigm of paramedic services. Despite this, little research has addressed how community paramedics are perceived by their clients. METHODS: This study took an interpretivist qualitative approach to examine participants' perceptions of paramedics providing a community paramedicine program, named the Community Health Assessment Program through Emergency Medical Services (CHAP-EMS). Both participant observation and semi-structured interviews conducted with program participants were used to gain insight into the on-the-ground experiences of the program. Thematic analysis was employed to analyze all data. RESULTS: Three themes emerged: i) Caring and trusting relationships; ii) paramedics as health advocates; iii) the added value of EMS skills. Paramedics were perceived by residents as having dual identities: first in a novel role as health advocates and secondly in a traditional role as emergency experts despite lacking contextual features associated with emergency response. CONCLUSIONS: From this exploratory, qualitative study we present an emerging framework in which to conceptualize paramedic roles in community paramedicine settings. Future research should address the saliency of these roles in different contexts and how these roles relate to paramedic practice.

Community-based personal support workers' satisfaction with job-related training at the organization in Ontario, Canada: Implications for future training.

BACKGROUND AND AIMS: Complexity of community-based homecare for older adults has increased significantly in the past decade in Ontario, Canada. Personal support workers (PSWs), who are unregulated and vary in formal education, provide the majority of community homecare work for increasingly complex clients. This paper seeks to understand community-based PSWs' satisfaction with opportunities for job-related training at their employing organization to provide the skills and knowledge to meet the demands of their evolving role. METHODS: Data for this paper are from a cross-sectional survey of 1746 community-based PSWs in Ontario, Canada entitled, "The PSW Health and Safety Matters Survey" www.pswshaveasay.ca. This survey was part of a research project "Keeping Community Based PSWs Safe in a Changing World of Work," funded by the Ontario Ministry of Labour. The data were analyzed using descriptive statistics, correlations, multivariate regression, and thematic analysis. RESULTS: Quantitative analysis revealed most community homecare organizations offer PSWs job-related training to help them retain and update their skills and that PSWs have a moderate level of satisfaction with their job-related training. The analysis revealed that PSWs' satisfaction with organizational training is greater when the organization provides work-related training on challenging tasks, lifting and transferring tasks, and tasks delegated by nurses and supervisors. Data from the open-ended question highlighted seven key themes for desired training by PSWs: safe body mechanics for moving/lifting clients, managing aggression primarily with clients, infection control, CPR/first aid, mental illness, equipment training, and basic health and safety. CONCLUSION: Implications for factors associated with PSWs' satisfaction with opportunities for job-related training are discussed along with recommendations for mitigating variability in education and training to meet the demands of their evolving role.

Violence, Harassment, and Turnover Intention in Home and Community Care: The Role of Training.

BACKGROUND: Violence and harassment affect healthcare workers' well-being and career decisions in the home and community care sector. PURPOSE: The objective of this study is to assess the role of training in alleviating the relationship between violence and harassment at work and turnover intention among personal support workers (PSWs). METHODOLOGY/APPROACH: Cross-sectional survey data from 1401 PSWs in Ontario, Canada are analyzed with structural equation modeling. Utilizing a resource perspective, the associations between job demands (i.e., violence and harassment at work), personal resources (i.e., self-esteem), job resources (i.e., workplace violence training and challenging task training), stress, and intention to stay among personal support workers (PSWs) are examined. RESULTS: Challenging task training is positively associated with self-esteem and negatively associated with stress, whereas workplace violence training does not have a significant association with either variable. Stress has a negative relationship with intention to stay. Self-esteem is the mediator of both associations between violence and harassment at work and stress and between challenging task training and stress. DISCUSSION: The results point to varied degrees of training effectiveness that may be shaping turnover decisions of PSWs who experience violence and harassment in home and community care organizations. PRACTICE IMPLICATIONS: There seems to be a need to assess and redesign workplace violence training. Home and community care managers might be able to lower the impact of violence and harassment on PSWs' turnover by providing training that is not directly related to workplace violence and harassment.

Casualized employment and turnover intention: home care workers in Ontario, Canada.

The purpose of this paper is to examine the associations between casualized employment and turnover intention in home care. Casualized employment refers to employment conditions of non-permanent contracts, part-time or casual hours, involuntary hours, on-call work, split shifts, pay per visit, and hourly pay with variable hours. Casualized employment also refers to perceived employment insecurity and labour market insecurity. Data are from a survey of 991 visiting nurses, therapists and home support workers in a medium-sized city in Ontario, Canada. Results show that, controlling for many other factors, casual hours and perceived employment insecurity and labour market insecurity are positively and on-call work is negatively associated with home care workers' turnover intention. Non-permanent contract, part-time hours, involuntary hours, split shifts, and non-salaried pay are features of the market-modelled home care work environment and therefore may not be associated with turnover intention. Results provide evidence on the effects of casualized employment strategies on home care workers' turnover intention.

Older adults' awareness of community health and support services for dementia care.

ABSTRACTThe article examines where older adults seek help in caring for a parent with dementia and the factors associated with their identification of community health and support services as sources of assistance. The authors conducted telephone interviews, using random digit dialing, of 1,152 adults aged 50 and over in the city of Hamilton. Respondents received a vignette that raised issues related to parental dementia. In identifying support sources, over 37 per cent of respondents identified their physician, 33 per cent identified informal support such as family and neighbors, and 31 per cent identified home health services. Only 18 per cent identified community support services. Female participants having higher levels of education were more likely to identify their physician as a source of support. Knowing where to find information about community support services was associated with an increased likelihood of mentioning physicians and home health services as sources of assistance.

Implementing Montessori Methods for Dementia™ in Ontario long-term care homes: Recreation staff and multidisciplinary consultants' perceptions of policy and practice issues.

Montessori-based activities use a person-centred approach to benefit persons living with dementia by increasing their participation in, and enjoyment of, daily life. This study investigated recreation staff and multidisciplinary consultants' perceptions of factors that affected implementing Montessori Methods for Dementia™ in long-term care homes in Ontario, Canada. Qualitative data were obtained during semi-structured telephone interviews with 17 participants who worked in these homes. A political economy of aging perspective guided thematic data analysis. Barriers such as insufficient funding and negative attitudes towards activities reinforced a task-oriented biomedical model of care. Various forms of support and understanding helped put Montessori Methods for Dementia™ into practice as a person-centred care program, thus reportedly improving the quality of life of residents living with dementia, staff and family members. These results demonstrate that when Montessori Methods for Dementia™ approaches are learned and understood by staff they can be used as practical interventions for long-term care residents living with dementia.

Retaining nurses in their employing hospitals and in the profession: effects of job preference, unpaid overtime, importance of earnings and stress.

The purpose of this paper is to examine the effects of job preference, unpaid overtime, importance of earnings, and stress in retaining nurses in their employing hospitals and in the profession. Data come from our survey of 1396 nurses employed in three teaching hospitals in Southern Ontario, Canada. Data are analyzed first for all nurses, then separately for full-time, part-time, and casual nurses. Results show that the key to understanding the effects of these variables may be to pay attention to the work status of nurses. With regards to retaining nurses in their hospitals, working in their preferred type of job is important, particularly for part-time nurses. Working unpaid and longer than agreed hours is also a factor for increasing the likelihood of part-time nurses to leave the profession. All nurses are less inclined to leave as the importance of their earnings for the family increases, but it is particularly important for part-time nurses. Stress is an ongoing concern for retaining nurses in their hospitals and within the profession. We suggest managers and policy makers pay attention to employing nurses in jobs they prefer, decrease unpaid overtime, and consider the importance of earnings for them and their families in developing policies and programs to retain nurses. More importantly, stress levels should be lowered to retain nurses.

Primary Health Care Providers' Perspectives: Facilitating Older Patients' Access to Community Support Services.

The purpose of the study examined in this article was to understand how non-physician health care professionals working in Canadian primary health care settings facilitate older persons' access to community support services (CSSs). The use of CSSs has positive impacts for clients, yet they are underused from lack of awareness. Using a qualitative description approach, we interviewed 20 health care professionals from various disciplines and primary health care models about the processes they use to link older patients to CSSs. Participants collaborated extensively with interprofessional colleagues within and outside their organizations to find relevant CSSs. They actively engaged patients and families in making these linkages and ensured follow-up. It was troubling to find that they relied on out-of-date resources and inefficient search strategies to find CSSs. Our findings can be used to develop resources and approaches to better support primary health care providers in linking older adults to relevant CSSs.

Full-time or part-time work in nursing: preferences, tradeoffs and choices.

Nursing human resources are limited; thus, effective deployment of personnel is essential to optimize staff capacity. The nursing profession competes for staff in environments where human capital is at a premium. To maximize recruitment and retention, it is imperative that nurses' work preferences be taken into account.

Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care.

Growing healthcare costs have caused home-care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home-care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home-care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010-2011. Using a purposive sampling strategy, semi-structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home-care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust-based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.

Home Care Workers' Skills in the Context of Task Shifting: Complexities in Care Work.

Task shifting, which involves the transfer of care work from regulated health-care professionals to home care workers (HCWs), is a strategy to ensure the efficient delivery of home care services in Canada and internationally. Using a feminist political economy approach, this paper explores the effects of task shifting on HCWs' skills. Task shifting may be understood as a form of downward substitution-and an effort to increase control over workers while minimizing costs-as some of health-care professionals' responsibilities are divided into simpler tasks and transferred to HCWs. Our interviews with 46 home health-care providers in Ontario, which focused explicitly on HCWs' role in care provision, problematize the belief that "low skilled" care workers have little control over their work. HCWs' skills become more complex when they do transferred tasks, and HCWs sometimes gain greater control over their work. This results in increased autonomy and mastery for many HCWs. In turn, this serves to reinforce the intrinsic rewards of care work, despite the fact that it is low paid and undervalued work.

Gender differences in health: a Canadian study of the psychosocial, structural and behavioural determinants of health.

Gender-based inequalities in health have been frequently documented. This paper examines the extent to which these inequalities reflect the different social experiences and conditions of men's and women's lives. We address four specific questions. Are there gender differences in mental and physical health? What is the relative importance of the structural, behavioural and psychosocial determinants of health? Are the gender differences in health attributable to the differing structural (socio-economic, age, social support, family arrangement) context in which women and men live, and to their differential exposure to lifestyle (smoking, drinking, exercise, diet) and psychosocial (critical life events, stress, psychological resources) factors? Are gender differences in health also attributable to gender differences in vulnerability to these structural, behavioural and psychosocial determinants of health? Multivariate analyses of Canadian National Population Health Survey data show gender differences in health (measured by self-rated health, functional health, chronic illness and distress). Social structural and psychosocial determinants of health are generally more important for women and behavioural determinants are generally more important for men. Gender differences in exposure to these forces contribute to inequalities in health between men and women, however, statistically significant inequalities remain after controlling for exposure. Gender-based health inequalities are further explained by differential vulnerabilities to social forces between men and women. Our findings suggest the value of models that include a wide range of health and health-determinant variables, and affirm the importance of looking more closely at gender differences in health.

Job stress and job dissatisfaction of home care workers in the context of health care restructuring.

Changes in the social organization of home care work due to health care restructuring have affected the job stress and job dissatisfaction of home care workers. This article reports the results of a survey of 892 employees from three nonprofit home care agencies in a medium-sized city in Ontario, Canada. Survey results are complemented by data from 16 focus groups with 99 employees. For the purposes of this study, home care workers include both office workers (managers, supervisors, coordinators, office support staff, and case managers) and visiting workers (nurses, therapists, and visiting homemakers). Focus group participants indicated that health care restructuring has resulted in organizational change, budget cuts, heavier workloads, job insecurity, loss of organizational support, loss of peer support, and loss of time to provide emotional laboring, or the "caring" aspects of home care work. Analyses of survey data show that organizational change, fear of job loss, heavy workloads, and lack of organizational and peer support lead to increased job stress and decreased levels of job satisfaction.

The interplay between women's life course work patterns and financial planning for later life.

In order to gain a comprehensive understanding of the interplay between women's life course work patterns and their financial planning for later life, we examined data from semi-structured interviews with retired women (n = 28) aged 59 to 92. The majority of women disrupted their careers at some point in time, for an average of 14 years, primarily for child-rearing responsibilities. We found that financial preparedness and income security in later life are structured by women's life course work patterns. However, individuals also have the ability to shape their own lives and many of the women took the initiative to acquire financial knowledge irrespective of their work situation. Financial-planning advice that participants gave to future generations of older women was also explored and centred on the importance of saving, avoiding debt, maintaining financial independence, and planning ahead.

Publicly funded and family-friend care in the case of long-term illness: the role of the spouse.

In recent years, considerable attention has been devoted to the value of unpaid work in the economy. One very important aspect of unpaid work is caregiving for chronically ill or disabled people and the question of whether or not family-and-friend caregiving eases the burden on the publicly funded system. Using data from the 1996 General Social Survey, this paper investigates the extent to which the presence of a spouse of a senior aged 55 and over with a long-term illness reduces the amount of publicly funded care received. The findings from the multivariate Tobit analysis show that the presence of the spouse does significantly reduce the amount of publicly funded care used. This result is not gender-specific. The total hours of caregiving by the spouse are valued, as well as the savings generated for the publicly funded system, and the policy issue of tax relief for spouses who are engaged in long-term caregiving is explored.