Prairie Women's Health Centre of Excellence

  Women's Formal (paid) Home Care Work in Transition: The Impact of Reform on Labour Process Change in Saskatoon, SK


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The research and publication of this study were funded by the Prairie Women's Health Centre of Excellence (PWHCE). The PWHCE is financially supported by the Women's Health Contribution Program, Bureau of Women's Health and Gender Analysis, Health Canada. The views expressed herein do not necessarily represent the views of the PWHCE or the official policy of Health Canada.

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A. Williams, S. Wagner, M. Buettner, A. Coghill

Executive Summary

The research presented herein has examined the subjective quality of work life of three primary home care practitioner groups - Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Home Health Aides (HHAs) - after the implementation of the planned restructuring strategies, defined by and implemented by Saskatoon Home Care. The main elements of the restructuring include: the integration of all practitioner categories into geographic teams, role changes for practitioners via collaborative case management, changes in office personnel, and transfer of medication management from RNs to HHAs and LPNs. These changes took place from April to September 1999, inclusive; this six-month period operates as the study period for the project concerned herein. Research data specific to practitioners' assessments of quality of work life, overall quality of life and personal health and well-being have allowed the impacts of the restructuring strategies on the labour process to be assessed.

The University of Saskatchewan (Department of Geography and College of Nursing) have worked in collaboration with what was once the Saskatoon District Health (SDH) Home Care Communications Committee (known as the Research Advisory Committee, RAC) - where all three home care practitioners and both unions are represented -- to better understand how labour processes are being redesigned in the home health care sector. The Research Advisory Committee has operated as the only community partner. Two people from Saskatoon Home Care Management (the Director and one Agency Supervisor) have operated as Research Auxiliaries and have facilitated the research endeavour. They have brought an enhanced understanding of the issues around restructuring, and have facilitated the research process through assisting with photocopying of surveys and various other 'in-kind' contributions. These administrators have not had any influence on the independence and autonomy of the RAC.

In order to achieve a clear understanding of the various experiences of home care practitioners, this study made use of three consecutive data collection methods; focus groups (n=4), a questionnaire survey (n=405) and a series of face-to-face interviews (n=20). Data was collected between October, 1999 and January, 2000 inclusive. Ethics protocol was used throughout the data collection process, as approved by the University Research Ethics Committee. Saskatoon District Health Research Services Unit provided operational approval for the work before the complete project was introduced to home care practitioners in November of 1999. In the case of the questionnaire survey, the small number of LPNs were combined with the RN group due to the similarity in educational preparation; this was done to enhance the rigour of the quantitative analysis.

The socio-economic characteristics of the two practitioner groups were gleaned from the questionnaire survey data. Data illustrate that nurses (the RN/LPN group) have objectively higher socio-economic status when compared to the HHA group. The RN/LPN group is not only better educated, but are significantly better paid than are the HHA group. The greater representation of HHAs in ethnic groups other than English Canadian further confirm that class and race interrelate with gender to further disadvantage women. In addition, HHAs are significantly less satisfied with their marital status when compared to the RN/LPN group. The fact that a larger percentage of HHAs are the main wage earners is revealed in the lower household income for HHAs. A larger percentage of nurses (the RN/LPN group) still have children at home (81%) when compared to the HHA group (59%); this may reflect the relatively greater degree of marital instability characteristic of the HHA group.

For both practitioner groups, work satisfaction and overall health and well-being was rated more poorly over the study period concerned when compared to the six months previous to the study period. The HHA group appear to be having a more difficult time than are the RN/LPN group with the restructuring experienced. HHAs rated their overall health and well-being more poorly than did the RN/LPN group. HHAs are found to be using significantly more sick/stress days in the time period concerned, as compared with the previous time period, than are the RN/LPN group. This supports the hypothesis that restructuring is impacting the health and well-being of practitioners, and particularly those lower on the human health care hierarchy. The research team used a standardized index for determining work satisfaction. Stamp's (1986) Index of Work Satisfaction (IWS) provides a measure for work satisfaction that is statistically valid and reliable. The measurement tool is based on the assumption that satisfaction can be measured best by separating the concept into its component parts and measuring them separately. The six components and their respective definitions are:

Pay: dollar remuneration and fringe benefits received for work done
Autonomy: amount of job-related independence, initiative, and freedom, either permitted or required in daily work activities
Task Requirements: tasks or activities that must be done as a regular part of the job
Job Status: overall importance or significance felt about your job, both in your view and in the view of others
Interaction: opportunities presented for both formal and informal social and professional contact during working hours
Organizational Policies: policies and procedures of this home care program

In terms of job satisfaction or morale, the most important component for practitioners was Autonomy, followed by Interaction, then Pay. Pay was more important than Task Requirements, which was followed by Job Status, and finally Organizational Policies. The fact that the ranking of these components is the same for all practitioners (RN/LPN and HHA groups) is quite interesting, suggesting that they share the attraction to the same characteristics of the home care sector - Autonomy and Interaction. Practitioners all ranked Organization Policies as the least important/valued component, relative to the other five.


The ranking of the components on both level of importance/value and actual current satisfaction show that practitioners (the combined sample of both RN/LPN and HHA groups) are most satisfied with Job Status, followed by Interaction, Autonomy, Pay, Task Requirements. Organizational Policies is the component that practitioners are least satisfied. All practitioners are consistent with regards to their feelings (value/importance attached to components) and perceptions (level of satisfaction) of Organizational Policies. Practitioners not only hold little value for Organizational Policies, but also are least satisfied with them, relative to the other components. This may be due to the degree of change being experienced by practitioners as a result of ongoing restructuring.

The Index of Work Satisfaction is the total index that represents both the relative importance of the components and the current level of satisfaction. The range of this summary Value is 0.9 to 37.1. The IWS Value for the combined sample of practitioners is 12.9. This value is alike other IWS studies, as most obtain a value of around 12 out of a maximum possible 37, showing how low overall levels of satisfaction are. The IWS value for the RN/LPN group is higher than the average (13.6), and the IWS value for the HHA group is lower (12.7), again pointing to the fact that the RN/LPN group are feeling overall more satisfied about their work than are the HHA group. The qualitative data suggest that the HHAs, relative to the other two practitioner groups, are clearly being affected the most by the restructuring changes, in terms of both emotional and physical stress. Many of the LPN problems are similar to those of the HHAs, although they have additional problems related to their limited scope of practice. This had been a major cause of stress for them. Finally, the RNs are clearly frustrated by management's constant need to change things in the Home Care program, as well as the lack of respect for their professional needs. Although the continual restructuring within the organization, as initiated by management, brings stress and frustration to all three practitioner groups, all respondents emphasized the fact that the clients and the relationships established with clients are the reason that they enjoy their work.

Policy Directions
By combining both the quantitative and qualitative data, suggested policy directions are listed below.

  • Opportunities to reinforce the importance and value of work done by home care practitioners should continue to be employed, particularly for HHAs.
  • Practitioners' overwhelming commitment to home care as a choice for health employment should be recognized/acknowledged and rewarded, particularly for HHAs
  • Practitioners' belief that special skills and expertise are required in home care work should be reinforced/acknowledged and rewarded
  • In keeping with society's documented lack of appreciation for women's caring work, particularly in the home, opportunities should be ceased for increasing public knowledge about the value of home care work.
  • Enhancement and support of practitioners' independence should be upheld, facilitated via improved communication with office staff.
  • Policies which support the current perceptions of RNs around the control they have over their work and their freedom to make decisions should continue to be supported.
  • Policies which enhance the control HHAs feel over work, in addition to the freedom they have to make decisions should be put in place.
  • A number of scheduling issues remain unresolved and should be addressed in the near future, particularly for HHAs.
  • Existing opportunities for assisting one another and interacting informally should be encouraged.
  • Orientation programs for new staff should be reviewed to enhance opportunities for staff to interact with one another.
  • Mechanisms need to be explored and implemented for increasing trust, respect and collaboration across practitioner groups.
  • Management should continue to be approachable.
  • Management needs to show more respect for the skill and knowledge of staff, and work together with them as a team.
  • The amount of documentation required in daily work should be reviewed for possible reductions.
  • More time should be given for patient visits in order to eleviate the time stress practitioners are feeling in their attempts to deliver quality care.
  • Opportunities for staff to inform planning policies and procedures, particularly when they are slated for change should be provided, as should informal interaction between office and field staff.
  • Scheduling needs to be examined for improved effectiveness.

Follow-up Action
In addition to drafting our own recommendations for women's health policy and programming, based on the research results, the university researchers have met separately with both the RAC and Home Care management. In these meetings, research results were presented without recommendations (in order not to bias the policy process). This was followed by an open discussion of the changes that have occurred since data collection, as some of the concerns expressed by respondents have partly been addressed due to the recent implementation of union contracts. Both management and the RAC were requested to identify specific recommendations for improving work life and the health and well-being of home care practitioners.

All project participants have not yet had the opportunity to see each others' suggestions for policy change. At a meeting to be held in May of this year, recommendations will be shared and collaborative decisions made regarding structural and policy changes to enhance the work life, and overall health of practitioners. In this way, members of the RAC and management, together with the university researchers, will be able to work towards collaborative decisions regarding structural and policy changes to enhance the work life, and overall health of practitioners. This combined group will retain control of the timing and content of the Communications Plan. In doing this, each partner will be best equipped to deal most appropriately with outside scrutiny of the findings and their implications for home care practice.

Communication Plan
At this point in time, there are six defined possibilities for the dissemination of research results to community members, policy makers and the public. They include the implementation of a Workshop/Presentation to the SDH Home Care Program, affiliated associations and unions, offering copies of the Final Report and/or Presentations to all provincial District Health Boards outside of Saskatoon, participation in local, provincial, regional and national (if held in Saskatchewan or Manitoba) meetings/conferences, and publication of academic research article(s) in appropriate journals. Dissemination of research results, and well as methods for dissemination will be decided cooperatively between the university researchers, Home Care management and the Research Advisory Committee.

Discussing the effects of reform from the subjective perspective of home health care practitioners provides a new viewpoint in the growing debate on health care restructuring. Research carried out elsewhere has concluded that home care practitioners are experiencing deteriorating working conditions as a result of changes in the labour process brought about by health reform (Glazer, 1990; Neysmith, 1997). Owing to poor working conditions being the major cause of practitioner burnout and turnover (Canadian Nurses Association and Canadian Hospital Association, 1990; Canadian Council on Homemaker Services, 1982; Martin Matthews, 1991), labour process change is found to be threatening the work life, overall quality of life, and ultimately, the health and well-being of these women. Undoubtedly, the labour process changes being experienced throughout the health care system has been a contributing factor in the human health care resource shortages - particularly registered nurses -- presently being acutely felt in Saskatchewan and across the country. This has serious repercussions for home care, given the rate of deinstitutionalization, increased brevity of hospital stays, a growing aging population, and the changing family structure which impacts the availability of informal caregivers. Consequently, this research not only has practical significance, specific to human health care resource availability, but also has implications for policy change, in that it provides an illustration of the impact of the changing welfare state on women's work and indirectly, on women's lives in society. Further, exploring the impacts of the restructuring strategies have shed light on women's caring work, women's health, and the place of women in society.

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