Massive use of home care workers in New York City began in 1975 as a response to the needs of the growing population of chronically ill and frail elderly and as an alternative to more expensive care in nursing homes, many of which had long lists of such people waiting for admission. Additionally, it allowed for more personal assistance at a time when nursing homes were perceived as impersonal and uncaring. It also provided entry-level employment to unskilled individuals, mostly women, many of whom were recipients of welfare.
Initially, these workers were employees of the City’s Department of Human Resources but, in 1980, this service was “privatized” and they were recruited, trained and employed by non-profit, community-based social agencies and traditional health care organizations such as hospitals which had to be certified by the State of New York as providers of home care services. The workers are categorized as home makers, personal care workers, health aides, home care attendants and housekeepers, depending on their levels of skills and the kinds of services they provide. Which of these services a particular client uses depends on an evaluation of that person’s health status and needs which is conducted by a licensed health professional, such as a physician, nurse or social worker.
The Home Care Workforce
Home care workers in New York City present a conglomerate of characteristics that provide a unique profile. A recent survey by Donovan, Kurzman and Rotman (1993) found that 94% are female with an average age of 45. About 56% were not born within the continental US and about 51% never completed high school. Only 32% were identified as married, 33% were separated or divorced and 26% were single, while 86% have children, 44% with children under 18 years of age. According to the survey, 63% live with their children and 26% live with a spouse.
The median family income for this group in 1991 was $12,000 per year. In 81% of these families, the home care worker was the primary breadwinner. In 1996, the annual salary of full-time home care workers’ ranged between $16,000 and $28,000; part-time workers earned less.
Such low earnings represent significant economic hardship to the survey respondents: 56% said they could not afford adequate housing; 61% reported being unable to afford furniture or household equipment; 35% said they lacked funds to purchase enough food for their families; and 36% were ineligible for Medicare and unable to afford needed medical care for themselves and their families. As a group, their financial status will inevitably worsen as cuts in government funding force curtailment of the amount and intensity of home care services being provided.
Home Care Services
The services provided by home care workers depend on the needs of the clients being served. Those with greater disability require assistance with the “basic activities of daily living”, which consist of bathing, dressing, toileting, transferring (moving in or out of bed and chairs) and feeding. Those with higher levels of functional capacity need help with the “instrumental activities of daily living”, which comprise housekeeping (cleaning, bed making, dishwashing, and so forth), shopping, food preparation and serving, laundry, using public or private transportation and managing finances. Home care workers may give injections, dispense medications and provide such treatments as passive exercise and massage as prescribed by the client’s physician. A most appreciated service is companionship and assisting the client to participate in recreational activities.
The difficulty of the home care worker’s job is directly related to the home environment and, in addition to physical status, the behaviour of the client and any family members who may be on the scene. Many clients (and the workers as well) live in poor neighbourhoods where crime rates are high, public transportation often marginal and public services substandard. Many live in deteriorated housing with no or non-functioning elevators, dark and dirty stairwells and hallways, lack of heat and hot water, dilapidated plumbing and poorly functioning household appliances. Commuting to and from the client’s home may be arduous and time-consuming.
Many of the clients may have very low levels of functional capacity and require assistance at every turn. Clients’ muscle weakness and lack of coordination, loss of vision and hearing and incontinence of bladder and/or bowels add to the burden of care. Mental difficulties such as senile dementia, anxiety and depression and difficulties in communication because of memory loss and language barriers may also magnify the difficulty. Finally, abusive and demanding behaviour on the part of both clients and their family members may sometimes escalate into acts of violence.
Home Care Work Hazards
Work hazards commonly encountered by home care workers include:
- working alone without assistance
- lack of education and training and remote, if any, supervision
- working in substandard housing in high risk neighbourhoods
- back pain and musculoskeletal injuries incurred while lifting, transferring and supporting clients who may be heavy, weak and poorly coordinated
- violence in the home and in the neighbourhood
- infectious diseases (the health care worker may not have been fully informed of the client’s medical status; recommended gloves, gowns and masks may not be available)
- household chemicals and cleaning supplies (often incorrectly labelled and stored)
- sexual harassment
- work stress.
Stress is probably the most ubiquitous hazard. It is compounded by the fact the worker is usually alone in the home with the client with no simple way to report trouble or summon assistance. Stress is being exacerbated as cost-containment efforts are reducing the hours of service allowed for individual clients.
A number of strategies have been suggested to promote occupational health and safety for home care workers and to improve their lot. They include:
- development and promulgation of standards of practice for home care accompanied by improved education and training so that home care workers can meet them
- education and training in the recognition and avoidance of chemical and other hazards in the home
- training in lifting, carrying and giving physical support to clients as needed in the course of providing services
- preliminary needs assessment of clients supplemented by inspections of their homes so that potential hazards can be identified and eliminated or controlled and needed materials and equipment can be procured
- periodic meetings with supervisors and other home care workers to compare notes and receive instruction. Videotapes may be developed and used for skills demonstrations. The meetings may be supplemented by telephone networks through which workers may communicate with each other to exchange information and alleviate any feelings of isolation.
- establishment of a health and safety committee within each agency to review work-related accidents and problems and develop appropriate preventive interventions
- establishment of an Employee Assistance Programme (EAP) through which the workers may receive counselling for their own psychosocial problems both on- and off-the-job.
Educational and training sessions should be conducted during working hours at a place and time convenient for the workers. They should be supplemented by the distribution of instructional materials designed for the low educational levels of most of the workers and, when necessary, they should be multilingual.
Case study: Violence in health care work
A psychotic patient in his thirties had been forcibly committed to a large psychiatric hospital in the suburbs of a city. He was not regarded as having violent tendencies. After a few days he escaped from his secure ward. The hospital authorities were informed by his relatives that he had returned to his own house. As was routine an escort of three male psychiatric nurses set out with an ambulance to bring the patient back. En route they stopped to pick up a police escort as was routine in such cases. When they arrived at the house, the police escort waited outside, in case a violent incident developed. The three nurses entered and were informed by the relatives that the patient was sitting in an upstairs bedroom. When approached and quietly invited to come back to hospital for treatment the patient produced a kitchen knife which he had hidden. One nurse was stabbed in the chest, another a number of times in the back and the third in the hand and the arm. All three nurses survived but had to spend time in hospital. When the police escort entered the bedroom the patient quietly surrendered the knife.