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The role of unregulated care providers in Canada-A scoping review
Abstract
Aims and objectives
This scoping review explored: (i) the role of unregulated care providers in the healthcare system; (ii) their potential role on interprofessional teams; (iii) the impact of unregulated care provider’s role on quality of care and patient safety; and (iv) education and employment standards.
Background
Unregulated care providers in Canada assist older adults with personal support and activities of daily living in a variety of care settings. As the care needs of an aging population become increasingly complex, the role of unregulated care providers in healthcare delivery has also evolved. Currently, many unregulated care providers are performing tasks previously performed by regulated health professionals, with potential implications for quality of care and patient safety. Information is fragmented on the role, education and employment standards of unregulated care providers.
Methods
A scoping review was conducted following the methods outlined by Arksey and O'Malley (International Journal of Social Research Methodology, 8, 2005, 19) and Levac, Colquhoun, and O'Brien (Implementation Science, 5, 2010, 69). An iterative search of published and grey literature was conducted from January 2000 to September 2016 using Medline, CINAHL, SCOPUS and Google. Inclusion and exclusion criteria were applied to identify relevant studies published in English.
Results
The search yielded 63 papers for review. Results highlight the evolving role of unregulated care providers, a lack of recognition and a lack of authority for unregulated care provider decision‐making in patient care. Unregulated care providers do not have a defined scope of practice. However, their role has evolved to include activities previously performed by regulated professionals. Variations in education and employment standards have implications for quality of care and patient safety.
Conclusions
Unregulated care providers are part of an important workforce in the long‐term care and community sectors in Canada. Their evolving role should be recognised and efforts made to leverage their experience on interprofessional teams and reduce variations in education and employment standards.
Implications for practice
This study highlights the evolving role of unregulated care providers in Canada and presents a set of recommendations for implementation at micro, meso, and macro policy levels.
... 218,294,313 We found 18 systematic reviews on this topic of which five were scoping reviews. 13,85,110,121,131,169,185,206,226,227,235,268,281,291,401,407,539,568 Most of these studies documented how the development of both advanced practice and assistant roles are improving access to primary healthcare, in both LMIEs and HIEs. 13,110,121,169,185,226,281,407,568 Most studies on regulation of APN scopes of practice were comparative studies from the USA, examining the impacts of restrictive state-based legislation. ...
... 13,85,110,121,131,169,185,206,226,227,235,268,281,291,401,407,539,568 Most of these studies documented how the development of both advanced practice and assistant roles are improving access to primary healthcare, in both LMIEs and HIEs. 13,110,121,169,185,226,281,407,568 Most studies on regulation of APN scopes of practice were comparative studies from the USA, examining the impacts of restrictive state-based legislation. Practice restrictions on nurses and midwives have been linked to adverse impacts on population healthcare utilization rates, costs and health outcomes. ...
... Several of these studies, from both HIEs and LMIEs highlighted safety concerns where task shifting or delegated practice involving the administration of medicines occurred without adequate supervision and often beyond what was authorized by law. 13,50,51,85,153,157,211 An international survey found that nurse prescribing occurs extensively in all six continents. 291 Ladd & Schober found the predominant model of nurse prescribing in HICs is at the advanced level role by post basic or post professional nurses and through less formal task-sharing arrangements, primarily in low-to middle-income countries. ...
Health systems worldwide face considerable challenges in recruiting, training, distributing and retaining a sufficiently skilled and competent workforce when and where it is needed. Brought into sharp focus by the COVID-19 pandemic, these challenges are compounded by the myriad of changes to health systems and workforces – increasing volume and privatization of health practitioner education; accelerating health workforce international mobility and cross-border service delivery; more team-based models of care; and the growing importance of unregulated health workers, such as in community support and traditional and complementary medicine (T&CM).
In response to these complex demands, some governments have reformed health practitioner regulation (HPR) systems to better serve the public interest. 8,47,118,119,128,189 Strengthening the way health practitioners are regulated can help to assure the safety and effectiveness of the health workforce and foster the flexibility and innovation needed to better meet population needs.
There is increasing recognition that HPR systems have an essential role to play in supporting health workforce availability, accessibility, acceptability, quality, and sustainability that is fundamental to achieving Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs). 541,541 HPR can optimize the capability of the existing health workforce and assist in better aligning health workforce investments with health system needs. 128,189,541 There are significant gaps in our knowledge about leading HPR policy and practice, such as which regulatory models, institutional governance and core regulatory functions work best in different contexts, particularly in low and lower-middle income economies (LMIEs).
This large-scale rapid review examines the diversity of regulatory principles, elements, and approaches to developing, implementing, and strengthening HPR. The aim is to identify the evidence base around HPR design and delivery, to help governments, regulators and other stakeholders better achieve health workforce and health system goals. The World Health Organization (WHO) commissioned this review to assist in the preparation of new global guidance on HPR.
... Internationally, nursing assistants are not considered health care professionals, although they provide direct patient care in health care facilities (Afzal et al., 2018;Blay & Roche, 2020;Lancaster et al., 2015;Munn et al., 2013). Nursing assistants' tasks are institutionalized as job descriptions, and their roles have been studied in terms of these tasks. ...
... listening to their feelings about their illness and learning about their home life (Afzal et al., 2018). However, nursing assistants may only perform tasks as directed and report to the nurse if they perceive that nurses do not expect them to perform the roles captured in this study. ...
Aims
To examine the gap between nursing assistants' desired roles and their perceptions of nurses' expectations, and the relationship between these perceptions and nursing assistants' nursing team participation.
Background
Nursing assistants' role perceptions may be related to their participation in nursing teams.
Methods
We performed a secondary analysis of questionnaire data from 1,316 nursing assistants in Japan.
Results
Participants rated their desired roles higher than their perceptions of nurses' expectations of them. Where perceptions of nurses' expectations were higher, higher desired role scores were associated with greater nursing team participation. Where perceptions of nurses' expectations were lower, the desired role score was not associated with team participation.
Conclusions
Nursing assistants perceive their roles as higher and inclusive of more duties than what nurses have expected of them. When perceptions of nurse expectations were high, they performed at a higher level. When perceptions of nurse expectations were low, they performed at a lower level, despite their desire to do more.
Implications for Nursing Management
It may be useful for nurses and nursing assistants to jointly reflect on and promote awareness of nursing assistants' functional roles in the ward. This would promote nursing assistant team participation and optimize their scope of practice.
... In LTC, care aides provide upward of 70-90% of the direct care [3] and therefore, hold significant potential for impacting residents' quality of life and EoL experience [4][5][6]. They are the largest unregulated workforce in health and social care globally in high-income countries, without any consistent educational standards, legally defined scope of practice, professional practice, professional conduct review process and regulatory or governing body [3,[7][8][9][10]. ...
... Care aides hold little autonomy in their role and are consistently reported as an understudied and underrepresented workforce in the international literature [2,[7][8][9][10][11][12]. As a workforce, care aides are 90% women, and in urban centres in high-income countries, they are prominently made up of migrant women [6,10,[12][13][14][15]. ...
Background:
Care aides provide up to 70-90% of the direct care for residents in long-term care (LTC) and thus hold great potential in improving residents' quality of life and end-of-life (EoL) care experiences. Although the scope and necessity of the care aide role is predicted to increase in the future, there is a lack of understanding around their perceptions and experiences of delivering EoL care in LTC settings. The aim of this study was to gain an understanding of the perspectives, experiences, and working conditions of care aides delivering end-of-life care in LTC in a rural setting, within a high-income country.
Methods:
Data were collected over ten months of fieldwork at one long-term care home in western Canada; semi-structured interviews (70 h) with 31 care aides; and observation (170 h). Data were analysed using Reflexive Thematic Analysis.
Results:
Two themes were identified: (i) the emotional toll that delivering this care takes on the care aids and; (ii) the need for healing and support among this workforce. Findings show that the vast majority of care aides reported feeling unprepared for the delivery of the complex care work required for good EoL care. Findings indicate that there are no adequate resources available for care aides' to support the mental and emotional aspects of their role in the delivery of EoL care in LTC. Participants shared unique stories of their own self-care traditions to support their grief, processing and emotional healing.
Conclusions:
To facilitate the health and well-being of this essential workforce internationally, care aides need to have appropriate training and preparation for the complex care work required for good EoL care. It is essential that mechanisms in LTC become mandatory to support care aides' mental health and emotional well-being in this role. Implications for practice highlight the need for greater care and attention played on the part of the educational settings during their selection and acceptance process to train care aides to ensure they have previous experience and societal awareness of what care in LTC settings entails, especially regarding EoL experiences.
... The global aging trend poses significant challenges and opportunities for healthcare systems worldwide. By 2050, the number of adults aged 65 and over is expected to reach an unprecedented 1.5 billion globally (Afzal et al., 2018). This demographic shift is not just a global phenomenon; in Canada, for instance, it is projected that by 2036, approximately 25% of the population will be aged 65 or older, with the most rapid increase seen in those aged 85 and above (Ng et al., 2020). ...
Rapidly growing populations of older adults rely heavily on formal long-term care services such as those provided in nursing homes. Nursing home staff are confronted with complex challenges. We explored how staff (N = 88), particularly care aides, interpreted challenges and responded to them by taking adaptive leadership roles, and engaging in technical and adaptive work in nursing homes. We conducted analysis of the ethnographic case studies. In long-term care settings, staff face complex challenges in improving resident care due to contextual barriers. These include demanding work conditions and inadequate resources. Additionally, top-down communications, despite being well-intentioned, often lead to misinterpretation and a lack of staff motivation. Nonetheless, we found that certain staff managed to overcome these contextual barriers and effectively execute change initiatives by assuming adaptive leadership roles. Formal leaders have a vital role in empowering staff, including care aides, and facilitating their adaptive leadership behaviors.
... 37 Up to 80% of home and community care is delivered by unregulated care workers in Canada (eg, personal support workers, community health workers). 38 Other health and social care providers in these settings include other paid (eg, nurses, occupational therapists, recreationists) and unpaid individuals (eg, family caregivers, volunteers). 37 Providers often work independently in personal environments like an older adult's home, which offers a unique insight into life circumstances (eg, relationships, culture) and helps build trusting therapeutic relationships. ...
Introduction
The mental health of ageing Canadians is a growing concern, particularly post-pandemic. Older adults face systemic ageism and mental health stigma as pervasive barriers to seeking needed mental health support, care and treatment within health and social care systems. These barriers are exacerbated when service providers focus on physical healthcare needs or lack the skills and confidence to talk about and/or address mental health during routine visits. This study aims to co-design and test an evidence-based approach to mental health conversations at the point-of-care in home and community settings with older adults, family and friend caregivers and health and social care providers that could facilitate help-seeking activities and care access.
Methods and analysis
A participatory mixed-methods study design will be applied, guided by a Working Group of experts-by-experience (n=30). Phase 1 engages ageing Canadians in four online workshops (n=60) and a national survey (n=1000) to adapt an evidence-based visual model of mental health for use with older adults in home and community care. Phase 2 includes six co-design workshops with community providers (n=90) in rural and urban sites across three Canadian provinces to co-design tools, resources and processes for enabling the use of the adapted model as a conversation guide. Phase 3 involves pilot and feasibility testing the co-designed conversations with older adult clients of providers from Phase 2 (n=180).
Ethics and dissemination
Phases 1 and 2 of this study have received ethics clearance at the University of Waterloo (ORE #44187), University of British Columbia (#H22-02306) and St. Francis Xavier University (#26075). While an overview of Phase 3 is included, details will rely on Phase 2 outcomes. Knowledge mobilisation activities will include peer-reviewed publications, conference presentations, webinars, newsletters, infographics and policy briefs. Interested audiences may include community organisations, policy and decision-makers and health and social care providers.
... UCPs are now considered an essential component of the healthcare team, especially in preventive healthcare services. 98 Their role has expanded over time to assume certain tasks that were traditionally provided by regulated healthcare professionals. 98 99 UCPs have the potential to deliver both accessible (in community settings or at home services) and acceptable (culturally and linguistically appropriate) preventive healthcare services that can improve patient outcomes. ...
Objective
We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented.
Design
We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance.
Data sources
We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022.
Eligibility criteria
We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs’ training was described.
Data extraction and synthesis
The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency.
Results
Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes.
Conclusion
This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations.
PROSPERO registration number
CRD42022369208.
... The review found diverse literature indicating increasing reliance on and expanding scopes of practice of registered and unregistered health associate professionals 7 -in both HICs [215,[251][252][253][254] and LMICs [255][256][257][258]. ...
Background
Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions.
Methods
We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework.
Findings
This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures–processes–outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners.
Conclusion
We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.
Baby boomers were at the forefront of profound social changes in sexual attitudes and many have expressed a desire to remain sexually active throughout their life course. The purpose of this survey study was to assess the perceived preparedness of Ontario’s long-term care (LTC) homes to meet the changing sexuality needs and expectations of LTC residents. We examined sexuality-related attitudes, including in the context of dementia, among 150 LTC administrators. Participants also completed a questionnaire assessing their experiences and perceptions regarding existing and anticipated supports, barriers, and priorities. Most participants demonstrated positive sexual attitudes; however, multiple challenges to meeting residents’ sexuality needs were noted, including assessing capacity to consent, limited privacy, staff training, conflicting attitudes, and a lack of adequate policy and guidelines. Challenges are broad and significant and considerable attention is required to meet the expectations of the next generation of LTC residents, including gender and sexual minority elders.
Rapidly growing populations of older adults rely heavily on formal long-term care services such as those provided in nursing homes. Nursing home staff are confronted with complex challenges. We explored how staff ( N = 88), particularly care aides, interpreted challenges and responded to them by taking adaptive leadership roles, and engaging in technical and adaptive work in nursing homes. We conducted analysis of the ethnographic case studies. In long-term care settings, staff face complex challenges in improving resident care due to contextual barriers. These include demanding work conditions and inadequate resources. Additionally, top-down communications, despite being well-intentioned, often lead to misinterpretation and a lack of staff motivation. Nonetheless, we found that certain staff managed to overcome these contextual barriers and effectively execute change initiatives by assuming adaptive leadership roles. Formal leaders have a vital role in empowering staff, including care aides, and facilitating their adaptive leadership behaviors.
One of the consequences of ineffective governments is that they leave space for unlicensed and unregulated informal providers without formal training to deliver a large proportion of health services. Without institutions that facilitate appropriate health care transactions, patients tend to navigate health care markets from one inappropriate provider to another, receiving sub-optimal care, before they find appropriate providers; all the while incurring personal transaction costs. But the top-down interventions to address this barrier to accessing care are hampered by weak governments, as informal providers are entrenched in communities. To explore the role that communities could play in limiting informal providers, we applied the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market are greater than within a firm. In a realist analysis of qualitative data from Nigeria, we found that community health committees sometimes seek to limit informal providers in a manner that is consistent with the transaction costs theory of the firm. The committees deal not through legal sanction but by subtle influence and persuasion in a slow and faltering process of institutional change, leveraging the authority and resources available within their community, and from governments and NGOs. First, they provide information to reduce the market share controlled by informal providers, and then regulation to keep informal providers at bay while making the formal provider more competitive. When these efforts are ineffective or insufficient, committees are faced with a " make-or-buy " decision. The " make " decision involves coordination to co-produce formal health services and facilitate referrals from informal to formal providers. What sometimes results is a quasi-firm—informal and formal providers are networked in a single but loose production unit. These findings suggest that efforts to limit informal providers should seek to, among other things, augment existing community responses.
Aims and objectives:
Heart failure (HF) is a complex syndrome in which abnormal heart function results in clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion. HF is common among long-term care (LTC) residents, and is associated with significant morbidity and acute care utilization. HF guidelines endorse standard therapies, yet LTC residents are less likely to receive recommended treatments. The objective of this paper is to understand the perceptions and potential role of unregulated care providers (UCPs) in contributing to better HF management among in LTC residents.
Design:
Focus group interviews.
Methods:
This qualitative study employed focus groups to explore perceptions from 24 UCPs in 3 Ontario, Canada LTC homes, about barriers to the optimal management of HF.
Results:
Three overarching concepts emerged characterizing UCPs' experiences in caring for residents with HF in LTC: 1) the complexity of providing HF care in a LTC setting, 2) striving for resident-centred decision making; and 3) UCP role enactment nested within an interprofessional team in LTC. These concepts reflect the complex interplay between individual UCPs and residents, and HF-related, socio-cultural and organizational factors that influence HF care processes in the LTC system.
Conclusions:
Optimizing the management of HF in LTC is contingent on greater engagement of UCPs as active partners in the interprofessional care team. Interventions to improve HF management in LTC must ensure that appropriate education is provided to all LTC staff, including UCPs, and in a manner that fosters greater and more effective interprofessional collaboration. This article is protected by copyright. All rights reserved.
Background: Diabetes care in the long-term care (LTC) setting is complicated by increased prevalence of comorbidities, age-related changes in medication tolerance, frailty and limited resources. Registered nurses (RNs), registered practical nurses (RPNs) and personal support workers (PSWs) are responsible for front line diabetes care; however, there is limited formal diabetes education in this setting.
Purpose: The current study aimed to assess the knowledge confidence and desire for additional diabetes education among nurses and PSWs in the LTC setting.
Methods:We studied 89 RNs, RPNs and PSWs (Mage=43.6, 94.3% female) in 2 LTC facilities in the Kitchener-Waterloo area who participated in an online survey assessing knowledge and confidence in 6 key areas of diabetes care (nutrition, insulin, oral medications, hypoglycemia, hyperglycemia and sick-day management). Interest in further diabetes education was also explored.
Results: Self-rated knowledge and confidence were generally moderate to high, ranging from 46% to 79% being moderately to very knowledgeable and from 61% to 74% being moderately to very confident. Knowledge and confidence was highest for nutrition and management of hypo- and hyperglycemia and lower for sick-day management, oral medications and insulin. There were significant differences between clinicians such that PSWs reported less knowledge and confidence than RNs and RPNs on most parameters. Among the whole sample, 85% wanted education about diabetes, and this rate did not vary by occupation. The most commonly reported areas for additional education concerning diabetes were for management of hypo- and hyperglycemia (30% to 31%) and insulin (31%).
Conclusion: Overall, the findings indicate moderate levels of self-rated knowledge across diabetes care areas; however, most clinicians feel there is room for more diabetes-care education, particularly regarding insulin and management of hypo- and hyperglycemia.setting.
Personal support workers (PSWS) provide hands-on assistance in a variety of long-term care and community settings. The question of whether psws should become regulated similar to other self-regulating health professions is a perennial concern in policy circles, especially because of the intimate nature of their work and the potential for abuse of clients and workers. This article explores a chain of policy decisions around psws in ontario culminating in the creation of a common educational standard for psw programs, titled the psw program standard. We argue that these policy developments may represent an alternative pathway to self-regulation of an essential workforce.
Copyright © 2015 Longwoods Publishing.
Background:
Health care discourse is replete with references to building partnerships between formal and informal care systems of support, particularly in community and home based health care. Little work has been done to examine the relationship between home health care workers and family caregivers of older clients. The purpose of this study is to examine home support workers' (HSWs) perceptions of their interactions with their clients' family members. The goal of this research is to improve client care and better connect formal and informal care systems.
Methods:
A qualitative study, using in-depth interviews was conducted with 118 home support workers in British Columbia, Canada. Framework analysis was used and a number of strategies were employed to ensure rigor including: memo writing and analysis meetings. Interviews were transcribed verbatim and sent to a professional transcription agency. Nvivo 10 software was used to manage the data.
Results:
Interactions between HSWs and family members are characterized in terms both of complementary labour (family members providing informational and instrumental support to HSWs), and disrupted labour (family members creating emotion work and additional instrumental work for HSWs). Two factors, the care plan and empathic awareness, further impact the relationship between HSWs and family caregivers.
Conclusions:
HSWs and family members work to support one another instrumentally and emotionally through interdependent interactions and empathic awareness. Organizational Care Plans that are too rigid or limited in their scope are key factors constraining interactions.
The recent commitment to investment in continuing care services demands a sound grasp of workforce utilization in continuing care facilities. This article examines workforce utilization in continuing care as a key component of effective service delivery. We used a case study design with three continuing care facilities in Alberta, Canada. Data were collected over one year through interviews, group discussions and observations. The data revealed workforce issues around staff mix, responsibilities and role clarity that negatively affect staff and residents. Using an ecological framework, we developed ‘upstream workforce strategies targeting barriers that can be influenced by the three facilities. Limited research exists on how regulated and unregulated healthcare providers are organized and deployed in different continuing care environments. In our sociological analysis of workforce utilization at three continuing care facilities, we illuminated the relations between staff and the contextual elements surrounding them.
Assistive personnel are the primary caregivers in long-term residential care (LTRC) in industrialized countries. Our goal is to describe and compare the work-related characteristics of assistive personnel in LTRC in five countries (Canada, Germany, Norway, U.K., and U.S), which may reflect how various societies view their responsibility to aging populations and the workers who care for them. OECD and national statistical databases are used to assess and compare the work context for assistive personnel. Analysis of the statistical data is informed by on-site observations in nursing homes with reputations for high quality, close readings of these organizations’ documents and records, and interviews with LTRC staff. Pay is generally low and the work required of assistive personnel is often demanding in all countries studied. While most assistive personnel have completed high school, formal certification requirements vary considerably. Professionalization is increasing in Norway with its high school major in eldercare, and in Germany, which has a 2-year certificate program. Financial compensation for assistive personnel in Norway and Canada is greater than in the other countries. Union membership for assistive personnel ranges from very high in Canada to negligible in the U.S. Some countries studied have training programs of only a few months duration to prepare assistive personnel for highly demanding jobs. However, in Germany and Norway, training aims to professionalize the work of assistive personnel for the benefit of workers, employers, and residents. There are high rates of part-time and/or casual work among assistive personnel, associated with reduced employment-related benefits, except in Germany and Norway, where these benefits are statutory for all. Data suggest that unionization is protective for assistive personnel, however union coverage data were not available for all countries. The need to improve the qualifications and training of assistive personnel was observed to be a national priority everywhere except in the U.S. Compensation is relatively low in the U.K., the U.S. and Germany, despite the important jobs performed by assistive personnel. Finally, to improve future research, statistical mapping of this critical component of the labour force in LTRC should be a greater priority across high-income countries.
Aims and objectives:
The purpose of the study was to examine nurses' and nursing assistants' perspectives of a palliative approach in a variety of nursing care settings that do not specialise in palliative care.
Background:
Ageing populations worldwide are drawing increasing attention to palliative care. In particular, people with advancing chronic life-limiting conditions often have unmet needs and may die in acute medical, residential care and home health settings without access to palliative care. A palliative approach offers an upstream orientation to adopt palliative care principles to meet the needs of people with life-limiting chronic conditions, adapt palliative care knowledge to other chronic illness conditions, and integrate and contextualise this knowledge within the healthcare system (Sawatzky et al. 2016).
Design:
A qualitative study using the method of interpretive description carried out by a nursing research-practice collaborative, Initiative for a Palliative Approach: Evidence and Leadership (iPANEL).
Methods:
Twenty-five nurses and five nursing assistants from across British Columbia, Canada participated in interviews and focus groups. Thematic analysis was used to analyse the data.
Results:
The overarching theme was that of participants close to a palliative approach in that they cared for people who would benefit from a palliative approach, they were committed to providing better end-of-life care, and they understood palliative approach as an extension of specialised palliative care services. Participants varied in their self-reported capacity to integrate a palliative approach, as they were influenced by role clarity, interprofessional collaboration and knowledge.
Conclusions:
Integration of a palliative approach requires a conceptual shift and can be enhanced through interpersonal relationships and communication, role clarification and education.
Relevance to clinical practice:
Nurses care for people with advancing chronic life-limiting conditions in a variety of settings who would benefit from a palliative approach.
Purpose of the study:
Health care aides (HCAs) provide most direct care in long-term care (LTC) and home and community care (HCC) settings but are understudied. We validate three key work attitude measures to better understand HCAs' work experiences: work engagement (WEng), psychological empowerment (PE), and organizational citizenship behavior (OCB-O).
Design and methods:
Data were collected from 306 HCAs working in LTC and HCC, using survey items for WEng, PE, and OCB-O adapted for HCAs. Psychometric evaluation involved confirmatory factor analysis (CFA). Predictive validity (correlations with measures of job satisfaction and turnover intention) and internal consistency reliability were examined.
Results:
CFA supported a one-factor model of WEng, a four-factor model of PE, and a one-factor model of OCB-O. HCC workers scored higher than LTC workers on Self-determination (PE) and lower on Impact, demonstrating concurrent validity. WEng and PE correlated with worker outcomes (job satisfaction, turnover intention, and OCB-O), demonstrating predictive validity. Reliability and validity analyses indicated sound psychometric properties overall.
Implications:
Study results support psychometric properties of measures of WEng, PE, and OCB-O for HCAs. Knowledge of HCAs' work attitudes and behaviors can inform recruitment programs, incentive systems, and retention/training strategies for this vital group of care providers.
