Why I Became a Home Support Worker: Recruitment in the Home Health Sector

Abstract

Home care is considered an essential pillar of the health care systems in many industrialized countries. With an increased demand for home health workers, there has been growing interest in examining recruitment and retention of these workers. With a focus on recruitment of home support workers, in this study we draw on data from interviews with 57 home support workers in three Canadian provinces, to examine the factors that attract individuals to employment in this sector. These factors include: previous experience, financial considerations, and enjoying working with people. Understanding these overlapping factors can aide in the recruitment of future workers.

Keywords:

• framework analysis
• health human resources
• home support
• recruitment

INTRODUCTION

Home health care, often referred to as home care, is considered an essential pillar of the health care systems in many industrialized countries (Broese van Groenou, Glaser, Tomassini, & Jacobs, 2006; Cangiano, Shutes, Spencer, & Leeson, 2009, Carrière, 2006; McClimont, Grove & Berry, 2004; Stone & Dawson, 2008; Tarricone & Tsouros, 2008). In Canada, where our study was conducted, home care costs have doubled over the past decade, from $1.6 billion to $3.4 billion (Canadian Institute for Health Information, 2007). An 80% increase in home care expenditures is expected by 2026 (Coyte & McKeever, 2001). Health human resource projections suggest that Canada will need to double the number of home care workers in order to meet demands (Havens, 2003). Throughout Europe, “all countries are similarly facing a set of common demographic, social, technological, epidemiological and political pressures that influence both the demand and supply of home care” (Tarricone & Tsouros, p. 3). Many OECD (Organization for Economic Co-operation and Development) countries have identified future shortages in the long-term care sector (Fujisawa & Colombo, 2009; Yamada & Sekiya, 2003), with the United States projecting 1 million new jobs between 2004 and 2014 (Stone & Dawson), and the United Kingdom forecasting 1.1 million new jobs by 2025 (Cangiano et al., 2009).

Home care involves a wide variety of workers with different levels of training and qualifications. They include nurses, care managers, social workers, physiotherapists, occupational therapists, and home support workers. Most home care workers are employed in home support, and are often unregulated workers who provide non-professional services in the form of personal assistance with daily activities such as bathing, dressing, grooming, and light household tasks. They are variously known across Canada as home support workers, personal support workers, community health workers, community health care aides, home helpers, and homemakers (Martin-Matthews, 2007; Sims-Gould & Martin-Matthews, 2010). In the United States they are often referred to as direct care workers (Stone, 2004 ) and in Europe they are known as domiciliary workers (Doyle & Timonen, 2007).

Within the home health care sector, the recruitment, training, and retention of these personnel are considered to be the “number one challenge” (Anderson, 1999; Canadian Home Care Association, 2008, p. xix; Fujisawa & Colombo, 2009; Hussein & Manthorpe, 2005). In Canada, labor shortages are “increasingly dire” (Côté & Fox, 2007, p. 11) and, while shortages already exist, they are forecast to rise dramatically (Burke & Ng, 2006; Lilly, 2008; Keefe, Martin-Matthews, & Légaré, 2009a). While there is research that examines recruitment and retention of home health workers (e.g., Ayalon, 2010; Benjamin, Matthias, Kietzman, & Furman, 2008; Denton, Zeytinoglu, Davies, & Hunter, 2006; Kemper et al., 2008; Mittal, Rosen, & Leana, 2009; Morris, 2009; Nugent, 2007; Stone & Dawson, 2008, Zeytinoglu, Denton, Davies, & Plenderleith, 2009), the bulk of this work focuses on the retention and turnover of workers (a notable exception being the work of Yamada, 2002). While Yamada notes that home care representatives report being more acutely concerned with recruitment, rather than retention, less is known about what initially attracts workers to the home health care sector.

A study focused on home care (Havens, 2003) found that home support workers had worked with their current employer for an average of 6 to 7 years, and worked in the home care profession for 8 to 9 years. This same study notes higher than expected workplace stability but also underscores “that there are not a large number of new entrants into the sector” (Havens, p. 16). It is also important to recognize that the number of new entrants to the sector is limited on account of gender; the feminization of home support substantially narrows the pool of recruits (Havens; Lilly, 2008; Smith & Baughman, 2007). A number of recent studies have also noted poor pay, lack of benefits, inconsistent work hours, and limited opportunities for advancement as key issues with resultant negative effects on the recruitment and retention of home care workers (Denton, Zeytinoglu, Kusch, & Davies, 2007; Ejaz, Noelker, Menne, & Bagaka, 2008; Feldman, 1993; Mittal et al., 2009; Morris, 2009; Nugent, 2007; Zeytinoglu & Denton, 2005).

Although these studies have predominantly focused on retention and staff turnover in the sector, research also demonstrates that home care workers do for the most part enjoy their work (Canadian Healthcare Association, 2009; Sims-Gould & Martin-Matthews, 2010) and their clients (Denton, Zeytinoglu, Davies, & Lian, 2002; Byrne, Sims-Gould, Martin-Matthews, Frazee, & Dorsey, 2009; Sims-Gould & Martin-Matthews) and report high to moderate levels of job satisfaction (Decker, Harris-Kojetin, Bercovitz, 2009; Delp, 2006). In most developed countries, the reasons why home support workers are “leaving in droves” are well-documented and generally agreed upon (Denton et al., 2002; Howes, 2008; Hussein & Manthorpe, 2005); however, the reasons for why people choose to join this profession are less understood in current research. Understanding what motivates an individual to work in this sector, and developing strategies to target the appropriate personnel has implications not only for recruitment, retention, and worker satisfaction (Zeytinoglu & Denton, 2005), but likely also for the quality of client care (Dawson & Surpin, 2001).

There are a number of theories of motivation that delineate between the intrinsic and extrinsic factors which motivate an individual to join a particular profession (see, for example, Herzberg, 1987; Ryan & Deci, 2000). Extrinsic motivational factors are those which are “activated from outside the person concerned” (Frey, 1997, p. 429), and can include: wages and benefits, job security, vacation, supervision, opportunities for promotion, and workplace policies (Herzberg). Conversely, intrinsic motivation is defined as the “motivation to engage in work primarily for its own sake, because the work itself is interesting, engaging or in some way satisfying” (Amabile, Hill, Hennessey & Tighe, 1994, p. 950). Examples of intrinsic factors include: personal autonomy and responsibility on the job, opportunities for growth and skills development, and having an opportunity to make a difference (Herzberg). This article examines the factors, both intrinsic and extrinsic, that attract individuals to employment as a home support worker.

DESIGN AND METHODS

This article is based on an analysis of data collected as part of a larger mixed methods study (Martin-Matthews & Sims-Gould, 2008; Sims-Gould & Martin-Matthews, 2010) aimed at understanding key issues in the delivery and receipt of home support services from the perspective of home support workers, elderly clients, and family members. In this article we report data from the home support worker interviews.

Recruitment

Our study was conducted in three Canadian provinces: British Columbia, Ontario, and Nova Scotia. Research participants were recruited at three sites: the Lower Mainland of British Columbia, the city of Guelph, Ontario, and the Halifax, Nova Scotia region. Upon receipt of ethical approval from the University of British Columbia, the University of Guelph, and Mount Saint Vincent University, data were collected from March 2007 to May 2008. Recruitment was limited to English-speaking home support workers, employed by home care agencies, who provide primarily “non-professional” services (e.g., non-medical services) to clients over the age of 65. For this analysis, a subsample of participants who had been working in the profession for 5 years or less (N = 57) was selected from the larger study sample (N = 186). This subsample of participants was purposefully selected with the expectation that, being closer in time to the experience, they would be able to speak more precisely about what initially attracted them to the field. The 5-year cut-off was also selected as it precedes the 8-year mark, which is the average tenure for a Canadian home support worker (Havens, 2003).

In British Columbia, 118 workers were interviewed; 29 of these workers were employed for 5 years or less. Two methods of recruitment were used. First, three home care agencies were purposively selected to represent the spectrum of contracted agencies (two private and one not-for-profit) serving a mixture of both urban and rural clients. However, this method resulted in very low response rates, 3–11% depending on the agency (see Sims-Gould & Martin-Matthews, 2010). As a result of our low agency response rates, a second recruitment strategy was used. Participants were randomly selected from a list of workers represented by the British Columbia Government Employees Union (BCGEU local 403). Workers were contacted by the union, provided with a brief description of the study, and asked for their consent to be contacted by our team. The response rate through the union recruitment proved to be better at 52%, consistent with other studies involving home support workers (Sims-Gould & Martin-Matthews; Stone & Dawson, 2008).

In both Nova Scotia and Ontario, the agency recruitment strategy was used. In Ontario three agencies were purposefully selected (one private and two not-for-profit). Twenty-eight workers were interviewed in Ontario; 13 of these workers were employed for 5 years or less. In Nova Scotia, five agencies (one private and four not-for-profit) were purposively selected. Forty workers were interviewed in Nova Scotia, with 15 of these workers employed for 5 years or less.

Data Collection

Interviews were scheduled with interested home support workers at a time and location convenient for them. Data were obtained through face to face, in-depth, semi-structured interviews (see Table 1 for sample questions). Several questions were modified, added, or deleted based on feedback and results from the BC pilot study (Martin-Matthews & Sims-Gould, 2008). The interviews, approximately 60 to 90 minutes in length, were audio recorded and transcribed verbatim by a transcription agency. Data were saved using ID numbers and pseudonyms to ensure anonymity, and were uploaded into the qualitative software database, NVivo 8. Descriptive and categorical data were analyzed using SPSS version 17.0.

TABLE 1 Sample Interview Questions

Sample questions from the Interview Guide used in all three provinces(BC, ON, & NS):

What attracted you to becoming a home support worker?

Do you have other demands outside of paid work?

What training program have you completed for your work as a home support worker?

Do you feel you are prepared for the work responsibilities you are currently assigned in clients' homes?

What do you think are the most pressing issues facing HSWs?

What do you like best/least about working with elderly clients?

As a home support worker do you feel that you are part of a team with other health care workers?

Does your work give you a feeling of accomplishment?

Additional questions asked in the Nova Scotia interviews:

Are you looking for or considering a new career?

What would you require to continue working in this profession for the next 5–10 years?

Sample

As expected, the majority of the 57 workers selected for this analysis were female (96%; see Table 2), ranging in age from 22 to 70 years of age (M = 44, SD = 12 years). Reflecting the growing international trend linking immigrant labor to home support work (Stacey, 2005), nearly half (47%) of these HSWs were born outside Canada. The majority of migrant workers in our sample resides in British Columbia and was born in Asia. The proportion of migrant workers in British Columbia is not surprising, as most of these interviews were held in the Lower Mainland, one of the top three areas of settlement for newcomers to Canada (Schellenberg, 2001). Education ranged from less than high school (7%) to completed post secondary (51%). Of the 29 workers in this subsample who had completed post-secondary education, 12 had university degrees from other countries and three were registered nurses from other countries.

TABLE 2 Sample Characteristics (N = 57)

	Total (57)		BC (29)		ON (13)		NS (15)
	Average	Range	Average	Range	Average	Range	Average	Range
Age	44 years	22–70 years	44 years	27–59 years	45 years	22–70 years	43 years	22–60 years
Years as HSW	2 years	0–5 years	1.7 years	0–5 years	2.8 years	0–5 years	2.3 years	0–5 years
Hourly rate of pay	$15.48	$10.00–$19.87	$17.34	$10.42–$19.87	$13.09	$10.50–$14.70	$13.98	$10.00–$15.00
Number of clients per day	4	1–8	4	2–8	5	2–8	5	3–6
	Number	Percent of total	Number	Percent in prov.	Number	Percent in prov.	Number	Percent in prov.
Gender
Female	55	96.49	27	93.10	13	100	15	100
Education
Less than high school	4	7.02	2	6.90	2	15.38	0	0
High school	19	33.33	5	17.24	7	53.86	7	46.67
Some post secondary	5	8.77	3	10.34	2	15.38	0	0
Completed post secondary	29	50.88	19	65.52	2	15.38	8	53.33
Place of birth
Canada	30	52.63	6	20.69	11	84.61	13	86.67
Asia*	21	36.84	21	72.41	0	0	0	0
Other**	6	10.53	2	6.90	2	15.39	2	13.33
Union status
Unionized	38	66.67	29	100	1	7.69	8	53.33
Note. *The category “Asia” includes individuals in our sample from China, including Hong Kong; Fiji; India; Iran; and the Philippines. For a more in-depth ethno-cultural analysis of some of the Home Support Workers in our study, see Martin-Matthews, Sims-Gould, & Naslund (forthcoming).
**“Other” places of birth include the Czech Republic, Hungary, the Netherlands, the United States, and Zimbabwe.

Workers were employed full-time (23%), part-time (30%), or casual (46%). The majority described their work schedules as irregular, split-shifts, or on-call within specified “windows of availability.” Rate of pay ranged from $10.00/hour to $19.87/hour (M = 15.48, SD = 2.59), with the highest hourly wages in British Columbia. Workers had an average caseload of 4 clients per day, although this ranged from a minimum of 1 to a maximum of 8 clients per day.

Analysis

Transcripts were reviewed using a framework analysis (Ritchie & Spencer, 1994; Pope, Ziebland, & Mays, 2000) including five stages: familiarization; identifying a thematic framework; indexing; charting; mapping and interpretation. Initially, all transcripts were read independently by three members of the research team in their entirety to get a sense of the interviews as a whole. Through a series of 6 meetings with the three researchers, a preliminary thematic framework was identified based on key issues, concepts, and themes derived from the original objectives of the study and experiences that were found to be recurring in the data. Next, the thematic framework was applied to all of the data and rearranged into charts that grouped similar excerpts together and provided summaries of each key concept. Comparisons were made between and within cases (constant comparison) until the data were sorted into the appropriate thematic content. The authors discussed cases that did not clearly “fit” the thematic framework. Final categories were developed with a consideration of relationships among themes, the original research objectives, as well as other themes that surfaced during the analysis process.

Throughout the analysis process, team members also compiled a list of transcripts that would lend well to the development of individual worker “vignettes” (Ely, Vinz, Anzul, & Downing, 1997; Schoenberg & Ravdal, 2000; Sims-Gould & Martin-Matthews, 2008). By cross-referencing this list of transcripts with the final three key themes, six workers (two from each province) were identified for inclusion in the vignettes. The transcripts for these workers were re-read and vignettes were built from them; two worker vignettes are included in this article to illustrate the overlapping themes in our data.

Strategies for establishing rigor in this study included engaging in peer debriefing with the research team (via team meetings and smaller focused discussion about the developing themes), memo writing throughout the analysis process, and a recording of decisions made throughout data collection and analysis (i.e., an audit trail; Bradbury-Jones, 2007; Cutcliffe & McKenna, 2004; Koch, 2006). In addition, members of our team participated in two Pan-Canadian consultations regarding the recruitment and retention of home support workers. The discussions and reflections of home support managers, policy makers, and health care advocates participating in these consultations reinforced our findings and influenced our thinking around this analysis.

RESULTS

Based on the framework analysis, we identified three key themes that attract workers to home support: caring and sharing; experience and exposure; and finances and flexibility. Although each theme was clearly identified by participants, in many instances the themes overlapped and intersected with one another. Figure 1 illustrates the themes, highlighting the intersections. The vignettes assist in animating each theme and illustrate the interconnected nature of these themes.

FIGURE 1 Factors Influencing the Recruitment of Home Support Workers.

Caring and Sharing

Caring and sharing merged as a dominant theme in our data. Workers across all three provinces indicated that their “sociable” personalities and desire to work with people was a motivating factor in selecting their profession. For example, in response to the question about what attracted them to the profession of home support, three workers stated:

Well, my love for people and wanting to help them (Carly, BC, 1 year as HSW, Canadian born).

When I come here [to Canada] I really love the elderly. Even back home … I love my neighbors, I like them, like the older people. I like to talk to them … I just love the elderly (Frida, BC, 5 years as HSW, born in the Philippines).

I worked with elderly clients, the elderly population. I've always did for a very long time … Being able to help them and being able to do things for them, you know, it's nice (Melinda, BC, 6 months as HSW, born in Fiji).

While some workers entered the sector as a first career, other workers had found previous enjoyment in other highly interpersonal fields, such as hairdressing, esthetics, and personal fitness. These workers had previously been in a caring and sharing profession.

Well, I always liked older people. I always worked with the public. I'm a hairdresser. I like taking care of people (Leah, NS, 3 years as HSW, Canadian born).

Conversely, some workers had previously worked in less “social” careers, and were specifically seeking a second career that was more suitable to their personalities and needs. Amber, for example, was seeking a transition out of the corporate environment that she had worked in for more than a decade.

I had a life-altering experience where I lost … a career … after 14 years. It was devastating and … I had to make … changes in my life. I wasn't sure at middle-age … what route I was going to go. But I knew … I had climbed a mountain and all of a sudden I was at back at the bottom and that was hard for me. And so I didn't want to be in that same environment, in the corporate environment, and so through my own personal experience in my family and—I saw the need for the caregiving. (Amber, BC, 3 years as HSW, Canadian born)

Amber's case begins to illustrate the interconnected nature of the themes in that her desire for a career of “sharing and caring,” coupled with previous experience in her own family caregiving situation, led her to seek out a career as a home support worker. The following section further elaborates on the theme of experience and exposure as it relates to recruitment.

Experience and Exposure

Experience and exposure in helping a relative or friend was a strong factor in many workers' decisions to choose home support as a profession. Previous experience or exposure meant that prior to entering the field of home support, workers had been involved in the provision of formal and/or family care. Some workers provided unpaid care for family members, such as Darlene, who had cared for a family member.

Well, I took care of my brother for about a year. He was terminally ill and I guess … I'm very compassionate to people … I'm sympathetic and compassionate towards them when they're in a lot of pain and they really need help with basics. (Darlene, BC, less than 1 year as HSW, Canadian born)

Other workers provided care for friends and acquaintances. Sidney, for example, was motivated to join this profession after spending time with her boyfriend's grandmother, who suffered from Alzheimer's disease. Sidney recalls: “if you had asked me 5 years ago I would have said, ‘you’re crazy.’ I would never do this, but she just made me see a whole ‘other side.’”

Gloria, on the other hand, was inspired to enter this profession by seeing a home support worker providing care to an elderly person in need:

I used to live with this lady, her name was Francesca and she passed away before her 91st birthday. And there used to be a lady coming in, Milla, and I don't know, I just liked what she was doing. She came in and first it was once a week and then twice a week and then at the end four times a week. And I just liked, you know. (Gloria, NS, 2.5 years as HSW, born in Hungary)

While some workers cited experiences specific to seniors, others cited experiences with individuals of all ages. For example, Shelby's exposure to a helping career began at the age of 15, when she worked at a camp for youth with disabilities. Throughout her childhood Shelby's mother also operated a live-in care facility for adults with disabilities. This early exposure to community-based health care inspired Shelby to volunteer in the facility, and to later become a home support worker. Due to her extensive exposure to this type of work at a young age, Shelby reports feeling extremely comfortable and confident in the work she does. In her words, “I love [working with elderly clients]. I absolutely love it.” Although Shelby reports enjoying all aspects of her work, she particularly appreciates home care because it allows her to cultivate interpersonal relationships. She explains:

I absolutely love the personal rapport. That's why I refuse to work in a nursing home because everything is just so busy and run, run, run, run. When I go into the home, I can sit and talk to them because they don't have a lot of contact with the outside world. They like to sit and talk. They … love to reminisce. They just love someone to sit and talk and listen to them. That's what I love the most out of it. (Shelby, ON, 3 years as HSW, Canadian born)

There were also several examples where workers had previous exposure to this sector via relatives working in caring professions. Mallory, a home support worker in Nova Scotia, for example, is the daughter of a home support worker and granddaughter of a nurse and she states that it's “in the blood.”

Finally, for some of the foreign-born workers in our sample, previous experience and exposure was gained by working as health care professionals in their country of origin. Nina, for example, reports:

I like this job. I like [to] work with seniors, like, touch the seniors' hands … because I was a nurse before… . I always [was a] nurse and now [I am] a home support worker. I like this. I know how. (Nina, BC, 2 years as HSW, born in China)

Similarly, Grace formerly worked as a nurse in the Philippines. She explains:

I know that I cannot be a nurse here … so I just found ways how to be a health worker… . When I read this [about] home support workers like that, I apply. I faxed my resume like that. They called me in 2 days… . So they called me for an interview, then I got the job. I said “Oh, thank you,” because it's long classes for me to wait to be a nurse here. (Grace, BC, 1.5 years as HSW, born in the Philippines)

For Grace, a single mother, the lag-time to become an accredited nurse in Canada would have been too lengthy and costly. In order to work sooner, rather than later, she opted for work in home support instead.

Finances and Flexibility

Finances and flexibility played a significant role in attracting workers to the home support sector. In addition to discussing direct financial remuneration such as wages, workers noted other key considerations including the following: affordable and timely training; training bursaries; and the provision of benefits. As well, the flexibility afforded due to the nature of the scheduling, was discussed as an attractor to the position. For example, while Nicole indicated she was attracted to the profession because of the “money,” Charlotte, who has school-aged children, valued the scheduling options identified as convenient for her family life:

I love my job and I like that you're not in the same job 9:00 to 5:00. You have the flexibility to move around and you know when you're casual, well, my hours are between 8:00 and 2:30, so I have my kids after school for 1 more year and then I'll work more … And it also allows me time here with my husband too, to ensure that I get him to appointments and stuff. (Charlotte, BC, 1.5 years as HSW, Canadian-born)

In some cases, it was the balance of financial considerations and flexibility that attracted workers to the profession. For instance, Roxanne explained:

I like the flexibility that I can take on clients or not, you know, so on one side of it, it's financially stressful if I don't have enough work. But on the other side of it, I can cut back my caseload if it gets too busy and I've taken on too much. (Roxanne, ON, 5 years as HSW, Canadian-born)

Similarly, Lewis noted:

I heard it from my friends saying that firstly, the time is flexible, right. I'm semi-retired so I want some flexible. I only work … 3 days a—3 days a week, right. Also it's a union job that pays not bad, right… . I work in a second [job as] a property manager's only—only 10 bucks an hour, right. But this is more … It's good. Not bad. (Lewis, BC, 1 year as HSW, born in Hong Kong)

The breadth of the financial considerations is reflective of the diverse contexts in which the home support workers in our study are trained, employed, unionized, and remunerated (see Table 2). Unlike the other themes where there was little provincial variation in the findings, there were differences with respect to financial considerations across the provinces. In British Columbia, wages and benefits were major attractors to the field of home support. This is not surprising given that the wages in BC for those workers who are unionized is higher than in the other provinces. In addition to currently working in British Columbia, all of the workers who discussed wages and benefits as being attractors to the profession, were foreign born. When asked what attracted her to the profession, one immigrant home support worker replied: “Salary to be frank with you, right” (Cassandra, BC, 1.5 years as HSW, born in the Philippines). Similarly, Macy, a recent immigrant, stated: “First of all that it's a good job with good pay” (Macy, BC, 1 year as HSW, born in China). Monica, also a recent immigrant from China, notes that what first attracted her to the position was financial considerations, she said: “First I want to say salary… . I don't want to lie [and] say, ‘Oh, I like to help other people.’ That's the second” (Monica, BC, 2.5 years as HSW).

In contrast, in Ontario and Nova Scotia, wages and benefits were considered to be the main challenges affecting home support workers.

We're not getting paid enough. And the time, how they're trying to squeeze it in so that we're always being gypped, you know, we're always being shortchanged. And that we're just not … I feel that we're just not respected you know. We're so disposable, you know, like “Okay, well, she'll quit. We'll hire another girl tomorrow.” (Winona, ON, age 54, 5 years as HSW, Canadian born)

For these workers, other aspects of the job proved to be attractors, such as flexible hours and the opportunities for training: “[pay] is an issue for me, but it's—where my hours are flexible, it's of like, give and take. So it's something I kind of have to deal with” (Eileen, NS, 3 years as HSW, Canadian born). Marlene, a home support worker for 2 years, explains how an offer of paid schooling “really got her attention”:

I was looking for a job and I kept seeing this in the paper and the way that they had it described, it—I thought, “I could do that.” So when I went in for my interview, they said that they'd pay for you to go to school and stuff. That's what really got my attention ‘cause I thought that was good. (Marlene, ON, 3 years as HSW, Canadian-born)

As this example demonstrates, finances don't necessarily refer to wages once working. For Marlene it was the ability to receive affordable training in Ontario that facilitated her entry into the home support sector.

Naomi and Renit: Intersecting Themes

In the following section, we outline the experiences of Naomi and Renit using vignettes to highlight the multiple interconnected factors that contributed to their decision to choose employment in this sector. Vignettes function as a snapshot to represent the issue of recruitment and help to provide “a contextualized single picture” (Ely et al., 1997, p. 74).

For example, Naomi's story illustrates how the themes of sharing and caring, experience and exposure, and finances and flexibility overlap to provide an understanding of how she came to the profession.

Naomi is a French-Canadian mother of two. She is 54-years-old and has worked in home support for 1.5 years. Naomi completed university studies and previously worked as an ESL teacher. A few years earlier, Naomi also completed a course in personal fitness. Upon completion of her course she was immediately recruited as personal fitness assistant for elderly people who are required to visit the local hospital on a daily basis for medication. Despite her minimal training, Naomi accepted the position because it worked around her children's schedule. Her work with personal fitness eventually transitioned into serving elderly individuals living in care homes. Naomi has been working in home support ever since.

Naomi derives a significant amount of pleasure from her new profession, and she has been told by her clients' children how much they appreciate the care that she provides. In addition to the paid care she provides, Naomi, as well as her husband and children, work as volunteers who take many of her clients to church services every Sunday. The flexible nature of her current position affords Naomi time to volunteer both on weekends with elderly people and during the week at her children's school. Naomi counts volunteering as one of her stress management techniques. Although she loves the work, Naomi struggles with the rapid health declines that her clients experience, especially those with dementia. The emotional impact of the work requires a variety of stress management techniques; in her words, “it is tough.” This emotional impact, however, is outweighed by the satisfaction that Naomi derives from her clients and the caring nature of the profession. She reports:

When you come in and you see them smile when you're there, they just come running for you. They're just so happy to see you… . I enjoy being with them. Taking their hand, bringing them up. Read to them. They all enjoy reading and music. So I do a lot of reading… . I enjoy them. They have a lot of patience.

When asked what she does not like about her job, Naomi replies “there's nothing I don't like. I enjoy it. I really enjoy it” (Naomi, NS, 1.5 years as HSW, Canadian born).

In the following vignette, the multifaceted nature of Renit's pathway to becoming a home support worker is demonstrated. This vignette also shows that it is not just one caring experience that can lead to the choice of becoming a home support worker, but rather multiple caring experiences.

Renit is a middle-aged university graduate from India. In 1983 Renit and her husband re-located to Canada. Renit notes that her Indian heritage remains vibrant, cooperative, and community-oriented in her new country of residence. Upon arrival in Canada, Renit enrolled in an English as a Second Language (ESL) course to improve her communication skills. She took ESL, high school equivalency, and care aide courses at a local college during the evenings while working as a housekeeper during the day. Renit recalls this busy period of adjustment being very difficult for her. In order to make ends meet she also worked in a kitchen and a greenhouse, both physically demanding positions which aggravated an injured knee and resulted in multiple falls. While studying and working in Canada, Renit's mother fell gravely ill. This encouraged Renit to return home to India to provide care for her mother. The trip was initially meant to last a brief 4 to 5 weeks. Upon arrival, however, Renit came to the sobering conclusion that her mother's condition required her to stay much longer. Renit provided care for her mother for 5 months, until she passed away. Renit credits both her mother and mother-in-law, who lives with her in Canada, for motivating her to work in the Home Support sector.

Upon returning to Canada and with a clean bill of health herself, Renit was able to return to work. It was at this point that Renit decided to put into practice the training she had previously completed as a care aide. Although Renit was interested in a caring profession since she was a small child, she notes: “I got lots of experience from my Mom. That's why I want to help other people.”

Renit also discussed the flexible nature of the position and described her schedule as follows: “It is like my own. Like when I want to. So, my kids are not that little … but still I want to stay with them.”

However, sometimes the demands of the position require her to work split shifts, which interfere with her family's dinner schedule. Despite these challenges, she continues to enjoy work . Renit's passion for the profession is multifaceted, as she enjoys both the caring and social aspects of the position. She takes pleasure in helping people, getting to know others, and making new friends. (Renit, BC, 1 year as HSW, born in India)

DISCUSSION

Our findings from interviews with 57 home support workers employed less than 5 years in this sector highlight the multiple interconnected factors that contribute to an individual's decision to choose employment in home support. Participants consistently state that one of the biggest factors influencing their decision to work in home support is an enjoyment of working with people (i.e., caring and sharing). The relational aspect of working in home support is a major attractor. For some workers, it was a previous position working with the public; for other workers they were making a distinct change in their vocational lives in order to work more directly with people. Either way, the interpersonal nature of home support work is an extremely important factor in the decision to work in home support. In their work with home care workers, Denton and colleagues (2002, 2007) note that “for visiting home care workers, the caring relationship with clients was identified in focus groups as the most positive aspect of their job” (Denton et al., 2002, p. 341). We know from our previous research on home support (e.g., Martin-Matthews & Sims-Gould, 2008; Sims-Gould & Martin-Matthews, 2010) that one of the biggest issues for workers currently employed in home support are threats to a worker's ability to form and maintain relationships with clients (e.g., increasing workloads, constantly changing case loads, variable work schedules, etc.). The very reason that workers choose to work in home support, if violated, will likely be the dominant reason they choose to leave.

As identified in research, the breadth, scope, and intrinsic value of the services that home care workers provide is often not recognized. A recent Health Canada funded Pan Canadian Consultation ¹ with stakeholders in home support confirmed these challenges (Keefe, Légaré, & Martin-Matthews, 2009b, 2009c). Stakeholders in Ontario and Quebec proposed public relations and marketing efforts need to grapple with increasing the job profile of the workers and the valuing of the work that they do in order to enhance recruitment opportunities. These public relations and marketing efforts could emulate existing media campaigns already implemented in other provinces—including British Columbia, and other countries, including the United Kingdom—which are designed to highlight the intrinsic value of the work (Care Careers, n.d.; BC Care Providers Association, 2010).

The two vignettes underscore the importance of previous experience in workers' decisions to work in home support, particularly prior experience providing care to a relative or friend. Although we are not suggesting that all family caregivers are willing or able to transition to formal home support work, our findings suggest that individuals with prior caring experiences are motivated by the interpersonal rewards and intrinsic value associated with these types of caregiving interactions. An initiative to strengthen the direct care workforce in the United States (i.e., Better Jobs Better Care) also identified individuals with previous caring experiences as a pool of potential recruits to the sector (Bryant, 2007; Benjamin et al., 2008). In conjunction with Better Jobs Better Care, Benjamin and colleagues found that a significant proportion of individuals who previously cared for relatives in need of home support services could be recruited into the formal, paid caregiving sector. Out of 383 relative caregivers surveyed, 180 pursued a home care career after their family caregiving duties were completed. Those who elected to work as formal caregivers for individuals other than their relatives; that is, the “stayers,” were likely to cite motivations such as a desire to help others (Benjamin et al.). The authors are also careful to note, however, that the long-term implications of this recruitment strategy are not fully understood, especially for the “stayers” whose family caregiving duties were completed due to the death of a loved one. As well, the quality of workers recruited in this way is unknown. While our data support the notion that previous caring experiences may positively influence potential recruits, our findings suggest that individuals working in other caring or “people” professions may also be potential recruits. For instance, a potential recruit might be a personal fitness instructor such as Naomi, or a former esthetician such as Amber, looking for an opportunity to “make a difference.” This is consistent with Dill's (2009) analysis of continuing care aides in Nova Scotia, where intrinsic factors such as personal values, attitudes, and an opportunity to “make a difference” contributed to workers' reasons for joining the home support sector.

For many, working in home support is extrinsically motivated, it is a financial decision. In many parts of Canada, throughout the United States, and throughout Europe, the work is readily available and in some cases it can also provide a stable income base. However, our findings suggest that financial considerations are more than salary. Rather, job availability, stability, and the opportunity to advance in the field are all included in worker responses related to finances and flexibility of scheduling. Other research has similarly shown that financial considerations are not just about direct pay. For example, in a study of home care workers in California, Howes (2008) found that the provision of health insurance, even for part-time workers, and the flexible nature of home support were both factors that attracted individuals to the profession. The issue of insurance was less of a concern for workers in our study as we have a national universal health insurance program. However, the issue of extended benefits such as dental and prescription coverage did figure into workers' overall view of their compensation. The development of a comprehensive recruitment strategy for home support will require more research into the various facets of the financial considerations that attract workers to this sector.

These findings were similarly confirmed in the centrality of the issue of finances and flexibility in the Pan Canadian consultation. Stakeholders reported that wages were only part of the response and guaranteeing hours of care emerged as a critical need in all jurisdictions approached. Neighborhood home support or “cluster care” was a strategy employed by two district health regions in British Columbia (Cohen, Hall, Murphy, & Priest, 2009). These pilot projects attempted to serve clients in clusters of geographic proximity and enabled workers to travel less, have guaranteed hours, and even a career ladder mechanism as one worker became the supervisor for the cluster of workers. Despite positive feedback from workers and their supervisors, financial and technical challenges of a salaried-based system as well as managing client expectations remained as barriers to moving this approach from the pilot stage to full implementation.

While our findings indicate that extrinsic motivators such as wages, benefits, and flexibility with regard to scheduling and remuneration are important recruitment considerations, one of the first requisite steps in recruiting individuals to this sector is to provide appropriate and affordable training. Students need training that is affordable and comprehensive, and that will not require them to shoulder costly student loan payments, especially in certain jurisdictions where their future earning potential is relatively low. For example, in British Columbia, Canada the BC Cares initiative is developing strategic partnerships with the provincial government, various ministries, and education providers in order to improve the availability and visibility of subsidy options (e.g., loan reduction) for recruits to this sector (BC Care Providers Association, 2010). Nova Scotia has a bursary program to attract potential workers to recognized training programs as well as Prior Learning and Assessment in place to facilitate recruitment to the training program and eventually to the career (Anningson, Desjardin, Everest, MacLellan, & Porter, 2007). While the subsidy of training is essential to recruitment we can also speculate that the content of training is equally important to retention in particular in the face of increasing client frailty.

Limitations

There were three main limitations to our research. First, we interviewed individuals currently working within the home care sector as opposed to those who had left. Those who had left may have had different reasons for joining the field initially and we do not have this perspective. Second, we interviewed individuals who had been employed for less than 5 years. While we did not observe differences in our data, indeed someone who is very new may have a different set of reasons for joining than someone who has been working for 5 years. Finally, in accordance with local contexts, the recruitment strategies varied by province. For example, recruiting using the union listings method would not have been appropriate in Ontario given that most of the workers do not belong to a union. Although these modifications to the research design were made corresponding to the realities of each research site, they might limit our ability to make comparisons across the three provinces. While there were additional questions asked in Nova Scotia, for the purposes of these analyses we only focused on questions asked across all three provinces.

CONCLUSION

The recruitment of home health workers is clearly multifaceted and therefore the steps taken to recruit these workers must reflect this. In addition to strategies such as marketing to workers in other helping professions and/or ensuring a comprehensive remuneration package inclusive of wages and benefits, it is important to consider strategies beyond these traditional human resource policy domains. Policy developments in immigration, labor, technological advancement, and health promotion may affect both the demand for new workers by improving health and by adapting technology and the supply of potential recruits by expanding immigration and labor policies. These macro-level initiatives at a national or provincial (state) level can enhance current strategies offered by agencies and regional health authorities.

For example, accessing a surplus pool of labor to recruit new workers to meet an increasing demand appears to be an obvious policy direction. Countries have traditionally relied on foreign workers to fill labor shortages in agriculture, construction, health care and more recently home care. The Live-In Caregiver program within Citizenship and Immigration Canada (CIC, 2010) is designed to increase the number of workers to care for children, elderly people, or those with a disability. Qualified workers may apply for landed immigrant status following the equivalent of 2 years of service over a 4-year period. Several other potential suppliers of this labor are retired or unemployed persons including those current on social assistance, or those in using the Employment Insurance (EI) program. For example, in the past Canadian EI policy has enabled qualified people who receive EI benefits to attend training sessions for home support workers without changes to their benefits.

Our study highlights the aspects of home support that led workers to be attracted to the industry. Recruitment strategies must consider the attractors to the profession of home support so that these attributes can be showcased and further developed in campaigns within the home support industry. An improved understanding as to why people are drawn to work in the home health sector helps to provide insight into how to attract future workers. It also provides information on some of the key threats to retention of current employees. Consideration of the broader policy context illustrates where governments can work to support agencies and regional health authorities in their recruitment efforts.

The first author gratefully acknowledges the Canadian Institutes of Health Research (#180727) for her post-doctoral funding. The authors gratefully acknowledge funding from Health Canada (PI: Keefe), and from the Canadian Institutes of Health Research for the original research project that yielded original data collection (#IOP-70684). Thank you to research assistants Renae Dorsey and Krista Frazee for their assistance in the preparation of this manuscript.

Notes

1. Funding from Health Canada enabled a Pan Canadian consultation with over 100 representatives from government and regional health authorities, from advocacy organizations, unions, and education/training programs in five provinces—British Columbia (21 participants), Nova Scotia (25), Ontario (28), Saskatchewan (18), and Quebec (26)—between March 2009 and May 2010. The purpose of these consultations was to bring together stakeholders in each province to confirm the issues affecting home support workers (Keefe et al., in press) and to identify and assess appropriate human resource strategies to improve recruitment and retention of these workers. The process of identifying future directions adds contextual information to the themes that emerge from the interviews with the workers (see Keefe et al., 2009a, 2009b, 2009c).