Health and Social Care in the Community (2015) 23(5), 485–492
doi: 10.1111/hsc.12168
Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care Margaret Denton PhD1, Catherine Brookman and Rachel Barken MA5
PhD
2
, Isik Zeytinoglu
PhD
3
, Jennifer Plenderleith
MSc
4
1
Departments of Health, Aging & Society, and Sociology, McMaster University, Hamilton, Ontario, Canada, 2Catherine Brookman Consulting, Richmond Hill, Ontario, Canada, 3Human Resources and Management, DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada, 4Department of Nursing, McMaster University, Hamilton, Ontario, Canada and 5Department of Sociology, McMaster University, Hamilton, Ontario, Canada
Accepted for publication 19 August 2014
Correspondence Margaret Denton Departments of Health, Aging & Society, and Sociology McMaster University 1280 Main Street West Hamilton, Ontario, Canada L8S 4M4 E-mail: [email protected]
What is known about this topic
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More than half of the home-care workforce consists of home-care workers (HCWs). Quality of home care is achieved through consistency and continuity of care and the development of trusting relationships.
What this paper adds
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Many home healthcare workers feel that task shifting improves quality of care through the provision of more consistent care, the development of trust-based relationships and the reduction in the number of care providers entering the client’s home. Challenges associated with task shifting include safety issues due to HCWs’ lack of knowledge and training, supervision, inconsistent scheduling, lack of time and increase in client acuity. Regulating bodies, employers and educators should improve training and supervision to address HCWs’ changing tasks.
© 2014 John Wiley & Sons Ltd
Abstract Growing healthcare costs have caused home-care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home-care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home-care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010–2011. Using a purposive sampling strategy, semi-structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home-care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust-based relationships with clients; and because task shifting reduced the number of care providers entering the client’s home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed. Keywords: home care, home-care workers, home-care workforce, quality of care, skill mix, task shifting
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Introduction Growing healthcare costs, coupled with the desire of people to be cared for in their own homes, has caused governments and home-care providers in Canada and elsewhere to look to more efficient and effective use of healthcare resources (Health Council of Canada 2012, Rostgaard 2012, Vabø 2012). Changing workforce skill mix (Buchan & Dal Poz 2002, Sibbald et al. 2004, Dubois & Singh 2009) by delegating or transferring care tasks has been suggested in Ontario, Canada (Keefe et al. 2011, Commission on the Reform of Ontario’s Public Services 2012) and globally (WHO 2008, Bystedt et al. 2011, Craftman et al. 2013) to improve the efficiency and effectiveness of home healthcare. In Ontario, task shifting refers to the delegation of tasks by a nurse to a HCW, or the transfer of tasks from a physiotherapist or occupational therapist to a home-care worker (HCW) (Ministry of Health and Long-Term Care 2006, World Health Professions Alliance 2008). There is some research exploring nurses’ perceptions and experiences of task shifting processes. For example, in a recent study in Sweden, the delegation of tasks raised contradictions regarding nurses’ roles, their relationship with unlicensed workers and the continuity of care provided to the client (Bystedt et al. 2011, Craftman et al. 2013). This research calls for clearer procedures and better communication between nurses and HCWs to ensure the quality of care. No empirical studies, however, examine the effects of task shifting on the quality of care from the perspectives of a variety of home healthcare workers. Further, research does not explore task shifting in Canada. Seeking to fill these gaps, this paper explores the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. Data were gathered through interviews with HCWs, home-care worker supervisors, nurses and therapists across Ontario. Literature review In this study, we use the generic term HCWs to refer to a group of unregulated health workers trained in the provision of personal care, homemaking duties, clinical care services and delegated acts in clients’ homes. HCWs also provide personal interaction to clients, many of whom are socially isolated. They typically spend more time with clients than other healthcare providers working in home care and are sometimes considered the ‘eyes and the ears’ of the care system (Stone 2004, Sharman et al. 2008, MartinMatthews et al. 2013, Sims-Gould et al. 2013). Data 486
from various countries suggest that more than half of the home-care workforce consists of HCWs (Colombo et al. 2011). There is ambiguity regarding HCWs’ education, training and work responsibilities. Often, the vocation is defined by a job description specified by the employer and varies by sector and setting. In Ontario, HCWs fall under the limits of the Regulated Health Professions Act. This Act, which specifies each health professional’s scope of practice, outlines the tasks for which HCWs are educated, are accountable for and considered competent to perform. The Act specifies the tasks HCWs may perform independently; the tasks that require supervision; and delegated tasks, which require additional training and supervision. Despite these guidelines, scopes of practice are constantly evolving. Officially mandated personal, medical and household tasks are essential for all home healthcare providers, but high-quality care extends beyond these tasks being performed competently. High-quality care involves consistency and continuity in service provision and, relatedly, the development of trusting relationships between care providers and home-care clients (Olsson & Ingvad 2001, Cabana & Jee 2004, Saultz & Lochner 2005). Woodward et al. (2004, p. 177) suggest that two interacting dimensions contribute to continuity in home care: managing care, which involves planning, monitoring, review and co-ordinating care and direct service provision, which involves: Uninterrupted service delivery; consistent, appropriate knowledge and skills; ongoing accurate observation; trusting relationship between service provider and client/caregiver; rapport among team members and consistent timing.
When care is consistent and continuous, providers are better positioned to develop close and trusting relationships with clients (Olsson & Ingvad 2001, Aronson 2004, Raynes et al. 2004, Woodward et al. 2004, Wiles 2005, Gantert et al. 2008, Sharman et al. 2008) and to develop an in-depth knowledge of clients’ care preferences and health conditions (Byrne et al. 2012). By contrast, lack of continuity in service provision – for example, due to inconsistent schedules among care providers – leaves clients feeling devalued (Martin-Matthews et al. 2013). Clients also tend to feel that the quality of care is higher when they are involved in directing care (Leviten-Reid & Hoyt 2009). They appreciate care that supports their autonomy, control and dignity (Piercy & Dunkley 2004, Byrne et al. 2012). Preserving autonomy requires care providers to collaborate and negotiate with clients in the performance and © 2014 John Wiley & Sons Ltd
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scheduling of activities; responding to individuals’ shifting needs and preferences rather than simply performing mandated tasks (Byrne et al. 2012). Trust is an important component of care provider–client relationships (Piercy & Wooley 1999, Holmberg et al. 2012) because care providers work in clients’ personal home spaces and because trusting relationships contribute to clients’ emotional security (Soodeen et al. 2007). In summary, clients appreciate care providers who are reliable, flexible, patient and have time to listen and interact with them on a personal level. These interpersonal dimensions of care work are known as ‘emotional labour’ and are an integral component of what care workers do on a daily basis (James 1992, Dyck & England 2012). Emotional labour has positive impacts on the well-being of HCWs (Denton et al. 2002) as well as clients. Yet, official definitions, descriptions and recording practices emphasise the physical, rather than the emotional, aspects of home-care work (Byrne et al. 2012, Martin-Matthews et al. 2013). The literature we reviewed and our experience in the field led us to explore how task shifting affects the quality of care.
Methods This qualitative study was conducted in collaboration with a large home and community care organisation in Ontario, Canada. Academic researchers and the Vice-President of Research for the organisation worked collaboratively to obtain funding, develop recruitment strategies, research questions, obtain approval for the research from a university research ethics board and analyse findings. Using a purposive sampling strategy, the research co-ordinator recruited HCWs, home-care worker supervisors, therapists and nurses with knowledge regarding task shifting. Recruitment occurred in multiple stages. First, permission to participate in the project was sought from management of the 10 distinct regional centres of the home and community care organisation. Seven regional centre managers agreed to send e-mail invitations to HCWs, supervisors, therapists and nurses. To increase recruitment efforts, senior management of the home and community care organisation sent a follow-up e-mail to supervisors and therapists reminding them of the research project. An incentive of $35 was offered to each participant. Those interested in participating contacted the research co-ordinator. She then sent them an invitation with information about the research project and its merits and indicated that their names and identifying information would be kept confidential. No one © 2014 John Wiley & Sons Ltd
in the home and community care organisation had access to this information. Data were collected through semi-structured telephone interviews between October 2010 and February 2011. Written informed consent was collected from all participants prior to the telephone interview. Interviews lasted approximately 30–40 minutes and were digitally recorded. There were 46 participants: 20 HCWs, 9 supervisors, 9 therapists and 8 nurses. We used two different questionnaires as interview guides: one for HCWs and one for supervisors, therapists and nurses. Following a few demographic questions, participants were asked about task shifting and its impacts on health human resource issues, including intention to continue working in home care, job satisfaction, and health and safety. Participants were also asked about their perceptions regarding the sufficiency of supervision and training for the transferred or delegated tasks and the impacts of task shifting on the quality of care. Findings on the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers are the focus of this paper. Findings regarding the impact of task satisfaction on HCWs’ retention are reported elsewhere (Zeytinoglu et al. 2014). To ensure trustworthiness and rigour, an audit trail was kept throughout the study to record all key procedural and analytical decisions. Interviews were taped, transcribed and transcripts were cross-checked against original audio files for quality and completeness. A principal investigator and a research associate each conducted a thematic analysis of the data and then met to review their analysis and draft themes. All principal investigators read the transcriptions and met to review the draft themes and establish a coding scheme. The research assistant entered the codes in NVivo 8, a software package for qualitative data (QSR International 2014). In presenting the results, we include quotations from the interviews to give voice to our participants and to give readers a better sense of their experiences.
Findings Demographic and employment characteristics of the participants Participants were female, and on average, in their late forties. Most of the home-care worker supervisors were Registered Practical Nurses (7/9), while visiting nurses were more likely to be Registered Nurses (RNs, 7/8). Of the nine therapists interviewed, five were occupational therapists (OTs) and four were physiotherapists. The average number of hours 487
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worked in a week varied among participants: supervisors worked an average of 52 hours per week, HCWs worked 32 hours, therapists worked 30 hours and nurses worked 28 hours. Half of the HCWs and nurses, and one-third of the therapists, worked parttime. The supervisors all worked full-time hours. Common delegated or transferred tasks Most participants agreed that there has been an increase in the number of transferred skills or delegated acts to HCWs in the last 3 years. This task shifting, they noted, changes HCWs’ role in care provision. Community Care Access Centres (government centres tasked with managing service delivery in Ontario), other service providers, clients and families all hold higher expectations of HCWs. They are increasingly likely to do more medically complex tasks, make referrals and chart the client’s progress. The eight most common skills that are transferred or delegated to HCWs included transfers, simple wound care, exercises, medication management, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. Participants were asked if the transfer of skills from a regulated healthcare professional to a HCW has a positive or negative impact on the quality of care. Analysis of the 46 interviews revealed both advantages and disadvantages to task shifting. HCWs and their supervisors were more likely to feel that task shifting improves the quality of care, but they did express concerns that the delegation or transfer of tasks might compromise clients’ well-being. Nurses, followed by therapists, were more likely to discuss the problems associated with task shifting. They felt that task shifting had either a negative or a mixed impact on the quality of care delivered to clients. Health system challenges associated with task shifting include lack of training, safety and liability issues. The positive impacts of task shifting on quality of care Participants’ views regarding the positive impacts of task shifting are centred on the following themes: consistency and continuity of care, ensuring clients’ comfort, developing relationships and reducing the number of people in the home. Overall, HCWs felt that task shifting improved the consistency and continuity of care. With limited home-care budgets, the number of visits and the time spent with clients by regulated healthcare professionals is limited. A visit by a HCW costs significantly less money. As one supervisor commented: 488
It’s cheaper to have a HCW going in there daily, assist with bathing and be looking for any skin breakdown versus having a nurse going in daily. (HCS 09)
HCWs visit clients more frequently and spend more time with them; visiting some clients every day and others several times a week. Visits can last from 30 minutes to 2 hours or longer. With longer and more frequent visits, HCWs spend more time with clients and are less rushed with care activities. One HCW commented: Actually, I think a HCW does a better job than . . . ’cos they spend more time with them than an OT or you know, RN. So, we could take our time which is better for the client than rushing through everything. (HCW 08)
In addition to spending more time with clients, HCWs also tend to follow more consistent schedules than healthcare professionals. As one HCW explained: We try and keep the same people, the same time every day in there. However, when the nurses come in, they have a schedule that they just have to fit them in. It’s never, never the same time. (HCW 15)
Consistent visits typically enhance the quality of care, but sometimes flexibility is required to meet clients’ needs. HCWs may accommodate clients’ schedules by reorganising their visit in the light of other commitments, such as doctor’s appointments. In the words of one HCW: And if they have to be at the doctor’s at 10, well then you go there first. You try and accommodate them as much as possible. (HCW 15)
With task shifting, clients may receive some types of delegated of transferred care more consistently. Where clients may not always follow through with the exercises a therapist recommends on their own, training HCWs to help with exercises increases the chances of exercise routines being followed. As one therapist explained, if the therapy is delegated to the HCW: It’s a contract. They have to do it . . . they [the patient] are receiving care versus if they were asked to do on their own. So, yeah I mean quality of life . . . the patients are better off that way than having to do exercise themselves. (T 04)
Ongoing and accurate observation is another component of continuity of care. Good observation is necessary to ensure that changes in the client’s condition are monitored, are reported to the agency and are appropriately treated. Supervisors and HCWs felt that HCWs are best suited to monitor the client’s health status because they visit more frequently and © 2014 John Wiley & Sons Ltd
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are more familiar with clients’ conditions. As one supervisor explained, this ongoing observation can enhance the quality of care: . . .because the HCWs usually have more frequent visits and are able to monitor and understand signs and symptoms . . . an example would be if we were doing intermittent catheterisations, we’d be alert to possible urinary tract infections a lot easier than say a family member doing it or a nurse who has limited visits and that way, the client would get treatment quicker and be proactive. (HCS 07)
Thus, training HCWs to observe and monitor clients’ health status can benefit clients and can also reduce government spending on home care. One supervisor said that task shifting was of: Benefit to the client because it’s more affordable, so the HCW can then report to the nurse or report to the agency that they might need somebody to come and take a look. Something just doesn’t look right. So, they’re kind of the eyes and ears. (HCS 09)
Developing personal, trust-based relationships is an important component of good quality care and is closely related to consistent and continuous service provision. HCWs are well positioned to develop trusting relationships with clients because they consistently spend more time assisting them with personal care and activities of daily living. Through ongoing interactions, HCWs and clients often develop close bonds. One HCW explained the impact of her visit on the quality of care in the following way: It really makes their life a lot better. I mean sometimes I know they look forward to us coming for a lot of different reasons, not just how they feel after we leave, but while we’re there, you know, they love . . . they just love being with us. Not always though. (HCW 19)
When HCWs develop relationships with clients, they are well positioned to provide care in a way that meets individual preferences. Accommodating client preferences then enhances the overall quality of care, as one supervisor explained: If the HCW really knows the client, then the care is going to be good . . . ’cos they know the client’s preferences and likes and dislikes and about every situation. (HCS 06)
Clients tend to be more comfortable with HCWs than with nurses because they interact with them more frequently and consistently. In reference to one of the clients, a HCW explained: As a matter of fact I have a client. I was telling him about me doing this [the interview] and I had told him that I was going to mention it. And he says ‘well that’s so true. You have no idea how intimidating nurses can be’. They come © 2014 John Wiley & Sons Ltd
in, they do their job, they get out. We sit and chat. And the client feels like we’re more human. (HCW 04)
Clients often dislike having multiple care providers in their homes. One of their most frequent complaints is that they receive too many visits from different people. The transfer or delegation of tasks to HCWs may enhance clients’ satisfaction with care by reducing the number of people visiting them. One HCW explained: Things can be taken care of with one person coming in their home instead of three or four. With physiotherapy, the therapist will come and often show us what she wants to be done and we can continue those exercises with the client, without her having someone else come in her home or an inconvenient time. We can do it while we’re there. (HCW 03)
The negative impacts of task shifting on quality of care Some participants clearly identified the benefits of task shifting, but others expressed concerns that the transfer or delegation of tasks from nurses and therapists to HCWs might decrease the quality of care. These concerns centred on the following themes: insufficient training, inadequate delegation or supervision, and scheduling and time constraints. Having the appropriate knowledge, training and skills to carry out the delegated or transferred tasks is an important component of high-quality care. When a case manager decides that a task is to be transferred or delegated, the supervisor, a nurse or a therapist meets with the HCW at the client’s home. Relevant skills are demonstrated, practised and observed. Training usually (but not always) takes place in one visit. More complicated or individualised care, such as Hoyer lifts, catheterisation, ostomy care, injections, physiotherapy and G-tube feeding, may require more than one visit. Supervisors are responsible for determining if additional training is necessary. Concerns regarding the client’s or the HCW’s health and safety, or changes in the client’s condition, may lead supervisors to schedule more training visits. HCWs may also request more training. About half of the participants commented that one visit is usually sufficient for training. Some healthcare professionals expressed concern, though, that a single visit is inadequate and that HCWs lack necessary knowledge and skills. A therapist commented: They may not understand everything, they may be afraid to ask questions, they cannot understand everything because they don’t have the level of education. (T 02)
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well as good communication between the healthcare professional and the HCW. One supervisor explained that effective training ‘all depends on who’s teaching the skills and how competent and confident they are’ (HCS 05). A therapist noted that in doing the training it is important:
as long as the HCW is competent in performing the procedure’ (HCS 01). Conversely, some supervisors felt that training is necessary every time tasks are delegated or transferred to ensure that HCWs meet each client’s individual needs:
To make sure there is an understanding, things are demonstrated well, they can say their understanding of how things should be performed. (T 01)
Each client is different, especially with transfers, and individual training is necessary for some tasks . . . the clients and the way the clients respond, their weight, their ability, their mental function, physical function are all different. So, that needs to be done individually as well. (HCS 06)
A number of nurses, therapists and supervisors felt that task shifting might compromise the quality of care because HCWs are not trained to recognise changes in the client’s condition, to modify procedures when appropriate or to recognise other medical concerns that may arise. One therapist emphasised that active treatment, which involves assessing and re-assessing the client’s condition as they receive care, is necessary to ensure the client’s well-being. She felt that HCWs do not have the skills to give active treatment. Another therapist explained: The professionals can identify any new problem and they can modify the procedure or whatever we are working on. However, the HCW may not have the ability or the skill to notice if there’s a change in the client’s condition or how to change the procedure. (T 07)
Some participants felt that task shifting might negatively impact quality of care due to problems with the processes in place to monitoring care once tasks are delegated. Nurses’ lack of involvement in monitoring was identified as a problem. A supervisor argued: I think with the transfer of skills and delegated tasks that it should be the professional who’s doing that and at least monitoring it. Like, it’s okay to delegate, but have them monitor it down the road to see, you know, is everything okay? (HCS 06)
Ongoing supervision is ideal, but participants realised that supervisors’ heavy workloads were a constraint. As one supervisor noted, there is ‘one supervisor to maybe 50 HCWs’ (HCS 04). Inadequate knowledge, training and supervision are concerns, but some HCWs felt that the skills acquired through practical experience go unrecognised. They did not think it was necessary to train experienced HCWs each time a task was transferred or delegated. Participants also pointed out that task shifting does not compromise the quality of care if the HCW is competent and is not being asked to accept the transferred or delegated task in a high-risk situation with an unstable client. One supervisor commented that ‘it doesn’t impact the quality of care
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These findings demonstrate mixed opinions regarding the training for HCWs to do delegated or transferred tasks. The extent to which task shifting impacts quality of care depends on the nature of each task; the effectiveness of teaching; and the training, monitoring, skill level, education and motivation of the HCW. Scheduling problems may compromise the quality of care when tasks are delegated or transferred. One HCW may be trained to do a delegated task with a specific client. If she is away temporarily, the supervisor may assign a replacement, and this replacement may not have the same training. A supervisor explained: So you’ve gone out and trained somebody and then on the weekend maybe somebody gets sent in that they don’t have the training or you haven’t personally signed off. It makes it much more difficult to provide care at all times. (HCS 08)
HCWs typically spend more time with clients and are responsible for various types of care, including assisting clients with activities of daily living and instrumental activities of daily living. Transferred or delegated tasks are an added responsibility. HCWs felt that insufficient time to carry out various tasks might compromise the overall quality of care clients receive. A HCW commented: Well if we have to worry about what has been transferred to us and doing that job versus our own job, well then it definitely would affect the quality of care. (HCS 18)
Discussion With demand for home-care services increasing, community care organisations in Ontario and elsewhere are adopting task shifting strategies to reduce the costs of care and to provide care to a greater number of clients. The purpose of this paper was to gain an understanding of the impacts of task shifting on the quality of care provided to clients from the perspectives of home healthcare workers. Findings reveal
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important insights regarding the advantages and disadvantages of task shifting. On the one hand, task shifting may be advantageous because HCWs are well positioned to provide more consistent care; to develop personal, trust-based relationships with clients; and because task shifting reduces the number of care providers entering clients’ homes. As the ‘eyes and the ears’ of the home healthcare system, HCWs can liaise between clients and other healthcare professionals. In these ways, task shifting may improve the quality of care clients receive. On the other hand, task shifting has disadvantages because HCWs do not always have the knowledge, training and education necessary to perform more complex tasks and because scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. This might compromise the quality of care clients receive. Qualitative interviews were used to collect data for this study. A strength of this method is that it allowed us to examine the impacts of task shifting on the quality of care in an in-depth manner. The findings are transferable to similar home-care organisations in Ontario and elsewhere. There are, however, some limitations to the study. First, the small sample size and specific context from which the data were drawn means that findings cannot be generalised to other settings such as private home-care services or the long-term care setting. Another limitation is that we did not collect information on healthcare workers’ length of employment in the field. Those employed in home healthcare for longer might have a deeper understanding of the issues being addressed in this paper. They might also be less reticent to share concerns about their work should fear of reprisal be an issue. Length of employment might thus have an impact on participants’ views of task shifting. The final limitation is that we did not address clients’ views on task shifting and the quality of care. This is an important question for future research and would complement the findings presented here. These results of this research have implications for regulating bodies, employers, educators, unions and professional associations. Echoing other recent studies (Bystedt et al. 2011, Craftman et al. 2013), further examination of the delegation of acts and the transfer of tasks is necessary, along with recommendations to support the necessary competency development among HCWs to ensure the quality of care. Regulatory acts that govern the delegation and transfer of tasks should be reviewed in light of changes to the workforce skill-mix brought on by task shifting. Canadian research has highlighted the need for more standardised training among HCWs and supervisors © 2014 John Wiley & Sons Ltd
(Martin-Matthews et al. 2013). To ensure adequate and appropriate training, employers need to give additional orientation training for HCWs to ensure all staff has a baseline of expertise in commonly transferred or delegated tasks, as well as ongoing professional development as the tasks being transferred or delegated evolve. For educators, these results present an opportunity to refresh HCW curriculum and/or offer enhanced training. For unions, this may require revisiting union regulations. HCWs, unlike regulated workers, do not have a body that oversees their professional development as a requirement to maintain certification. These results present a case for ongoing professional development for those HCWs who are involved in the transfer of tasks or delegated acts. Finally, this research raises a few other issues for future consideration, including: fair compensation for HCWs whose job duties and training are expanding; more formalised training guidelines for supervisors; the need for a sufficient number of health professionals to provide the required training, supervision and continuing education of HCWs; and regulations for task shifting to be set with the professions involved.
Acknowledgements Support for this project was provided through a research grant from the Ontario Health Human Resource Research Network. Thank you to Kate Ducak for assistance with the analysis of the data.
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Piercy K.W. & Woolley D.N. (1999) Negotiating worker-client relationships: A necessary step to providing quality home health care. Home Health Care Services Quarterly 18 (1), 1–24. Piercy K.W. & Dunkley G.J. (2004) What quality paid home care means to family caregivers. Journal of Applied Gerontology 23, 175–192. QSR International (2014) NVivo 8. Available at: http:// www.qsrinternational.com/products_previous-products_ nvivo8.aspx (accessed on 14/8/2014). Raynes N., Coulthard L., Glenister C. & Temple B. (2004) Age does not come alone: identifying and implementing older people’s views of quality in home care services. Quality in Ageing 5, 24–31. Rostgaard T. (2012) Quality reforms in Danish home care – balancing between standardisation and individualisation. Health and Social Care in the Community 20 (3), 247–254. Saultz J.W. & Lochner J. (2005) Interpersonal continuity of care and care outcomes: a critical review. Annals of Family Medicine 3, 159–166. Sharman Z., McLaren A.T., Cohen M. & Ostry A. (2008) “We only own the hours”: discontinuity of care in the British Columbia home support system. Canadian Journal on Aging 27, 89–99. Sibbald B., Shen J. & McBride A. (2004) Changing the skillmix of the health care workforce. Journal of Health Services Research and Policy 9, 28–38. Sims-Gould J., Byrne K., Beck C. & Martin-Matthews A. (2013) Workers’ experiences of crises in the delivery of home support services to older clients: a qualitative study. Journal of Applied Gerontology 32 (1), 31–50. Soodeen R., Gregory D. & Bond J. (2007) Home care for older couples: “It feels like a security blanket. . .”. Qualitative Health Research 17, 1245–1255. Stone R. (2004) The direct care worker: a key dimension of home care policy. Home Health Care Management and Practice 16, 339–349. Vabø M. (2012) Norwegian home care in transition – heading for accountability, off-loading responsibilities. Health and Social Care in the Community 20 (3), 283–291. WHO (2008) Task Shifting: Rational Distribution of Tasks among Health Workforce Teams: Global Recommendations and Guidelines. World Health Organization, Geneva. Available at: http://www.who.int/healthsystems/TTR-TaskShifting. pdf (accessed on 28/2/2012). Wiles J. (2005) Home as a new site of care provision and consumption. In: G.J. Andrews & D.R. Phillips (Eds) Ageing in Place, pp. 79–87. Routledge, London. Woodward C.A., Abelson J., Tedford S. & Hutchison B. (2004) What is important to continuity in home care? Social Science and Medicine 58, 177–192. World Health Professions Alliance (2008) Joint health professions statement on task shifting. Available at: http://www. whpa.org/statements.htm (accessed on 28/2/2012). Zeytinoglu I.U., Denton M., Brookman C. & Plenderleith J. (2014) Task shifting policy in Ontario, Canada: Does it help personal support workers' intention to stay? Health Policy 117 (2), 179–186.
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doi: 10.1111/hsc.12168
Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care Margaret Denton PhD1, Catherine Brookman and Rachel Barken MA5
PhD
2
, Isik Zeytinoglu
PhD
3
, Jennifer Plenderleith
MSc
4
1
Departments of Health, Aging & Society, and Sociology, McMaster University, Hamilton, Ontario, Canada, 2Catherine Brookman Consulting, Richmond Hill, Ontario, Canada, 3Human Resources and Management, DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada, 4Department of Nursing, McMaster University, Hamilton, Ontario, Canada and 5Department of Sociology, McMaster University, Hamilton, Ontario, Canada
Accepted for publication 19 August 2014
Correspondence Margaret Denton Departments of Health, Aging & Society, and Sociology McMaster University 1280 Main Street West Hamilton, Ontario, Canada L8S 4M4 E-mail: [email protected]
What is known about this topic
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More than half of the home-care workforce consists of home-care workers (HCWs). Quality of home care is achieved through consistency and continuity of care and the development of trusting relationships.
What this paper adds
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Many home healthcare workers feel that task shifting improves quality of care through the provision of more consistent care, the development of trust-based relationships and the reduction in the number of care providers entering the client’s home. Challenges associated with task shifting include safety issues due to HCWs’ lack of knowledge and training, supervision, inconsistent scheduling, lack of time and increase in client acuity. Regulating bodies, employers and educators should improve training and supervision to address HCWs’ changing tasks.
© 2014 John Wiley & Sons Ltd
Abstract Growing healthcare costs have caused home-care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home-care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home-care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010–2011. Using a purposive sampling strategy, semi-structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home-care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust-based relationships with clients; and because task shifting reduced the number of care providers entering the client’s home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed. Keywords: home care, home-care workers, home-care workforce, quality of care, skill mix, task shifting
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Introduction Growing healthcare costs, coupled with the desire of people to be cared for in their own homes, has caused governments and home-care providers in Canada and elsewhere to look to more efficient and effective use of healthcare resources (Health Council of Canada 2012, Rostgaard 2012, Vabø 2012). Changing workforce skill mix (Buchan & Dal Poz 2002, Sibbald et al. 2004, Dubois & Singh 2009) by delegating or transferring care tasks has been suggested in Ontario, Canada (Keefe et al. 2011, Commission on the Reform of Ontario’s Public Services 2012) and globally (WHO 2008, Bystedt et al. 2011, Craftman et al. 2013) to improve the efficiency and effectiveness of home healthcare. In Ontario, task shifting refers to the delegation of tasks by a nurse to a HCW, or the transfer of tasks from a physiotherapist or occupational therapist to a home-care worker (HCW) (Ministry of Health and Long-Term Care 2006, World Health Professions Alliance 2008). There is some research exploring nurses’ perceptions and experiences of task shifting processes. For example, in a recent study in Sweden, the delegation of tasks raised contradictions regarding nurses’ roles, their relationship with unlicensed workers and the continuity of care provided to the client (Bystedt et al. 2011, Craftman et al. 2013). This research calls for clearer procedures and better communication between nurses and HCWs to ensure the quality of care. No empirical studies, however, examine the effects of task shifting on the quality of care from the perspectives of a variety of home healthcare workers. Further, research does not explore task shifting in Canada. Seeking to fill these gaps, this paper explores the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. Data were gathered through interviews with HCWs, home-care worker supervisors, nurses and therapists across Ontario. Literature review In this study, we use the generic term HCWs to refer to a group of unregulated health workers trained in the provision of personal care, homemaking duties, clinical care services and delegated acts in clients’ homes. HCWs also provide personal interaction to clients, many of whom are socially isolated. They typically spend more time with clients than other healthcare providers working in home care and are sometimes considered the ‘eyes and the ears’ of the care system (Stone 2004, Sharman et al. 2008, MartinMatthews et al. 2013, Sims-Gould et al. 2013). Data 486
from various countries suggest that more than half of the home-care workforce consists of HCWs (Colombo et al. 2011). There is ambiguity regarding HCWs’ education, training and work responsibilities. Often, the vocation is defined by a job description specified by the employer and varies by sector and setting. In Ontario, HCWs fall under the limits of the Regulated Health Professions Act. This Act, which specifies each health professional’s scope of practice, outlines the tasks for which HCWs are educated, are accountable for and considered competent to perform. The Act specifies the tasks HCWs may perform independently; the tasks that require supervision; and delegated tasks, which require additional training and supervision. Despite these guidelines, scopes of practice are constantly evolving. Officially mandated personal, medical and household tasks are essential for all home healthcare providers, but high-quality care extends beyond these tasks being performed competently. High-quality care involves consistency and continuity in service provision and, relatedly, the development of trusting relationships between care providers and home-care clients (Olsson & Ingvad 2001, Cabana & Jee 2004, Saultz & Lochner 2005). Woodward et al. (2004, p. 177) suggest that two interacting dimensions contribute to continuity in home care: managing care, which involves planning, monitoring, review and co-ordinating care and direct service provision, which involves: Uninterrupted service delivery; consistent, appropriate knowledge and skills; ongoing accurate observation; trusting relationship between service provider and client/caregiver; rapport among team members and consistent timing.
When care is consistent and continuous, providers are better positioned to develop close and trusting relationships with clients (Olsson & Ingvad 2001, Aronson 2004, Raynes et al. 2004, Woodward et al. 2004, Wiles 2005, Gantert et al. 2008, Sharman et al. 2008) and to develop an in-depth knowledge of clients’ care preferences and health conditions (Byrne et al. 2012). By contrast, lack of continuity in service provision – for example, due to inconsistent schedules among care providers – leaves clients feeling devalued (Martin-Matthews et al. 2013). Clients also tend to feel that the quality of care is higher when they are involved in directing care (Leviten-Reid & Hoyt 2009). They appreciate care that supports their autonomy, control and dignity (Piercy & Dunkley 2004, Byrne et al. 2012). Preserving autonomy requires care providers to collaborate and negotiate with clients in the performance and © 2014 John Wiley & Sons Ltd
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scheduling of activities; responding to individuals’ shifting needs and preferences rather than simply performing mandated tasks (Byrne et al. 2012). Trust is an important component of care provider–client relationships (Piercy & Wooley 1999, Holmberg et al. 2012) because care providers work in clients’ personal home spaces and because trusting relationships contribute to clients’ emotional security (Soodeen et al. 2007). In summary, clients appreciate care providers who are reliable, flexible, patient and have time to listen and interact with them on a personal level. These interpersonal dimensions of care work are known as ‘emotional labour’ and are an integral component of what care workers do on a daily basis (James 1992, Dyck & England 2012). Emotional labour has positive impacts on the well-being of HCWs (Denton et al. 2002) as well as clients. Yet, official definitions, descriptions and recording practices emphasise the physical, rather than the emotional, aspects of home-care work (Byrne et al. 2012, Martin-Matthews et al. 2013). The literature we reviewed and our experience in the field led us to explore how task shifting affects the quality of care.
Methods This qualitative study was conducted in collaboration with a large home and community care organisation in Ontario, Canada. Academic researchers and the Vice-President of Research for the organisation worked collaboratively to obtain funding, develop recruitment strategies, research questions, obtain approval for the research from a university research ethics board and analyse findings. Using a purposive sampling strategy, the research co-ordinator recruited HCWs, home-care worker supervisors, therapists and nurses with knowledge regarding task shifting. Recruitment occurred in multiple stages. First, permission to participate in the project was sought from management of the 10 distinct regional centres of the home and community care organisation. Seven regional centre managers agreed to send e-mail invitations to HCWs, supervisors, therapists and nurses. To increase recruitment efforts, senior management of the home and community care organisation sent a follow-up e-mail to supervisors and therapists reminding them of the research project. An incentive of $35 was offered to each participant. Those interested in participating contacted the research co-ordinator. She then sent them an invitation with information about the research project and its merits and indicated that their names and identifying information would be kept confidential. No one © 2014 John Wiley & Sons Ltd
in the home and community care organisation had access to this information. Data were collected through semi-structured telephone interviews between October 2010 and February 2011. Written informed consent was collected from all participants prior to the telephone interview. Interviews lasted approximately 30–40 minutes and were digitally recorded. There were 46 participants: 20 HCWs, 9 supervisors, 9 therapists and 8 nurses. We used two different questionnaires as interview guides: one for HCWs and one for supervisors, therapists and nurses. Following a few demographic questions, participants were asked about task shifting and its impacts on health human resource issues, including intention to continue working in home care, job satisfaction, and health and safety. Participants were also asked about their perceptions regarding the sufficiency of supervision and training for the transferred or delegated tasks and the impacts of task shifting on the quality of care. Findings on the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers are the focus of this paper. Findings regarding the impact of task satisfaction on HCWs’ retention are reported elsewhere (Zeytinoglu et al. 2014). To ensure trustworthiness and rigour, an audit trail was kept throughout the study to record all key procedural and analytical decisions. Interviews were taped, transcribed and transcripts were cross-checked against original audio files for quality and completeness. A principal investigator and a research associate each conducted a thematic analysis of the data and then met to review their analysis and draft themes. All principal investigators read the transcriptions and met to review the draft themes and establish a coding scheme. The research assistant entered the codes in NVivo 8, a software package for qualitative data (QSR International 2014). In presenting the results, we include quotations from the interviews to give voice to our participants and to give readers a better sense of their experiences.
Findings Demographic and employment characteristics of the participants Participants were female, and on average, in their late forties. Most of the home-care worker supervisors were Registered Practical Nurses (7/9), while visiting nurses were more likely to be Registered Nurses (RNs, 7/8). Of the nine therapists interviewed, five were occupational therapists (OTs) and four were physiotherapists. The average number of hours 487
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worked in a week varied among participants: supervisors worked an average of 52 hours per week, HCWs worked 32 hours, therapists worked 30 hours and nurses worked 28 hours. Half of the HCWs and nurses, and one-third of the therapists, worked parttime. The supervisors all worked full-time hours. Common delegated or transferred tasks Most participants agreed that there has been an increase in the number of transferred skills or delegated acts to HCWs in the last 3 years. This task shifting, they noted, changes HCWs’ role in care provision. Community Care Access Centres (government centres tasked with managing service delivery in Ontario), other service providers, clients and families all hold higher expectations of HCWs. They are increasingly likely to do more medically complex tasks, make referrals and chart the client’s progress. The eight most common skills that are transferred or delegated to HCWs included transfers, simple wound care, exercises, medication management, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. Participants were asked if the transfer of skills from a regulated healthcare professional to a HCW has a positive or negative impact on the quality of care. Analysis of the 46 interviews revealed both advantages and disadvantages to task shifting. HCWs and their supervisors were more likely to feel that task shifting improves the quality of care, but they did express concerns that the delegation or transfer of tasks might compromise clients’ well-being. Nurses, followed by therapists, were more likely to discuss the problems associated with task shifting. They felt that task shifting had either a negative or a mixed impact on the quality of care delivered to clients. Health system challenges associated with task shifting include lack of training, safety and liability issues. The positive impacts of task shifting on quality of care Participants’ views regarding the positive impacts of task shifting are centred on the following themes: consistency and continuity of care, ensuring clients’ comfort, developing relationships and reducing the number of people in the home. Overall, HCWs felt that task shifting improved the consistency and continuity of care. With limited home-care budgets, the number of visits and the time spent with clients by regulated healthcare professionals is limited. A visit by a HCW costs significantly less money. As one supervisor commented: 488
It’s cheaper to have a HCW going in there daily, assist with bathing and be looking for any skin breakdown versus having a nurse going in daily. (HCS 09)
HCWs visit clients more frequently and spend more time with them; visiting some clients every day and others several times a week. Visits can last from 30 minutes to 2 hours or longer. With longer and more frequent visits, HCWs spend more time with clients and are less rushed with care activities. One HCW commented: Actually, I think a HCW does a better job than . . . ’cos they spend more time with them than an OT or you know, RN. So, we could take our time which is better for the client than rushing through everything. (HCW 08)
In addition to spending more time with clients, HCWs also tend to follow more consistent schedules than healthcare professionals. As one HCW explained: We try and keep the same people, the same time every day in there. However, when the nurses come in, they have a schedule that they just have to fit them in. It’s never, never the same time. (HCW 15)
Consistent visits typically enhance the quality of care, but sometimes flexibility is required to meet clients’ needs. HCWs may accommodate clients’ schedules by reorganising their visit in the light of other commitments, such as doctor’s appointments. In the words of one HCW: And if they have to be at the doctor’s at 10, well then you go there first. You try and accommodate them as much as possible. (HCW 15)
With task shifting, clients may receive some types of delegated of transferred care more consistently. Where clients may not always follow through with the exercises a therapist recommends on their own, training HCWs to help with exercises increases the chances of exercise routines being followed. As one therapist explained, if the therapy is delegated to the HCW: It’s a contract. They have to do it . . . they [the patient] are receiving care versus if they were asked to do on their own. So, yeah I mean quality of life . . . the patients are better off that way than having to do exercise themselves. (T 04)
Ongoing and accurate observation is another component of continuity of care. Good observation is necessary to ensure that changes in the client’s condition are monitored, are reported to the agency and are appropriately treated. Supervisors and HCWs felt that HCWs are best suited to monitor the client’s health status because they visit more frequently and © 2014 John Wiley & Sons Ltd
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are more familiar with clients’ conditions. As one supervisor explained, this ongoing observation can enhance the quality of care: . . .because the HCWs usually have more frequent visits and are able to monitor and understand signs and symptoms . . . an example would be if we were doing intermittent catheterisations, we’d be alert to possible urinary tract infections a lot easier than say a family member doing it or a nurse who has limited visits and that way, the client would get treatment quicker and be proactive. (HCS 07)
Thus, training HCWs to observe and monitor clients’ health status can benefit clients and can also reduce government spending on home care. One supervisor said that task shifting was of: Benefit to the client because it’s more affordable, so the HCW can then report to the nurse or report to the agency that they might need somebody to come and take a look. Something just doesn’t look right. So, they’re kind of the eyes and ears. (HCS 09)
Developing personal, trust-based relationships is an important component of good quality care and is closely related to consistent and continuous service provision. HCWs are well positioned to develop trusting relationships with clients because they consistently spend more time assisting them with personal care and activities of daily living. Through ongoing interactions, HCWs and clients often develop close bonds. One HCW explained the impact of her visit on the quality of care in the following way: It really makes their life a lot better. I mean sometimes I know they look forward to us coming for a lot of different reasons, not just how they feel after we leave, but while we’re there, you know, they love . . . they just love being with us. Not always though. (HCW 19)
When HCWs develop relationships with clients, they are well positioned to provide care in a way that meets individual preferences. Accommodating client preferences then enhances the overall quality of care, as one supervisor explained: If the HCW really knows the client, then the care is going to be good . . . ’cos they know the client’s preferences and likes and dislikes and about every situation. (HCS 06)
Clients tend to be more comfortable with HCWs than with nurses because they interact with them more frequently and consistently. In reference to one of the clients, a HCW explained: As a matter of fact I have a client. I was telling him about me doing this [the interview] and I had told him that I was going to mention it. And he says ‘well that’s so true. You have no idea how intimidating nurses can be’. They come © 2014 John Wiley & Sons Ltd
in, they do their job, they get out. We sit and chat. And the client feels like we’re more human. (HCW 04)
Clients often dislike having multiple care providers in their homes. One of their most frequent complaints is that they receive too many visits from different people. The transfer or delegation of tasks to HCWs may enhance clients’ satisfaction with care by reducing the number of people visiting them. One HCW explained: Things can be taken care of with one person coming in their home instead of three or four. With physiotherapy, the therapist will come and often show us what she wants to be done and we can continue those exercises with the client, without her having someone else come in her home or an inconvenient time. We can do it while we’re there. (HCW 03)
The negative impacts of task shifting on quality of care Some participants clearly identified the benefits of task shifting, but others expressed concerns that the transfer or delegation of tasks from nurses and therapists to HCWs might decrease the quality of care. These concerns centred on the following themes: insufficient training, inadequate delegation or supervision, and scheduling and time constraints. Having the appropriate knowledge, training and skills to carry out the delegated or transferred tasks is an important component of high-quality care. When a case manager decides that a task is to be transferred or delegated, the supervisor, a nurse or a therapist meets with the HCW at the client’s home. Relevant skills are demonstrated, practised and observed. Training usually (but not always) takes place in one visit. More complicated or individualised care, such as Hoyer lifts, catheterisation, ostomy care, injections, physiotherapy and G-tube feeding, may require more than one visit. Supervisors are responsible for determining if additional training is necessary. Concerns regarding the client’s or the HCW’s health and safety, or changes in the client’s condition, may lead supervisors to schedule more training visits. HCWs may also request more training. About half of the participants commented that one visit is usually sufficient for training. Some healthcare professionals expressed concern, though, that a single visit is inadequate and that HCWs lack necessary knowledge and skills. A therapist commented: They may not understand everything, they may be afraid to ask questions, they cannot understand everything because they don’t have the level of education. (T 02)
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well as good communication between the healthcare professional and the HCW. One supervisor explained that effective training ‘all depends on who’s teaching the skills and how competent and confident they are’ (HCS 05). A therapist noted that in doing the training it is important:
as long as the HCW is competent in performing the procedure’ (HCS 01). Conversely, some supervisors felt that training is necessary every time tasks are delegated or transferred to ensure that HCWs meet each client’s individual needs:
To make sure there is an understanding, things are demonstrated well, they can say their understanding of how things should be performed. (T 01)
Each client is different, especially with transfers, and individual training is necessary for some tasks . . . the clients and the way the clients respond, their weight, their ability, their mental function, physical function are all different. So, that needs to be done individually as well. (HCS 06)
A number of nurses, therapists and supervisors felt that task shifting might compromise the quality of care because HCWs are not trained to recognise changes in the client’s condition, to modify procedures when appropriate or to recognise other medical concerns that may arise. One therapist emphasised that active treatment, which involves assessing and re-assessing the client’s condition as they receive care, is necessary to ensure the client’s well-being. She felt that HCWs do not have the skills to give active treatment. Another therapist explained: The professionals can identify any new problem and they can modify the procedure or whatever we are working on. However, the HCW may not have the ability or the skill to notice if there’s a change in the client’s condition or how to change the procedure. (T 07)
Some participants felt that task shifting might negatively impact quality of care due to problems with the processes in place to monitoring care once tasks are delegated. Nurses’ lack of involvement in monitoring was identified as a problem. A supervisor argued: I think with the transfer of skills and delegated tasks that it should be the professional who’s doing that and at least monitoring it. Like, it’s okay to delegate, but have them monitor it down the road to see, you know, is everything okay? (HCS 06)
Ongoing supervision is ideal, but participants realised that supervisors’ heavy workloads were a constraint. As one supervisor noted, there is ‘one supervisor to maybe 50 HCWs’ (HCS 04). Inadequate knowledge, training and supervision are concerns, but some HCWs felt that the skills acquired through practical experience go unrecognised. They did not think it was necessary to train experienced HCWs each time a task was transferred or delegated. Participants also pointed out that task shifting does not compromise the quality of care if the HCW is competent and is not being asked to accept the transferred or delegated task in a high-risk situation with an unstable client. One supervisor commented that ‘it doesn’t impact the quality of care
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These findings demonstrate mixed opinions regarding the training for HCWs to do delegated or transferred tasks. The extent to which task shifting impacts quality of care depends on the nature of each task; the effectiveness of teaching; and the training, monitoring, skill level, education and motivation of the HCW. Scheduling problems may compromise the quality of care when tasks are delegated or transferred. One HCW may be trained to do a delegated task with a specific client. If she is away temporarily, the supervisor may assign a replacement, and this replacement may not have the same training. A supervisor explained: So you’ve gone out and trained somebody and then on the weekend maybe somebody gets sent in that they don’t have the training or you haven’t personally signed off. It makes it much more difficult to provide care at all times. (HCS 08)
HCWs typically spend more time with clients and are responsible for various types of care, including assisting clients with activities of daily living and instrumental activities of daily living. Transferred or delegated tasks are an added responsibility. HCWs felt that insufficient time to carry out various tasks might compromise the overall quality of care clients receive. A HCW commented: Well if we have to worry about what has been transferred to us and doing that job versus our own job, well then it definitely would affect the quality of care. (HCS 18)
Discussion With demand for home-care services increasing, community care organisations in Ontario and elsewhere are adopting task shifting strategies to reduce the costs of care and to provide care to a greater number of clients. The purpose of this paper was to gain an understanding of the impacts of task shifting on the quality of care provided to clients from the perspectives of home healthcare workers. Findings reveal
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Task shifting and the quality of home and social care
important insights regarding the advantages and disadvantages of task shifting. On the one hand, task shifting may be advantageous because HCWs are well positioned to provide more consistent care; to develop personal, trust-based relationships with clients; and because task shifting reduces the number of care providers entering clients’ homes. As the ‘eyes and the ears’ of the home healthcare system, HCWs can liaise between clients and other healthcare professionals. In these ways, task shifting may improve the quality of care clients receive. On the other hand, task shifting has disadvantages because HCWs do not always have the knowledge, training and education necessary to perform more complex tasks and because scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. This might compromise the quality of care clients receive. Qualitative interviews were used to collect data for this study. A strength of this method is that it allowed us to examine the impacts of task shifting on the quality of care in an in-depth manner. The findings are transferable to similar home-care organisations in Ontario and elsewhere. There are, however, some limitations to the study. First, the small sample size and specific context from which the data were drawn means that findings cannot be generalised to other settings such as private home-care services or the long-term care setting. Another limitation is that we did not collect information on healthcare workers’ length of employment in the field. Those employed in home healthcare for longer might have a deeper understanding of the issues being addressed in this paper. They might also be less reticent to share concerns about their work should fear of reprisal be an issue. Length of employment might thus have an impact on participants’ views of task shifting. The final limitation is that we did not address clients’ views on task shifting and the quality of care. This is an important question for future research and would complement the findings presented here. These results of this research have implications for regulating bodies, employers, educators, unions and professional associations. Echoing other recent studies (Bystedt et al. 2011, Craftman et al. 2013), further examination of the delegation of acts and the transfer of tasks is necessary, along with recommendations to support the necessary competency development among HCWs to ensure the quality of care. Regulatory acts that govern the delegation and transfer of tasks should be reviewed in light of changes to the workforce skill-mix brought on by task shifting. Canadian research has highlighted the need for more standardised training among HCWs and supervisors © 2014 John Wiley & Sons Ltd
(Martin-Matthews et al. 2013). To ensure adequate and appropriate training, employers need to give additional orientation training for HCWs to ensure all staff has a baseline of expertise in commonly transferred or delegated tasks, as well as ongoing professional development as the tasks being transferred or delegated evolve. For educators, these results present an opportunity to refresh HCW curriculum and/or offer enhanced training. For unions, this may require revisiting union regulations. HCWs, unlike regulated workers, do not have a body that oversees their professional development as a requirement to maintain certification. These results present a case for ongoing professional development for those HCWs who are involved in the transfer of tasks or delegated acts. Finally, this research raises a few other issues for future consideration, including: fair compensation for HCWs whose job duties and training are expanding; more formalised training guidelines for supervisors; the need for a sufficient number of health professionals to provide the required training, supervision and continuing education of HCWs; and regulations for task shifting to be set with the professions involved.
Acknowledgements Support for this project was provided through a research grant from the Ontario Health Human Resource Research Network. Thank you to Kate Ducak for assistance with the analysis of the data.
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