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Illustration by Tim Boelaars

The Fixing Health Care series presents 10 common problems faced by patients in Canada, along with 10 solutions that the authors argue can be achieved within our existing publicly funded health system. While the ‘problem’ scenarios in the series are fictional, the authors offer these examples to echo the patient experiences they have encountered through their work in health care and social services.

The Problem: Canadians mistrust the quality of care offered to aging family members

Mark’s mother is now in her late 80s, while her sister is in her 90s, and Mark is the only “child” of his generation who lives close to them both. He is going to be increasingly responsible for helping them as they age, which means he’s learning a lot about the importance of personal support workers, or PSWs.

His aunt was admitted to a nursing home run by the province two years ago, just before the start of the pandemic. She caught the virus during its first wave in 2020, but fortunately recovered; many people in her nursing home were not as lucky.

Most of the people looking after Mark’s aunt are PSWs. Many of them became sick before everyone started getting vaccinated. For the first nine months of the pandemic, his aunt said that many of the PSWs had to isolate after COVID exposure, that she was not really getting much care and that her hygiene suffered. She said they were incredibly short-staffed because of COVID.

Fortunately, with everyone vaccinated, Mark can visit her again and has now met many of the PSWs at the home. Now that they know him, several of the PSWs tell him that they are always looking for new jobs and won’t be staying at the nursing home much longer. Even though they are short-staffed, the residence won’t give them full-time hours and they end up having to work in other homes or at other jobs. They say that they can now make more money working in retail or food service and are probably going to leave health care altogether.

Mark’s mother is doing much better than her sister, but she has been slowing down and has recently started getting PSW-based home care. Knowing that a PSW is coming in to help her shower and ensure she is taking her meds is a great relief to Mark. There are issues with the PSW care though – his mother says they rarely show up at their appointed time, and the personnel who visit her are constantly changing.

Mark spoke to a couple of the PSWs taking care of his mum about this inconsistency. They told him that with COVID, the shortage of home-care PSWs has become severe. They apparently earn less than the PSWs in nursing homes, and they don’t get paid for the time (or the expenses, such as gasoline) they spend travelling between clients. A couple of the workers told him that they love helping seniors like his mother, but that being a home-care PSW is a terrible job.

The Fix: Canadian governments must improve employment standards for PSWs, regulate the vocation, and pay attention to the PSW career trajectory

The role of the personal support worker in Canadian health care (referred to as PSWs throughout this essay, though they are also known as care aides, continuing-care assistants, home-support workers and other titles across the country) became a galvanizing topic of conversation during the COVID-19 pandemic, particularly when residents in nursing homes suffered real hardship because of inadequate long-term-care home staffing. These workers were not provided with personal protective equipment during the early days of COVID-19. As the virus rapidly spread, many PSWs could not work because of sickness or because they were told to isolate after contact with infected individuals. The issue was exacerbated by the fact that many PSWs had to work in multiple homes to earn a living wage.

Unfortunately, we now know that the lack of staffing in long-term care homes led to some of the most horrific circumstances experienced by Canadians during the pandemic. Most shockingly, dozens of people in long-term care homes died not from COVID-19, but from neglect.

Why did this system of care collapse so quickly at the onset of COVID-19? Clearly, Canada has become increasingly reliant on PSWs to take care of its aging population. But despite the obvious importance of the role, these workers generally remain underpaid and undervalued.

PSWs in Canada provide care mainly to seniors or people living with disabilities. PSWs work in a variety of settings, including home care, privately and publicly funded long-term care and retirement homes, group homes, hospital settings and even prisons. PSWs are trained to assist with the activities of daily living (i.e. getting dressed and maintaining hygiene), preparing meals, light housekeeping and the supervision of medications, among other tasks.

They represent a large group of workers across Canada – Ontario has an estimated 100,000 PSWs, which is about the same as the number of nurses in the province. Exact numbers are difficult to come by, however, as the number of people working as PSWs is not actively tracked or regulated across the country.

The vocation also has a high degree of turnover. An Ontario long-term care staffing study published in July, 2020, reported that around 25 per cent of PSWs who have two or more years of experience leave the sector annually. In September, 2020, the SEIU Healthcare union said that 30 per cent of the nurses and PSWs it represents (around 7,500 people total) were planning to leave their jobs. At present, nearly every province and territory in the country is struggling to respond to PSW shortages and turnover rates. The conditions faced by these workers can offer insight as to why.

Around 90 per cent of PSWs in Canada are women, with one study estimating that around 40 per cent of PSWs in Ontario identify as visible minorities. Many PSWs are new migrants, who take on the role in order to enter the Canadian work force (some have worked as nurses or in other health care positions in their home countries, but their training is not recognized in Canada). Often, the contracts given to PSWs are part-time or casual, which allows employers to forgo offering them benefits. One 2017 study characterized Canada’s PSWs as the health care sector’s “new precariat” – a group of workers faced with the combined precariousness of low wages and high job insecurity, noting that “the gendered and ethnic nature of PSW work” likely contributes to the marginalized status of PSWs across the Canadian health care sector.

PSW compensation is at the very lowest end of the health care pay scale and is often determined not by the type of work the worker does, but rather the sector in which she is employed. While there is no significant difference in the work that PSWs provide across the various settings they work in, discrepancies in compensation abound. In Ontario, the high end of PSW pay is about $25 an hour (plus benefits) for those lucky enough to work in municipal long-term care homes. Private retirement-home PSWs are the lowest paid, at about $16 an hour – just slightly above Ontario’s minimum wage. In Quebec, some PSWs were paid as little as $13 an hour during the pandemic.

PSWs working in home care face particular challenges as well. In a survey released in March, the SEIU Healthcare union found that 72 per cent of its home-care PSW members were planning to leave their jobs because of the recent increase in gas prices; 90 per cent of those surveyed said the home-care corporations they work for do not compensate workers for gas expenses. However, 90 per cent of respondents also noted they would stay in the home-care industry “if full-time jobs, higher wages, and stronger benefits were the conditions of employment.”

The first change governments need to make in supporting PSWs is in recognizing the insecure nature of their work. PSWs working in all sectors need to be offered more full-time employment opportunities, and their wages must be standardized across their various employment settings – since most PSWs are paid through government funding, this should be reasonably straightforward. In addition to improving their wages, job conditions must also be addressed. PSWs working in home care, for example, need to be routinely compensated for the travel time reasonably taken between clients.

Changes to PSW pay and employment standards will increase costs to the health system. However, at present (and even before the pandemic) the PSW shortage has led to more patients being cared for in higher-cost environments. For example, they may be kept in hospital because a long-term care bed is not available, and patients who could otherwise maintain their independence at home with appropriate PSW care are added to long-term-care wait lists because reliable home care is not available. While costs may increase in the short term, transforming the system of care for our seniors is a Canadian imperative that will pay out financial and societal dividends in the long run.

With a burgeoning human-resource shortage spreading across most health care roles, we need to develop a better career trajectory for PSWs. Subsidies for the community college diploma required to become a PSW and paid on-the-job training experience are a must (the governments of Manitoba, New Brunswick, Nova Scotia and Prince Edward Island are all leading the way in this regard by fully covering tuition for certain PSW education streams).

PSWs should also have the opportunity to train for registered practical nurse and registered nurse roles as part of their job trajectory. PSWs also lack a regulatory body to register with after completing their education. This is a particularly worrisome gap in the system of care, as complaints about individual PSWs are logged only with their current employers and are left behind once the PSW moves on. As they care for some of the most vulnerable members of our population, we must better regulate the PSW role with the same approach taken in nursing and medicine.

The PSW role needs to be understood as the fundamental job that supports seniors in our health system. In the wake of the pandemic, if our goal as a country is to indeed reform how we care for our aging population, understanding the importance of well-trained and accountable personal support workers is essential. Creating respect for the role, as well as accountability, requires that PSWs be part of a regulated vocation, compensated fairly and provided with the opportunity to advance their careers in the Canadian health system.

About the authors:

Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former deputy minister of health for Ontario and former CEO of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.

Open this photo in gallery:

Illustration by Tim Boelaars

More from the Fixing Health Care series:

Seniors need communities that cater to their whole selves, not just their bodies

The pandemic revealed brutal realities about long-term care. Canada has a moral obligation to fix the system

Transitional-care facilities will stop Canada’s ERs from resorting to ‘hallway medicine’

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