Demand for home and community care services has continuously increased in Canada and elsewhere in the last few decades due to aging of the population and healthcare policy changes shaped by budgetary limitations. As a result, home and community care organizations are having trouble hiring adequate numbers of healthcare workers to meet the escalating demand, the result being increased workload on these workers. Another stream of literature has shown that care recipients and their family members, frustrated with the limited ability of healthcare workers to provide adequate care because of increased workload, might resort to violence and harassment. Bringing these two streams of literature together, we examined the relationships among three variables : workload ; workplace violence and harassment ; and well-being of personal support workers (PSWs).
Using structural equation modeling, we analyzed a 2015 Ontario-wide survey of 1,347 PSWs employed in the home and community care sector. The results indicate that workload is negatively associated with extrinsic and intrinsic job satisfaction, and this relationship is mediated by violence and harassment and by stress. Specifically, workload is positively associated with violence and harassment at work, which in turn is positively associated with stress, which in turn is negatively associated with extrinsic and intrinsic job satisfaction.
Our study contributes to the literature by examining the impact of a work environment factor, workload, on the well-being of PSWs. This approach makes it possible to expand the current literature’s focus on psychological processes at the individual level to a more contextual approach. Furthermore, the results have important implications for home and community care organizations as well as for the healthcare sector in general. The well-being of PSWs is critical to retaining them and to ensuring the quality of care they provide their clients. Thus, their workload should be lowered to a more manageable level to help minimize the violence and harassment they experience.
- healthcare workers,
- extrinsic job satisfaction,
- intrinsic job satisfaction,
Avec le vieillissement de la population et l’évolution des politiques de santé en raison de contraintes budgétaires, le Canada connait depuis quelques décennies, tout comme d’autre pays, une augmentation continue de la demande de services de soins à domicile et en milieu communautaire. Ainsi, les fournisseurs de ces services ont du mal à embaucher suffisamment de personnel de santé pour répondre à la demande croissante, ce qui augmenterait la charge de travail qui pèse sur ces travailleurs. Un autre courant de littérature montre que certains bénéficiaires de soins, ainsi que les membres de leur famille, frustrés par la capacité limitée du personnel de santé à fournir des soins adéquats en raison de la charge de travail accrue, risquent de recourir à la violence ou au harcèlement. En réunissant ces deux courants de littérature, nous nous sommes penchés sur les relations entre trois variables, soit la charge de travail, la violence et le harcèlement au travail et le bien-être des préposés aux bénéficiaires (PAB).
En utilisant la modélisation par équation structurale, nous avons analysé les données provenant d’une enquête ontarienne menée en 2015 sur 1347 PAB ouvrant dans le secteur des soins à domicile et en milieu communautaire. D’abord, les résultats indiquent que la charge de travail est négativement associée autant à la satisfaction intrinsèque au travail qu’à la satisfaction extrinsèque au travail ; cette relation est influencée par la violence et le harcèlement, ainsi que par le stress. Plus particulièrement, la charge de travail est positivement associée à la violence et au harcèlement sur le lieu de travail, qui sont à leur tour positivement associés au stress, qui est à son tour négativement associé autant à la satisfaction intrinsèque au travail qu’à la satisfaction extrinsèque au travail.
La présente étude contribue à la littérature par une analyse de l’impact d’un facteur du milieu de travail, soit la charge de travail, sur le bien-être des PAB. Cette approche permet d’élargir la portée de la littérature, qui est actuellement centrée sur les processus psychologiques de l’individu, pour tenir davantage compte du contexte. De plus, les résultats ont des implications importantes autant pour les fournisseurs de soins à domicile et en milieu communautaire que pour le secteur de santé en général. Le bien-être des PAB est essentiel pour les retenir et pour garantir la qualité des soins fournis. Ainsi, pour aider à minimiser la violence et le harcèlement qu’ils subissent, la charge de travail devrait être réduite à un niveau plus facile à gérer.
- personnel de santé,
- satisfaction extrinsèque au travail,
- satisfaction intrinsèque au travail,
In the last few decades, with the aging-in-place approach to elderly care and with shorter patient stays in hospitals, demand for home and community care services has continuously increased in Canada and elsewhere (Colombo et al., 2011 ; Keefe et al., 2011 ; Macdonald et al., 2017). Budgets for home care services, however, have not increased commensurately (Home Care Ontario, 2011 and 2017 ; Wetzel et al., 2005). It is thus difficult for home and community care organizations to hire a sufficient number of workers to provide services for the increased demand (Ontario Community Support Association, 2016). Consequently, the workload has become heavier for those employed in the home and community care sector, with many reporting decreased well-being, particularly stress and lower job satisfaction (Denton et al., 2002).
In a different stream of literature, studies have shown a high incidence of workplace violence and harassment among workers in the healthcare sector (Canadian Centre for Occupational Health and Safety (CCOHS), 2019 ; Eurofound, 2012 ; European Foundation, 2010 ; Lippel, 2016 ; Ontario Ministry of Labour, 2018), in long-term care institutions (Armstrong et al., 2011), and in the client’s home (Barling et al., 2001). Stress and job dissatisfaction are some of the consequences of violence and harassment at work (European Foundation, 2010 ; Lanctôt and Guay, 2014 ; see also Lippel’s 2016 review). Studies in the home and community care sector have shown similar consequences of workplace violence and harassment, (Denton, Zeytinoglu and Webb, 2000 ; Zeytinoglu, Denton, and Plenderleith, 2012 ; Hanson et al., 2015 ; Panagiotoglou et al., 2017). In the related sector of long-term care, the literature has shown that the demand for care, coupled with insufficient staffing, has increased the workload and decreased the ability of workers to provide adequate care, with frustrated care recipients exhibiting violence and harassment (Armstrong et al., 2009 and 2011 ; Banerjee et al., 2008, 2012, 2015). In addition, in their attempts to finish their own work with limited time and resources, workers and supervisors act in ways toward co-workers and subordinates that can be construed as violent and harassing (Armstrong et al., 2009 and 2011 ; Banerjee et al., 2008, 2012, 2015). In the related occupation of nursing, there have been reports of similar experiences of heavy workloads leading to violence at work (Choiniere et al., 2014 ; Gacki-Smith et al., 2009 ; Hesketh et al., 2003 ; Nowrouzi-Kia et al., 2019).
In this article we focus on the relationship between workload and workplace violence and harassment and on the consequences of such experiences for the well-being of personal support workers (PSWs). Our aim is to provide insight into this relationship with respect to PSWs, and the mediating role of workplace violence and harassment between workload and well-being. In this paper, well-being refers to strain and job satisfaction.
Our broader aim is to contribute to theoretical and practical knowledge about workplace violence and harassment. First, for the theoretical contribution, we will introduce workload as a work environment factor that contributes to the risk of workplace violence and harassment, which in turn increases strain and decreases extrinsic and intrinsic job satisfaction. Our study will bring together several important perspectives on job satisfaction : the theory of structural violence (Galtung, 1969) ; the demand-control model (Karasek and Theorell, 1990), which demonstrates the importance of work factors in well-being ; job satisfaction theory (Mobley, 1977 ; Mobley et al., 1979), which postulates that job content affects job satisfaction ; and strain as important job factors affecting job satisfaction (Locke, 1976). Our study will enhance theoretical understanding by explaining how the association between workload and well-being is mediated by workplace violence and harassment. Second, through the findings of this article, we will contribute to the knowledge of practitioners (policy makers, employers, unions and workers) by providing insight into how heavy workloads can contribute to violence and harassment experienced at work and how this experience can in turn affect PSWs’ well-being.
PSWs included in our study provide care to the elderly, to patients discharged from hospitals and to persons with disabilities in their homes or in the community. These workers are also called personal care workers, home support workers or healthcare aides (Macdonald et al., 2017), though the most commonly used occupational title in Ontario is PSW (Ontario Ministry of Advanced Education and Skills Development, 2011). Because personal support work is not a separate occupation in government data collection for health and safety, there is no specific information on this workforce. The provincial government, employers, unions, employee associations and workers have themselves been interested in data on PSWs’ experiences (see the project website, pswshaveasay.com).
In our earlier study conducted in 1995-1996, we demonstrated that workplace violence and harassment were common experiences of visiting nurses, therapists and home support workers in three non-profit home and community care organizations located in a mid-sized city in Ontario (Denton, Zeytinoglu and Webb, 2000). Violence and harassment were associated with workers reporting increased stress and decreased intrinsic job satisfaction (Denton, Zeytinoglu and Webb, 2000). In 2002, there were similar results from a study in the same location with an expanded number of workplaces covering all organizations, both for-profit and not-for-profit (Zeytinoglu, Denton, and Plenderleith, 2012). In 2015, we expanded the study to include PSWs working in the home and community care sector in Ontario. This paper uses the data collected in 2015.
Our paper was a response to stakeholders who seek evidence on the health and safety experiences of PSWs and to researchers who argue that work environment factors, including workload, contribute to the risk of violence and harassment at work (see Lippel’s 2016 review) in the long-term care sector (Armstrong et al., 2009 and 2011 ; Banerjee et al., 2008, 2012, and 2015) and in the related occupation of nursing (Choiniere et al., 2014 ; Gacki-Smith et al., 2009 ; Hesketh et al., 2003 ; Nowrouzi-Kia et al., 2019).
Theory and the conceptual model
Violence is defined as threatened, attempted or actual use of physical force against a worker, and harassment as behaviour that demeans, humiliates, annoys, alarms or verbally abuses a worker and is unwelcome or expected to be unwelcome (CCOHS, 2019). Violence can manifest itself directly or indirectly. Direct violence occurs between actors (e.g., individuals, groups, organizations) whereas indirect violence may not have a clear target but is deeply embedded in society (Galtung, 2013). While direct violence is easier to observe and comprehend, indirect violence renders itself invisible (Winter, 2012). First coined by Galtung (1969), the term ‘structural violence’ means an indirect form of violence that prevents certain groups in society from satisfying their physical, psychological and economic needs due to social, economic and political factors (Christie, 1997). For example, structural violence has a gendered nature (Anglin, 1998), thus implying that it might have more detrimental outcomes for women than for men. Structural violence implies that certain contexts can produce violence (Anglin, 1998). It can manifest itself in many forms, including inequality of power (Galtung, 1969), limitation of life opportunities (Anglin, 1998 ; Winter, 2012), economic exploitation and poverty (Christie, 1997). Structural violence and direct violence are interdependent and can reinforce each other (Christie, 1997). For example, Finstad et al. (2019) showed that violence might be a symptom of a high-strain work environment. In this study, workload is conceptualized as structural violence, and workplace violence and harassment experienced by PSWs as direct violence.
In the home and community care sector, a heavy workload is associated with several wellness problems, including stress and decreased job satisfaction (Zeytinoglu, Denton, and Plenderleith, 2012). An earlier study showed that PSWs perceive their pace of work as too fast, their workload as too heavy and their work as too demanding for the time allocated to performance of their tasks (Denton et al., 2002). Literature on the healthcare sector has shown that heavy workloads can increase violence at work when patients feel neglected and not adequately cared for (Banerjee et al., 2012 and 2015 ; Hesketh et al., 2003 ; Nowrouzi-Kia et al., 2019 ; Park et al., 2015). Such violence can be structural, and violence and harassment at work will be more likely if residents do not receive “the care they need” (Armstrong et al., 2011 : 127) and if patients feel powerless (Nowrouzi-Kia et al., 2019).
These findings are hardly surprising. Empirical research on workplace violence and harassment has documented violence to be high in the healthcare sector, particularly violence by clients, patients and their family members (Canton et al., 2009 ; Lippel, 2016 ; Eurofound, 2012). Independently of workload, violence and harassment at work can also affect workers’ well-being : research has shown that workplace violence and harassment can lead to stress (Denton, Zeytinoglu, and Webb, 2000 ; Zeytinoglu, Denton, and Plenderleith, 2012 ; Nielsen et al. 2015 ; Lippel, 2016).
The job demands-control model (Karasek, 1979) is one of the most tested and supported models in the occupational work stress literature. According to this model, employees experience stress at work if subjected to a high level of work demand with little control over their work (Kain and Jex, 2010). Their stress level in turn predicts their well-being (Luchman and González-Morales, 2013). Such jobs (i.e., high demand-low control) are defined as high-strain jobs (Karasek, 1979). In this paper, we argue that personal support work is a high-strain job. Extant research using the job demands-control model (Karasek and Theorell, 1990) has shown the importance of work factors in stress, which in turn reduces job satisfaction (Canton et al., 2009 ; Locke, 1976). For organizations in the healthcare sector, as with organizations in the service sector (Lawler III, 2005), having employees satisfied with their jobs is crucial to the quality of the care and service.
Job satisfaction can be described as a person’s response to what happens at work (Lawler III, 2005). Theoretical work on job satisfaction has shown that the work environment is an important factor in job satisfaction (Mobley, 1977 ; Mobley et al., 1979). Individuals have different experiences and expectations and perceive their work tasks differently. They thus vary in the satisfaction they derive from intrinsic and extrinsic facets of their jobs (Decker et al., 2009 ; Iseke, 2014 ; Mottaz, 1985 ; Rice et al., 1989). In this study, we differentiate between intrinsic (e.g., sense of accomplishment) and extrinsic (e.g., perception of fair pay and benefits) aspects of job satisfaction to develop a more refined understanding of PSWs’ well-being.
As presented in Figure 1, we built a model using the above-discussed theories of structural violence (Galtung, 1969) : the job demands-control model of stress (Karasek and Theorell, 1990 ; Locke, 1976) and job satisfaction (Mobley, 1977 ; Mobley et al., 1979), as well as the empirical research on workplace violence and harassment (Karaeminogullari, Erdogan, and Bauer, 2018 ; Lanctôt and Guay, 2014 ; Schat and Kelloway, 2003 ; Vessey, DeMarco, and DiFazio, 2011 ; Yragui et al., 2017). We thus developed a model to show how the experience of PSWs with workplace violence and harassment leads to strain, which affects extrinsic and intrinsic job satisfaction. We incorporated workload as a work environment factor and as an embodiment of structural violence that contributes to the risk of workplace violence and harassment, a form of direct violence. On this basis, we hypothesized that,
Hypothesis 1 : Workload will be positively associated with the PSWs experiencing workplace violence and harassment at work.
Hypothesis 2 : Workplace violence and harassment will be positively associated with strain.
Hypothesis 3a : Strain will be negatively associated with extrinsic job satisfaction.
Hypothesis 3b : Strain will be negatively associated with intrinsic job satisfaction.
In addition to examining the above-mentioned relationships, we also used our model to test whether workplace violence, harassment and strain mediate the relationship between workload and job satisfaction, be it intrinsic or extrinsic. Our hypotheses were :
Hypothesis 4a : Heavy workload is associated with PSWs experiencing workplace violence and harassment, which in turn mediates the association of workload with strain, which in turn is hypothesized to mediate the association of workload, through workplace violence and harassment, with extrinsic job satisfaction.
Hypothesis 4b : Heavy workload is associated with PSWs experiencing workplace violence and harassment, which in turn mediates the association of workload with strain, which in turn is hypothesized to mediate the association of workload, through workplace violence and harassment, with intrinsic job satisfaction.
Data collection process
Out study used data from a 2015 Ontario-wide survey called ‘PSW Health and Safety Matters !’[hereafter the survey] (pswshaveasay.com). A Research Advisory Committee (RAC) was formed to guide this project. The RAC was composed of representatives from two employer associations of home care organizations, from two PSW employee associations, from a health and safety association with expertise on PSWs, from two unions in the healthcare sector and from a project research team (see the Acknowledgments section).
The research team encouraged PSWs to participate in the survey through several means : email blasts sent out by partner organizations ; advertisements on several organizations’ websites, newsletters and Twitter accounts ; and an in-house training session followed by requests to go to the study website and fill out the survey. We used LimeSurvey, an online web application, and, if requested, a print mail-out survey for data collection. PSWs were asked to respond to the survey only if they worked in the home and community care sector. Although respondents were encouraged to complete the entire survey, they were not required to do so or answer every question. They were given minor incentives to complete the survey, such as draws for gift cards.
Population and sample
The study population was composed of PSWs employed in the home and community care sector in Ontario, Canada. The population size was estimated at 34,000 at the time of data collection. A total of 1,746 respondents completed the entire survey (i.e., they filled it out to the last page). For the online survey, they selected ‘submit the survey’ option ; for the print-mail survey, they mailed it back to us. Analysis of the survey responses showed that 21 percent of the respondents had been a victim of physical or sexual violence or harassment at work in the past 12 months. While 71 percent were satisfied or very satisfied with their work, 25 percent reported that most days at work were quite a bit or extremely stressful. The gender and age breakdown was 94 percent female and 69 percent 45 years old or older. Two thirds of the respondents were married or living with a partner.
In the analyses, we excluded observations with missing values ; thus, the final sample consisted of 1,347 PSWs. To check for bias due to observations with missing values, we compared our results using multiple imputation for missing data with results using list-wise deletion of missing data. We found that both were very similar in terms of level of significance, direction and magnitude. Therefore, we report our sample results with list-wise deletion. The means and standard deviations are presented in Table 1.
All variables were measured on a five-point Likert scale anchored with ‘1=strongly disagree’ to ‘5= strongly agree’ unless otherwise stated. To create scores for each scale, responses to each item were summed, with some items reverse-coded as suggested by the scale developer. All descriptive statistics and internal reliability measures are presented in Table 1.
The dependent variables were extrinsic job satisfaction and intrinsic job satisfaction. Using exploratory factor analysis, Denton et al. (2002) developed both scales following Locke’s (1976) conceptualization, where job satisfaction is defined as the degree to which workers perceive that their job is fulfilling important values that are consistent with their needs. The four items of the extrinsic job satisfaction scale were : “you feel that you are fairly paid ; your benefits are good ; your job security is good ; and your chances for promotion are good.” For the intrinsic job satisfaction scale, the items were : “you get a sense of accomplishment from your job ; your job gives you a sense of purpose in life (a reason to get up in the morning) ; your job builds your self-esteem through helping clients ; your job is interesting.” Cronbach’s α values for extrinsic job satisfaction and intrinsic job satisfaction were 0.71 and 0.75, respectively.
The independent variable was a seven-item workload scale from Denton et al. (2002). Two sample items were : “your job is very hectic” and “you are expected to do too many different tasks at the same time.” Descriptive statistics showed that the respondents considered their workloads to be moderately heavy. The work intensification index indicated high internal reliability (α = 0.89).
There were two mediating variables : workplace violence and harassment and strain. In line with Galtung’s (1969) conceptualization of violence, we used a broad conceptualization of violence and harassment that included all kinds of violence and harassment as perceived by the participants. Specifically, the survey described workplace violence as “[…] either the threat of, attempt to, or exercise of physical force against you. This may be physical (i.e., scratching, pinching, pushing, spitting, slapping/hitting, kicking, biting, punching, restraining) or sexual violence.” Harassment was described as “any behaviour that demeans, humiliates, annoys, alarms or verbally abuses you and that is or would be expected to be unwelcome. This includes words, gestures, intimidation, bullying, or other inappropriate activities.” The variable ‘workplace violence and harassment’ was a dichotomous measure worded in the survey as “In your job as a PSW in the community, in the past twelve months, have you been a victim of physical or sexual violence or harassment at work ?” Approximately 21 percent reported being a victim of physical or sexual violence or harassment at work in the past 12 months. Strain was measured by a 14-item symptoms of stress scale (Denton et al., 2002). The following was a sample item from the scale : “During the past month, how often have you felt exhausted at the end of the day ?” Inter-item reliability was measured at α = 0.86.
Control variables were tenure, immigrant status, level of education and living alone. Gender was not included as a control variable, since 94 percent of the respondents were female. There was consequently not enough variance in the gender variable to allow a meaningful comparison between female PSWs and male PSWs. ‘Tenure’ was the number of years of experience as a PSW. ‘Immigrant status’ was whether the respondent was an immigrant or born in Canada (1 = immigrant, 0 = Canadian-born). ‘Level of education’ had four categories : high school or lower (reference) ; trade school ; college ; and university or higher. ‘Living alone’ was whether the respondents shared their dwelling with others (1 = living alone, 0 = sharing dwelling with others). The respondents had approximately 10 years of tenure, and 62 percent of them were immigrants. About 73 percent of them had a college degree or higher, and 15 percent reported living alone.
In addition to descriptive statistics, our analysis included correlations and structural equation modeling (SEM) with maximum likelihood estimation. We calculated several goodness of fit indices to ensure a good fit between the data and the model : χ2=2349.05, d.f. 518 ; RMSEA=0.05 ; SRMR=0.08 ; CFI=0.87 ; TLI=0.85. STATA 14 was used for the analysis. It should be emphasized that the data were cross-sectional. Thus, the SEM analysis indicated associations, not causal relationships. Standardized beta coefficients are presented to enable the reader to interpret the results in standard deviation units.
We used data from one survey, and the responses came from PSWs only. To alleviate common-method variance (CMV), we used both procedural and statistical remedies, specifically the procedural remedies suggested by Podsakoff, MacKenzie and Podsakoff (2012). For statistical examination of CMV, we examined a first-order factor that included all items for all scales as indicators, and there were no significant factor loadings for any of the items (Podsakoff, MacKenzie, Lee, and Podsakoff, 2003). Analysis did not raise any multi-collinearity concerns, since the inter-variable correlations had low values (see Table 1).
The correlations are presented in Table 1. Extrinsic job satisfaction is significantly and negatively correlated with three variables : workplace violence and harassment, strain, and workload. Similar associations can be observed for intrinsic job satisfaction. As expected, extrinsic and intrinsic job satisfaction are positively associated. The variable of workplace violence and harassment is positively associated with strain and workload. Strain and workload show a significant positive association. Among the control variables, tenure has a positive association with workload. Immigrant status is significantly and negatively associated with extrinsic job satisfaction and significantly and positively associated with workplace violence and harassment and with strain. Among the education variables, high school or less has a significant negative association with workplace violence and harassment, with strain and with workload. College is significantly and positively associated with strain.
Figure 2 depicts the direct and indirect effects with solid lines and dashes, respectively. Focusing on the direct effects, we find a significant and positive association between workload and workplace violence and harassment (β = 0.13, p < 0.001). Thus, Hypothesis 1 is supported. The variable of workplace violence and harassment is significantly and positively associated with strain, supporting Hypothesis 2 (β = 0.31, p < 0.001). Hypotheses 3a and 3b suggest that strain should be negatively associated with PSWs’ extrinsic job satisfaction and intrinsic job satisfaction, respectively. We find that strain is significantly and negatively associated with extrinsic job satisfaction (β = -0.34, p < 0.001) and intrinsic job satisfaction (β = -0.48, p < 0.001). Thus, Hypotheses 3a and 3b are supported.
Hypothesis 4a proposes that workplace violence and harassment and strain mediate the association between workload and extrinsic job satisfaction. An indirect association between dependent and independent variables supports the existence of mediation (Shrout and Bolger, 2002). The negative and significant indirect effect (indicated by dashes in Figure 2) between workload and extrinsic job satisfaction supports Hypothesis 4a (β = −0.01, p < 0.001). Similarly, there is a significant negative indirect effect between workload and intrinsic job satisfaction, supporting Hypothesis 4b (β = −0.02, p < 0.001).
Looking at the remaining indirect effects in the model, we find that workload is positively associated with strain (β = 0.04, p < 0.001). The variable of workplace violence and harassment is negatively associated with extrinsic job satisfaction (β = −0.10, p < 0.001) and intrinsic job satisfaction (β = −0.15, p < 0.001). Overall, the indirect associations among endogenous and exogenous variables are significant and in the expected directions.
Among the control variables, tenure is negatively associated with intrinsic job satisfaction (β = -0.01, p < 0.05). Immigrant status has a negative association with extrinsic job satisfaction (β = -0.13, p < 0.01) and a positive association with intrinsic job satisfaction (β = 0.09, p < 0.05), with workplace violence and harassment (β = 0.12, p < 0.001) and with strain (β = 0.17, p < 0.001). Among the education variables, trade school has a positive association with workplace violence and harassment (β = 0.13, p < 0.01). College is positively associated with workplace violence and harassment (β = 0.07, p < 0.05) and with strain (β = 0.12, p < 0.01). University or higher has a positive association with strain (β = 0.16, p < 0.01). Finally, living alone is negatively associated with strain (β = -0.09, p < 0.05). The rest of the control variables have no significant associations at p < 0.05.
In this study, we investigated the role of workload in workplace violence and harassment, and the consequences for the well-being (i.e., strain and job satisfaction) of PSWs in Ontario. The results suggest that the association of workload with decreased extrinsic and intrinsic job satisfaction is partially mediated by workplace violence and harassment and by strain. Specifically, with increased workload, there is an escalation of experiences with workplace violence and harassment. When PSWs are exposed to workplace violence and harassment, they also experience strain, which in turn is associated with decreased extrinsic and intrinsic job satisfaction. Our findings are in line with previous studies in the healthcare sector, in related sectors (e.g., long-term care) and in occupations (e.g., nurses) (Banerjee et al., 2012 and 2015 ; Nielsen et al., 2015 ; Canton et al., 2009 ; Hesketh et al., 2003 ; Lippel, 2016 ; Nowrouzi-Kia et al., 2019 ; Park et al., 2015), and with our earlier studies of home care workers in a city in Ontario (Denton, Zeytinoglu, and Webb, 2000 ; Zeytinoglu, Denton, and Plenderleith, 2012).
Because the home and community care sector is female-dominated, it is not surprising that our respondents were predominantly (94%) female. As discussed in the literature, social relationships operate within a highly gendered workforce, and the violence against care workers occurs within a set of gendered relations, expectations and dynamics (Banerjee et al., 2012 and 2015 ; Armstrong et al., 2011 ; Choiniere et al., 2014 ; Daly et al., 2011 ; Baines and Cunningham, 2011). The female-dominated PSW workforce in the home and community care sector does important work for care receivers by contributing to the well-being of individuals and society in general. Nevertheless, the importance of their work and the difficulties they experience in the workplace, including a heavy workload and workplace violence and harassment, are rarely seen or recognized. One has only to look at the response to the recent COVID-19 pandemic, the Ontario government’s ad-hoc temporary pay-raise for PSWs in long-term care (Global News, 2020) and the lack of recognition for similarly important and dangerous work in home and community care (Denton, 2020 ; Brookman, 2020) to notice the low profile of this highly gendered work (care work) and workforce (PSWs) (Zeytinoglu et al., 1999). The PSWs in home and community care are not seen by decision makers in the government and the healthcare sector, and their work in the long-term care sector is visible only on an ad-hoc basis during an emergency.
If we look at workload, at workplace violence and harassment and at job dissatisfaction as a continuum in occupational health and safety, we can see that workload and workplace violence and harassment take a heavy toll on PSW well-being. As we have discussed elsewhere, various aspects of PSW work, such as work intensification (Sayin et al., 2019), occupational safety (Denton et al., 2018) and organizational practices (Zeytinoglu et al., 2017), affect PSW well-being, and other aspects show the detrimental effects of workplace violence and harassment on workers’ physical health, such as injury, illness, musculoskeletal disorders and various other physical and psychological health problems (Karaeminogullari, Erdogan, and Bauer, 2018 ; Lanctôt and Guay, 2014 ; Vessey, DeMarco, and DiFazio, 2011 ; Yragui et al., 2017). The results of our analysis provide further evidence of the detrimental impact of workplace violence and harassment on PSWs.
Our study makes two main theoretical contributions. First, it fills a gap in the literature : the well-being of workers has been predominantly studied at the individual level with an emphasis on psychological processes, but there has been very limited effort to investigate contextual factors (Calvard and Sang, 2017 ; Godard, 2014). One reason for this literature gap is that contextual factors often have indirect and long-term impacts on individuals. Structural violence is not an exception (Winter, 2012), and the limited research has left structural violence as a ‘black box’ (Herrick and Bell, 2020). Our study addresses that gap and examines the potential impact of structural violence (i.e., indirect violence) on workplace violence and harassment (i.e., direct violence), which in turn can affect the well-being of PSWs (i.e., strain and job satisfaction). Thus, conceptually, our model is a multilevel one where a work environment factor (i.e., workload) is associated with a relational outcome (i.e., workplace violence and harassment experienced by PSWs), which in turn is linked to psychosocial outcomes (i.e., strain and job satisfaction). Thus, our study helps unpack structural violence in the workplace by bringing together the theory of structural violence and the job demands-control model.
Second, while the relationships among the variables in our model have been examined separately in other studies, the present study brings them together, to our knowledge for the first time, to examine the workload/well-being relationship holistically and test a process model with multiple mediating variables. By doing so, we extend the job demands-control model (Karasek and Theorell, 1990 ; Karasek, 1979) and the theory of structural violence (Galtung, 1969) by introducing workplace violence and harassment as a key driving mechanism that integrates these two models.
Our study greatly contributes to knowledge of policy makers, employers and unions. The results suggest that the workload of PSWs should be moderate to prevent the violence and harassment they experience in home and community care, and to lower their stress levels and increase their job satisfaction. Several factors may account for the heavy workload, including restructuring of the hospitals and earlier discharge of patients into the community, aging in the community and under-resourcing of the home care sector (Home Care Ontario, 2011 and 2017 ; Wetzel et al., 2005).
In Ontario, the shortage of PSWs may play a role in causing heavy workloads (Laucius, 2018). As the population ages, and as the shortage worsens, the situation of PSW workloads will become critical. More government funding will be needed to improve PSW working conditions if we are to recruit and retain workers in this field (Ontario Community Support Association, 2017).
We have demonstrated that structural violence and direct violence are more strongly associated with intrinsic job satisfaction than with extrinsic job satisfaction. This finding implies that workplace violence and harassment might affect intrinsic job satisfaction more severely than extrinsic job satisfaction. Managers and policymakers should prioritize the development of healthcare employer policies that can enhance PSWs’ intrinsic job satisfaction. These findings exhibit the multilayered nature of job satisfaction, which can reveal itself differently in certain occupational groups.
It is crucial to provide organizational learning through training and peer support to mitigate the impact of workplace violence and harassment on PSW’s well-being. With the downloading of more medically related tasks to PSWs, it is important that each PSW be able to rely on their employer to receive the necessary training and ongoing support to carry out their work. It is equally important that PSWs have the opportunity to develop peer relationships with other PSWs so that they may seek support and discuss the challenges of their occupation. This goal can be achieved within generic training sessions, such as Gentle Persuasive Approaches : a research-based training course that teaches PSWs how to mitigate responsive behaviours by clients and solve problems collectively. Despite the often limited funding for organizations to bring PSWs together, monthly newsletters, lunch-and-learn events and free webinars could be used more frequently to help PSWs support one another and learn about client care. Organizations can further mitigate the potential risk of workplace violence and harassment by ensuring that all PSWs attend a standardized organizational orientation and in-house training program, regardless of their years of service and prior workplaces.
PSWs especially need safety training to alleviate the violence and harassment they experience. Before they start working in a client’s residence, they could complete safety training and risk assessments, such as learning how to identify the attributes of a building, becoming familiar with the safe exit routes and receiving safety equipment, such as whistles and key chain alarms. For example, a toolkit was developed for this purpose by the Public Services Health and Safety Association of Ontario (Public Services Health and Safety Association of Ontario, 2019).
Scheduling can be an important factor in PSWs’ well-being. A significant number of PSWs continue to be notified at the last minute about scheduling changes, with the result that a PSW may serve a new client without having the necessary training to meet the client’s specific care needs. The onus is on the employer to have practices in place to accommodate PSWs who call in sick and, thus, to ensure that clients and incoming PSWs are not adversely affected. To alleviate negative impacts, it is important to have a consistent and competent team of PSWs who can provide the client with reliable care.
At the inter-organizational level, organizations have tried to address PSW shortages through different models, such as cluster care, which increase not only the workload of PSWs but also, as our study demonstrates, their risk of experiencing violence and harassment. Cluster care is the allocation of a PSW or a team of PSWs to a geographic area or a client care activity, such as transferring or bathing. PSWs can thus travel from client to client and perform a single task each time, thereby becoming more proficient and efficient at that task. Organizations have also begun to specialize through partnering to share and deliver expertise, rather than trying to be all things to all people. For example, one organization may specialize in client mental health and another in personal care and nursing services. These service providers may thus partner with each other and share clients, training and supervision to improve PSWs’ quality of care and work experiences.
Our study comes with several limitations and strengths. First, our study design was cross-sectional ; therefore, the associations we examined were not shown to be causal. Future studies may employ a longitudinal research design to overcome this issue. Second, there might have been a respondent bias (i.e., the respondents were only those PSWs who were interested in our survey’s topic). Third, because Ontario did not have a regulatory agency for PSWs at the time of this study, it was impossible for us to find out the exact number of PSWs working in Ontario and available during the time of data collection. Thus, our sample should be considered a non-probability sample and is not generalizable to all PSWs in Ontario or elsewhere. Nonetheless, the demographic characteristics of our survey were similar to those of previous PSW surveys in Ontario (Lum et al., 2010) and Canada (Home Care Sector Study Corporation, 2003). Therefore, our findings are potentially generalizable to all PSWs in Ontario and in Canada as a whole. Another limitation was our single-item workplace violence and harassment measure. While this item was measured by a single question, we intentionally kept the question as broad as possible to allow our participants to include all actions that they considered to be violence and harassment in the workplace. Our study had two strengths : its large sample size and the comprehensiveness of its variables. The large sample size enabled us to explore an understudied problem : the antecedents and outcomes of the violence and harassment experienced by PSWs at work. Because the variables were comprehensive in our study, we were able to control for the possible effects of other variables. Thus, our findings provide a foundation for future studies.
The authors would like to thank the PSWs who shared their experience with us by responding to our survey, co-investigators of the grant Susan VanderBent and Patricia Boucher, and the Research Advisory Committee members (Patricia Boucher, Advanced Gerontological Education, St. Peter’s Hospital; Brigid Buckingham, SEIU Healthcare; Henrietta Van hulle, Public Services Health and Safety Association; Janitha Joseph, Canadian Union of Public Employees, Local Union 3358-01; Margaret McAlister, Home Care Ontario; Wendy Robertson, St. Clair West Services for Seniors; Deborah Simon, Ontario Community Support Association; Susan VanderBent, Home Care Ontario; Ronda Dickie, PSW Representative, PSNO; and Stefanie Nucci, PSW Representative, OPSWA) for their advisory role in the project. Special thanks to Steve De Lisser for graphic design, communications assistance, and suggesting the survey title and the project logo. Special thanks to Bruno Marsala for the design, development and maintenance of the study micro website and contents including the production of the project website promotional video.
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