Community-based personal support workers' satisfaction with job-related training at the organization in Ontario, Canada: Implications for future training.

BACKGROUND AND AIMS: Complexity of community-based homecare for older adults has increased significantly in the past decade in Ontario, Canada. Personal support workers (PSWs), who are unregulated and vary in formal education, provide the majority of community homecare work for increasingly complex clients. This paper seeks to understand community-based PSWs' satisfaction with opportunities for job-related training at their employing organization to provide the skills and knowledge to meet the demands of their evolving role.
METHODS: Data for this paper are from a cross-sectional survey of 1746 community-based PSWs in Ontario, Canada entitled, "The PSW Health and Safety Matters Survey" www.pswshaveasay.ca. This survey was part of a research project "Keeping Community Based PSWs Safe in a Changing World of Work," funded by the Ontario Ministry of Labour. The data were analyzed using descriptive statistics, correlations, multivariate regression, and thematic analysis.
RESULTS: Quantitative analysis revealed most community homecare organizations offer PSWs job-related training to help them retain and update their skills and that PSWs have a moderate level of satisfaction with their job-related training. The analysis revealed that PSWs' satisfaction with organizational training is greater when the organization provides work-related training on challenging tasks, lifting and transferring tasks, and tasks delegated by nurses and supervisors. Data from the open-ended question highlighted seven key themes for desired training by PSWs: safe body mechanics for moving/lifting clients, managing aggression primarily with clients, infection control, CPR/first aid, mental illness, equipment training, and basic health and safety.
CONCLUSION: Implications for factors associated with PSWs' satisfaction with opportunities for job-related training are discussed along with recommendations for mitigating variability in education and training to meet the demands of their evolving role.

INTRODUCTION

The demand for home and community‐based services for older adults has significantly increased over the past few decades as a result of a focus on “aging in place.” , , This demand extends beyond Canada and has been seen in the United States of America and Europe. , , , , In addition, due to an increasingly aging population and the demand for hospital beds, patients are being released with greater acuity and faster into the community. In home‐and community‐based care, client acuity is on the rise and care for individuals living with chronic conditions and co‐morbidities are expected to triple by 2050. In Ontario, Canada, older individuals who would have moved into a long‐term care (LTC) home or needed this type of housing are being encouraged to remain in their own homes due to a shortage of LTC home beds and stricter admission criteria for those entering LTC. In addition to this and of equal importance, is the consideration that it is often the preference of older individuals to remain in their own homes which have been found to be linked to better well‐being. Growing health care costs and shortages of nurses and other professional staff are a couple of other factors that have forced governments in Canada and abroad to look for more efficient ways of utilizing health care human resources such as care provided by personal support workers (PSWs) along with an expansion of their role. , , , , , , This role expansion has been referred to in the literature as “task‐shifting,” whereby more advanced care activities are being transferred to PSWs. , ,

PSWs are the human resources that provide 70% to 80% of homecare to the aging population in the community. , , A study on the self‐reported data of over 32 000 individuals in the Ontario PSW Registry who work primarily in public homecare agencies found that PSWs in the Registry are largely between the ages of 40 and 59, and the majority, 92% are female with more than 30% having 10 years of experience in the profession.

PSWs are also referred to as Home Support Workers, Homecare Workers, and Home Health care aids in other jurisdictions. There are approximately 100 000 PSWs in Ontario, Canada of which it is estimated that 34 000 work in the home and community care sector. As personal support work is an unregulated occupation and there is no mandatory registry for PSWs, estimates come from a variety of sources and the actual number of PSWs may be larger.

In Ontario, publicly funded PSW services are provided through 14 home and community care support services (HCCSS) bodies (formerly the local health integration networks [LHINs]). The newly developed Ontario Health Teams (OHT) are responsible for overall health system planning and the funding functions of these HCCSS bodies. Access to government‐funded home and community care support services is through HCCSS. Each HCCSS provides a single point of access. While they provide some specialized direct client care such as case management, the majority of client care is contracted to home and community care organizations. These organizations employ PSWs, nurses, and other health practitioners in specified geographic areas. The structure of the funding arrangements between the HCCSS and provider organizations can result in clients receiving more than one type of service from multiple organizations. PSWs are employed in many different types of funded services, including homecare services, supportive housing services, adult day program services, and LTC homes and as such, provide a variety of different client care services. All employers in Canada have a legal requirement to provide workplace hazardous materials information system training as these workers work with or are exposed to hazardous substances. As well, the Occupational Health and Safety Act requires Ontario employers to provide basic occupational health and safety awareness training for all workers and their supervisors. For those community health care organizations whose services have been purchased to provide PSW services through a request for proposal process (RFP), they have a legal obligation to train their PSWs based on what is specified in the RFP signed contract. For community health care organizations that have been funded to provide PSW services through LHINs/HCCSS funded programs, they have a legal requirement to abide by whatever is required of them through their Multi‐Sector Service Accountability Agreement (M‐SAA).

The LHIN/HCCSS M‐SAA agreements included text on Indigenous Cultural Safety training whereby health service providers are required to complete the Indigenous Cultural Competency/Cultural Safety Report through the period 2019 to 2022 M‐SAA. No other reference to training was found for home and community care organizations. Document analysis and an environmental scan of accountability for home and community care organizations in Ontario, Canada revealed that there are many different accountability requirements for service delivery from a range of stakeholders that mainly focus on regulatory and expenditure instruments.

The community care sector is faced with the challenge of retaining PSWs who have adequate skills to meet the needs of community care clients. PSWs provide a variety of tasks, including assistance with personal care, homemaking, personal interaction and more recently, clinical‐based activities, and delegated acts in clients' homes. , The work of PSWs has gone from assisting with light housework to providing care that was previously provided by registered nurses. As health care practices continue to support the increasing number of individuals facing health challenges in their own homes, more pressure is put on PSWs to have the knowledge and skill sets to meet the increasing needs of these individuals and also to provide care to a greater number of clients. Quality, safety, and feasibility of PSWs performing these added skills have been identified as issues in the literature , , , , ; however, previous research has demonstrated that with added training and support, PSWs can play a critical role in the provision of good homecare services such as palliative care, , team‐based stroke care, and home ventilation. , Performing these tasks are a significant undertaking because the formal education of PSWs is varied. This reality has resulted in an increased need for research to ascertain if the knowledge and skills of PSWs are aligned with the work now being required of them, and whether or not they are receiving the necessary training to perform these tasks. , Research undertaken in Canada, has highlighted the need for both standardized training among PSWs, as well as with their supervisors. It has also been demonstrated that training is important for job satisfaction. The ability to learn new skills on the job such as those associated with task shifting as well as receiving continuing education was valued by PSWs and sometimes increased satisfaction with their work. , Along with the shortage of nurses and other professional practitioners mentioned above, there is now also an Ontario‐wide shortage of PSWs. It is estimated that the demand growth for PSW homecare services is projected to be nine times the workforce growth rate, supporting more than ever the need to address any possible measures related to augmenting job satisfaction.

While there is extensive research examining the use of PSWs in homecare and the expansion of their job duties, research is limited related to their satisfaction with job‐related training at their organizations. Because of this need for more research, it is essential to study if home and community homecare organizations offer PSWs job‐related training and delegated task training to help them perform their tasks and provide care, and to examine their satisfaction with organizational job‐related training. This information will assist health care organizations, educational institutions, and the health care system in planning for, advocating, and delivering relevant training to equip PSWs to respond to the growing and changing needs of today's home and community care client.

A research project entitled “Keeping Community Based Personal Support Workers (PSWs) Safe in a Changing World of Work” was conducted in 2015. The goal of this research project was to provide information that would lead to the prevention of injury and occupational health problems in PSWs providing home and community care in Ontario, Canada. This was accomplished through the development and administration of a survey and interview to community‐based PSWs in Ontario that gathered information on their occupational health and work life. The survey was divided into sections related to health; injuries at work; most serious injury; workplace violence and harassment; workplace theft; characteristics of work; work life (changes in community care: work as a PSW in the community: task shifting: clients receiving care: hazards of work); your organization (job security: health and safety prevention, and training in your organization); and background (general demographics and education). Data from this survey are used to understand home and community care PSWs' satisfaction with opportunities for job‐related training at their employing organization to provide them with the skills and knowledge to meet the demands of their evolving role.

LITERATURE REVIEW

PSW work is unregulated, and workers' formal education is varied, although there have been strides made by the Ontario, Canada Ministry of Training Colleges and Universities to address this. There is no defined scope of practice for the role of the PSW and there can be a large variation in the duties they perform, their level of autonomy, and their work environment. A scoping literature review of the barriers and facilitators to the expanded roles of the unregulated care provider in Ontario, highlighted the need to reduce variations in education and employment standards. Lack of education standardization and inconsistent requirements in the preparation of PSWs were highlighted as a challenge in Ontario, Canada. The literature indicates that this is not only a Canadian challenge. For example, it was found that the experiences of both the client and family have highlighted a lack of care provider competence and insufficient training in homecare organizations in Sweden.

In Ontario, PSWs receive their formal training through a variety of sources: community college programs, private career colleges (also known as vocational schools), boards of education adult learning programs, not‐for‐profit organizations, and other organizations. In a large study of approximately 7000 annual graduates from PSW Certificate Programs in Ontario, 20% graduated from community college programs, 45% from career colleges, and approximately 35% from the board of education adult learning programs, not‐for‐profit organizations, and other organizations. These programs are typically 8 to 9 months in length. Their total number of program hours varies approximately from 770 to 540 in total. For community college programs, there are 384 in‐class hours and 386 practicum hours; private career college provides 285 in class hours and 255 practicum hours; and the Board of Education provides adult learning programs with 540 in class hours and 270 practicum hours. There are no prerequisites for enrollment other than to be qualified to work in Ontario, Canada.

Provincial curricula exist in Ontario, Canada for public institutions offering PSW training and private institutions follow either curriculum developed by the National Association of Career Colleges or the provincial curriculum by the government. In 2014, the Ontario, Canada Ministry of Training Colleges and Universities released the PSW Program Standard to address the three distinct provincial legislations that outline educational standards. The Program Standard does not, however, specify the curriculum that is to be taught or by whom, rather it details 14 vocational learning outcomes, essential employability skills, and an optional general education requirement. To graduate from the formal educational program, PSWs are to have reliably demonstrated their learning and achievements in adhering to these vocational learning outcome statements. In a research study that explored the education experiences of PSWs in Ontario, a disconnect was found between many of the concepts and techniques learned in their formal education compared to the reality of workplace settings. Placements were almost exclusively in LTC settings as were the course content examples provided by PSW instructors. These results have implications for home and community care organizations who need to ensure that newly hired PSW graduates have the skills and knowledge necessary to provide care to home and community care clients. Research has also indicated that there is a trend whereby more complex tasks formally carried out by regulated health care providers such as registered practical nurses are being carried out by unregulated health care providers. , , , It is, however, not outlined if the skills for tasks delegated or assigned by regulated professionals are covered or taught as core competencies.

In early 2021, the Government of Ontario announced an accelerated tuition‐free PSW formal education program through Ontario's 24 community colleges. This is targeted to train 6000 new students by the fall of 2021, and includes 3 months of coursework, an experiential learning component in a clinical setting, and final months in paid onsite training in a long‐term care home or in a home and community care environment. This effort was introduced primarily to increase the needed supply of PSWs.

To work in an Ontario LTC home, PSWs must have completed a formal education program, however, in homecare, this requirement for formal education does not exist. PSWs in homecare can be hired with no formal PSW education and are provided on‐the‐job training which is the sole responsibility of the employer with no checks and balances from the government. For those Ontario homecare PSWs without any formal education, the Ministry of Health annual training funds can be accessed to pay for the PSW to attend a formal education program should the health care employer apply for these funds. However, this is not a requirement of the employer. While it is not a requirement in home and community care organizations to have a PSW certificate upon hire, there are many merits to enroll in formal PSW education. Obtaining a PSW certificate provides the student with knowledge and skills to provide care when assisting individuals living in a variety of settings, such as hospitals, homes, schools, community residential agencies, and long‐term or chronic care facilities with broad‐spectrum conditions and health care needs. It focuses on a range of home and health‐related services required by individuals with physical disabilities, cognitive impairments, and chronic and acute illnesses. It also provides the opportunity for students to learn how to effectively communicate and collaborate with members of an interprofessional health care team. For those graduates who wish to further their career as a PSW, it also provides the opportunity for entrance into other vocational programs such as a Practical Nursing program. From time to time, the LHINs across Ontario, have funded individual and joint agency projects that can serve as generic training tools to be used across the province. One such tool is the PSW Medication Management Training Tool, funded by the Toronto Central LHIN to provide a consistent approach to an area of PSW training. This tool was created by a multidisciplinary team that included PSWs in the development of content, design, and video productions addressing relevant client care tasks, such as oral medication assistance, eye drop administration, blood glucose monitoring, ostomy care, and oxygen assistance.

Research has highlighted that the shift in PSWs carrying out health‐related functions has transferred costs to the clients in some geographies such as in the United Kingdom. This is currently not the case in Ontario. Rather, in Ontario, a strategy to reduce community homecare costs and allocate health care resources more efficiently, many homecare services normally carried out by regulated professionals are now being delegated to PSWs. This strategy is referred to as “task shifting.” ,

The delivery of client care outside of the scope of PSW basic training has been highlighted as an integral role in the delivery of homecare. , , , , These added skills can only be carried out by a PSW when they are formally trained by a regulated health care professional or when the task to be carried out is considered a routine activity of daily living. To be considered a routine activity of daily living, the need for the activity and the client's response to care must be predictable and well established. Examples of these types of tasks include medication assistance/administration (insulin, chemotherapy agents, eye drops, nebulisers, and suppositories); transfers and exercises; wound and stoma care; continence care and catheterizations; tube feeding; blood sugar monitoring/diabetes care; application of compression stockings; ventilator care, and home hemodialysis. Previous research demonstrated that PSWs, along with some of their supervisors, nurses, and therapists, were concerned that task shifting may compromise the quality of client care because they believed PSWs lacked the knowledge, training, and education necessary to carry out more complex tasks. PSWs have expressed concern related to a lack of training for the provision of added skills. , , In a series of 13 focus groups held across Ontario, Canada PSWs reported mixed feelings on the effectiveness of how training was being carried out. Specifically, group‐related training for certain tasks such as the application of compression stocking was highlighted as less than adequate due to the individualized characteristics of clients.

A Belgium study on palliative care in the community found the majority of nursing managers, nurses and health care aids did not believe that the delegated activities should be expanded because health care aids were not trained adequately to carry out these types of technical nursing activities. As well, the nurses indicated while they believed that supervision by them of health care aids was a necessity, it was not part of their basic education and believed they needed additional training. Other studies also found the unregulated care providers were not always supported in the assignment with their increased responsibilities. , , This poses a challenge as it is not outlined if the skills for tasks delegated or assigned by regulated professionals are covered or taught as core competencies.

However, research has also indicated that with added training and support, PSWs can have a significant role in demonstrating competency and quality client care in the delivery of delegated homecare services. , , Studies that have looked at specialty roles for unregulated care providers (UCPs) such as in end‐of‐life care, along with roles focused on rehabilitation and function improvement of clients where services were provided in the community home setting with an interdisciplinary team, support the expansion of their role. , , , On the job training was demonstrated as effective in Sweden for UCPs caring for clients needing complex medical interventions such as home mechanical ventilation and in Ontario, Canada for medically stable clients needing home hemodialysis. A study in the United Kingdom in palliative care examining the role of health and personal care assistants (HPCAs), found demonstrated competencies in communication, the delivery of client care including medication administration and the provision of emotional support to clients and family members. This study highlighted that with attention given to selection and training, HPCAs proved to be an integral part of the palliative care team. Training included shadowing other HPCAs and district nurses, time spent on‐site at hospices and receiving formal instruction on the aspects of end‐of‐life care. While the time and workload of the nurses were increased in the shifting of tasks to PSWs, it was believed that these workers may have an important role to play. Challenges related to the performance of these added skills to PSWs when delivering care can be mitigated if PSWs are given the time to develop and practice skills , the time to deliver these skills when providing care for the client and effective on‐the‐job training and education.

Furthermore, it has been determined that the expanded role of the PSW can lead to an increase in job satisfaction, providing a sense of purpose and increased self‐esteem for the PSW. The level of health care knowledge was also a key factor for increased job satisfaction along with the potential for these types of workers to remain in homecare. PSWs have indicated the importance of understanding the particulars related to the client and acquiring client information and knowledge. Research has demonstrated that this can be accomplished by having PSWs participate in meetings about the client. ,

Research that examined the relationships between work outcomes, work attitudes, and work environments of health support workers in Ontario, Canada LTC homes and home and community care settings found that performance (ability to carry out the work) is directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment.

The complexity of home‐ and community‐based homecare for older adults has increased significantly in the past decade in Ontario, Canada. PSWs, who are unregulated and vary in formal education, provide the majority of community homecare work for increasingly complex clients. This paper seeks to understand community‐based PSWs' satisfaction with opportunities for job‐related training at their employing organization to provide them with the skills and knowledge to meet the demands of their evolving role.

METHODS

Setting and ethics

This paper uses results from a 2015 cross‐sectional survey “The PSW Health and Safety Matters Survey” (www.pswshaveasay.ca) conducted in Ontario, Canada. This survey was part of a larger research project entitled “Keeping Community Based Personal Support Workers (PSWs) Safe in a Changing World of Work,” funded by the Ontario Ministry of Labour, Research Opportunities Program, #13‐R‐030. The purpose of the research project was to provide information that will lead to the prevention of injury and occupational health problems for PSWs who provide home and community care. The survey included instructional information about confidentiality, informed consent, and contact information. The survey also included training provided by home and community care organizations on delegated tasks and internal and external training opportunities. This research project was guided by a Research Advisory Committee which includes the Principal and Co‐investigators of the project as well as representatives from homecare organizations, unions, and a health and safety association which have expertise on the occupational health of Ontario, Canada home and community care PSWs. The survey process was initiated after receiving ethics approval from McMaster University, Research Ethics Board, MREB 2014 132. After receiving the ethics approval, we conducted a pilot study with 10 PSWs from a home and community care organization in Toronto, Ontario, Canada and did not find any potential problems with the survey. This paper draws on the data generated by the survey, under the health and safety section, to examine if health care organizations offered PSWs organizational (work‐related, challenging tasks, and delegate tasks) training to help them retain and update their skills, and whether this training was associated with their satisfaction of the job‐related training provided. In the survey, there was an open‐ended question where PSWs were also provided with the opportunity to indicate what additional type of health and safety training they believed they needed.

The population survey and data

The study population includes PSWs who worked for organizations that provide home and community care services in various contexts in the community such as client residences (eg, houses and apartments), adult day programs, retirement homes, and supportive housing programs. Data were not collected on the for‐profit/not‐for‐profit status or other characteristics of the organizations employing the PSWs although the survey did ask whether the training organization was non‐profit, along with other descriptive information such as years of employment. Due to the lack of a professional registry, a comprehensive list of PSWs working in the home and community care sector in Ontario, Canada does not exist.

Data collection process

The respondents were recruited to participate in the survey in several ways. First, respondents were invited to participate in the survey through an email blast sent out through PSW employers, unions, and health and safety organizations. PSW employers were reached through email blasts sent by two homecare associations, Ontario Community Support Association, and Home Care Ontario having a combined membership of over 280 employers. Two unions, Canadian Union of Public Employees (CUPE) and Service Employees International Union (SEIU) along with the Public Services Health and Safety Association (PSHSA) also sent an email blast to all of their health care members. Many PSWs work in both the home and community care and LTC homes sectors. In the survey, PSWs were asked to identify where in the home and community care sector they work: for an organization providing care to clients in their houses/apartments; privately (on their own, no employer oversight); adult day program; supportive housing (excluding LTC homes, nursing homes, and hospitals); and other (please specify). They were also asked if they worked for organizations that were NOT in the home and community care sector (ie, LTC homes, hospital, or others). The email blast also directed participants to a website where a video explained the importance of the survey and details on how to complete it. Participants could either click on a link to complete the online survey or click on a link to request a print‐mail survey. The second method of recruitment was the placement of advertisements on various home and community care organizations' websites, newsletters, and Twitter. A third recruitment strategy at the organization level was the use of several tools, including a flyer to promote the survey which could be placed on the organization's bulletin boards or sent out to employees; a newsletter article that organizations could include in their monthly newsletters; and a mini health and safety in‐service PowerPoint presentation which incorporated the survey. Organizations were invited to use these strategies to promote the survey. Participants were not required to complete the entire survey, although this was encouraged. The survey was offered online or in print‐mail formats. Most respondents completed the survey online.

The survey, “The PSW Health & Safety Matters” was divided into seven sections: your health; injuries at work and most serious injury at work; workplace violence and harassment and workplace theft; characteristics of work; work life; organization; and background characteristics. The data for this research paper were drawn from the survey questions under sections and subsections: Your Organization: health and safety prevention and training; Work Life: changes in community care, work as a PSW in the community, task shifting, clients receiving care; and Background questions. Many of the questions and scales used in this paper were developed in the authors' previous research on homecare workers. , The Statistics Canada Canadian Community Health Survey was used for questions on health conditions diagnosed by a physician, depression, and self‐esteem.

Variables

All variables except organizational training satisfaction and tenure are dichotomous. A decision was made to dichotomize these variables due to highly skewed variables.

Endogenous variable

The endogenous variable in this analysis is organizational job‐related training satisfaction, which indicates satisfaction with job‐related training provided or supported by PSWs' organization. This is a single item worded as, “How satisfied are you with your opportunities for job‐related training provided or supported by your organization?” For this paper, this question was selected as the dependent variable. This was for two reasons: firstly, the question was specifically on the satisfaction with employer‐provided or supported job‐related training, rather than a broad job satisfaction that can include other aspects of the job such as wage and benefits satisfaction, satisfaction with the supervisor, satisfaction with co‐workers, and so on and secondly, it has been established in the literature that job satisfaction can be measured accurately with a single item variable. , Responses are coded on a five‐point Likert‐type scale with “1 = very dissatisfied” to “5 = very satisfied.”

Exogenous variables

Organizational training is measured by five variables. Framed by the statement, “The next set of questions is about health and safety prevention and training in your organization,” respondents were asked to agree or disagree on a five‐point Likert‐type scale to the following statements: “Your organization offers you work‐related training to help you retain and update your skills”; “You have enough training to perform the tasks required to do the job”; “Based on the training you receive, you feel confident to perform the tasks required to do your job”; “Your organization provides you with the appropriate training to handle challenging tasks”; and “Your organization provides you with enough training on safe lifting/transferring techniques.” Respondents who agreed or strongly agreed were considered a “yes” and all others were considered a “no” response.

Delegated task training was measured with two dichotomous variables asking about respondent's experiences with task shifting. Task shifting refers to the delegation of a controlled act or transfer of task by a nurse, physiotherapist, or occupational therapist to a PSW. Respondents were asked, “Based on the training you received, do you feel confident to perform delegated tasks from nurses or PSW supervisors” and “Based on the training you received, do you feel confident to perform delegated tasks from physiotherapist or occupational therapists?”

External training (formal education): Respondents were asked, “Where did you receive your PSW training?” Respondents were provided with a list of choices which included community college, private career college (also known as vocational school), board of education adult learning program, not‐for‐profit organization, and other organizations. We also created the category of “no training” (reference group) for those who did not choose any of these categories.

Control variables are “learn new things,” “adequate information,” and “tenure.” It was believed that based on the community care client profile mentioned in the introduction, PSWs were required to learn new things, and to carry out their client care duties properly they should have adequate client information. It was further believed that if PSWs agreed that they need to continually learn new things they may be more likely to be satisfied with their training. The years of work experience of a PSW might have an influence on their perception of training needs and therefore this was also a control variable. Framed by the introduction, “Each of the statements below is something a person might use to describe his/her work as a PSW in the Community,” respondents were asked to disagree or agree to the statement, “Your Job requires that you learn new things.” The second variable is from the question which asked respondents to agree or disagree with the statement, “You receive adequate information to care for your clients.” The final variable, “tenure,” was calculated from a question asking respondents which year they started working as a PSW in the community.

Open‐ended question in a quantitative survey. An open‐ended question “what additional type of health and safety training do you believe you need?” was asked in the survey after the training questions. The responses to this question were believed to be valuable as many PSWs took this opportunity to add information on all types of training they desired or other unsolicited information that could prove important for this paper.

ANALYSIS

The data were analyzed using both quantitative and qualitative techniques. Descriptive statistics, correlations, and multivariate regression analyses were conducted. The variables were selected based on how they were grouped in the questionnaire. The questionnaire included specific questions based on the researchers' knowledge and views on the topic with the Advisory Committee's input. Based on these variables, we decided to conduct multiple regression. All significance levels are indicated in Table 2. A total of 2341 PSWs participated in the survey and 1746 completed (ie, reached the end of the on‐line survey or mailed back a copy of the survey) the survey. Among those who completed the survey (ie, 1746 respondents), the listwise deletion method, was used for missing observations and the sample analyzed in this article included 1552 respondents. Listwise deletion was preferred as pairwise deletion is widely considered a poor practice compared to listwise deletion in the literature. We did not find any statistically significant differences among 194 respondents removed after listwise deletion and the respondents in the final sample. The highest correlation among the variables is 0.59 and the mean‐variance inflation factor is 2.12. Thus, we do not observe a significant multicollinearity issue.

TABLE 2

Multivariate regression analysis: factors associated with organizational job‐related training satisfaction

Organizational job‐related training satisfaction	B	Std error	t	P > |t|	Beta
Organizational training
Receives work‐related training	0.68	0.07	9.28	<.001	0.25
Receives enough training	0.06	0.09	0.69	.49	0.02
Confidence in training	0.14	0.10	1.35	.18	0.04
Training for challenging tasks	0.23	0.08	3.02	<.001	0.09
Training for lifting and transferring tasks	0.39	0.07	5.71	<.001	0.15
Delegated task training
Nursing or supervisor tasks	0.17	0.05	3.20	<.001	0.08
Therapist tasks	−0.02	0.05	−0.38	.70	−0.01
External training (formal education)
Community college	−0.06	0.17	−0.34	.74	−0.03
Private career college	−0.12	0.18	−0.65	.51	−0.05
Board of education	−0.07	0.18	−0.41	.68	−0.03
Not‐for‐profit	−0.06	0.20	−0.31	.75	−0.01
Other	−0.35	0.18	−1.94	.05	−0.07
Control variables
Job requires to learn new things	0.27	0.06	4.47	<.001	0.10
Job requires adequate information about client	0.26	0.05	4.96	<.001	0.12
Job tenure	0.00	0.00	0.35	.73	0.01
Constant	2.09	0.18	11.91	<.001

Note: N = 1552. F(16, 1535) = 45.37. Prob > F = 0.00, R‐squared = 0.32. Adj R‐squared = 0.31. Root mean squared error = 0.89.

The subjectively assessed variables may not be completely independent of each other, and thus collinearity diagnostics (tolerance and variance inflation factor analyses) were also conducted. Collinearity with the dependent variable was not found. STATA 15 was used in the analysis.

The open‐ended question, “what additional type of health and safety training do you believe you need?” was thematically analyzed and the first author of this paper and a different co‐principal investigator reviewed the established coding scheme to arrive at a coding consensus. Excluding those that said none and those that did not answer this question, it yielded 383 respondents for the analysis.

FINDINGS

Quantitative findings

Findings revealed that 94% of respondents were female and 6% were male. The age range of respondents indicated that 12% were between 26 and 35, 20% between 36 and 45, 35% between 46 and 55, and 26% were between 56 and 65 years of age. Under two‐thirds, 59% were born in Canada and of the 42% who were not born in Canada, 27% were born in Latin America, 18% in Europe, and 40% in Asia.

Table 1 shows the descriptive statistics (means and standard deviations) for all variables included in the analysis. The mean values of all dichotomous variables are shown in percentages for ease of interpretation. Correlations are available from the second author on request.

TABLE 1

Descriptive statistics

Exogenous, control, and endogenous variables	% / Mean (n)	SD
Exogenous variables a :
Organizational training
Receives work‐related training (%)	80.67 (1252)	.40
Receives enough training (%)	84.67 (1314)	.36
Confidence in training (%)	89.11 (1383)	.32
Training for challenging tasks (%)	75.13 (1166)	.43
Training for lifting and transferring tasks (%)	77.58 (1204)	.42
Delegated task training
Nursing or supervisor tasks (%)	61.02 (947)	.49
Therapist tasks (%)	52.84 (820)	.50
External training (formal education)
Community college (%)	44.85 (696)	.50
Private career college (%)	30.41 (472)	.46
Board of education (%)	16.05 (249)	.37
Not‐for‐profit (%)	2.90 (45)	.18
Other (%)	4.25 (66)	.21
Control variables
Job requires to learn new things (%)	80.99 (1257)	.39
Job requires adequate information about the client (%)	63.98 (993)	.48
Job tenure (years) (Mean)	9.82	7.6
Endogenous variable
Organizational job‐related training satisfaction (Mean)	3.58	.48

Note: N = 1552.

In “organizational training” and “job requires to learn new things” and “job requires adequate information about the client” variables, the percentage (%) responses refer to “yes” = agreed or strongly agreed, and in all other variables the percentage (%) responses refer to “yes.”

As can be seen in Table 1, on average, the respondents have a moderate level of organizational training satisfaction. In terms of organizational training, about 81% agreed or strongly agreed that their organization offers them work‐related training to help them retain and update their skills, 85% agreed or strongly agreed that they have enough training to perform the tasks required to do the job, 89% agreed or strongly agreed that they feel confident to perform the tasks required to do their job, 75% agreed or strongly agreed that their organization provides them with the appropriate training to handle challenging tasks, and 78% agreed or strongly agreed that their organization provides them with enough training on safe lifting/transferring techniques.

With respect to the training for delegated tasks, 61% agreed or strongly agreed that they get enough training to perform delegated tasks from nurses or PSW supervisors and 53% agreed or strongly agreed that they get enough training to perform delegated tasks from physiotherapists or occupational therapists.

Focusing on external (ie, formal) training, nearly half of the PSWs obtained their PSW certification from a community college (45%) and about a third from private colleges (30%). Only about (16%) got their training from the board of education and very few received training from non‐profit organizations (3%) or other training organizations (4%).

Table 1 also shows results for the control variables. Most, 81% of PSWs agreed or strongly agreed that their job requires them to learn new things and 64% agreed or strongly agreed that they receive adequate information to care for their clients. On average, PSWs in this study have been employed for approximately 10 years.

Findings from the correlations show satisfaction with organizational training is significantly associated with their organization providing them with work‐related training (r = 0.46, P < .05), enough training (r = 0.31, P < .05), training on challenging tasks (r = 0.44, P < .05), training for lifting and transferring tasks (r = 0.41, P < .05) as well as training on the tasks delegated by their supervisors or nurses, (r = 0.28, P < .05) and therapists (r = 0.20, P < .05). Further significant associations are present for the job requires PSWs to learn new things (r = 0.25, P < .05) and to have adequate information about their clients (r = 0.31, P < .05).

Table 2 reports the results of the multivariate regression analysis. We report coefficients and beta values (ie, standardized coefficients). Organizational training satisfaction is positively and significantly associated with the following organizational training variables: receives work‐related training; training for challenging tasks; and training for lifting and transferring tasks. Among these variables, receiving work‐related training has the strongest association with organization training satisfaction followed by training for lifting and transferring tasks and training for challenging tasks. Among the delegated task training variables, nursing or supervisor tasks are positively and significantly associated with organizational training satisfaction and therapist tasks do not have a significant association with the dependent variable. None of the external training variables were statistically significant at P < .05. “Learn new things” and “adequate information” are the control variables that are positively and significantly associated with organizational training satisfaction. The remaining variables do not have statistically significant associations with the dependent variable.

Thematic analysis findings

The qualitative question on what additional health and safety training do PSWs believe they need was answered by 22% (n = 383). Their views were centered on the following seven key themes: Safe body mechanics for moving/lifting clients—8%; Managing aggression primarily with clients—12%; Infection control—8%; CPR/First Aid—8%; Mental illness—8%; Equipment training—6%; Basic health and safety—6%. Table 3 shows the seven key themes along with two examples of the PSWs' responses for each of these themes.

TABLE 3

Key themes and examples for question “What additional health and safety training do you believe you need”

Key themes	PSW response
Safe body mechanics for moving/lifting clients	“Lots of training, lifts, transfer, how to keep yourself safe from injuries when transferring” (PSW262). “Moving clients in very small confined space. Especially washrooms” (PSW258).
Managing aggression primarily with clients	“How to deal with aggressive clients, how to deal with aggressive dementia clients” (PSW138). “To deal with the reactive client, we go to their home alone and sometimes the client charges us, throw things etc” (PSW364).
Infection control	“How to work in homes where client or family does not like using disposables and family member has very unhygienic practices like not washing hands after using bathroom and blowing their noses in towels” (PSW133). “Training in handling/cleaning ostomy bag, urine bag etc” (PSW367).
CPR/First Aid	“All workers should receive basic health and safety certification/training First Aid, yearly” (PSW04). “First aid & CPR mandatory for all PSWs in home care” (PSW85).
Mental illness	“How to deal with mentally ill patients who may be verbally abusive, violent, or self‐destructive” (PSW145). “How to deal with mental conditions of a client” (PSW121).
Equipment training	“For all clients coming on program to be fully assessed with all the right equipment and needs to perform our job” (PSW97). “How to use lifts properly” (PSW131).
Basic health and safety	“Annual health and safety training should be provided. I have not had any such training since starting work with my organization four years ago” (PSW06). “We should receive regular in services' on all types of health and safety training. Our organization does none at our particular location” (PSW369).

DISCUSSION

This paper provides important insights into community‐based PSWs' satisfaction with opportunities for job‐related training at their employing organizations to provide them with the skills and knowledge to meet the demands of their evolving role. While data are from a 2015 cross‐sectional survey, the training, working conditions, and organizational support for PSWs, as well as the health care system context, has not changed significantly since the survey was conducted, and therefore our findings should be considered relevant. Furthermore, the demographic characteristics of our sample are comparable to that of previous studies and industry reports. For example, the percentage of female PSWs in this study is very similar to the 2007 levels. , The average age of PSWs and the percentage of immigrants in our sample are also similar to that of earlier studies. The findings suggest that when an organization provides PSWs with work‐related training to help them retain and update their skills, training on challenging tasks, training on lifting and transfers, and training to perform delegated tasks from their supervisors and nurses, they receive adequate client information, and their job requires them to learn new things, PSWs are satisfied with opportunities for job‐related training provided or supported by their community homecare organization. These insights have implications at the individual practitioner (ie, PSW), community homecare organization, and health care system levels related to the training needs of PSWs.

The findings on formal education from this project indicate PSWs pursue their formal education through a diversity of avenues with the community and private career colleges providing the majority of this education. This coupled with the findings from the literature that the formal education of PSWs lacks an emphasis on the community client population, and no standardized direction to employers on education requirements and on‐site training point to the importance of examining the factors influencing the satisfaction of PSWs with organizational training.

The study revealed that while most of the PSWs were satisfied with organizational training to update and retain their skills, almost one in five PSWs were not. Similarly, almost one in five PSWs indicated that they are not getting enough training on safe lifting/transferring techniques. These results were reinforced through the open‐ended question which identified that again almost one in five PSWs desired to have additional health and safety training on safe body mechanics for moving/lifting clients. This is a significant challenge for PSW employers should a two‐person transfer be needed due to staffing and equipment availability. These findings would suggest that given the variability in PSW formal education and the changing profile of the home and community care client with enhanced complex needs, more attention is needed on what is provided across the formal curriculum related to the moving of clients including knowledge of basic body mechanics to keep both the client and the PSW safe while aiding the client in this function. Community PSWs are challenged not only by the potential lack of equipment in the home of the client but also by the physical diverse environment of each client which can also provide movement restrictions.

PSWs are no longer simply providing light housekeeping and limited client personal care. The scope of their duties has expanded over the past decade to include those tasks once only provided by regulated health care providers. , , , With the economic challenges facing the health care system and the focus on “aging in place” , it is highly likely that the role of the PSW will continue to expand. The results of this research support that PSWs desire effective on‐the‐job training and education. Successful on the job training for the expansion of PSWs duties has been associated with the time to develop and practice skills , time to deliver these skills when providing care for the client and training methodologies that include knowledge enhancement through formal instruction on specialized client conditions and duties, shadowing peers and regulated health care providers along with time spent in the client environment. , It is recommended that health care organizations support their PSWs through comprehensive ongoing in‐service training that includes a diversity of methodologies for instruction and the imparting of relevant client care information. The research data revealed that while PSWs were satisfied with opportunities for training to perform delegated tasks from their supervisors and nurses with 61% agreeing, there is room for improvement. The literature also reinforced this finding. For example, when large group training were conducted on the application of compression stockings, it was not deemed adequate due to the impact of individualized client characteristics. This is an important consideration as the literature indicated that task‐shifting sometimes increased PSWs' satisfaction with their work. , It is, therefore, recommended that health care organizations examine the typical expanded duties that their PSWs are having to carry out and develop with regulated practitioners in‐service training that incorporates the breath of modalities highlighted above. Given the health care human resource challenges, it may be sensible to design an infrastructure that supports the delivery of specialized services by a group of PSWs that could be potentially shared across organizations. This could mitigate the challenge of workload and time already being faced by those regulated health care practitioners.

With no regulatory body encouraging or supporting the ongoing competencies of PSWs, it is imperative that the health care system support organizations to ensure PSWs get the necessary training they need to address the breadth of tasks they are providing to community care clients. An organization's ability to provide training is often dependent on discretionary annual training funding by the Ontario Ministry of Health and the Ontario Ministry of Long‐Term Care. Standardizing core PSW orientation upon hiring across community health care organizations could facilitate creating a baseline of updated consistent knowledge and associated skill sets across community homecare in Ontario such as those described by Saari and colleagues and the medication management tool funded by the Central LHIN. This orientation could be funded by the Home and Community Care Support Services bodies (formally the LHINs). Consideration could also be given to the development of standardization of pre‐service education perhaps developed by the Ontario Ministry of Training Colleges and Universities in collaboration with the regulatory bodies whose members are now delegating tasks to PSWs. Prior to the development of any new standardized PSW training, research would need to be carried out to ascertain if this has already been successfully done along with examining the uptake and impact of such training. An approach such as this would go a long way to mitigate the variability in the knowledge and skill sets of PSWs graduating from different educational bodies and provide a foundation to address changing competencies needed to care for the community homecare client. In addition, the incorporation of those mechanisms, such as on the job practice, collegial learning, and self‐learning was identified in the literature as useful to mitigate not only the competency gap related to insufficient job training but also challenges related to the home setting, poor supervision, and detachment to the patient care system.

The thematic responses of PSWs to the open‐ended training question have implications for both PSW educational institutions and health care organizations. PSW curriculum should address these themes and include case‐based community client examples of safe body mechanics for moving clients, managing client aggression, infection control, CPR/First Aid, mental illness, and basic health and safety. Homecare organizations should ensure that the proper equipment if required is provided for caring for clients prior to the PSW visit and that PSWs are trained on using this equipment for each client along with reviewing health and safety practices on a regular basis.

Finally, while the research found that PSW's perceptions of their environments influence their feelings about their work and that these attitudes about their work influence their work behaviors and their performance, there was nothing relating this to impact on outcomes for older people. Personal support workers provide a critical role in the care of older adults. The care they provide has expanded beyond assistance with personal care such as bathing, toileting, and personal hygiene to tasks such as lifts, transfers, tube feeding, and intermittent catheterization and with varied formal education, it is important to examine their satisfaction with job‐related training. The increase in the complexity of the tasks carried out by PSWs has implications for the quality and safety of their training and support, as well as the quality of client care. Should the health care system continue to rely on PSWs to provide the bulk of direct care to older adults, it would be useful to understand if there exists any relationship between PSW's job satisfaction and the impact of their care on the older adult.

This paper highlights the satisfaction of community‐based PSWs with their job‐related training at their employing organization, potential employer mitigating practices for supervisory support, and training by a regulated health care professional to address the evolving role of the PSW. It also asserts that the root challenge surrounding the role of PSW education and training lays in the necessity of the education system to define core curricula and standards for community‐based PSWs along with the funders of community homecare employers to define standards for the supervision of PSWs. Inconsistent PSW education and employer training and PSW supervision will continue to plague the health care system if it is not addressed.

The data from this study come from the first province‐wide gathering of occupational health and safety data on PSWs in community homecare in Ontario, Canada, “The PSW Health and Safety Matters Survey.” Our study findings are critical in understanding the type of work‐related training provided to PSWs by community homecare organizations, training desired by PSWs, and the factors associated with their satisfaction with the training provided. The response rate of the survey is unknown as PSWs completed the survey anonymously and the researchers did not know exactly how many of the estimated 34 000 community‐based PSWs in Ontario were reached in our email blasts. However, the significant number of PSWs that participated in this study and the extensiveness of the survey provide strong information for homecare organizations, and the health care system in understanding what facilitates PSW job‐related training satisfaction and data to substantiate new models for practice and training leading to better client care.

The data and study results are limited by the fact that the total number of PSWs in Ontario was not known due to the lack of a professional registry. While PSWs were recruited through the two Ontario, Canada homecare employer associations with over 280 homecare employers as members, two large Ontario homecare unions, and an Ontario, Canada Health and Safety Association with health and community service clientele, it is recognized that PSWs were reached indirectly through these groups. It is, therefore, possible that not all PSWs working in the community sector were reached. The surveys were offered on‐line and in print‐mail formats. While most respondents completed the survey on‐line some were completed in the print‐mail format. We did not collect data on the percentage of either format. This is a limitation of our study as it could have provided information to inform future research methodologies to reach PSWs. Furthermore, our survey was only offered in English and PSWs whose first language was other than English may have been less likely to complete the survey. Therefore, it is not possible to generalize our findings to all PSWs in Ontario due to potential bias. It is recommended that national‐level data collection be carried out, possibly through Statistics Canada, whereby PSWs would be defined as a separate occupational category for the future collection of extensive foundational data on their conditions of work, health, and safety. Another limitation is that our data are cross‐sectional, which means that our results should be interpreted as correlational and not causal. Future studies can be designed and conducted longitudinally to overcome this limitation. Our survey consists of self‐reported data only. While this is considered a limitation, we believe that our data fills an important gap in the literature since the data on PSWs in Ontario was limited at the time of data collection. Future studies can overcome this limitation by triangulation of data from multiple resources. Another potential limitation was our decision to dichotomize some of the dependent variables due to highly skewed variables. While this may have caused some loss of data, dichotomizing certain variables also allowed for an easier interpretation of results. The open‐ended question “what additional type of health and safety training do you believe you need” was asked as part of the survey. While this question provided PSW respondents with the opportunity to add unsolicited information and potentially richer information, it could have been collected with a closed question about extra training areas, with some categories and an “other” please specify option. This would have provided an opportunity to collect specific health and safety training data that the authors thought to be important based on home and community care working conditions PSWs often face in the home of a client. Therefore, it is recognized that this open‐ended question while providing a quantified summary of key themes, could have been approached differently. Similarly, the question “Your organization provides you with the appropriate training to handle challenging tasks” could have been a closed question providing some task‐related categories and an “other” please specify option rather than coded on a five‐point Likert scale from strongly disagree, to strongly agree. Another limitation is the survey questions on delegation. The overview provided in the survey under the task shifting section, distinguished between the delegation of a controlled act with that of a transferred task by a nurse, physiotherapist, or occupational therapist. However, the questions asked on delegation training did not make any distinction. No differentiation was made for the difference in training provided to PSWs by regulated staff for the transferring of tasks that are not controlled acts. This has implications for further research on the differentiation of task shifting for those tasks that are controlled acts compared to other transferred tasks. While our analytical decision of treating the Likert scales as interval scales is a very common practice, future studies can use 10‐point Likert scales for having scales closer to the underlying distributions. A final limitation of our study is that no organizational‐specific data on training issues were collected and matched individual respondents with data from their organizations. Future studies that collect employer‐employee data are recommended and would highlight any distinction between geographic differences.

CONCLUSION

This paper provides important insights into the factors associated with community‐based PSWs' satisfaction with opportunities for job‐related training at the organization as well as addresses implications for the focus of both job‐related training and education. It identifies key areas for the development of education and training information from the perspective of PSWs working in the field. It also emphasizes that the training of PSWs cannot be considered outside of the health care system as a whole. The duties of the PSWs involve interaction with other health care providers whose training in relation to working with PSWs and the duties they are delegating need to be examined. When PSWs are given work‐related training, training on challenging tasks, training on lifting and transferring tasks, as well as training on the tasks delegated by nurses and supervisors, they are satisfied with job‐related training at their organization.

These insights are essential considerations to address the changing nature of community care clients. The lack of oversight of the PSW occupation by a regulated body, variability in formal education, and the changing nature of the duties they perform, challenge the PSW, the PSW homecare organization, and the health care system to ensure PSWs have the competencies necessary to retain and update their skills. Potential practice and health care system recommendations are made, including standardization of PSW homecare organizational orientation along with providing the outlined thematic training desired by PSWs. Addressing the factors identified in this paper that are positively associated with PSW satisfaction with job‐related training will facilitate the ability of the PSW to provide and be prepared to address the care needs of the changing community care client.

As we have been writing this paper, the COVID‐19 pandemic has brought significant attention to the role of the PSW. In particular, as many LTC Homes and community agencies struggled to keep up with the demand for PSWs, who worked to protect residents of LTC homes and clients of community agencies, a report by the 4th Canadian Division Joint Task Force Canadian Armed Forces (2020) highlighted staggering inadequacies within our health care system and inadequate practices by PSWs including infection control, lack of equipment/supplies, and their lack of training and orientation. Daily articles and editorials , on the importance of the PSW and their invaluable role in providing care appeared across Ontario and Canada. If anything, positive can come of this pandemic surely it can be the attention of the public, the policy makers, the homecare organizations, and the PSWs themselves to address what this occupation needs to support this role in keeping Ontarians and Canadians safe including the necessary training to equip these workers to provide quality client care.

FUNDING

The authors wish to acknowledge the “Keeping Community Based Personal Support Workers (PSWs) Safe in a Changing World of Work,” funded by the Ministry of Labour, Research Opportunities Program, (2014‐2016), #13‐R‐030 for the funding of the research pertaining to this paper. The funder had no role in study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit this report for publication.

CONFLICT OF INTEREST

No conflict of interests to declare.

AUTHOR CONTRIBUTIONS

Conceptualization: Catherine Brookman, Firat Sayin, Margaret Denton, Sharon Davies, Isik Zeytinoglu.

Data Curation: Firat Sayin, Isik Zeytinoglu, Sharon Davies.

Formal Analysis: Firat Sayin, Isik Zeytinoglu.

Funding Acquisition: Isik Zeytinoglu, Margaret Denton, Catherine Brookman, Sharon Davies.

Investigation: Catherine Brookman, Sharon Davies.

Methodology: Firat Sayin, Catherine Brookman, Isik Zeytinoglu.

Project Administration: Catherine Brookman, Sharon Davies, Isik Zeytinoglu, Margaret Denton.

Writing ‐ Original Draft Preparation: Catherine Brookman, Firat Sayin, Margaret Denton, Sharon Davies, Isik Zeytinoglu.

Writing ‐ Review & Editing: Catherine Brookman, Firat Sayin, Margaret Denton, Sharon Davies, Isik Zeytinoglu.

All authors have read and approved the final version of the manuscript.

Catherine Brookman had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

TRANSPARENCY STATEMENT

Catherine Brookman affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.