Safety Trade-Offs in Home Care During COVID-19: A Mixed Methods Study Capturing the Perspective of Frontline Workers

Abstract

Background: Home care workers help older individuals and those with disabilities with a variety of functional tasks. Despite their core role providing essential care to vulnerable populations, home care workers are often an invisible sector of the healthcare workforce. The transmission of COVID-19 and the nature of home care work raise several questions about the overall safety of these workers during the pandemic. Objective: To examine the experiences of home care workers during COVID-19, particularly their access to information about infection status, to testing, and to personal protective equipment (PPE); their understanding of guidelines; and trade-offs associated with protecting workers’ safety. Methods: A mixed methods study including qualitative analysis of guided discussion questions and quantitative analysis of multiple-choice survey questions was conducted. Eleven virtual focus groups in October and November 2020 involved 83 home care workers who care for clients/consumers in Massachusetts. Thirty-nine participants worked as personal care attendants (PCAs) employed directly by a consumer and 44 participants worked for an agency. Ninety percent self-identified as female and 54% had worked in home care for more than five years. Qualitative data was analyzed using thematic analysis, with identification of major and minor themes. Likert scale survey question data on perceptions of COVID-19 exposure, access to resources to prevent transmission, and perceptions of safety at work were dichotomized into agree or disagree. Results: PCAs and agency-employed home care workers were regularly faced with trade-offs between meeting client/consumer needs and protecting themselves from COVID-19 exposure. Twenty-five percent of participants reported serving a client/consumer who had COVID-19, 75% reported worrying about getting COVID-19 at work, and 29% reported thinking about stopping their work in home care. Despite a low pay structure, participants reported opting to risk exposure rather than to leave their clients/consumers without essential care. However, workers often lacked the resources (e.g., PPE, testing) to feel truly protected. This scarcity of resources combined with insufficient guidance and policies specific to home care settings led many workers to informally collaborate with clients/consumers to assess exposure risks and agree upon safety protocols. Focus group participants expressed uncertainty as to whether workers were truly empowered to ask for changes if conditions seemed unsafe. The burden of determining safety protocols was felt more strongly by PCAs who operate more independently than agency-employed workers who have supervisors to consult. Conclusions: Home care workers expressed deep commitment to continuing to care for their clients/consumers during COVID-19, but often had to operate with insufficient resources and under conditions that made their work environments feel unsafe. Their ability to identify exposure risks and make decisions on how to protect themselves often hinged on a transparent and trusting relationship with their clients/consumers. These relationships were particularly important for PCAs who did not have access to safety guidance from a home care agency.

Barriers and facilitators to infection prevention practices in home healthcare: a scoping review and proposed implementation framework

“…31 of the publications were in English, 2 in German. 3 of the recent studies primarily reflected on the COVID-19 pandemic [ [30] , [31] , [32] ]. All included studies were published in peer-reviewed journals.…”

“…[ 30 ], 2021 US Interview study general Osei-Poku et al. [ 31 ], 2021 US Focus groups; Survey general Pogorzelska et al. [ 51 ], 2020 US Interview study general Popp et al.…”

“…Studies further emphasised that patients needed to consent to the use of their facilities such as sinks [ 49 ]. Unique position of and expectations towards HHC providers : Studies revealed that HHC professionals lacked the power to impose safety practices on patients, or to refuse care if they felt it was unsafe [ 31 , 41 , 43 , 50 ]. PPE use had to be negotiated when it was not appreciated by a patient [ 30 , 49 ].…”

“…HCWs were reported to feel pressured to execute tasks that were not formally assigned, such as helping the patient with sharps use [ 33 , 41 ]. Working alone with little support: Studies revealed impracticality of correct PPE use and hand hygiene adherence during typical tasks, such as helping a patient with mobility, or bathing a patient, which was perceived as a high-exposure-risk activity for HCWs [ 31 , 39 , 47 ]. HHC professionals were found to rely on the varying quality of medical information (e.g.…”

Aide and Client Safety “Should Go Hand-In-Hand”: Qualitative Findings From Home Care Aides, Clients, and Agency Leaders

“…Because of the close nature of HC work, aides are often empathetic to client suffering. Additionally, the COVID-19 pandemic highlighted the essential care provided by aides (Guerrero et al, 2020; Markkanen et al, 2021; Osei-Poku et al, 2021; Sama et al, 2021). A noted challenge is the difficulty in expressing compassion due to social distancing practices (Markkanen et al, 2021).…”