Abuse and violence during home care work as predictor of worker depression

Classifying Studies on Workplace Violence for Visiting Nurses Using the Social-Ecological Model: A Scoping Review

PURPOSE

To prevent workplace violence (WV) against visiting nurses (VNs), understanding the influencing factors is crucial. To better comprehend potential violence prevention strategies, the U.S. Centers for Disease Control and Prevention has presented the four-level social-ecological model (SEM) at the 1) individual, 2) relationship, 3) community, and 4) societal levels. This study aims to quantify WV studies against VNs, examine the influencing factors, identify gaps based on SEM levels, and propose future research and policy directions.

DESIGN

A scoping review was conducted following the five-stage protocol proposed by Arksey and O'Malley in 2005.

METHODS

Systematic searches, including manual searches, were performed using English and Korean databases. Published journal articles including editorials on WV against VNs were included, irrespective of the publication date.

FINDINGS

Sixty journal articles were finally selected. Until the 1990s, most of the literature comprised editorials, with empirical research emerging after the 2000s. Classifying studies by SEM level, many studies have focused on individual (86.7%) and community (66.7%) factors, but fewer have addressed relationship (21.7%) and societal (16.7%) factors.

CONCLUSIONS

The study revealed that much research has focused on individual-centered training, with gaps in risk assessment tool development, training incorporating relational aspects, standardized protocols, and understanding of the impact of legal rights and policies. This article advocates a comprehensive approach that considers all SEM levels to address WV against VNs.

CLINICAL EVIDENCE

The findings confirm a research gap, which suggests the direction for future research and policies. Stakeholders should be urged to implement evidence-based strategies that contribute to safer work environments for VNs.

Research on Abuse in Home Care: A Scoping Review

Home care is the preferred care option for most people who need support; yet abuse exists in these settings toward both home care workers and clients. There are no existing reviews that assess the scope of current research on abuse in home care, and tangentially related reviews are dated. For these reasons, a scoping review is warranted to map the current state of research on abuse in home care and examine current interventions in this field. Databases selected for searching were Medline and EMBASE on OVID, Scopus, and the following databases in EBSCOhost: Academic Search Complete, AgeLine, and Cumulative Index to Nursing and Allied Health Literature. Records were included if: (a) they were written in English; (b) the participants were home care workers or clients age 18 years or older; (c) they were published in journals; (d) they undertook empirical research; and (e) they were published within the last 10-year period. Following Graham et al. (2006), the 52 included articles are categorized as either knowledge inquiry or as intervention studies. We find three themes among knowledge inquiry studies: (1) prevalence and types of abuse in home care, (2) abuse in the context of living with dementia, and (3) working conditions and abuse. Analysis from the intervention studies suggest that not all organizations have specific policies and practices to prevent abuse, and no existing interventions to protect the well-being of clients were identified. Findings from this review can inform up-to-date practice and policymaking to improve the health and well-being of home care clients and workers.

Occupational safety in homecare organizations: the design and implementation of a train-the-trainer program

Homecare workers face significant occupational risks, necessitating effective safety training programs. This paper presents a comprehensive Train-the-Trainer (TTT) program developed to enhance occupational safety in homecare organizations. Through an analysis of 229 reported safety events, the frequency and type of incidents, such as injuries during handling, road crashes, slips, trips, and falls, were identified and primarily attributed to human errors and violations. Based on the results, a TTT program was designed and implemented. The TTT successfully engaged Health, Safety, and Environment managers, fostering collaborative activities, knowledge sharing, and resource discussions. The program modules address critical areas, including distractions and inattentions, fatigue, time pressure, frustration and aggressiveness, and safety behaviors. This innovative approach provides valuable insights for organizations seeking to improve homecare workers' safety. The findings add to the broader comprehension of occupational safety in the homecare sector, proposing a pragmatic framework for future interventions.

Employers' Perception and Practice of Workplace Violence Prevention at Healthcare Facilities Questionnaire: A Confirmatory Factor Analysis

Background

Workplace violence prevention initiatives are undeniably lacking in healthcare facilities. The aim of this study was to validate a newly developed questionnaire and assess employers' perceptions and practices towards workplace violence prevention at healthcare facilities.

Methods

A cross-sectional study was conducted from October 2021 to November 2021 by recruiting 333 employers at healthcare facilities in Kelantan, Malaysia. The original draft of the Malay version of the questionnaire comprised 62 items constructed under two domains (perception and practice). A confirmatory factor analysis was conducted to evaluate construct validity and internal consistency using R software.

Results

The final model for the perception and practice domain of the questionnaire consisted of 13 factors and 56 items. The factor loadings for all items were above 0.6. The fit indices used for confirmatory factor analysis in the final model were as follows: χ2 = 2092.6 (P < 0.001), standardised root mean squared residual (SRMR) = 0.053, root mean square error of approximation (RMSEA) = 0.042, comparative fit index (CFI) = 0.928 and Tucker Lewis index (TLI) = 0.920. The construct reliability for all factors was reliable, with Raykov's rho coefficients above 0.70.

Conclusion

The newly developed questionnaire demonstrated excellent psychometric properties and adequate validity and reliability, confirming that this instrument is reliable and valuable for evaluating employers' perceptions and practices towards workplace violence prevention at healthcare facilities.

Live-in migrant home care workers in Germany: Stressors and resilience factors

BACKGROUND

Thousands of Eastern Europeans find employment caring for older individuals as transmigrating live-in home care workers in private households in Germany. Studies have shown that the stressors threatening their well-being are multifaceted and include inequalities and a high practical and emotional workload, but research on protective factors is still scarce.

AIM & METHODS

This qualitative descriptive study focuses on both the stressors and factors that promote care workers' well-being and contribute to their psychological resilience. In guideline-based interviews, 14 female and one male care workers were asked about their stressors and the factors that help them cope.

RESULTS

Identified stressors included separation from their own family, strained relationship with either or both the care recipient (dementia) and their relatives (violation of worker´s rights and devaluation of care work), and permanent availability and lack of free time due to a 24-h care schedule. Resilience factors were both external and internal and included positive social relationships, self-determination, experience in care work, and intrinsic job motivation.

CONCLUSION

Live-ins reside in an ambiguous setting, exposed to both structural and individual strains. However, external and internal resilience factors contribute to a generally positive attitude toward their job and indicate the agency of this precariously employed group. A socially anchored appreciation of their work and an officially controlled expansion of free time are mandatory to improve the working conditions of live-in care workers.

Occupational Violence Experienced by Care Workers in the Australian Home Care Sector When Assisting People with Dementia

BACKGROUND

People with advancing dementia may be dependent on community services from home care workers and nurses to be supported at home. However, these care workers face difficulty undertaking their roles due to challenging behaviours or occupational violence. This study aimed to explore the challenges faced by home care workers and nurses working with people diagnosed with dementia in the community, to identify job demands contributing to their vulnerability to occupational violence, and to determine ways to help manage occupational violence.

METHODS

A qualitative descriptive study was conducted by interviewing 10 homecare workers and six registered nurses from agencies in South Australia and New South Wales, Australia. Interviews were audiotaped, transcribed and inductive thematic data analysis was conducted.

RESULTS

The following themes were identified: (i) sources of threats; (ii) categories of violent, threatening or challenging behaviour; (iii) aggravating factors; (iv) early warning signs; (v) education and training; (vi) managing occupational violence, (vii) resources, (viii) outcomes associated with exposure to occupational violence.

CONCLUSION

Serious issues were identified by participants, yet very little is known about occupational violence for these community care workers. Findings can inform what aspects of work design can be improved to moderate the effects of occupational violence exposure or mitigate rates of exposure, to enable long-term services for people with dementia.

Subjective Perception of Work and the Home Care Workers' Depression

The care crisis has become a global trend, and the demand for child and elderly care is increasing worldwide. The increasing number of home care workers plays a significant role in meeting this demand in developing countries. The mental health of these workers is associated with the quality of care they provide, which has rarely been studied. This paper explored the factors that affect home care workers' depression, including their socio-demographic characteristics, working environment, relationship with clients, social support networks, economic burden, and subjective perceptions of discrimination and work. It utilized data from the Shanghai Domestic-work Professionalization Survey (SDPS), which was conducted among four types of in-home caregivers (n = 1000) in Shanghai over a period ranging from May to September 2021. The results show that the variables of marriage, education, self-reported health, relationship with client, economic burden, and subjective perceptions of discrimination and care work are significantly associated with home care workers' level of depression. However, the variables of gender, age, household registration, and work environmental factors have no significant effect on their level of depression, which differs from the findings of previous studies on care workers in other institutions.

Nurses’ experiences of the ethical values of home care nursing: A qualitative study

Objective

Considering the importance of out-of-hospital services, the emergence of home care nursing, and the need for an ethical framework in nursing practice, the present study aimed to explore the nurses’ experience of ethical values of home care nursing.

Methods

The data of the study was collected using face-to-face individual interviews. Through purposive sampling, 20 nurses who worked in the home care centers in four cities of Iran in 2020 were interviewed. They shared their experiences of the ethical values of home care nursing. Then, the interviews were analyzed based on the content analysis approach and using Graneheim and Lundman method.

Results

In the present study, 416 codes were extracted. Merging these codes based on the similarity, seven main themes, and 16 sub-themes were extracted. The themes included perception of the professional identity, respect for the client’s autonomy, respecting privacy, establishing human interaction, maintaining mutual safety, observance of justice, and cultural-religious competence. The sub-themes included responsibility, development of professional and inter-professional interactions, maintaining the professional status at home, providing the holistic artistic care, patient’s privacy, nurse’s privacy, and maintaining the confidentiality of information, respect for the client’s choice, honestly informing, empathetic interaction, adjusting the power positions, client's safety, nurse’s safety, establishing justice, respect for the religious beliefs at home and cultural sensitivity.

Conclusion

The participants stated that due to entering the patient’s privacy in the home care cases, the ethical values such as perception of the professional identity, privacy, family interactions’ management, mutual security, and cultural-religious competence became doubly important compared to the hospital caring.

Empathy With Patients and Post-Traumatic Stress Response in Verbally Abused Healthcare Workers

OBJECTIVE

The current study examined the differential empathic capacity, post-traumatic symptoms, and coping strategies in healthcare workers (HCWs) according to the exposure of verbal or physical workplace violence (WPV).

METHODS

Using online survey, a total of 422 HCWs employed at a training general hospital of South Korea participated and completed self-reporting questionnaires including the WPV questionnaire with coping strategy, the Jefferson Scale of Physician Empathy.

RESULTS

Those who experienced either only verbal violence or both physical and verbal violence had lower Jefferson Scale of Physician Empathy scores (p<0.05). Posttraumatic stress symptom severity was higher among people who experienced verbal violence than physical violence. HCWs' exposure to verbal violence was associated with severe posttraumatic symptoms and a low level of empathy with patients (p<0.05). More than half of the victims of verbal violence responded that they did not take any action, receive organizational protection, or peer support, while most physically-abused HCWs received institutional intervention or help from others.

CONCLUSION

Our findings highlight the critical importance of reducing verbal violence, which may represent a larger psychological burden compared to physical violence, by actively implementing effective strategies and policies at the institutional level.

Workplace violence toward resident doctors in public hospitals of Syria: prevalence, psychological impact, and prevention strategies: a cross-sectional study

INTRODUCTION

Workplace violence (WPV) against healthcare workers is a common and daily problem in hospitals worldwide. Studies in different countries indicated that exposure to WPV potentially impacts the psychological status of healthcare workers. However, there is a paucity of studies approaching this issue in the Syrian healthcare system.

OBJECTIVES

This study had three objectives: (1) to estimate the prevalence of violence against resident doctors in Syria, (2) to examine the association between WPV and resident doctors' psychological stress, sleep quality, depression, and general health and (3) to suggest approaches to tackle this problem from the resident doctors' perspectives.

METHODS

A cross-sectional study was conducted in 8 out of 14 provinces, and covered 17 out of 56 accessible functioning hospitals in Syria. Data were collected using anonymous, self-administered questionnaires during February 2020. A total of 1226 resident doctors volunteered to participate in the study. Finally, 1127 valid questionnaires were used in the final data analysis. The overall response rate was 91.92%.

RESULTS

A total of 955 participants (84.74%) reported exposure to WPV in the 12 months prior to the study. In specific, 84.74% exposed to verbal violence and 19.08% to physical violence. Patients' associates were the predominant aggressors in both verbal and physical violence (n = 856; 89.63%, n = 178; 82.79%, respectively). Most resident doctors (87.31%) suggested enacting more legislation to protect doctors as the best solution to reduce WPV. Verbal and physical violence showed a significant positive correlation with each item of depression and stress, and a significant negative correlation with both subjective sleep quality and subjective health.

CONCLUSION

Workplace violence against resident doctors in Syria is highly common. Therefore, policymakers, hospital managers, and supervisors should work collaboratively in order to minimize WPV and ensure resident doctors' safety and psychophysical stability.

Prevalence of Workplace Sexual Violence against Healthcare Workers Providing Home Care: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis sought to explore the prevalence of sexual violence including both sexual harassment and abuse, perpetrated by clients against home healthcare workers (HCWs), including professional and paraprofessional HCWs. To this end, we systematically searched five relevant databases. Two reviewers extracted data from the included studies independently and performed a quality appraisal. Overall and subgroup random-effects pooled prevalence meta-analyses were performed. Due to high heterogeneity, a more robust model using a quality effect estimator was used. Fourteen studies were included, and the prevalence of sexual violence was 0.06 (95% confidence interval (CI): 0.01–0.13). Paraprofessionals had a higher prevalence of sexual violence (0.07, 95% CI: 0.00–0.18 vs. 0.05, 95% CI: 0.00–0.12), and the prevalence of sexual abuse was lower than that of sexual harassment (0.04, 95% CI: 0.00–0.10 vs. 0.10, 95% CI: 0.03–0.18). This systematic review estimated the prevalence of sexual violence across home HCWs from different high-income countries, highlighting the presence of this phenomenon to a lesser but nevertheless considerable extent compared to other healthcare settings. Health management should consider interventions to prevent and reduce the risk of home HCWs from being subjected to sexual violence, as the home-care sector presents particular risks for HCWs because clients’ homes expose them to a relatively uncontrolled work environment.

Sleep and Mental Health among Paramedics from Australia and Saudi Arabia: A Comparison Study

Paramedics face many challenges while on duty, one of which is working different types of shifts. Shift work has been linked to a number of health issues such as insomnia, depression, and anxiety. Besides shift work, Saudi paramedics, a group that has not been investigated for sleep or mental health issues previously, may be facing more demands than Australian paramedics due to lower numbers of paramedics in comparison to the general population. The aim of this study was to investigate the prevalence of sleep and mental health disorders among paramedics in Saudi Arabia and Australia. Paramedics were invited to complete a survey to assess stress, post-traumatic stress disorder (PTSD), depression, anxiety, daytime sleepiness, insomnia, sleep quality, shift work disorder, obstructive sleep apnoea, fatigue, and general health. A total of 104 males Saudi paramedics (M age = 32.5 ± 6.1 years) and 83 males paramedics from Australia (M age = 44.1 ± 12.1 years) responded to the survey. Significantly higher rates of depression, PTSD, insomnia, and fatigue, along with significantly poorer physical functioning were observed among Saudi paramedics in comparison with Australian paramedics. However, Australian paramedics reported significantly poorer sleep quality and general health in comparison to Saudi paramedics. After removing the effect of driving and working durations, outcomes were no longer significant. The higher burden of depression and PTSD among Saudi paramedics may be explained by longer hours spent driving and longer work durations reported by this group. Taking into consideration the outcomes reported in this study, more investigations are needed to study their possible effects on paramedics' cognition, performance, and safety.

Prevalence of type II workplace violence among home healthcare workers: A meta-analysis

BACKGROUND

Home healthcare workers (HHWs) provide medical and nonmedical services to home-bound patients. They are at great risk of experiencing violence perpetrated by patients (type II violence). Establishing the reliable prevalence of such violence and identifying vulnerable subgroups are essential in enhancing HHWs' safety. We, therefore, conducted meta-analyses to synthesize the evidence for prevalence and identify vulnerable subgroups.

METHODS

Five electronic databases were searched for journal articles published between 1 January 2005 and 20 March 2019. A total of 21 studies were identified for this study. Meta-analyses of prevalence were conducted to obtain pooled estimates. Meta-regression was performed to compare the prevalence between professionals and paraprofessionals.

RESULTS

Prevalence estimates for HHWs were 0.223 for 12 months and 0.302 for over the career for combined violence types, 0.102 and 0.171, respectively, for physical violence, and 0.364 and 0.418, respectively, for nonphysical violence. The prevalence of nonphysical violence was higher than that of physical violence for professionals in 12 months (0.515 vs 0.135) and over the career (0.498 vs 0.224) and for paraprofessionals in 12 months (0.248 vs 0.086) and over the career (0.349 vs 0.113). Professionals reported significantly higher nonphysical violence for 12-month prevalence than paraprofessionals did (0.515 vs 0.248, P = .015).

CONCLUSION

A considerable percentage of HHWs experience type II violence with higher prevalence among professionals. Further studies need to explore factors that can explain the differences in the prevalence between professionals and paraprofessionals. The findings provide support for the need for greater recognition of the violence hazard in the home healthcare workplace.

Home care aides' experiences of verbal abuse: a survey of characteristics and risk factors

OBJECTIVE

Violence from care recipients and family members, including both verbal and physical abuse, is a serious occupational hazard for healthcare and social assistance workers. Most workplace violence studies in this sector focus on hospitals and other institutional settings. This study examined verbal abuse in a large home care (HC) aide population and evaluated risk factors.

METHODS

We used questionnaire survey data collected as part of a larger mixed methods study of a range of working conditions among HC aides. This paper focuses on survey responses of HC aides (n=954) who reported on verbal abuse from non-family clients and their family members. Risk factors were identified in univariate and multivariable analyses.

RESULTS

Twenty-two per cent (n=206) of aides reported at least one incident of verbal abuse in the 12 months before the survey. Three factors were found to be important in multivariable models: clients with dementia (relative risk (RR) 1.38, 95% CI 1.07 to 1.78), homes with too little space for the aide to work (RR 1.52, 95% CI 1.17 to 1.97) and predictable work hours (RR 0.74, 95% CI 0.58 to 0.94); two additional factors were associated with verbal abuse, although not as strongly: having clients with limited mobility (RR 1.35, 95% CI 0.94 to 1.93) and an unclear plan for care delivery (RR 1.27, 95% CI 0.95 to 1.69). Aides reporting verbal abuse were 11 times as likely to also report physical abuse (RR 11.53; 95% CI 6.84 to 19.45).

CONCLUSIONS

Verbal abuse is common among HC aides. These findings suggest specific changes in work organisation and training that may help reduce verbal abuse.

Home Care Workers' Experiences of Client Death and Disenfranchised Grief

While many types of health care workers experience patient death, home care workers do so under vastly different social and economic circumstances. When a client dies, home care workers often lose both a close relationship and a job. Though research suggests that health care workers' grief may frequently be disenfranchised, there is no in-depth study of the mechanisms that disenfranchise home care workers' grief specifically. To address this gap, our study used focus groups and peer interviews between home care workers in New York City. We describe four interrelated grief strategies they employ to navigate social and employer-based "grieving rules." Our findings suggest that home care workers' grief is disenfranchised via employer and societal underestimations of their relationships with clients and their losses when clients die, particularly job loss. Building on our findings, we suggest alterations to agency practices and home care systems to improve support for workers.

An international perspective on improving occupational conditions for direct care workers in home health

The occupational health and safety of direct care workers in the home health setting has been the focal point of a somewhat scarce, though highly important, body of research. Although the demand for home care services continues to expand with the rapidly growing population of older adults worldwide, home care workers - such as home health aides and personal care attendants - do not have the same level of protections by workplace safety policies such as those implemented in hospitals and nursing homes. This commentary synthesizes international perspectives on the occupational health and safety of home care workers, including the problem of workers’ rights violations and abuse by clients and their families. Prior policy and practice efforts have focused on improving the training, supervision, job satisfaction, and retention of home care workers, but have focused less on addressing issues of abuse. This paper recommends potential strategies to be developed and tested to provide a stronger support system for home care workers, more fully integrate them into the care team, and improve the occupational health and safety of this diverse, rapidly expanding workforce.

Violations of workers' rights and exposure to work-related abuse of live-in migrant and live-out local home care workers - a preliminary study: implications for health policy and practice

BACKGROUND

Home care workers work in an isolated environment, with limited supervision and guidance which makes them more prone to abuse and exploitation. While past research focused mostly on the well-being of care recipients, this study aimed to shed light on the care workers' daily reality and explore if and how boundaries of professional care work are blurred. Our primary aim was to assess the working conditions and the prevalence of abuse and exploitation among live-in migrant home care workers and live-out local home care workers.

METHODS

A random stratified sample of Israeli older adults aged over 70, who are entitled by law to home care services was used to recruit 338 migrant live-in home care workers and 185 local live-out home care workers to a face-to-face survey. The participants were asked about their relationship with the care recipient and their exposure to violations of workers' rights and work-related abuse.

RESULTS

Almost all the participants reported exposure to certain workers' rights violations. Among the migrant live-in care workers, it was found that 58% of them did not receive any vacation days besides the weekly day-off, about 30% reported not get even a weekly day-off on a regular basis, and 79% did not get paid sick days. Local live-out care workers also suffered from a high prevalence of exploitation - 58% did not get any vacation days besides the weekly day-off, and 66% did not get paid sick leave. 20% of the local live-out care workers, and 15% of the migrant live-in care workers did not receive a signed contract. A smaller portion (7.4% among migrant care workers, 2.5% among local care workers) reported work-related abuse. When compared to local workers, migrant home care workers were more vulnerable to some worker's rights violations, as well as emotional abuse.

CONCLUSION

These findings are disturbing, as work-related abuse and exploitation affect not only the well-being of the care worker but also the health of the care recipients, as the quality of care provided deteriorates. At the public policy level, more significant attention and regulation of the home care industry is needed. The frequency and the nature of home visits made by home care agencies must be changed. Also, home care workers should be offered emotional support.

Incident Reporting by Health-Care Workers in Noninstitutional Care Settings

Patient-perpetrated violence and aggression toward health-care workers, specifically in noninstitutional health-care settings, cause concerns for both health-care providers and the clients whom they serve. Consequentially, this presents a public affairs problem for the entire health-care system, which the current research has failed to adequately address. While the literature overwhelmingly supports the assertion that accurate incident reporting is critical to fully understanding patient violence and aggression toward health-care providers, there is limited research examining provider decision making related to reporting incidents of patient violence and aggression targeted toward the provider. There is an even greater paucity of research specifically examining this issue in noninstitutional health-care settings. It is therefore the objective of this review to examine this phenomenon across disciplines and service settings in order to offer a comprehensive review of incident reporting and to examine rationales for providers reporting or failing to report instances of patient violence and aggression toward health-care providers.

Workplace sexual harassment and depressive symptoms: a cross-sectional multilevel analysis comparing harassment from clients or customers to harassment from other employees amongst 7603 Danish employees from 1041 organizations

Background

Previous research has reported that sexual harassment can lead to reduced mental health. Few studies have focused on sexual harassment conducted by clients or customers, which might occur in person-related occupations such as eldercare work, social work or customer service work. This study examined the cross-sectional association between sexual harassment by clients or customers and depressive symptoms. We also examined if this association was different compared to sexual harassment conducted by a colleague, supervisor or subordinate. Further, we investigated if psychosocial workplace initiatives modified the association between sexual harassment by clients or customers and level of depressive symptoms.

Methods

We used data from the Work Environment and Health in Denmark cohort study (WEHD) and the Work Environment Activities in Danish Workplaces Study (WEADW) collected in 2012. WEHD is based on a random sample of employed individuals aged 18–64. In WEADW, organizational supervisors or employee representatives provided information on workplace characteristics. By combining WEHD and WEADW we included self-reported information on working conditions and health from 7603 employees and supervisors in 1041 organizations within 5 occupations. Data were analyzed using multilevel regression and analyses adjusted for gender, age, occupation and socioeconomic position.

Results

Exposure to workplace sexual harassment from clients or customers was statistically significantly associated with a higher level of depressive symptoms (2.05; 95% CI: 0.98–3.12) compared to no exposure. Employees harassed by colleagues, supervisors or subordinates had a higher mean level of depressive symptoms (2.45; 95% CI: 0.57–4.34) than employees harassed by clients or customers. We observed no statistically significant interactions between harassment from clients and customers and any of the examined psychosocial workplace initiatives (all p > 0.05).

Conclusions

The association between sexual harassment and depressive symptoms differed for employees harassed by clients or customers and those harassed by colleagues, supervisors or subordinates. The results underline the importance of investigating sexual harassment from clients or customers and sexual harassment by colleagues, supervisors or subordinates as distinct types of harassment. We found no modification of the association between sexual harassment by clients or customers and depressive symptoms by any of the examined psychosocial workplace initiatives.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4669-x) contains supplementary material, which is available to authorized users.

Safety of union home care aides in Washington State

INTRODUCTION

A rate-based understanding of home care aides' adverse occupational outcomes related to their work location and care tasks is lacking.

METHODS

Within a 30-month, dynamic cohort of 43 394 home care aides in Washington State, injury rates were calculated by aides' demographic and work characteristics. Injury narratives and focus groups provided contextual detail.

RESULTS

Injury rates were higher for home care aides categorized as female, white, 50 to <65 years old, less experienced, with a primary language of English, and working through an agency (versus individual providers). In addition to direct occupational hazards, variability in workload, income, and supervisory/social support is of concern.

CONCLUSIONS

Policies should address the roles and training of home care aides, consumers, and managers/supervisors. Home care aides' improved access to often-existing resources to identify, manage, and eliminate occupational hazards is called for to prevent injuries and address concerns related to the vulnerability of this needed workforce.

The Impact of Work/Family Conflict and Workplace Social Support on Mental Distress in Home Health Workers

The study explored the role of work/family conflict and workplace social support in predicting home health workers’ mental distress using a sample of home health workers in Central Texas ( n = 150). The result of multivariate analysis showed that work/family conflict increased mental distress, while client support and organizational support decreased mental distress. In addition to the direct effects, client support was found to buffer the negative impact of work/family conflict. Findings call attention to the ways to reduce work/family conflict and increase workplace social support in efforts to promote home health workers’ mental well-being.

"Then They Trust You …": Managing Ergonomics in Home Care

The home care workforce, already at 2.7 million caregivers, will become the nation's fastest growing occupation by 2024 as the senior boom generation accelerates the demand for in home services to meet its long-term care needs. The physically challenging work of assisting clients with intimate, essential acts of daily living places home care workers (HCWs) at risk for musculoskeletal disorders (MSDs); yet, HCWs typically receive little formal job training and may lack appropriate assistive devices. In this qualitative pilot study, HCW focus groups described workplace MSD risk factors and identified problem-solving strategies to improve ergonomic conditions. The results revealed that HCWs rely on their behavioral insights, self-styled communications skills and caring demeanor to navigate MSD risks to themselves and increase clients' physical independence of movement. We suggest changes in employer and government policies to acknowledge HCWs as valued team members in long-term care and to enhance their effectiveness as caregivers.

Whom Do Migrant Home Care Workers Contact in the Case of Work-Related Abuse? An Exploratory Study of Help-Seeking Behaviors

Migrant home care workers constitute an "invisible" and vulnerable group in society, as they work in isolation in the homes of frail older adults. Past research has shown that this population is particularly vulnerable to work-related abuse. The aim of the present study was to explore the help-seeking behaviors of migrant home care workers who were exposed to work-related abuse. Overall, 187 Filipino home care workers completed a self-report questionnaire regarding four types of work-related abuse (sexual, physical, emotional, and exploitation), help-seeking strategies (i.e., formal and informal reporting), and reasons for not disclosing abusive incidents. A total of 56.7% reported some type of abuse. Of these, less than half reported the abuse, mostly informally to family and friends. None reported the abuse to the police. Main reasons for not disclosing the abuse were fears that things would get worse and the belief that it will take too much time and effort. The findings demonstrate that migrant home care workers are highly vulnerable to work-related abuse but are not likely to report work-related abuse and put an end to the cycle of abuse and violence. This calls for the development of further policy and interventions to protect this already vulnerable population.

Violence at work and depressive symptoms in primary health care teams: a cross-sectional study in Brazil

PURPOSE

Implementation of primary care has long been a priority in low- and middle-income countries. Violence at work may hamper progress in this field. Hence, we examined the associations between violence at work and depressive symptoms/major depression in primary care teams (physicians, nurses, nursing assistants, and community health workers).

METHODS

A cross-sectional study was undertaken in the city of Sao Paulo, Brazil. We assessed a random sample of Family Health Program teams. We investigated depressive symptoms and major depression using the nine-item Patient Health Questionnaire (PHQ-9), and exposure to violence at work in the previous 12 months using a standardized questionnaire. Associations between exposure to violence and depressive symptoms/major depression were analyzed using multinomial logistic regression.

RESULTS

Of 3141 eligible workers, 2940 (93 %) completed the interview. Of these, 36.3 % (95 % CI 34.6-38.1) presented intermediate depressive symptoms, and 16 % (95 % CI 14.6-17.2), probable major depression. The frequencies of exposure to the different types of violence at work were: insults (44.9 %), threats (24.8 %), physical aggression (2.3 %), and witnessing violence (29.5 %). These exposures were strongly and progressively associated with depressive symptoms (adjusted odds ratio 1.67 for exposure to one type of violence; and 5.10 for all four types), and probable major depression (adjusted odds ratio 1.84 for one type; and 14.34 for all four types).

CONCLUSION

Primary care workers presenting depressive symptoms and those who have experienced violence at work should be assisted. Policy makers should prioritize strategies to prevent these problems, since they can threaten primary care sustainability.

Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study

BACKGROUND

Consumer-driven homecare models support aging and disabled individuals to live independently through the services of homecare workers. Although these models have benefits, including autonomy and control over services, little evidence exists about challenges homecare workers may face when providing services, including workplace violence and the negative outcomes associated with workplace violence. This study investigates the prevalence of workplace violence among homecare workers and examines the relationship between these experiences and homecare worker stress, burnout, depression, and sleep.

METHODS

We recruited female homecare workers in Oregon, the first US state to implement a consumer driven homecare model, to complete an on-line or telephone survey with peer interviewers. The survey asked about demographics and included measures to assess workplace violence, fear, stress, burnout, depression and sleep problems.

RESULTS

Homecare workers (n = 1,214) reported past-year incidents of verbal aggression (50.3% of respondents), workplace aggression (26.9%), workplace violence (23.6%), sexual harassment (25.7%), and sexual aggression (12.8%). Exposure was associated with greater stress (p < .001), depression (p < .001), sleep problems (p < .001), and burnout (p < .001). Confidence in addressing workplace aggression buffered homecare workers against negative work and health outcomes.

CONCLUSIONS

To ensure homecare worker safety and positive health outcomes in the provision of services, it is critical to develop and implement preventive safety training programs with policies and procedures that support homecare workers who experience harassment and violence.

Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study

BACKGROUND

Consumer-driven homecare models support aging and disabled individuals to live independently through the services of homecare workers. Although these models have benefits, including autonomy and control over services, little evidence exists about challenges homecare workers may face when providing services, including workplace violence and the negative outcomes associated with workplace violence. This study investigates the prevalence of workplace violence among homecare workers and examines the relationship between these experiences and homecare worker stress, burnout, depression, and sleep.

METHODS

We recruited female homecare workers in Oregon, the first US state to implement a consumer driven homecare model, to complete an on-line or telephone survey with peer interviewers. The survey asked about demographics and included measures to assess workplace violence, fear, stress, burnout, depression and sleep problems.

RESULTS

Homecare workers (n = 1,214) reported past-year incidents of verbal aggression (50.3% of respondents), workplace aggression (26.9%), workplace violence (23.6%), sexual harassment (25.7%), and sexual aggression (12.8%). Exposure was associated with greater stress (p < .001), depression (p < .001), sleep problems (p < .001), and burnout (p < .001). Confidence in addressing workplace aggression buffered homecare workers against negative work and health outcomes.

CONCLUSIONS

To ensure homecare worker safety and positive health outcomes in the provision of services, it is critical to develop and implement preventive safety training programs with policies and procedures that support homecare workers who experience harassment and violence.

Musculoskeletal pain and reported workplace assault: a prospective study of clinical staff in nursing homes

OBJECTIVE

This study examined prospectively the effect of workplace violence on musculoskeletal symptoms among nursing home workers.

BACKGROUND

Previously we reported a cross-sectional relationship between physical assaults at work and musculoskeletal pain. This follow-up provides stronger evidence of the effect of workplace violence on musculoskeletal outcomes within the same workforce over two years.

METHOD

Nursing home workers who responded to three consecutive annual surveys formed the study cohort (n = 344). The outcomes were any musculoskeletal pain, widespread pain, pain intensity, pain interference with work and sleep, and co-occurring pain with depression. The main predictor was self-reported physical assault at work during the 3 months preceding each survey. Prevalence ratios (PRs) were assessed with log-binomial regression, adjusting for other workplace and individual factors.

RESULTS

Every fourth nursing home worker, and 34% of nursing aides, reported persistent workplace assault over the 2 years. Among respondents assaulted frequently, two thirds experienced moderate to extreme musculoskeletal pain, and more than 50% had pain interfering with work and/or sleep. Baseline exposure to assault predicted pain outcomes 1 year later. Repeated exposure was associated with a linear increase over 2 years in the risks of pain intensity, interference with work, and interference with sleep; co-occurring pain and depression had an adjusted PR of 3.6 (95% CI = 1.7-7.9).

CONCLUSION

Workplace assault, especially when repeated over time, increases the risk of pain that may jeopardize workers' ability to remain employed.

APPLICATION

More effective assault prevention would protect and support the workforce needed to care for our increasing elderly and disabled population.

What is known about dementia care recipient violence and aggression against caregivers?

Aggression is a known behavior in dementia, but there is little in the literature about risk to home-based caregivers in situations where severe aggression is present. This article examines this issue with a focus on what is known and where further research is needed. Rates of severe aggression by dementia care recipients against caregivers are estimated at greater than 20%, and may be the strongest predictor of nursing home placement. Measures containing both assessment of behavior and objective measures of caregiver trauma are needed, along with interventions aimed at educating and protecting caregivers while respecting communicative properties of behavior.

Enhancing Home Care Staff Safety Through Reducing Client Aggression and Violence in Noninstitutional Care Settings

The problematic occurrence of client violence and patient aggression toward health care workers is pervasive, with studies and reports finding that home health care workers experience one of the highest rates of client violence than any other career field. With the recent passage of the Patient Protection and Affordable Care Act in 2010, traditional health care delivery in institutional care settings is increasingly shifted to service delivery venues in noninstitutional care settings. During this transition, greater numbers of health care workers are providing services in patients’ private homes, increasing the potential risk to staff safety and well-being in these settings.

Personal service assistance: musculoskeletal disorders and injuries in consumer-directed home care

BACKGROUND

Like other types of care for disabled or elderly adults, consumer-directed personal assistance services may present multi-factorial risks for work-related musculoskeletal disorders (WRMSDs).

METHODS

Using survey data, we compared providers experiencing WRMSDs in the previous year to those who did not, seeking to identify functional, temporal, physical, and relationship risk factors for transient and chronic conditions.

RESULTS

Longer work experience with the recipient and more frequent bending increased the risk of being in the most chronic group (≥12 painful episodes), whereas predictable work hours with rest breaks and greater social support from the recipient appeared protective. For transient conditions (one to two episodes), longer work experience with the recipient and predictable hours with rest breaks appeared protective.

CONCLUSIONS

We offer recommendations to improve hazard assessment as well as training and information distribution related to home care programs. With the population aging, home care jobs require increasing oversight to prevent WRMSDs.

Association of depression and suicidal ideation with unreasonable patient demands and complaints among Japanese physicians: a national cross-sectional survey

BACKGROUND

Physicians' mental health can be affected by unreasonable demands and complaints made by patients.

PURPOSE

The purpose of this study is to determine the association between depressive symptoms and suicidal ideation among physicians working in hospitals in Japan and unreasonable patient demands and complaints.

METHODS

We sent an anonymous questionnaire to 10,000 randomly selected physicians working at hospitals who were members of the Japan Medical Association. The anonymous self-report questionnaire sought to determine the number of unreasonable demands and complaints made by patients or their family members reported by physicians in the previous 6 months. Depressive symptoms and suicidal ideation were measured using the Japanese version of the Quick Inventory of Depressive Symptomatology (QIDS). Logistic regression analysis was used to explore the associations of depressive symptoms and suicidal ideation with reported unreasonable demands and complaints.

RESULTS

Among the 3,864 respondents, men (46.3%) reported experiencing unreasonable patient demands and complaints more frequently than women (40.4%). Depressive symptoms were indicated in 8.3% of men and 10.5% of women, and 5.7% of men and 5.8% women were determined to exhibit suicidal ideation. The number of unreasonable demands and complaints in the previous 6 months was significantly associated with depressive symptoms and suicidal ideation for both men and women (P for trend <0.01).

CONCLUSIONS

Physicians should recognize the health risks of unreasonable demands and complaints, and hospitals should provide support for physicians dealing with these stressors.

Research to practice in occupational health nursing

Occupational health nursing research has gained a significant place in national and international nursing programs and has advanced occupational health nurses' understanding of the most effective ways to prevent occupational illness and injury, provide access to quality care for workers, and manage occupational injuries and return to work. This article describes the history of nursing research in general and highlights the current national shortages that must be addressed to ensure that nurses continue to impact the field. Occupational health nursing priorities are described and examples are given of nurse scientists who have established the foundation of occupational health nursing research and who illustrate varied expertise and the interdisciplinary context in which the work is conducted.

Work-related violence and incident use of psychotropics

Although the mental health consequences of domestic violence are well documented, empirical evidence is scarce regarding the mental health effects of violence in the workplace. Most studies have used data from small occupation-specific samples, limiting their generalizability. This article examines whether direct exposure to work-related violence is associated with clinically pertinent mental health problems, measured by purchases of psychotropics (antidepressants, anxiolytics, hypnotics), in a cross-occupational sample of 15,246 Danish employees free from using psychotropics at baseline. Self-reported data on work-related violence were merged with other data on purchases of medications through a national registry to estimate cause-specific hazard ratios during 3.6 years (1,325 days) of follow-up in the years 1996-2008. Outcomes were examined as competing risks, and analyses were adjusted for gender, age, cohabitation, education, income, social support from colleagues, social support from supervisor, and influence and quantitative demands at work. Work-related violence was associated with purchasing antidepressants alone (hazard ratio = 1.38, 95% confidence interval: 1.09, 1.75) or in combination with anxiolytics (hazard ratio = 1.74, 95% confidence interval: 1.13, 2.70) but not with purchasing anxiolytics or hypnotics only. The frequency of violent episodes and risk of caseness were unrelated. Work-related violence is associated with increased risk of clinically pertinent mental health problems. Reducing levels of work-related violence may help to prevent mental disorders in the working population.

Strategies used and challenges faced by a breast cancer patient navigator in an urban underserved community

Patient navigation has been widely implemented by cancer care programs across the United States. While activities of navigators have been described elsewhere, little has been documented regarding specific strategies used or challenges experienced by navigators from their own perspectives. We describe the experience of an African American patient navigator who promoted breast cancer screening and facilitated diagnosis and treatment among inner-city mostly African American women in Newark, New Jersey. We conducted qualitative analysis of journal notes, log data, and in-depth interviews with the patient navigator. Strategies used by the patient navigator to develop trust and rapport included: (1) "meet patients where they are" (outreach is best performed in locations women frequent, such as hair salons); (2) being accessible (must be flexible and available by phone or in person to meet patient's needs); and (3) "bring it down, sista" (must have "street credibility" in dress and language). Key challenges included experiencing threats to safety, setting boundaries, and facing and overcoming burnout. The patient navigator responded to these obstacles by creating new community linkages and resources and reaching out for emotional support from her mother and supervisor. Areas that need to be addressed further for future patient navigator programs include promoting safety in potentially dangerous neighborhoods and helping navigators set boundaries and avoid burnout. Further research into experiences of patient navigators in different settings is needed to build upon this preliminary data, and to consider character traits and attributes best suited for a patient navigator, as well as the support needed for this new health care worker.

Depressive symptoms and their social contexts: a qualitative systematic literature review of contextual interventions

BACKGROUND

Numerous observational studies demonstrate associations between social context and depressive symptoms, yet few intervention trials exist in this arena.

AIMS

This review examines intervention trials that explore the impact of contextual change on depressive symptoms.

METHODS

Electronic literature databases of PubMed and PsycINFO, bibliographies of retrieved articles and the publicly available internet were searched for English-language articles published between 1997 and 2008. Peer-reviewed studies were eligible for inclusion if they reported contextual interventions and depressive symptoms measures in adult populations without other significant underlying medical or psychological illness. In total, 2,128 studies met search term criteria. Of these, 13 studies meeting inclusion criteria were classified by type of intervention. Qualitative synthesis was used to interpret the mental health impact of contextual interventions.

RESULTS

The interventions focused on employment, housing, poverty, parenting and violence. Eight of these studies reported a decrease in depressive symptoms and/or psychological distress in intervention groups. Interventions varied in focus, length of follow-up and measures of depressive symptoms.

CONCLUSIONS

Contextual interventions for the prevention and treatment of depressive symptoms and psychological distress can be effective, though very limited data exist in this field. Policy implications include a greater emphasis on improving context to decrease depression and other mental disorders.

The political and economic context of home care work in California

California's primarily female, ethnically diverse home care workforce is at the intersection of the public and private spheres of work and at the front line of recurring policy and budget debates targeting government-funded long-term care services. The convening of a Home Care Research Working Group in 2001 has led to collaborative action research initiatives and advocacy for policies to improve working conditions and home care services. The study reported here demonstrates that: 1) current long-term care policy is inadequate to ameliorate home care stressors such as physical and emotional demands, schedule conflicts, financial strain, and job insecurity; 2) workers' experience of home care differs by gender and by race or ethnic group; and 3) a union that actively engages workers is a viable avenue to provide individual support and empowerment as well as collective advocacy for home care services, critical in an era of attacks against health and social service programs.

Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression

We assessed the role of promotoras--briefly trained community health workers--in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention's impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention's implementation, involving infrastructure at the health centers, boundaries of the promotoras' roles, and "turf" issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.

Risk factors associated with patient assaults of home healthcare workers

This study used surveys from 677 home healthcare aides and nurses to explore factors associated with assaults by patients. Among respondents, 4.6% reported one or more patient assaults (being hit, kicked, pinched, shoved, or bitten) during the past year. Logistic regression analysis examined associations between several potential risk factors and assaults. Three factors were significant, including having one or more patients with dementia (OR = 4.31, 95% CI 1.47-12.67), routinely handling patients (OR = 8.48, 95% CI 1.89-37.94), and perceiving threats of violence by others in and around patients' homes (OR = 4.45, 95% CI 1.75-11.32). Assaults were not significantly associated with worker age, gender, race, job title, hours of work, or use of needles during patient care. Assaulted workers and workers who perceived threats of violence by others were significantly more likely to have shortened home care visits. More detailed research is needed to confirm these results and evaluate methods to reduce assault risk.

Physically demanding workloads and the risks of musculoskeletal disorders in homecare workers in the USA

Although musculoskeletal disorders (MSDs) are prevalent among homecare workers, little is known about the MSD risk factors. This study investigated whether physically demanding workloads among homecare workers are related to MSDs, especially in neck, shoulder and back pain. Data were taken from two waves of a random sample (June to December 2003 and December 2003 to February 2004). The sample included 1643 homecare workers at Wave 1 and 1198 homecare workers at Wave 2, respectively. A basic telephone interview and 30 minutes computer-assisted interview were performed for homecare workers in Wave 1 and Wave 2. The prevalence of neck, shoulder and back MSDs was assessed at Wave 1 and Wave 2 using the Nordic questionnaire of musculoskeletal symptoms. The incidence of MSDs at 6 months was estimated at Wave 2 using only those who were in the asymptomatic reference group at Wave 1 as the denominator. At Wave 1, back MSDs were the most prevalent (10.2%), followed by neck (9.6%) and shoulder (7.1%) MSDs. After 6 months, the incidence of neck MSDs was the highest (7.0%), followed by back (6.4%) and shoulder (4.8%) MSDs. Physical demands of work were assessed using items developed from focus groups of workers. When compared with asymptomatic workers, those with MSDs showed a dose-response effect for physical job demands. After controlling for age, psychosocial demands and social support on-the-job, physical demands among homecare workers were significantly associated with an excessive odds of neck, shoulder and back MSDs incident at 6 months (odds ratios of 1.14-1.17 for each unit increase on a physical demand scale). Our study shows that the physical demands of work are a significant risk factor for MSDs among homecare workers. Considering the high physical demands among homecare workers, the finding in this study clearly indicates that practical intervention strategies should be implemented to protect homecare workers from exposure to MSD risk factors.

Assessing risk for violence on home health visits

The objective of this study was to develop and test measures for assessing risk of violence toward staff during home visits. Home visiting health workers from public and private home visiting programs in a Mid-Atlantic state (n = 130) were surveyed to assess exposure to risky home visits, verbal and physical violence, and workplace violence safety climate. Two measures demonstrated evidence of reliability and validity moving the safety research closer to developing tools and processes for protecting home care clinicians.

Job stress and job satisfaction: home care workers in a consumer-directed model of care

OBJECTIVE

To investigate determinants of job satisfaction among home care workers in a consumer-directed model.

DATA SOURCES/SETTING

Analysis of data collected from telephone interviews with 1,614 Los Angeles home care workers on the state payroll in 2003.

DATA COLLECTION AND ANALYSIS

Multivariate logistic regression analysis was used to determine the odds of job satisfaction using job stress model domains of demands, control, and support.

PRINCIPAL FINDINGS

Abuse from consumers, unpaid overtime hours, and caring for more than one consumer as well as work-health demands predict less satisfaction. Some physical and emotional demands of the dyadic care relationship are unexpectedly associated with greater job satisfaction. Social support and control, indicated by job security and union involvement, have a direct positive effect on job satisfaction.

CONCLUSIONS

Policies that enhance the relational component of care may improve workers' ability to transform the demands of their job into dignified and satisfying labor. Adequate benefits and sufficient authorized hours of care can minimize the stress of unpaid overtime work, caring for multiple consumers, job insecurity, and the financial constraints to seeking health care. Results have implications for the structure of consumer-directed models of care and efforts to retain long-term care workers.

Evaluating the working conditions and exposure to abuse of Filipino home care workers in Israel: characteristics and clinical correlates

BACKGROUND

Filipino home care workers provide the majority of around-the-clock personal care to frail individuals in Israel. To date, the working conditions as well as exposure to work-related abuse of Filipino home care workers in Israel have not been evaluated.

METHODS

A survey of 245 Filipino home care workers was conducted to evaluate their working conditions and exposure to abuse as well as their clinical correlates (e.g. burnout as measures by the Maslach Burnout Inventory). This was integrated with findings from interviews with Filipino home care workers, social workers, and family members of care recipients cared by Filipino home care workers.

RESULTS

A majority of the workers (88%) reported paying large amounts of money in order to work in the country. Overall, 43% reported being asked to do more than was specified in their job description, 41% reported being verbally abused, and 40% reported not receiving adequate food. Almost half reported work-related injuries. The most consistent predictor of burnout (as measured by the Emotional Exhaustion and Depersonalization scales) was exposure to work-related abuse. Interview data identified system and societal barriers that prevent workers from using the legal system for their protection.

CONCLUSIONS

The present study calls for further supervision of this caregiving arrangement. Psychoeducational programs directed towards all stakeholders (e.g. social workers, home care workers, care recipients, and family members of care recipients) are needed.

Safe in the city

Workplace danger and violence are complex problems that affect nurses more often than is recognized. The home healthcare work environment is challenging enough without the additional risks associated with working out in the open or within a client's home. Every clinician working in home health today understands the demands of visits or extended care in the home and often reluctantly accepts the involved risk. The clinician working in the rural setting may experience similar challenges, but in large metropolitan cities, it has become increasingly frightening as crime, drug use, gangs, violence, homelessness, and transportation issues have made the clinician's job much tougher. It is important to renew awareness and remind clinicians to maintain constant vigilance for personal safety.

Barriers to documenting occupational injuries among personal assistance services workers

BACKGROUND

Personal Assistance Services (PAS) workers provide essential support to disabled and elderly individuals living at home rather than institutions. Occupational injury risks are known, but limitations in occupational injury surveillance prevent assessing injury prevalence. Changing employment arrangements adopted by publicly funded programs may complicate the classification of PAS workers.

METHODS

We surveyed state workers' compensation agencies and Financial Management Services organizations used by state Medicaid programs.

RESULTS

Changing employment arrangements pose further barriers to classifying and documenting injury, and accessing workers' compensation coverage. Workers' Compensation coverage varies according to employment arrangements of the PAS workers. Financial Management Services organizations vary in their roles for reporting injury. Most frequent activities were providing written information about injury reporting, and reporting injuries to appropriate agencies or insurance companies.

CONCLUSIONS

Current limitations undercount the prevalence and consequences of PAS-related occupational injuries among agency workers and largely ignore independent providers. Policy and research recommendations are presented.