International Journal for Quality in Health Care 2012; Volume 24, Number 5: pp. 525–531 10.

1093/intqhc/mzs047
Advance Access Publication: 3 August 2012

Types and patterns of safety concerns in

home care: staff perspectives
CATHERINE CRAVEN , KERRY BYRNE , JOANIE SIMS-GOULD AND ANNE MARTIN-MATTHEWS
1 2 3 1

1 2
Department of Sociology, University of British Columbia, Vancouver, Canada, Tyze Personal Support Networks, Vancouver, Canada, and
3
Centre for Hip Health & Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
Address reprint requests to: Catherine Craven, Department of Sociology-ANSO Building, University of British Columbia, 6303 N.W.
Marine Drive, Vancouver, BC, Canada V6T 1Z1. Tel: þ 604-822-6683; Fax: þ604-822-9304; E-mail: catherine.craven@ubc.ca

Accepted for publication 9 July 2012

Abstract
Downloa
Background. Quality health care in the home is dependent on having a safe environment to provide care. This analysis is
based on the data from a larger study aimed at understanding key issues in the delivery and receipt of home support services
from the perspectives of home support workers (HSWs), older adult clients and family members. This analysis focuses on
HSWs perspectives of safety.
Objective. To explore the types and patterns of safety concerns staff encountered in home care settings.
Design. In-depth, semi-structured interviews were conducted with HSWs. The analysis included topic and analytical coding
of workers’ verbatim accounts.
Setting. Interviews were completed in British Columbia, Canada.
Participants. A total of 115 HSWs participated. The average age was 50 years, and the average tenure in this sector was 11.5
years. Fully, 71% of workers had completed at least some college-level education, and 69% of workers were born outside of
Canada.
Results. Workers identified four types of safety concerns: physical, spatial, interpersonal and temporal. We developed a con-
ceptual model of HSW safety that demonstrates the: types of safety concerns; the multi-dimensional and intersectional nature
of safety concerns and the factors that intensify or mitigate safety concerns.
Conclusions. Our study identifies numerous HSW safety concerns, each requiring tailored interventions and strategies. Where
multiple concerns intersect, the complexity and precarious nature of the home care workspace is revealed. The identification
of mitigating and intensifying factors points to future interventions.
Keywords: safety, occupational health, home care services, qualitative methods, elderly

Introduction guided by client preferences and cost containment pressures, are

Home support workers (HSWs), also known as direct care workers
and domiciliary care workers, play a vital role in home care by helping
older adults with personal care (e.g. bathing, dressing, toileting, etc.) in
private homes, thereby allowing these individuals to remain in their own
homes rather than accessing facility-based care. HSWs provide the
majority of direct care in home care settings [1, 2], having a
significant impact on the quality of home care. Their ‘work space’ in
clients’ homes is uncontrolled, unregulated and consists of minimal
supervision
[3]. As a result, HSWs are exposed to a variety of occupational health
and safety hazards [4]. The safety concerns of HSWs are important
and timely considerations for quality of care for several reasons. First,
both clients and families prefer home as the location of care.
Second, planning and policy-makers,
focused on ‘home first’ policies and aging in place initia- tives.
Quality care in the home is dependent on having a safe environment
to receive and provide care, despite the fact that the ‘home space’ of
each client is highly variable. A safe work environment in the home
cannot be standardized, equipped or regulated in the same manner as
a hospital or care facility. Third, although HSWs are the backbone
of paid home health care [5], HSWs’ perspectives are missing in
existing research about home care safety (for an exception, see 6).
Fourth, al- though there are numerous safety issues encountered by
paid care staff in home care settings, most research focuses on a
single type of safety concern, such as violence [7–9], musculo- skeletal
injury [4, 10, 11] or weather-related challenges [12].
In one of the few studies exploring safety of HSWs,
Stevenson et al. [6] found that HSWs had an alarming

International Journal for Quality in Health Care vol. 24 no. 5

# The Author 2012. Published by Oxford University Press in association with the International Society for Quality in Health Care;
all rights reserved 525
Craven et al.

tolerance for risk. Workers had been in risky situations for such a long Table 1 Participant characteristics
time, ‘that it had come to be assumed that such
risk acceptance was the norm for both themselves and their clients’ (p.
22) [6]. Finally, researchers have established a link HSW characteristics (n Average Range
¼ 115 ) a

between client and worker safety [3, 6], with an unsafe ‘work’ ....................................................................................
space meaning an unsafe ‘care’ space and vice versa [13]. Years as HSW 11.5 years 6 months–29
Although safety researchers have emphasized the interlinked years
nature of the worker–client safety agenda, client outcomes and Age b
50 27–65
experiences are still the focus of the key research in this area Hourly rate of pay $18.61 $10.42–$20.00
[6, 14–17]. For example, while Lang [3] identified four types Number of clients per day 4 1–9
of safety in home care (social, functional, emotional and Number Percent of total
physical), the focus is on patient safety. Gender
Guided by the gaps in home care safety research, includ- ing Female 108 94
those identified in a recent editorial by Lang [3] in the Education
International Journal for Quality in Health Care, is the need for Less than high school 12 10
textual data to capture the multi-dimensional nature of home High school 22 19
care safety. To address this, we answer the following ques- Some college 12 10
tion: What are the types and patterns of safety concerns Completed college 24 21
from the perspective of HSWs? We frame our findings using a Some university 8 7
conceptual framework that demonstrates the types of safety Completed university 27 24
concerns reported by HSWs and the critical patterns Registered nurse 10 9
reflected in the experiences of HSWs. Place of birth
Canada 36 31
Philippines 35 30
Asia 26 23
Methods
Europe 10 9
Other 8 7
This paper is based on data from a larger mixed-methods
Employment status
study [18–20] aimed at understanding key issues in the deliv-
Full time 70 61
ery and receipt of home support services from the perspec-
Part time 11 10
tives of HSWs, older adult clients and family members. We Downlo
Casual 34 29
collected qualitative and quantitative data through in-depth,
face-to-face, semi-structured interviews with workers. The aOf the 118 HSWs interviewed, two workers did not answer the
interview guide covered various thematic areas, including safety questions, and one worker was eliminated from this
basic demographics (as presented in Table 1), experience in analysis due to language/interpretation issues.
b
the home support sector, training and education, safety con- 114 HSWs reported their age, one participant declined response.
cerns and conflicts on the job and their responses, working with
clients or family members, ethno-cultural issues, com-
munication with other HSWs and agency staff, and recruit-
ment and retention within the home support sector. Drawing on Data collection
the qualitative interview data, this paper focuses on the HSWs’ Face-to-face in-depth interviews were conducted by trained
safety concerns. interviewers. Participants were asked if they had safety con-
cerns on the job; if yes, they were asked about the nature of
their concern and the types of responses and strategies that
Setting and participants they employ. Interviews were conducted at different locations
Ethics approval was granted from the University of British (primarily in the homes of these workers), and ranged from 60
Columbia Ethics Board and the regional health authority in to 90 min. They were digitally recorded, transcribed ver- batim
which our study was conducted. Data were collected from and saved using ID numbers.
March 2007 to October 2007 in British Columbia, Canada.
Eligible participants were employed HSWs who provided
care to older adults, and were able to participant in an Analytical strategies
English language interview. For more information about re- Our analysis team consisted of post-doctoral fellows, a
cruitment, see [18]. Of the 118 HSWs who participated in masters prepared research assistant and the principal investi-
these in-depth interviews, 115 were asked about their safety gator of the study, all experienced in qualitative research and
concerns on the job. Two participants did not have enough analysis. Two team members (the first and second authors)
time to complete the full interview guide, and one partici- engaged in topic and analytical coding of the transcripts [21];
pant’s transcript was excluded from the analysis due to lan- however, all authors contributed to the analysis through
guage and interpretation issues. meetings where we shared memos about the codes and the

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 Staff safety in home care † Patient safety

development of a conceptual model. Thus, coding, themes and the interplay between the following aspects of safety concerns: (i) the
model were developed through a process of collab- oration and types, (ii) the multi-dimensional and intersectional nature and (iii) the
consensus amongst the authors. Rigour was established through a intensifying or mitigating factors.
combination of standard techniques for qualitative research,
including team meetings, an audit trail, analytic memoing and peer
debriefing [22–24]. Types of safety concerns
In total, 97 (84%) of the workers in our study reported that they
Participant characteristics had safety concerns. Workers provided accounts of their safety
The personal care tasks performed by HSWs most common- ly concerns that were both retrospective (a reflection on a previous
include bathing (98%), dressing (98%), medication remin- ders safety experience that involved them or a co- worker) and
(92%), toileting (91%) and lifting and transferring (87%). Most prospective (a concern or worry for what ‘might’ or ‘could’
workers (80%) also provide assistance with exercise. Highlighting happen). Four types of safety concerns were identified (see Fig. 1
the physical nature of their work, HSWs provide housekeeping and Table 2).
services, including garbage and recycling (90%), laundry (86%), Workers most frequently identified issues of physical safety,
vacuuming (77%), floors (75%) and dusting (70%). See Table 1 for involving lifting and transferring clients, with concerns about
demographic information. potential back injury, followed by spatial concerns re- ferring to the
home space in which they worked. The third most cited were
Fully 58% of HSWs had worked in home support for more
temporal concerns, often referring to rushed travel between clients’
than 10 years, and just over 10% for over 20 years. Workers had an
homes. The fourth were interpersonal concerns. Typically framed
average caseload of four clients per day (SD ¼ 1.5), ranging from
by workers’ interactions within the private spheres of clients’
one to nine clients. While 69% of workers were born outside
homes, these involved client and family behaviours, conflicts and
Canada, 78% of these immigrant workers had lived in Canada for
specific client condi- tions. Many of these concerns, notably the
more than 10 years. In terms of age, gender, tasks, caseloads and
temporal and interpersonal, have an enduring, permanent quality:
length of tenure in the home support sector, the workers in this
they are ongoing, anticipated safety concerns associated with this type
study are similar to workers whom we have interviewed in two other
of work. Tables 3 and 4 include additional data.
Canadian provinces (Ontario and Nova Scotia, see [20]). In this
British Columbia study the workers were more likely to be foreign-
born and more highly educated. This is largely re- flective of Safety concerns: multi-dimensionality and intersectionality
migration trends in the urban area where we con- ducted our study,
As demonstrated in Fig. 1, safety concerns were not only multi- Downlo
and the fact that foreign-born workers frequently have overseas
dimensional (i.e. more than one type), but also intersectional; it is at
credentials in related health care professions (e.g. nursing). For an
these points of intersection that we are better able to understand the
in-depth analysis of these foreign-born workers, see [19].
patterns of HSW safety. Our analysis identi- fied that the most
common intersection occurred with spatial concerns, highlighting
Results the risks presented by each unique home environment. Safety
issues are rooted in the fact that care is provided in unregulated,
Based on our analysis of HSWs safety concerns, we developed a private residences. These residences also regularly undergo change,
conceptual framework (see Fig. 1), which demonstrates the for example when

Figure 1 HSW safety concerns: conceptual framework.

527
Craven et al.

Table 2 HSWs’ types of safety concerns

Type of safety concern Definition

.............................................................................................................................................................................

Physical Concerns of a physical/medical nature, including musculoskeletal injuries, trips, falls and
communicable diseases, related to both the experience of, and the potential risk for, physical harm
Spatial Concerns based on features of the home space including physical characteristics of the inside and
outside area of a client’s home; spatial layout of the home; geographic location (e.g. dangerous
neighbourhoods) and the adequacy of the ‘set-up’ of the home in terms of equipment and supplies;
presence of hazards or threats (e.g. client’s pet)
Interpersonal Concerns arising from interactions between workers and clients/clients’ family members, impacting
the worker psychologically, socially or emotionally
Temporal Concerns related to the timing of the service and the worker’s schedule, including the time of day,
week or year, rushing with clients and time pressures related to travelling to clients’ homes

Table 3 HSWs verbatim accounts of physical and spatial concerns

Physical concerns
I always wonder how long I’m going
to be able to do it. Because, yeah, there’s Safety concerns we’re getting is because Yeah, safety, yeah, and health because, I
a high rate of back injuries so I just—I there is more and more infectious have client [who] is heavy and you have
wonder how long the body’s going to last diseases out there that we have to care to lift them, you know, and sometimes,
(#55, HSW, 11 years) for, and it does bother me a lot, and I the wheelchair is too high for you
worry about them (#17, HSW, 13 because they’re small (#104, HSW,
Spatial safety concerns years) 18 years)
When the dog barks I’m jumping—
so I can’t do my job properly. I’m so Some of the clients’ homes, you can’t People’s houses is so crowded and then
worried, I am so nervous (#29, HSW, 14 get through the door they’re so dirty. That’s makes me—and then Downlo
years) cluttered (#34, HSW, 25 years) another thing . . . I have little bit of
bronchial asthma. So whenever we
cleaning, the cleaning stuff bothers
me . . . like a cleaning solution, strong like a
bleach (#10, HSW, 3 years)

family members move furniture, or when a client’s ability to and stuff like that. And, again, it’s like, ‘Were you wearing the
care for and clean their home fluctuates. Furthermore, the right shoes? Were you bending your back properly,’ you know,
workers in our study visit, on average, four homes per day. [but] she’s got no equipment in there to grip, you know . . .
Issues of physical safety especially when associated with (Gwyneth, #83)
inappropriate or insufficient supplies and equipment in the
home intersected with spatial concerns. For example, physic- al/ In addition, interpersonal concerns with family members
spatial safety issues involved inappropriate beds (e.g. need for a intersected with spatial issues about the ‘home space’.
hospital style bed) and the absence of functional lifts. Worker Uniquely in the home care context, family members often
Anita described this relationship between types of safety play an important role in setting up and managing the client’s
issues: living space, which simultaneously serves as the HSWs work
space. For example, worker Jane describes her concerns about a
Before I have a problem about the bed being low, her bed, family’s unwillingness or inability to purchase appropriate lift
because I have to keep turning her . . . you have a backache equipment for the home. In this situation, the worker is
because you keep turning . . . so now they have to raise up the bed . expected to compromise her physical safety by doing lifts
. . It’s been resolved that problem, yeah . . . They put that [bed on without mechanized assistance. Here we see the intersection of
a] block. (Anita, #71) interpersonal, spatial and physical concerns:

Gwyneth discussed the absence of appropriate equipment: The only safety concern I would have at the moment is . . . when it
involves a person that really wants to stay at home to the day they
. . . the bathroom is the main safety area, right., which apparently a die and they need a Hoyer lift and they need something, the only
lot [of] our home support workers have pulled their back out concern I have is that the family says, ‘Well, we can’t afford

528
 Staff safety in home care † Patient safety

Table 4 HSWs verbatim accounts of temporal and interpersonal concerns

Temporal safety concerns

Driving, yeah, driving. Like, you’re in
a hurry. I have had co-workers who get into
an accident and the office are calling them,
you know, so they get into a rush and they get
into an accident (#21, Male, HSW, 8 years)
Interpersonal safety concerns
So I went to the kitchen, prepare his
food and the medicine and when I
went back, he’s already nude . . . I told him,
‘Okay I’ll just put on your
jammies okay?’ But I was a little scared.
Because I know he’s still a little bit strong. I
didn’t go close to him. I just made a distance .
. . But I was really so scared . . . I feel uneasy
(#74, HSW, 9 years)
We are allowed to be really cautious when you Yes, traveling time because ah, they
do things . . . when we have in-service training, schedule us, they give us ten minutes
that’s what we discussed travel time between clients. So when it’s
there . . . but . . . you know, when you’re in traffic like this, you know, you need to be
a hurry sometimes some workers get hurt, yeah to that client at four o’clock . . . So there’s
(#114, HSW, 16 years) a tendency that you have to rush and ah,
beat the traffic. That’s kind of unsafe for
me, too, but you have to be there (#14,
HSW, 13 years)
Well, for falls . . . fall with them to make
Ah, I had a client who had severe dementia. sure you don’t hurt yourself or them. But if
And she was living by herself. And they, she you don’t happen to be close enough to
had no family or them, you know at
anything . . . she became incredibly agitated one the time to catch them, you know, accidents
time, that I thought she was going to hurt me. could still happen while you’re there. So I
She had a broom that she was threatening me would feel really bad if something like that
with and so I just kept backing up and I thought happened while
well you know I think I’m just going to leave. I was, you know, responsible for them
So I left (#35, HSW, for ,1 year)
(#16, HSW, 15 years)

it. We don’t want to do it. But you always did it this way? Why can’t you safety concern. This might include removing a worker from aDownlo
do it now?’ (Jane, #59) situation perceived as potentially unsafe. Patrick felt that the agency
was very responsive to workers’ safety requests: ‘you have the
Interpersonal concerns involving clients also intersected with spatial option, like, if you don’t feel physically pre- pared, then you can
elements. For example, Heather described how the client’s home say no and you can—it’s valid for them’. Many workers shared
situation left her feeling a certain level of ‘moral distress’ [25]: examples of pro-active, tailored strat- egies, which they employed as
concerns arose. Tailoring their strategies meant that workers made
I went into a house that was so dirty, uhm, and it was, there was nothing changes specific to the safety environment of particular
clean to put on a gentleman. He was grossly overweight, and you’re
households. Examples of tailored strategies included discussing the
supposed to do a bed bath and put clothes on him, and it was just nothing.
That was really, really discouraging and upset- ting . . . placement of rugs and furniture with family; changing burnt light
bulbs; taping cords out of the way to avoid trips; advocating for
Finally, workers identified safety issues in the travel between better supplies and equipment; carrying flashlights for late night
residences, situating these at the intersection of temporal and spatial shifts and collaborating with other HSWs through notes and phone
concerns (e.g. rushing from home to home). calls. Strategies were context-specific, imploring HSWs to make
judgment calls and activate appropriate responses as needed. These
strategies often involved negotiating with the client. Joyce explained:
Sometimes . . . we talk to our client and we don’t want to upset our
Mitigating and intensifying factors
clients. Just say, ‘Oh Mr. Smith, is it okay if you can’t smoke?’ I said,
While 84% of the workers in our study reported that they had ‘Oh we won’t stay here for a long time, can you—’ Sometimes he
safety concerns, workers’ responses also revealed various factors that said, ‘Okay.
mitigated their perceptions of potentially unsafe working conditions HSW Johanna explained her technique for speaking with clients
(See Fig. 1). Mitigating factors lessened the severity or perceived about safety concerns:
seriousness of the concern for workers and included positive client
and family characteristics and interactions, supportive organizational Yeah, lots of time I have solved the problem. In fact, sometimes they get
policies and prac- tices (e.g. responsive, readily available so pained in the house, instead of doing anything. So then I’ll take them
supervisors) and a HSW’s individual capacity to be pro-active in for a walk and then on the way I’ll talk and then I’ll find out what’s going
safe-guarding their safety. Indeed, numerous workers reported that on.
their concerns were addressed, and that they were able to speak with
their supervisors to assess, prevent or ameliorate a Conversely, as seen on the left side of Fig. 1, workers identi- fied
factors that intensified or exacerbated their safety con- cerns.
Intensifying factors increased the severity, seriousness

529
Craven et al.
or perceived likelihood that a safety concern could become an
incident. These included unresponsive families and
clients, and unsupportive organizational practices and policies
(e.g. working in isolation, limited preparation or training,
fears about insufficient coverage/insurance and inadequate
information about clients and families prior to first visits). Ellie,
for example, revealed a situation where a client’s highly
communicable disease wasn’t communicated to her for
nearly a week: ‘I don’t want to transfer it to other clients and my
family, too . . . It’s all about the agency. They have to be
responsible, [and] tell us right away’. Workers also discussed
their own inability or unwillingness to act on their concerns.
A few workers also identified personal financial risks in
reporting safety concerns. In these rare cases, workers felt
that they, or co-workers, risked losing clients or much-needed
hours of work if they disclosed their concerns. As Elaine
reported,
I know, out there if there are safety concerns, they don’t really
want to talk about it because they want to keep the hours.
There’s a lot of pressure to just keep quiet to get work, yeah . . .
Well, you know, we’re always told there will be no loss of hours.
But the truth of it is, like, we will lose these.
The failure to report a safety concern not only creates future
hazards, but also serves as a source of potential stress for the
HSW who knowingly accepts risk as a part of the daily work
environment.
Specific client conditions, including dementia or mental
health conditions heightened the perceived physical risk for
workers, including fire hazards, aggression and injury.
Insufficient training further exacerbates these situations. For
instance, Melissa reported: ‘We are getting more and more
extremely demented clients. And I sometimes worry whether or
not, you know . . . we’re not psychologists or psychiatrists or
anything. Like it’s really difficult sometimes to handle them’.
Discussion
Our findings highlight HSWs’ perspectives using textual data to
better understand the complexity of their safety concerns. While
Lang et al. [3, 16, 17] provided broad definitions for the
different types of safety issues in home care, we have
provided a typology of and definitions that are firmly rooted in
the worker experience. This is important because at
present, home care agencies and regional health authorities in
Canada primarily track physical safety concerns, formally
reported through occupational health and safety systems [e.g.
26]. However, our findings suggest that from the HSWs’
perspective, there are also temporal, interpersonal and spatial
concerns that are ongoing and persistent and create unsafe
work environments. For instance, repeat concerns about the
home space and equipment, ongoing interpersonal issues
with family members and rushing to and from client homes.
Extending the work of Lang et al. [3, 16, 17], we demon-
strate the critical intersectional nature of HSWs’ safety
530
concerns. That is, where multiple concerns intersect, the com-
plexity and precarious nature of the home care workspace is
revealed. As represented in our conceptual model, HSWs’
safety concerns continually intersect with the quality of the
workspace in individual homes (i.e. the spatial concerns).
HSWs identified a number of intensifying factors that point to
opportunities for intervention, including more thorough
training to work with persons with dementia, more frequent
assessments of the ‘home space’ and additional avenues for
workers to express and address their concerns. Also, workers
discussed a number of ‘proactive’ strategies that they
employed; thus, peer-to-peer safety training modules are a
potential mode of intervention. We concur with Lang [3],
who identified the need for interventions that respond to
individual safety concerns, which are different in each home.
Elsewhere, researchers have noted that the patient and
HSW safety agendas are interlinked [3, 6, 13, 16]. In our
study, workers described situations that presented threats to
their work environments; however, there are potential impli-
cations for the safety of the clients involved as well. For
instance, cluttered or unhygienic homes lacking in proper
equipment and supplies, influence the safety of the client
who is also exposed to this environment. HSWs safety issues
reveal hazards not only for the worker and client, but also
represent risks for other professionals who enter and work in
the home. HSWs provided valuable information about the
quality of the home and care space and it is essential that
they be consulted about the development of home care
safety interventions and approaches. As well, future research
should investigate the relationship between client and workerDownlo
safety concerns so that intervention efforts can be aligned.
There are some limitations to our study. As our data are
based on workers’ recollections of safety concerns, there may
be recall issues. Future studies should be based on immediate
reporting, thereby lessening potential recollection problems.
Also, our data rely solely on workers’ verbal descriptions of
their safety concerns in the home. Given the intersectional
nature of spatial concerns, it is essential that future studies
collect observational or visual data (e.g. photos and video) of
the home space.
Acknowledgments
The authors acknowledge the HSWs who participated in the
interviews upon which this article is based.
Funding
This work was supported by the Canadian Institutes of
Health Research [grant number IOP-70684].
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