key: cord-0899962-1i3nfe9d
authors: Brookman, Catherine; Sayin, Firat; Denton, Margaret; Davies, Sharon; Zeytinoglu, Isik
title: Community‐based personal support workers' satisfaction with job‐related training at the organization in Ontario, Canada: Implications for future training
date: 2022-01-20
journal: Health Sci Rep
DOI: 10.1002/hsr2.478
sha: f5d16a99a8d1c679af57d43a5e4253889ad12720
doc_id: 899962
cord_uid: 1i3nfe9d

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

The demand for home and community-based services for older adults has significantly increased over the past few decades as a result of a focus on "aging in place." [1] [2] [3] This demand extends beyond Canada and has been seen in the United States of America and Europe. 1, [4] [5] [6] [7] In addition, due to an increasingly aging population and the demand for hospital beds, patients are being released with greater acuity and faster into the community. In home-and community-based care, client acuity is on the rise and care for individuals living with chronic conditions and co-morbidities are expected to triple by 2050. 8 In Ontario, Canada, older individuals who would have moved into a long-term care (LTC) home or needed this type of housing are being encouraged to remain in their own homes due to a shortage of LTC home beds and stricter admission criteria for those entering LTC. 9 In addition to this and of equal importance, is the consideration that it is often the preference of older individuals to remain in their own homes which have been found to be linked to better well-being. 10 Growing health care costs and shortages of nurses and other professional staff are a couple of other factors that have forced governments in Canada and abroad to look for more efficient ways of utilizing health care human resources such as care provided by personal support workers (PSWs) along with an expansion of their role. [11] [12] [13] [14] [15] [16] [17] This role expansion has been referred to in the literature as "task-shifting," whereby more advanced care activities are being transferred to PSWs. 11, 18, 19 PSWs are the human resources that provide 70% to 80% of homecare to the aging population in the community. 1, 20, 21 A study on the self-reported data of over 32 000 individuals in the Ontario PSW Registry who work primarily in public homecare agencies found that PSWs in the Registry are largely between the ages of 40 and 59, and the majority, 92% are female with more than 30% having 10 years of experience in the profession.

PSWs are also referred to as Home Support Workers, Homecare Workers, and Home Health care aids in other jurisdictions. 22 There are approximately 100 000 PSWs in Ontario, Canada 23 of which it is estimated that 34 000 work in the home and community care sector. 22 As personal support work is an unregulated occupation 24 and there is no mandatory registry for PSWs, estimates come from a variety of sources and the actual number of PSWs may be larger.

In Ontario, publicly funded PSW services are provided through 14 home and community care support services (HCCSS) bodies (formerly the local health integration networks [LHINs] ). The newly developed Ontario Health Teams (OHT) are responsible for overall health system planning and the funding functions of these HCCSS bodies. 25 Access to government-funded home and community care support services is through HCCSS. Each HCCSS provides a single point of access. While they provide some specialized direct client care such as case management, the majority of client care is contracted to home and community care organizations. These organizations employ PSWs, nurses, and other health practitioners in specified geographic areas.

The structure of the funding arrangements between the HCCSS and provider organizations can result in clients receiving more than one type of service from multiple organizations. PSWs are employed in many different types of funded services, including homecare services, supportive housing services, adult day program services, and LTC homes 26 and as such, provide a variety of different client care services. All employers in Canada have a legal requirement to provide workplace hazardous materials information system training as these workers work with or are exposed to hazardous substances. As well, the Occupational Health and Safety Act 27 28 No other reference to training was found for home and community care organizations. Document analysis and an environmental scan of accountability for home and community care organizations in Ontario, Canada revealed that there are many different accountability requirements for service delivery from a range of stakeholders that mainly focus on regulatory and expenditure instruments. 29 The community care sector is faced with the challenge of retaining PSWs who have adequate skills to meet the needs of community care clients. PSWs provide a variety of tasks, including assistance with personal care, homemaking, personal interaction and more recently, clinical-based activities, and delegated acts in clients' homes. 30, 31 The work of PSWs has gone from assisting with light housework to providing care that was previously provided by registered nurses. 12 As health care practices continue to support the increasing number of individuals facing health challenges in their own homes, more pressure is put on PSWs to have the knowledge and skill sets to meet the increasing needs of these individuals and also to provide care to a greater number of clients. Quality, safety, and feasibility of PSWs performing these added skills have been identified as issues in the literature 13, 18, 19, 32, 33 ; however, previous research has demonstrated that with added training and support, PSWs can play a critical role in the provision of good homecare services such as palliative care, 34, 35 team-based stroke care, 36 and home ventilation. 26, 37 Performing these tasks are a significant undertaking because the formal education of PSWs is varied. 38 This reality has resulted in an increased need for research to ascertain if the knowledge and skills of PSWs are aligned with the work now being required of them, and whether or not they are receiving the necessary training to perform these tasks. 12, 21 Research undertaken in Canada, has highlighted the need for both standardized training among PSWs, as well as with their supervisors. 39 It has also been demonstrated that training is important for job satisfaction. The ability to learn new skills on the job such as those associated with task shifting as well as receiving continuing education was valued by PSWs and sometimes increased satisfaction with their work. 19, 40 Along with the shortage of nurses and other professional practitioners mentioned above, there is now also an Ontario-wide shortage of PSWs. It is estimated that the demand growth for PSW homecare services is projected to be nine times the workforce growth rate, supporting more than ever the need to address any possible measures related to augmenting job satisfaction. 41 While there is extensive research examining the use of PSWs in homecare and the expansion of their job duties, research is limited related to their satisfaction with job-related training at their organizations. Because of this need for more research, it is essential to study if home and community homecare organizations offer PSWs job-related training and delegated task training to help them perform their tasks and provide care, and to examine their satisfaction with organizational job-related training. This information will assist health care organizations, educational institutions, and the health care system in planning for, advocating, and delivering relevant training to equip PSWs to respond to the growing and changing needs of today's home and community care client.

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

PSW work is unregulated, and workers' formal education is varied, although there have been strides made by the Ontario, Canada Ministry of Training Colleges and Universities to address this. 38 There is no defined scope of practice for the role of the PSW and there can be a large variation in the duties they perform, their level of autonomy, and their work environment. 42 A scoping literature review of the barriers and facilitators to the expanded roles of the unregulated care provider in Ontario, highlighted the need to reduce variations in education and employment standards. 43 Lack of education standardization and inconsistent requirements in the preparation of PSWs were highlighted as a challenge in Ontario, Canada. 26 The literature indicates that this is not only a Canadian challenge. For example, it was found that the experiences of both the client and family have highlighted a lack of care provider competence and insufficient training in homecare organizations in Sweden. 37 In Ontario, PSWs receive their formal training through a variety of sources: community college programs, private career colleges (also known as vocational schools), boards of education adult learning programs, not-for-profit organizations, and other organizations. In a large study of approximately 7000 annual graduates from PSW Certificate Programs in Ontario, 20% graduated from community college programs, 45% from career colleges, and approximately 35% from the board of education adult learning programs, not-for-profit organizations, and other organizations. 21 These programs are typically 8 to 45 The Program Standard does not, however, specify the curriculum that is to be taught or by whom, rather it details 14 vocational learning outcomes, essential employability skills, and an optional general education requirement.

To graduate from the formal educational program, PSWs are to have reliably demonstrated their learning and achievements in adhering to these vocational learning outcome statements. In a research study that explored the education experiences of PSWs in Ontario, a disconnect was found between many of the concepts and techniques learned in their formal education compared to the reality of workplace settings. Placements were almost exclusively in LTC settings as were the course content examples provided by PSW instructors. 46 These results have implications for home and community care organizations who need to ensure that newly hired PSW graduates have the skills and knowledge necessary to provide care to home and community care clients. Research has also indicated that there is a trend whereby more complex tasks formally carried out by regulated health care providers such as registered practical nurses are being carried out by unregulated health care providers. 12, 19, 47, 48 It is, however, not outlined if the skills for tasks delegated or assigned by regulated professionals are covered or taught as core competencies. 43 In early 2021, the Government of Ontario announced an accelerated tuition-free PSW formal education program through Ontario's 24 community colleges. This is targeted to train 6000 new students by the fall of 2021, and includes 3 months of coursework, an experiential learning component in a clinical setting, and final months in paid onsite training in a long-term care home or in a home and community care environment. 49 This effort was introduced primarily to increase the needed supply of PSWs.

To work in an Ontario LTC home, PSWs must have completed a formal education program, however, in homecare, this requirement for formal education does not exist. 26 PSWs in homecare can be hired with no formal PSW education and are provided on-the-job training which is the sole responsibility of the employer with no checks and balances from the government. For those Ontario homecare PSWs without any formal education, the Ministry of Health annual training funds can be accessed to pay for the PSW to attend a formal education program should the health care employer apply for these funds.

However, this is not a requirement of the employer. While it is not a requirement in home and community care organizations to have a PSW certificate upon hire, there are many merits to enroll in formal PSW education. Obtaining a PSW certificate provides the student with knowledge and skills to provide care when assisting individuals living in a variety of settings, such as hospitals, homes, schools, community residential agencies, and long-term or chronic care facilities with broad-spectrum conditions and health care needs. It focuses on a range of home and health-related services required by individuals with physical disabilities, cognitive impairments, and chronic and acute illnesses. It also provides the opportunity for students to learn how to effectively communicate and collaborate with members of an interprofessional health care team. For those graduates who wish to further their career as a PSW, it also provides the opportunity for entrance into other vocational programs such as a Practical Nursing program. From time to time, the LHINs across Ontario, have funded individual and joint agency projects that can serve as generic training tools to be used across the province. One such tool is the PSW Medication Management Training Tool, funded by the Toronto Central LHIN to provide a consistent approach to an area of PSW training. This tool was created by a multidisciplinary team that included PSWs in the development of content, design, and video productions addressing relevant client care tasks, such as oral medication assistance, eye drop administration, blood glucose monitoring, ostomy care, and oxygen assistance. 50 Research has highlighted that the shift in PSWs carrying out health-related functions has transferred costs to the clients in some geographies such as in the United Kingdom. This is currently not the case in Ontario. Rather, in Ontario, a strategy to reduce community homecare costs and allocate health care resources more efficiently, many homecare services normally carried out by regulated professionals are now being delegated to PSWs. This strategy is referred to as "task shifting." 11, 47 The delivery of client care outside of the scope of PSW basic training has been highlighted as an integral role in the delivery of homecare. 11, 13, 18, 36, 42 These added skills can only be carried out by a PSW when they are formally trained by a regulated health care professional or when the task to be carried out is considered a routine activity of daily living. To be considered a routine activity of daily living, the need for the activity and the client's response to care must be predictable and well established. 51 Examples of these types of tasks include medication assistance/administration (insulin, chemotherapy agents, eye drops, nebulisers, and suppositories); transfers and exercises; wound and stoma care; continence care and catheterizations; tube feeding; blood sugar monitoring/diabetes care; application of compression stockings; ventilator care, and home hemodialysis. 31 Previous research demonstrated that PSWs, along with some of their supervisors, nurses, and therapists, were concerned that task shifting may compromise the quality of client care because they believed PSWs lacked the knowledge, training, and education necessary to carry out more complex tasks. 30 PSWs have expressed concern related to a lack of training for the provision of added skills. 18, 33, 37 In a series of 13 focus groups held across Ontario, Canada PSWs reported mixed feelings on the effectiveness of how training was being carried out. Specifically, group-related training for certain tasks such as the application of compression stocking was highlighted as less than adequate due to the individualized characteristics of clients. 26 A Belgium study on palliative care in the community found the majority of nursing managers, nurses and health care aids did not believe that the delegated activities should be expanded because health care aids were not trained adequately to carry out these types of technical nursing activities. As well, the nurses indicated while they believed that supervision by them of health care aids was a necessity, it was not part of their basic education and believed they needed additional training. 13 Other studies also found the unregulated care providers were not always supported in the assignment with their increased responsibilities. 32, 52, 53 This poses a challenge as it is not outlined if the skills for tasks delegated or assigned by regulated professionals are covered or taught as core competencies. 43 However, research has also indicated that with added training and support, PSWs can have a significant role in demonstrating competency and quality client care in the delivery of delegated homecare services. 35, 54, 55 Studies that have looked at specialty roles for unregulated care providers (UCPs) such as in end-of-life care, along with roles focused on rehabilitation and function improvement of clients where services were provided in the community home setting with an interdisciplinary team, support the expansion of their role. 13, 35, 36, 55 On the job training was demonstrated as effective in Sweden for UCPs caring for clients needing complex medical interventions such as home mechanical ventilation 56 and in Ontario, Canada for medically stable clients needing home hemodialysis. 54 35 While the time and workload of the nurses were increased in the shifting of tasks to PSWs, it was believed that these workers may have an important role to play. 13 Challenges related to the performance of these added skills to PSWs when delivering care can be mitigated if PSWs are given the time to develop and practice skills 11,18 the time to deliver these skills when providing care for the client 11 and effective on-the-job training and education. 57 Furthermore, it has been determined that the expanded role of the PSW can lead to an increase in job satisfaction, providing a sense of purpose and increased self-esteem for the PSW. 19 The level of health care knowledge was also a key factor for increased job satisfaction along with the potential for these types of workers to remain in homecare. 58 PSWs have indicated the importance of understanding the particulars related to the client and acquiring client information and knowledge. 13 Research has demonstrated that this can be accomplished by having PSWs participate in meetings about the client. 13, 35 Research that examined the relationships between work outcomes, work attitudes, and work environments of health support workers in Ontario, Canada LTC homes and home and community care settings found that performance (ability to carry out the work) is directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. 59 The complexity of home-and community-based homecare for older adults has increased significantly in the past decade in Ontario, Canada. PSWs, who are unregulated and vary in formal education, provide the majority of community homecare work for increasingly complex clients. This paper seeks to understand community-based PSWs' satisfaction with opportunities for job-related training at their employing organization to provide them with the skills and knowledge to meet the demands of their evolving role. 

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

All variables except organizational training satisfaction and tenure are dichotomous. A decision was made to dichotomize these variables due to highly skewed variables. 63 

The endogenous variable in this analysis is organizational job-related training satisfaction, which indicates satisfaction with job-related training provided or supported by PSWs' organization. This is a single item worded as, "How satisfied are you with your opportunities for jobrelated training provided or supported by your organization?" For this paper, this question was selected as the dependent variable. This was for two reasons: firstly, the question was specifically on the satisfaction with employer-provided or supported job-related training, rather than a broad job satisfaction that can include other aspects of the job such as wage and benefits satisfaction, satisfaction with the supervisor, satisfaction with co-workers, and so on and secondly, it has been established in the literature that job satisfaction can be measured accurately with a single item variable. 63, 64 Responses are coded on a five-point Likert-type scale with "1 = very dissatisfied" to "5 = very satisfied."

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

Respondents were asked, "Based on the training you received, do you feel confident to perform delegated tasks from nurses or PSW supervisors" and "Based on the training you received, do you feel confident to perform delegated tasks from physiotherapist or occupational therapists?"

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

Control variables are "learn new things," "adequate information," and "tenure." It was believed that based on the community care client profile mentioned in the introduction, PSWs were required to learn new things, and to carry out their client care duties properly they should have adequate client information. It was further believed that if PSWs agreed that they need to continually learn new things they may be more likely to be satisfied with their training. The years of work experience of a PSW might have an influence on their perception of training needs and therefore this was also a control variable.

Framed by the introduction, "Each of the statements below is something a person might use to describe his/her work as a PSW in the Community," respondents were asked to disagree or agree to the statement, "Your Job requires that you learn new things." The second variable is from the question which asked respondents to agree or disagree with the statement, "You receive adequate information to care for your clients." The final variable, "tenure," was calculated from a question asking respondents which year they started working as a PSW in the community.

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

The data were analyzed using both quantitative and qualitative techniques. Descriptive statistics, correlations, and multivariate regression analyses were conducted. The variables were selected based on how they were grouped in the questionnaire. The questionnaire included specific questions based on the researchers' knowledge and views on the topic with the Advisory Committee's input. Based on these variables, we decided to conduct multiple regression. All significance levels are indicated in Table 2 The open-ended question, "what additional type of health and safety training do you believe you need?" was thematically analyzed and the first author of this paper and a different co-principal investigator reviewed the established coding scheme to arrive at a coding consensus. 66 Excluding those that said none and those that did not answer this question, it yielded 383 respondents for the analysis.

Findings revealed that 94% of respondents were female and 6% were male. The age range of respondents indicated that 12% were between 26 and 35, 20% between 36 and 45, 35% between 46 and 55, and 26% were between 56 and 65 years of age. Under two-thirds, 59%

were born in Canada and of the 42% who were not born in Canada, 27% were born in Latin America, 18% in Europe, and 40% in Asia. Table 1 shows the descriptive statistics (means and standard deviations) for all variables included in the analysis. The mean values of all dichotomous variables are shown in percentages for ease of interpretation. Correlations are available from the second author on request.

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

With respect to the training for delegated tasks, 61% agreed or strongly agreed that they get enough training to perform delegated tasks from nurses or PSW supervisors and 53% agreed or strongly In "organizational training" and "job requires to learn new things" and "job requires adequate information about the client" variables, the percentage (%) responses refer to "yes" = agreed or strongly agreed, and in all other variables the percentage (%) responses refer to "yes." agreed that they get enough training to perform delegated tasks from physiotherapists or occupational therapists. have adequate information about their clients (r = 0.31, P < .05). Table 2 reports the results of the multivariate regression analysis.

We report coefficients and beta values (ie, standardized coefficients).

Organizational training satisfaction is positively and significantly associated with the following organizational training variables: 

The qualitative question on what additional health and safety training do PSWs believe they need was answered by 22% (n = 383). Their views were centered on the following seven key themes: Safe body mechanics for moving/lifting clients-8%; Managing aggression primarily with clients-12%; Infection control-8%; CPR/First Aid-8%; Mental illness-8%; Equipment training-6%; Basic health and safety-6%. PSWs are no longer simply providing light housekeeping and limited client personal care. The scope of their duties has expanded over the past decade to include those tasks once only provided by regulated health care providers. 12, 19, 31, 37 With the economic challenges facing the health care system and the focus on "aging in place" 1,2 it is highly likely that the role of the PSW will continue to expand. The results of this research support that PSWs desire effective on-the-job training and education. 57 Successful on the job training for the expansion of PSWs duties has been associated with the time to develop and T A B L E 3 Key themes and examples for question "What additional health and safety training do you believe you need"

Safe body mechanics for moving/lifting clients "Lots of training, lifts, transfer, how to keep yourself safe from injuries when transferring" (PSW262). "Moving clients in very small confined space. Especially washrooms" (PSW258).

"How to deal with aggressive clients, how to deal with aggressive dementia clients" (PSW138). "To deal with the reactive client, we go to their home alone and sometimes the client charges us, throw things etc" (PSW364).

Infection control "How to work in homes where client or family does not like using disposables and family member has very unhygienic practices like not washing hands after using bathroom and blowing their noses in towels" (PSW133). "Training in handling/cleaning ostomy bag, urine bag etc" (PSW367).

CPR/First Aid "All workers should receive basic health and safety certification/training First Aid, yearly" (PSW04). "First aid & CPR mandatory for all PSWs in home care" (PSW85).

Mental illness "How to deal with mentally ill patients who may be verbally abusive, violent, or self-destructive" (PSW145). "How to deal with mental conditions of a client" (PSW121).

Equipment training "For all clients coming on program to be fully assessed with all the right equipment and needs to perform our job" (PSW97). "How to use lifts properly" (PSW131).

"Annual health and safety training should be provided. I have not had any such training since starting work with my organization four years ago" (PSW06). "We should receive regular in services' on all types of health and safety training. Our organization does none at our particular location" (PSW369). practice skills 11, 18 time to deliver these skills when providing care for the client 11 Another limitation is that our data are cross-sectional, which means that our results should be interpreted as correlational and not causal.

Future studies can be designed and conducted longitudinally to overcome this limitation. Our survey consists of self-reported data only.

While this is considered a limitation, we believe that our data fills an important gap in the literature since the data on PSWs in Ontario was limited at the time of data collection. Future studies can overcome this limitation by triangulation of data from multiple resources.

Another potential limitation was our decision to dichotomize some of the dependent variables due to highly skewed variables. 69 taining to this paper. The funder had no role in study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit this report for publication.

No conflict of interests to declare. Catherine Brookman had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

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

The dataset this paper is based on is the original data collected and owned by Drs Zeytinoglu, Denton, and Brookman. This data can be available only after the owners have completed using the data for their submissions (journal articles and other media outputs).

https://orcid.org/0000-0002-3404-172X

Key issues in human resource planning for home support workers in Canada

Help wantedproviding and paying for long-term care Health Policy Studies

Public services for Ontarians: a path to sustainability and excellence. 2012. Queen's Printer for Ontario

Home and community care. A key partner in ending hallway healthcare and restoring Ontario's finances. Pre-budget submission 2019 Ontario Budget

Explaining government involvement in homecare across Europe: an international comparative study

Organization for Economic Cooperation and Development. Long-term care workers: needed but often undervalued. Organization for Economic Cooperation and Development

World report on ageing and health: World Health Organization

World Alzheimer report: an analysis of long-term care for Dementia

Ontario long-term care that works. For seniors. For Ontario. Budget submission

Randomized trail of restorative homecare for frail older people in New Zealand

Homecare workers' skills in the context of task shifting: complexities in care work

The evolving role of health care aides in the long-term care and home and community care sectors in Canada

Health care assistants in home nursing: the holy grail or the emperor's new clothes? A qualitative study. Home Health Care Manag Pract

Seniors in need, caregivers in distress: what are the homecare priorities for seniors in Canada. Health Council of Canada

Unregulated health workers: a Canadian and Global Perspective

Quality reforms in Danish homecare -balancing between standardisation and individualisation

Norwegian homecare in transition -heading for accountability, off-loading responsibilities

Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care

Task shifting policy in Ontario, Canada: does it help personal support workers' intention to stay? Health Policy

Measuring work engagement, psychological empowerment, and organizational citizenship behavior among health care aides

Ontario personal support workers in home and community care: CRNCC/PSNO survey results. Toronto, ON, Canada: Canadian Research Network for Care in the Community

Ontario Ministry of Advanced Education and Skills Development

Ontario increasing wages for personal support workers. Health Bulletin

Health Professions Regulatory Advisory Council. The regulation of personal support workers

Ontario Ministry of Health, Ministry of Long-Term Care. Home and community care support services. Facts about home and community care support services

Home-based care: barriers and facilitators to expanded personal support worker roles in Ontario

Ontario's Occupational Health and Safety Act (OHSA). (O.Reg. 297/13,2.1(1)

Multi-sector service accountability agreements

Home and community care sector accountability

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society

The role of unregulated care providers in homecare: a scoping review

Unlicensed personnel administering medications to older people living at home; a challenge for social and care services

Challenges for home care providers: a needs assessment

The role of healthcare support workers in providing palliative and end-of-life care in the community: a systematic literature review

The role of healthcare assistants in supporting district nurses and family carers to deliver palliative care at home: findings from an evaluation project

Observe, coach, assist, and report: an emerging framework for integrating unregulated healthcare providers into interdisciplinary healthcare teams

From risky to safer homecare: health care assistants striving to overcome a lack of training, supervision, and support

The personal support worker program standard in Ontario: an alternative to self regulation? Health Policy

Canada's complex and fractionalized homecare context: perspectives of workers, elderly clients, family carers, and homecare managers

Bagaka's JG. The impact of stress and support on direct care worker's job satisfaction

Leveraging Ontario's home and community care sector to end hallway medicine -Policy Brief

Invisible no more: a scoping review of the health care aide workforce literature

The role of unregulated care providers in Canada -a scoping review

Who is looking after mom and dad? Unregulated workers in Canadian long-term care homes

Canadian educational standards for personal care providers -environmental scan

Exploring experiences of personal support worker education in Ontario

Health and safety matters! Associations between organizational practices and personal support workers' life and work stress in Ontario

Government of Ontario. News release -Ontario Colleges now accepting applications for accelerated personal support workers program

Medication Management Training for Personal Support Workers

Practice guideline: working with unregulated care providers

Home care aides in the administration of medication

We only own the hours": discontinuity of care in the British Columbia home support system

Personal support worker (PSW)-supported home hemodialysis: a paradigm shift

Crossing professional and organizational boundaries: the implementation of generic rehabilitation assistants within three organizations in the northwest of England

On-the-job training makes the difference: healthcare assistants perceived competence and responsibility in the care of patients with home mechanical ventilation

Understanding the debate around regulation of support workers

From risky to safer home care: health care assistants striving to overcome a lack of training, supervision, and support

Relationships between work outcomes, work attitudes and work environments of health support workers in Ontario long-term care and home and community care settings

Working in clients' homes: the impact on the health and well-being of visiting home care workers

Associations between workers' health, non-standard employment and insecurity: the case of home care workers in Ontario, Canada

Canadian Community Health Survey (CCHS)

Reliability and validity of a single-item measure of job satisfaction

Overall job satisfaction: how good are single measures?

The analysis of missing data

Qualitative research in health: an introduction

The personal support worker improving work experiencea comparison across two health care sectors: Doctoral dissertation

The evolving role of the personal support worker in homecare in Ontario

On the practice of dichotomization of quantitative variables

Can Likert scales be treated as interval scales?-a simulation study

COVID-19 crisis shines light on neglected profession

The time has come to pay PSWs what they are worth. Toronto Star

Don't overlook home-care workers in long-term-care reform. The Hamilton Spectator

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