By Jenna Coles, Department of Health Sciences
It is estimated that by 2036 about 25% of the Canadian population will be over 65 years old. To meet the needs of these seniors, the demand for home and long-term care services is expected to grow. In response to the anticipation of such a financial burden, the Ontario government introduced market-modelled management principles within the healthcare sector in 1997 (Armstrong & Armstrong, 2008). Restructuring under market-modelled principles resulted in fundamental changes to work arrangements for employees working in the long-term and home care sectors. Task shifting is one such strategy that has been employed to reduce the costs of delivering services. Task shifting refers to the delegation of tasks from regulated healthcare professionals to home care workers. In Ontario, task shifting occurs most commonly between nurses and personal support workers (PSWs). RNs and RPNs are educated at a university or college level and regulated by The College of Nurses of Ontario, whereas PSWs are unregulated healthcare workers who provide personal support services for patients in a variety of healthcare settings.
Influence of Task-Shifting- Quality of Care
The question is what are the impacts of task shifting on the quality of care provided to clients? Studies such as those conducted by Denton and colleagues (2015) have demonstrated mixed opinions regarding the delegation of healthcare tasks among workers. Unregulated healthcare providers, such as PSW’s, are more likely to report that task shifting has increased the quality of care provided to patients. Unregulated workers cost significantly less money than nurses, which increases their scope of practice, and in fact, PSWs are often hired to work with patients more frequently for longer hours. These workers are able to not only spend more time with patients but also follow more consistent schedules than nurses. Consistency may make the PSW better suited to monitor a client’s health status, and thus enhances the quality of care as they become more familiar with a patient’s health conditions. Not surprisingly, patients report enhanced satisfaction with their quality of care when they are able to develop more meaningful and trusting relationships with their care worker. And the research confirms that trusting relationships place healthcare workers in a better position to provide patient-centered care – care that truly accommodates the patient’s particular needs and preferences (Denton et al., 2015).
While some workers have identified benefits of task shifting, others express concerns that the transfer of tasks from nurses to PSWs might decrease quality of care. An undeniable factor affecting one’s ability to provide high quality care is appropriate knowledge, training, and skills to carry out delegated tasks. In Ontario, when a task is determined as appropriate to be transferred downward by a case manager/primary care nurse, the nurse teaches the skills deemed relevant to performing the task. The training is typically limited to a single session due to scheduling and time constraints. Many nurses stated, however, that one training session is inadequate for the PSWs to be able to successfully carry out the care tasks (Bystedt et al., 2011). One of the major concerns for Ontario’s nurses is the ability for PSWs to be able to recognize changes in a patient’s condition status and to provide the patient with appropriate care (Denton et al., 2015).
Impact of Task-Shifting- Care Workers Health Status
The Regulated Health Professionals Act, 1991 and The Long- Term Care Act, 1994 enable nurses to teach PSWs new tasks that they themselves deem to appropriately fit within the PSW’s scope of practice. This policy action has two implications for job satisfaction: an increase in professional autonomy for the PSW, and a simultaneous loss of control experienced by the nurses (Bystedt et al., 2011; Denton et al., 2015). Task-shifting involves PSWs learning more complex skills in order to perform the newly delegated tasks. By expanding their skill set, many PSWs expressed an increased control over their practice and sense of autonomy experienced at work (Barken et al., 2015). Unfortunately, registered nurses have expressed opposite opinions.
Although Ontario employs the largest number of nurses, there has been recent concerns regarding a nursing labour shortage and high turnover rates. Workplace factors including employment status, job satisfaction, and work-related stress have all been credited with influencing the workforce shortage. One reason for the adoption of task-shifting strategies was that it would conveniently allow nurses to focus on tasks that are more knowledge intensive and appropriate to their profession (Bystedt et al., 2011). This policy was intended to lead to decreases in job-related stress and lower turnover rates. However, when nurses are required to give up components of their care plans to lower-skilled workers who are often inadequately trained, it is unsurprising that they report feeling a loss of control and work autonomy (Barken et al., 2015). Home care nurses declared that the relationships they developed with their patients contributed greatly to their overall job satisfaction (Barken et al., 2015). Task shifting moves many of the tasks that once provided nurses with an opportunity to build trusting relationships to PSWs. When the opportunity to perform this emotional labour decreased, the levels of stress nurses experienced increased (Barken et al., 2015).
Task-Shifting Policies – Evaluation from a Feminist Political Economy Framework
Social relations are shaped by dynamic interconnections between politics, economics, and ideology. From a political economy perspective, the regulation of home care workers can be seen as embedded in a profit-driven mode of production. In such a market-model system of healthcare delivery, the decrease of service costs becomes the central focus. Thus, while the number of seniors requiring care continues to increase, there has been no parallel increase in budgets for their long-term care. Cost-savings techniques are not only reflected in care workers’ low wages, but can have potentially major health implications for both patients and care workers. This raises the question of who benefits from such an approach, and at whose expense?
Home care work is predominantly done by women, and in particular by women of different intersectionalities (race, cultural ethnicity, class, etc.) (Armstrong & Armstrong, 2008). Women are increasingly expected to fill in the care gaps that have been created through restructuring in the larger global market-driven context. The failure to regulate PSWs so that their training and credentials are recognized means that non-white immigrant women are increasingly the source of cheap, readily available labour in the long-term and home care sectors. Consideration needs to be given to the ways in which cost-saving policies, such as task shifting, are not only affecting the health of clients, nurses and PSWs but the ways in which they may be exacerbating the tenuous situation of particular women who are already vulnerable to exploitation.
Key Considerations
With demand for home care services increasing, care organizations across Ontario have adopted task shifting as a strategy to reduce costs. These policies were initially developed as a means to decrease nurses’ overall workload and reduce work-related stress, which was believed to be contributing to nurses’ high turnover rates. A review of the impact of task shifting has revealed mixed results. On the one hand, task shifting may be advantageous as PSWs are able to spend more time with patients and feel an increase in their autonomy. On the other hand, nurses are reporting loss of control and increases in job-related stress. Although restructuring of the healthcare system may be a priority for the Canadian government, health policies should not be implemented without a thorough understanding of the impacts of these policies on the health of the public and our caregivers, and the underlying assumptions implicit in these policies.
References
Armstrong, P., & Armstrong, H. (2008). About Canada: Health care. Black Point & Winnipeg, Canada: Fernwood Publishing.
Barken, R., Denton, M., Plenderleith, J., Zeytinoglu, I.U., & Brookman, C. (2015). Home care workers’ skills in the context of task shifting: Complexities in care work. Canadian Review of Sociology/Revue Canadienne de Sociologie, 52(3), 289- 309.
Bystedt, M., Eriksson, M., & Wilde- Larsson, B. (2011). Delegation within municipal health care. Journal of Nursing Management, 19(4), 534-541.
Denton, M., Brookman, C., Zeytinoglu, I., Plenderleith, J., & Barken, R. (2015). Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care. Health and Social Care in the Community, 23(5), 485- 492.