Health and safety of homecare workers engaged by temporary employment agencies

Abstract

Shifts in demographics, lifestyles and employment and business practices are generating increased demand for homecare services. While providing support to vulnerable members of the community, homecare workers are themselves vulnerable. Precarious work and isolated workplaces expose them to poorly controlled occupational health and safety (OHS) hazards. This study examined OHS issues encountered by homecare agency workers. Eighteen carers working in aged care, disability support and youth services were interviewed in Adelaide and the Barossa Valley, South Australia. Participants identified a range of OHS problems, including inadequate risk assessment, unsatisfactory OHS policies and procedures, poor training, lack of employment benefits, problematic working hours, lack of agency support and the demands of particular types of work. These findings provide preliminary evidence of significant OHS management deficiencies. The results require further investigation to guide the development of policies and practices intended to provide healthy, productive and sustainable work environments for homecare workers. Such policies and practices should address compliance with OHS and workers’ compensation legislation, the prevention of negative OHS outcomes, provision of effective mechanisms for workers to raise OHS concerns and implementation of support structures.

Keywords

Job insecurity occupational health and safety temporary employment working arrangements working conditions

Introduction

This paper reports on a study that examined the interconnection between occupational health and safety (OHS) and temporary agency work in the South Australian homecare industry. Homecare is a significant and rapidly growing area of service sector employment but there has been limited research on the OHS of homecare workers, especially temporary agency workers. This study aimed to address this gap in knowledge and suggest avenues for further research.

Over the past three decades, employment in most developed countries has shifted toward the service sector. An important area of growth is the provision of services into the home, particularly in aged care, disability support and youth services. The growth of homecare can be attributed to changes in demographics (particularly population ageing), family structures and lifestyles, business practices, and the delivery of government services and labour market practices, including greater use of self-employed and temporary agency workers. In Australia, temporary agency workers are often known as labour hire workers, but the term agency workers will be used in this paper.

In Australia, there are limited data on the prevalence of home-based work. In 2008, however, 702,000 Australians (6.9% of the total workforce) worked in a home other than their own as part of their main job – a 75% increase since 2000 (Australian Bureau of Statistics (ABS), 2009). While ABS data do not indicate the proportion engaged in homecare, research from the National Institute of Labour Studies suggests homecare is a significant category of home-based work (Martin and King, 2008).

A growing body of research on precarious work arrangements, including agency work, subcontracting and outsourcing, has identified negative effects on mental and physical health, injury rates and regulatory compliance (Benach et al., 2007; Virtanen et al., 2005). However, there has been little investigation of the OHS of precariously employed homecare workers. A review of research on the OHS effects of subcontracting and home-based work revealed that workers based in homes experienced poorer outcomes than equivalent workers in formal workplaces (Quinlan and Bohle, 2008). Only nine studies of home-based work or homecare were identified, eight of which identified negative effects, including mental and emotional stress and musculoskeletal disorders (e.g. Zeytinoglu and Denton, 2005). Other studies have suggested lower rewards, job insecurity, workplace disorganisation and poor regulatory oversight contribute to elevated OHS risks in home-based work (Mayhew and Quinlan, 1999).

Safe Work Australia (2009) has revealed that workers in healthcare and community services experience a 10% higher incidence rate of work-related injury than the total Australian workforce. Instances of work-related stress also far exceed those recorded in workers’ compensation data. Specific data on homecare workers have not been reported, but other research indicates that compensation claims underestimate injuries for agency workers and the self-employed (Quinlan and Mayhew, 1999; Underhill, 2008). Evidence on post-injury outcomes and return-to-work in homecare is also scant. A study of homecare workers on disability pensions due to musculoskeletal disorders found that, although most attributed their disorder to work, only one-third received occupational rehabilitation (Dellve et al., 2002).

Research on subcontracting and outsourcing in healthcare has identified increases in injuries, psychological distress, burnout and occupational violence (Ostry and Speigal, 2004; Trinkoff et al., 2005). However, the OHS effects of self-employment and agency work have rarely been examined. The few studies on the OHS effects of self-employment (e.g. Jamal, 2007; Mirabelli et al., 2007) seldom recognise that self-employed workers are often located in the lower reaches of a subcontracting chain. Other research indicates that agency workers are at greater risk of injury, have poorer prospects of returning to work after injury and present a serious challenge to regulatory agencies (e.g. Johnstone and Quinlan, 2006; Underhill, 2008). However, it is unknown whether the risks of relocating care work to the home are exacerbated when workers are engaged via temporary employment agencies (a structured form of subcontracting) rather than directly employed. Working hours and payment systems are also significant, given that self-employed workers tend to work longer hours (Louie et al., 2006) and incentive or piecework payment systems have adverse OHS effects (Lacey et al., 2007).

There is limited research on the operation of agency work in homecare (for an exception, see David et al., 2011). In Australia, temporary employment agencies in homecare operate in much the same way as in other industries. However, there seem to be smaller specialist agencies, rather than large agencies providing a wide array of different types of workers, and less one-off or short-term provision of workers (Underhill and Quinlan, 2011). Agencies competitively bid for work offered by organisations responsible for outsourcing homecare services, including government departments. The successful bidder then signs a contract, typically for a year or more, to provide workers. Agencies retain a pool of workers, as either employees or self-employed subcontractors, whom they allocate to clients. The agency is responsible for paying and managing the workers, although both the ‘host’ organisation and the agency have responsibilities under Australian OHS legislation (Johnstone and Quinlan, 2006).

Homecare agency work differs from agency work in other industries in several ways. Agency homecare workers are allocated to several clients at once, whom they may service for extended periods, even years. Furthermore, they may provide various kinds of care to different clients and work in different workplaces, not only homes but also temporary accommodation, such as hotel rooms, or in public when taking clients shopping or on outings.

Precarious work undermines regulatory regimes designed to safeguard workers and provide compensation and rehabilitation to the injured (Johnstone et al., 2001; Quinlan, 2004; Waehrer et al., 2007). However, regulatory protection in homecare, in which precarious work is common, is unexamined. In Australia, home-based work poses major challenges to OHS inspectorates because of the number and dispersion of workplaces, insufficient guidance material, fractured management responsibility arising from subcontracting, and failure to undertake pre-placement risk assessments or implement adequate OHS management protocols (Quinlan et al., 2009). Furthermore, self-employment and home-based work are not conducive to worker input into OHS through trade unions or the participatory mechanisms in OHS legislation (Johnstone et al., 2005). More specifically, different types of homecare activities are subject to varying degrees of regulatory oversight, but the effects on OHS are unclear (Cloutier et al., 2008).

In general, knowledge of OHS in homecare is limited and more systematic research is required. Although available evidence is mostly indirect, it raises significant concerns, especially when workers are engaged by temporary employment agencies. This paper reports on a study that aimed to address this lack of knowledge by exploring the OHS risks reported by homecare agency workers.

Methods

Participants

In-depth interviews were conducted with 18 homecare workers engaged by temporary employment agencies (both employees and self-employed) to identify and explore the key OHS issues in their work.

Workers were sampled from an urban centre (Adelaide) and a rural location (the Barossa Valley) in South Australia to capture diversity and to allow for an examination of possible regional differences in employment agency practices and OHS experiences (Underhill and Quinlan, 2011). A representative from the South Australian Office of the Employee Ombudsman recruited participants from three homecare agencies operating in the two regions. These agencies were small to medium sized and were niche providers in the homecare industry.

In Adelaide, participants included four males aged 28–55 and four females aged 32–52 (average age 46 years), working in disability support, including autism (2), aged care and disability support (3), and youth services (3). In the Barossa, participants included two males aged 57–58 and eight females aged 26–66 (average age 53 years), working in personal aged care, including showering, cleaning, shopping and healthcare duties (5), aged care and disability support, including clients with Alzheimer’s and dementia (4), and aged care domestic services (1). Table 1 provides details of the participants.

Table 1.

Details of participants in Adelaide and the Barossa Valley.

	Participant #	Gender	Age	Type of homecare	Type of employment
Adelaide	1	F	52	Youth services	Employee and self-employed
	2	M	55	Aged care and disability support	Self-employed
	3	M	55	Disability support	Self-employed
	4	M	29	Youth services	Self-employed
	5	F	32	Youth services	Employee and self-employed
	6	F	46	Disability support	Self-employed
	7	M	54	Aged care and disability support	Self-employed
	8	F	45	Aged care and disability support	Employee and self-employed
Barossa Valley	9	F	62	Personal aged care	Self-employed
	10	F	66	Personal aged care	Self-employed
	11	F	51	Aged care and disability support	Self-employed
	12	M	58	Aged care and disability support	Self-employed
	13	F	38	Aged care domestic services	Self-employed
	14	F	26	Personal aged care	Self-employed
	15	F	46	Personal aged care	Self-employed
	16	F	62	Personal aged care	Self-employed
	17	F	62	Aged care and disability support	Self-employed
	18	M	57	Aged care and disability support	Employee and self-employed

Interview procedure

Separate convergent interview processes were conducted in Adelaide and the Barossa. Convergent interviewing is a structured process by which detailed, non-directive interviews are conducted and interpreted (Dick, 1990). The process involves systematic interpretation of findings after each interview to enable the interviewers to refine research questions and interpretations across successive rounds of interviews. After initial planning, interviewers separately interview one participant each. They then summarise and interpret responses before meeting to compare notes, test and refine interpretations and develop probe questions for later interviews. Tentative interpretations from early interviews converge toward firmer interpretations over successive cycles of interviews. Convergence is achieved by discarding idiosyncratic material mentioned by a single interviewee and exploring issues raised by multiple interviewees. Issues on which there is either substantial agreement or disagreement between participants are identified. Convergent interviewing is particularly suitable for exploratory research (Driedger et al., 2006; Jepsen and Rodwell, 2008).

The initial interview questions used in this study concerned participants’ OHS experiences, working hours and their agencies’ approach to OHS. Demographic information was also collected, including gender, date of birth, employment status, type of work arrangement and workers’ compensation cover. Probes developed during the Adelaide interviews examined OHS regulation, professional support and burnout. Probes developed during the Barossa interviews examined the emotional and physical impact of the work, employment benefits and professional support. The University of Sydney Human Research Ethics Committee approved the research protocol (Reference Number: 08-2009/11996).

Findings

Interviews in Adelaide and the Barossa revealed many similar issues but some differences. This regional contrast is significant and the findings from each location are reported separately. All direct quotations reported below are identified by the participant number and gender.

Adelaide: Convergent themes

Inadequate risk assessments

Despite OHS regulatory requirements, participants in Adelaide claimed their agencies rarely conducted risk assessments before the commencement of a contract. This omission often resulted in exposure to volatile and dangerous work environments:

You can pick up the kid at any given time when they phone you … and they’ll fail to give you some information … [such as] the child has sexualised behaviours, the child needs medication … It’s pick the ball up and run with it and hopefully you don’t fall over. (Participant #4, M)

Some participants claimed it was their responsibility to undertake risk assessments, which caused concern: ‘We’re not trained to assess risk, we’re just given the form … There’s no on-hand contact by our agency’ (Participant #7, M). Even when agencies did conduct risk assessments, participants were ill-informed about dangers posed by particular clients or specific contracts. One claimed agencies did this deliberately to ensure provision of care, because ‘there’s a few kids that they couldn’t get workers for’ (Participant #1, F). Others confirmed that risk assessments were irrelevant and self-defeating because evaluations could result in loss of contracts and termination of care for the client.

Inadequate safety policies and procedures

Participants agreed about insufficient safety policies and procedures within their agencies: ‘There’s no policies or anything in place’ (Participant #8, F). This created dangerous work environments: ‘How many of those houses have a locked cupboard that all sharp knives can be put in? Maybe two or three’ (Participant #4, M). Extant procedures were considered impractical or ineffective:

They say to us we’re not allowed to give the child our mobile phone number. Yet we’re supposed to pick the kids up from everywhere. So in the end we give them our mobile phone numbers. There’s so many things that they say … but there’s no way it would possibly work. (Participant #1, F)

Inadequate OHS training

Convergence emerged about insufficient OHS training. Lack of training contributed to vulnerability:

There was no training. My first job … I just didn’t know. That was a big shock to me. When I was driving, the first day I had him, [my client] started screaming and spitting, and grabbing the steering wheel, and I ran off the side of the road. (Participant #3, M)

Where training was available, participants had to complete it in their own time and at their own expense: ‘You only do the minimum because … you’ve got to miss a day’s work or you’ve got to do it on your day off’ (Participant #1, F). Participants questioned the value of mandatory OHS training, arguing they relied more on on-the-job experience:

When I was new at the job, … you’ve had all this training and you’ve got all these rules and regulations and acts and policies and procedures running through your head. And then you get out to the house and you think, ‘This is nothing like what I’ve been taught’ … You just learn to adapt. (Participant #6, F)

Lack of professional support

Homecare work can involve exposure to stressful, threatening or traumatic incidents and carers can experience difficulty coping with the emotional impact. Participants discussed the importance of being able to talk to professionals within their agency about the difficult aspects of their work, but the provision of such assistance was poor:

Recently, [a co-worker] walked in on a man who had fallen asleep with a cigarette and his skin had literally melted to his mattress. Now that is something that someone needs to debrief about … We debriefed with each other, but there are no systems put in place. (Participant #8, F)

Many participants felt isolated:

It’s very, very hard to manage your stress in this work, because of the nature of the work … The company never invites you to come in and sit down and discuss how it’s affecting you personally. (Participant #4, M)

Without agency support, participants managed work-related stress using peer support and other informal coping mechanisms, such as exercise and talking to friends and family.

Adelaide: Divergent themes

Knowledge of workers’ compensation entitlements

Divergence emerged regarding participants’ knowledge of their workers’ compensation cover, reflecting differences in employment status. Half the participants worked under a dual-employment arrangement, in which they were engaged by the same agency at different times as employees and self-employed workers. These participants were aware that they had workers’ compensation coverage only when working as employees: ‘You need to have income insurance as a self-employed contractor, otherwise you get nothing … But as an employee, there’s workers’ compensation’ (Participant #8, F). However, among the remaining participants, who were exclusively self-employed, one was aware of the need to self-insure but the others were uncertain:

I’m assuming that if I get injured at work that I should just ring my agency and that something would be done about it … they must have some sort of insurance for us. (Participant #6, F)

Problems with reporting and agency responses

Some participants affirmed they would not hesitate to report OHS problems to their agency. The main motivation was to ensure personal safety: ‘I think that I have a right to feel safe when I go in to somebody else’s home’ (Participant #6, F). However, others were reluctant due to negative consequences for clients, including termination of care:

There’s a compulsion to do the work as opposed to reporting back to somebody that it’s not safe to go there. Because that would … mean lack of service to the people that needed the service. (Participant #7, M)

Divergence also emerged about the quality of agency responses to reported problems. Some commended their agencies’ capacity to resolve OHS issues:

Quite often they will call you for a bit more information. And then they’ll obviously talk to the families concerned, and … I’d say ninety-nine per cent of the time, there is a positive change. (Participant #6, F)

However, others claimed that agencies failed to respond to reported problems: ‘You report it, you hope they’ve recorded it. Does it go any further? No’ (Participant #8, F). Some provided examples of negligence: ‘I know of carers that have taken older boys to buy marijuana and smoked it with the kids … There was never any action taken when workers should have been sacked’ (Participant #4, M). Agencies were perceived to be more concerned about covering shifts than workers’ safety or quality of care: ‘If there were young girls, the social workers would request for no male carers. [Agency name] just wanted their shifts filled, and a lot of the times they would put men in’ (Participant #5, F).

Regularity of working hours

Most participants reported they had regular hours within their contracts, but factors such as seasonality could affect working hours:

You might not have work for two or three months. So you think, ‘I might as well just do this because then there won’t be much work’ … There’s what they call ‘the quiet times’, usually around Christmas, January. (Participant #1, F)

Several participants reported pressure to do unpaid overtime because of emotional bonds with clients and their need for extra support:

I like the clients that I work with … but it does get difficult when you get asked to do things that overstep the contractual arrangements and step outside of the boundaries of what would be expected in your job description. (Participant #6, F)

Control over working hours

Lack of control over rosters could also result in irregular hours:

A roster could get put in place where you’re the weekend person, and you do a forty-eight hour shift over the weekend whether you like it or not … They will not negotiate a shift, roster it, so that everybody does a few of the weekend shifts and a few during the week. (Participant #4, M)

Divergence regarding control over working hours emerged between sectors. Youth services workers reported little control because they were required to remain on shift until a replacement carer arrived: ‘If the next person doesn’t turn up, you’re there, bad luck. And it could be twenty hours, it can be longer. You can’t leave’ (Participant #1, F). They also reported limited control over contracts because children in their care, who were wards of the State, could request a different carer. Aged care and disability support workers reported more control: ‘I haven’t found that I’ve been harassed to take on work, or that I’ve got so much work that I’ve got to knock it back’ (Participant #7, M).

Problematic job locations

Homecare agencies distribute contracts according to carers’ skills, qualifications and geographic location. Participants preferred work near their homes, but it was not guaranteed. While some reported their agency tried to match contracts with carer location, others were dissatisfied: ‘[Agency name] were just so unorganised. They would give you clients over on the other side of the city, when there were clients right in your suburb’ (Participant #5, F).

Continuity in the industry

Some participants intended to continue working in the homecare industry, but some were uncertain and others intended to leave. One referred to health as the main reason for changing occupations:

I am on sick leave because of deteriorating health … If there were things in my work that might have contributed, it would be the exhaust from vacuum cleaners … and cleaning products, primarily bleach … I am very unlikely to be going back into the industry. (Participant #7, M)

Another cited emotional exhaustion, despite the reward of having a positive influence on the lives of children: ‘I can probably name six or seven kids that I know I’ve helped … [But] I’ve recently quit working because I’ve got no more to give’ (Participant #4, M).

Table 2 presents the convergent and divergent themes identified in the Adelaide interviews, including degrees of convergence and divergence.

Table 2.

Convergent and divergent themes identified in Adelaide.

Themes		Participants
Themes		1	2	3	4	5	6	7	8
Convergent	Inadequate risk assessments	+	+	+	+	+		+	+
	Inadequate safety policies and procedures	+		+	+	+	+
	Inadequate OHS training	+	+	+	+	+	+	+	+
	Lack of professional support	+	+	+	+		+		+
Divergent	Knowledge of workers’ compensation entitlements		+	−	+	+	−	−	+
	Problems with reporting and agency responses		±	+	+	+	±	−	±
	Regularity of working hours	−	+	−	±	−	−	+
	Control over working hours	−	−	−	+	−	−	+
	Problematic job locations		±		±		+	−	−
	Continuity in the industry	+	+	−	−			±

+: agreement with the theme; −: disagreement with the theme; ±: agreement and disagreement with the theme or uncertainty.

Barossa Valley: Convergent themes

Inadequate OHS training

Participants in the Barossa reported that agencies had strict requirements regarding training and qualifications: ‘If we don’t go to training, we lose clients’ (Participant #9, F). Despite this requirement, agencies provided limited OHS training and carers relied on Technical and Further Education (TAFE) courses, which they undertook in their own time and at their own expense:

We have to toss up what we do – go without the money that we could be earning and go to the OHS training, or just not do the OHS training? … At times, I have missed them purely because I couldn’t have a day away from my clients. (Participant #9, F)

Lack of employment benefits

Convergence emerged about lack of employment benefits, which particularly concerned the self-employed: ‘We have no holiday pay. We have no sick pay. We have no superannuation. We have no insurance. All those things we have to provide ourselves’ (Participant #15, F). Participants were also dissatisfied about pay levels and their inability to negotiate improved rates: ‘We are working very, very cheaply … A contractor should be getting a contractor’s rate, not an hourly rate’ (Participant #9, F). Low earnings left many in dire financial situations: ‘We do without things, like income protection insurance or health insurance or superannuation’ (Participant #15, F). Because there was no provision of sick pay, some indicated they worked while unwell, potentially exposing elderly clients to illness:

There’s a chance that if you’re sick, you still roll up to work because you need the money, which is crazy, particularly when you’re dealing with people that are low down on the health scale. (Participant #18, M)

Transport costs

Transport costs were problematic, especially the lack of reimbursement for fuel despite having to travel long distances to service clients. Although able to claim a portion of their travel expenditures as a tax deduction, participants stressed that compensation for homecare workers, unlike tradesmen, was capped at 5000 km per year and most exceeded this limit. Other car expenses were mentioned: ‘Tyres, registration, insurance – everything that goes with a motor vehicle, I would cover myself’ (Participant #12, M). Work-related damage and wear to the vehicle was also raised: ‘You’re carrying groceries and putting wheelchairs in the back and walkers. You’re chipping paint, you’re denting it’ (Participant #15, F).

Poor bathroom design and safety

Aged care and disability support workers commented on the poor design of bathrooms and consequent safety implications for themselves and their clients: ‘Probably the most risky place to work in people’s homes is usually the bathroom – slippery floors, dealing with unsteady clients, dealing with taps or showerheads that aren’t set up for people with a disability’ (Participant #11, F).

Hospitalisation of clients

The majority of Barossa participants worked in aged care and several discussed the precariousness of working hours and income due to the constant possibility of clients being hospitalised: ‘You may have planned on doing Mrs Green, but she’s not there … and there’s no compensation whatsoever’ (Participant #17, F). While agencies might attempt to find additional contracts during the period of hospitalisation, participants reported practical difficulties:

There’s no way of replacing [a client] until a case manager gives you another contract. If your client has gone into hospital for say two weeks, you can’t fill that spot because you’re still contracted to that contract, and you have to wait until either the person passes away or gets better and comes home. (Participant #15, F)

Emotional and mental stress

High levels of emotional and mental stress were reported: ‘You are basically on call twenty-four/seven, [which can] affect your stress level and be mentally draining’ (Participant #14, F). The emotional impact of caring for aged clients was apparent:

I have often walked out with tears streaming down my face because of the situation that some of these people are in – loneliness, sitting there listening to the clock tick, their pain … I go away pretty heavily burdened some days. (Participant #9, F)

Deaths of clients could have serious emotional effects due to the bond between carer and client:

You can become very close to your clients and a lot of them you’ll deal with for years … When they suddenly pass away, it’s quite difficult … In my case, last year, I lost seven clients in the one winter, which was quite heartbreaking. (Participant #15, F)

Barossa Valley: Divergent themes

Inadequate risk assessments

Divergence emerged regarding risk assessments. Several participants claimed their agencies undertook risk assessments prior to the commencement of a contract. However, this information was not always available: ‘The case manager might have done the risk assessment or any hazard alerts, but as a contractor, I never got to see that’ (Participant #13, F). One participant claimed the agency sometimes passed on the responsibility for risk assessments to carers. Another believed agencies avoided risk assessments for fear of losing contracts: ‘I think [agencies] get the idea that if they did risk assessments, it would cause too many problems, so they just turn a blind eye to it’ (Participant #18, M).

Inadequate safety policies and procedures

Some participants reported they were informed of agency OHS policies and procedures, but others claimed they were either absent or inadequately implemented: ‘They’ve never been made clear to me what they are, whether there are any standards or anything’ (Participant #18, M).

Problems with reporting and agency responses

Some participants stated they would not hesitate to report OHS concerns and commented positively about responses from agencies. However, others were reluctant to report problems. One was concerned about losing work: ‘They’re not always easy to talk to, and you feel like if you make a complaint, they won’t give you any contracts’ (Participant #17, F). Others worried about the impact of complaints on services for clients: ‘If the agency moved in and tried to change everything to suit the contractor, [the client would] either drop out of the service or find somebody else’ (Participant #18, M). Others considered their agency was too detached to respond adequately:

The people in the office … are making all the decisions and choices for our elderly. But they’re not there. They don’t see how it is … When they come in to do an interview, the client is dressed and ready and waiting and on their best behaviour. We see them at their worst behaviour. (Participant #17, F)

Physical impact

Disagreement about the physical impact of homecare work reflected differences in work. Participants who experienced negative effects on their physical health reported back and shoulder pain and strain from activities such as cleaning and manual handling: ‘If I do the domestic work for all three of my clients, it can affect my back’ (Participant #13, F). Those whose work did not include domestic work or manual handling did not consider their work physically demanding.

Lack of professional support

Divergence emerged about the adequacy of professional support. Some participants reported they could talk to other carers: ‘I know the girls and I know I can ring them and they know they can ring me’ (Participant #16, F). Some agencies also facilitated contact between carers or encouraged carer support networks. However, other agencies discouraged contact between carers due to confidentiality and privacy laws prohibiting discussion of shared clients: ‘We’re not supposed to talk to another carer about the same client’ (Participant #10, F). Such strictures were frustrating: ‘I would love to go to a fellow carer and say to them, “I’m finding this, this, this, this and this about Mrs so and so. How are you managing?”’ (Participant #9, F). Participants were also reluctant to request support for fear of being deemed incompetent and risking job loss: ‘I would like someone to debrief with. But I am a bit scared to go to the agency, as they might think, “Oh, this lady cannot cope”’ (Participant #14, F).

Regularity of working hours

Some participants claimed they worked regular hours and identified benefits for both carer and client:

You’re providing a regular and consistent service for your clients … It’s important for them to know that they’re going to be able to do their shopping or get their medication or whatever. (Participant #11, F)

Others experienced changeable hours because of circumstances such as the hospitalisation of clients and weekend shifts.

Control over working hours

Several participants were able to select or refuse contracts according to the days or hours that suited them. Others complained about the prevalence of split shifts, which were interspersed with lengthy unpaid time: ‘I might have two or three clients in the morning, and there won’t be anything until maybe late afternoon … In between clients, what do you do?’ (Participant #15, F).

Table 3 presents the convergent and divergent themes identified in the Barossa interviews, including degrees of convergence and divergence.

Table 3.

Convergent and divergent themes identified in the Barossa Valley.

Themes		Participants
Themes		9	10	11	12	13	14	15	16	17	18
Convergent	Inadequate OHS training	+	+	+		+		+	+	+	+
	Lack of employment benefits	+	+	+	+	+			+	+
	Transport costs	+		+	+	+			+	+	+
	Poor bathroom design and safety	+		+	+	+	+	+	+	+	+
	Hospitalisation of clients		+	+		+			+	+	+
	Emotional and mental stress		+	+	+			+	+	+
Divergent	Inadequate risk assessments	−	+	±		−	+	−	−	−	+
	Inadequate safety policies and procedures	−	+	−		−	+	±	−	−	+
	Problems with reporting and agency responses	−	+	−	+	−			−	−	±
	Physical impact	−	−	+	−	+	+	+	+	+
	Lack of professional support	−		+	+		−	+
	Regularity of working hours	−	±		−	+	+	−	−	+	−
	Control over working hours	+	±	±	−	−	+	+	−	+	−

+: agreement with the theme; −: disagreement with the theme; ±: agreement and disagreement with the theme or uncertainty.

Discussion

This study identified OHS issues encountered by agency workers providing homecare services. While there was considerable overlap between issues identified in Adelaide and the Barossa, there were also significant differences, especially regarding whether an issue was a matter of convergence or divergence. Highlighting the significance of regional differences, only one issue converged in both locations – inadequate OHS training. It was consistent across two locations and three forms of homecare work, suggesting insufficient OHS training is pervasive, resulting in unnecessary vulnerability to hazards.

Divergent themes found in both locations were (1) OHS reporting and agency responses and (2) regularity and control over working hours. These findings suggest homecare agencies in South Australia vary in the quality of OHS management, attitudes towards workers, the emphasis placed on carers’ safety, and the provision of care to clients. Divergence regarding regularity of working hours, and workers’ control over them, may reflect differences between the needs of individual workers, but it is also related to the type of services provided. Carers in youth services had less control over hours than those in aged and disability care, although split shifts were a problem for some aged care workers in the Barossa. Unpaid overtime, because of emotional bonds with clients and needs for extra care, was reported in both locations, as was lack of control over weekend shifts. Irregularity of working hours, lack of control over them and interaction between the two can have negative effects on work–life conflict, health and wellbeing (Bohle et al., 2011; Mc Namara et al., 2011).

Several issues emerged about which there was agreement in Adelaide but disagreement in the Barossa, including risk assessments, OHS policies and procedures and professional support. Despite the lack of consistent agreement, a significant proportion of the Barossa participants considered these issues problematic, indicating the problems were present in both locations. Failings regarding risk assessment and risk management procedures are significant considering the range of hazards reported, including dangerous and violent clients, falls associated with untidy homes, poor bathroom design and safety, unhygienic environments, exposure to traumatic events and extended travel.

Failure of agencies to undertake risk assessments and implement effective policies and procedures (including adequate training) is a breach of OHS legislation in South Australia, but is not confined to homecare (Quinlan et al., 2010). The findings of obfuscation or risk-shifting of legal responsibilities, difficulties in raising OHS concerns and regulatory failure are consistent with previous research on agency workers and precarious work more generally (Aronsson, 1999; Underhill and Quinlan, 2011). These inadequacies are particularly acute in homecare because carers work in locations that lack supervisory oversight from an employer or principal contractor and work alone in locations not purpose-built as workplaces. It is also apparent that when homecare workers are engaged via employment agencies, OHS management and the implementation of legislative responsibilities are more complex and attenuated because there are two duty holders in addition to the worker (Johnstone and Quinlan, 2006).

Issues that were divergent in Adelaide but convergent in the Barossa included related concerns about workers’ compensation entitlements and lack of employment benefits. These concerns are consistent with previous research on precarious work and access to workers’ compensation (Quinlan, 2004; Quinlan and Mayhew, 1999). Self-employed homecare workers lack access to industrial conditions that could assist in managing their health and wellbeing, such as workers’ compensation, sick leave and trade unions.

Several findings were inconsistent across locations and between participants. Again, they may reflect diversity between workers or the varying demands of particular types of work. In Adelaide, participants disagreed about whether they would continue working in the homecare industry. In the Barossa, participants disagreed about the physical impact of the work but agreed about its emotional and mental impact.

The findings of this study are generally consistent with the results of international research on the negative OHS implications of precarious work (Quinlan et al., 2001). For example, they indicate that the precarious work of homecare workers is associated with emotional and mental stress, musculoskeletal injuries, irregular and long working hours, low rewards, and poor OHS management and risk assessment. However, the study also identified issues that have received little attention in previous research, including the importance of employment status, transport issues, problematic workers’ compensation cover and workplace disorganisation.

The present findings raise potential policy and practical issues for government, organisations outsourcing homecare services, agencies contracting for the provision of these services and the workers providing the services. These issues include ensuring compliance with OHS and workers’ compensation legislation, preventing negative OHS outcomes, providing effective mechanisms for workers to raise OHS concerns, and support structures to assist with the mental and emotional demands of their work. Until very recently, government agencies responsible for OHS and workers’ compensation have paid limited attention to homecare, but this study provides preliminary evidence of significant OHS management deficiencies in the sector.

Because of the exploratory nature of the research, and the limited sample size, the present findings cannot be generalised with confidence. However, they highlight issues that warrant further research, such as how OHS in homecare is affected by precarious work, regional factors and the type of homecare provided. This study suggests that the type of homecare service influences both the nature and level of risk encountered. It also indicates regional and organisational differences between agencies, which are consistent with the findings of a study of labour hire in Queensland, Australia, that also examined homecare (Underhill and Quinlan, 2011).

Most studies of outsourcing and subcontracting have focused on male-dominated occupations and industries. However, the growth of these work arrangements, especially in the service sector, has meant many more women are now engaged in them. The evidence available highlights gender, ethnicity and age differences in the impact of precarious work, the vulnerable position of women in some forms of home-based work, and the proportionately greater impact of labour market changes on women (Bohle et al., 2010; Menendez et al., 2007; Siefert and Messing, 2006). These differences appear particularly relevant to homecare, given the high proportion of women, immigrants and older workers working in the sector. Indeed, the limited research in the service sector has revealed specific health risks for female carers, particularly when they work in others’ homes (see Aronson and Neysmith, 1996; Baines, 2006; Barling and Rogers, 2001). Unfortunately, the exploratory, non-directive methodology and small sample in this study precluded systematic and valid examination of gender, age or ethnicity differences, especially as the distributions of each varied substantially across the different domains of homecare examined. However, the specific risks associated with them clearly warrant detailed investigation in the future.

Other potentially significant issues in homecare, such as occupational rehabilitation and return to work, did not emerge in this study. More research is required to examine these issues, and those revealed in this study, in greater depth. Now that a range of specific issues has been identified, future research should employ more confirmatory methodologies that are based, for example, on representative samples and stratifications by demographic variables (particularly gender, age and ethnicity), employment status (e.g. direct employment vs agency hire) and categories of homecare work. Longitudinal data collection would facilitate evaluation of the consistency of effects and the impact of changes in employment.

Conclusion

The findings of this study are consistent with broader research on OHS in precarious work, which reveals that those working under such arrangements are exposed to the same hazards as non-precarious counterparts, but also confront additional risks from irregular earnings and working hours, inadequate training and supervision and weaker regulatory protection. Homecare workers are faced with financial pressures associated with irregular hours and additional costs (such as providing their own car); disorganisation, including a limited capacity to report or rectify problems; and ineffective regulatory oversight. However, industry-specific factors cannot be ignored. For example, homecare usually entails a transfer of paid work from settings designed to be workplaces that may be visited by OHS inspectors, such as aged care facilities, to settings not designed for work that are extremely unlikely to be visited by an inspector, usually a home. Nonetheless, this study suggests that the risks of disorganisation and regulatory failure are increased when labour is supplied by a third-party arrangement, which is again consistent with previous evidence (see Johnstone et al., 2001).

This study was exploratory with a limited sample size. Its most important contribution is to guide future research on precarious work and OHS in homecare. A key strength of the convergent interviewing method is that it provides a structured but non-directive method of identifying issues that warrant deeper investigation, so subsequent research can be more focussed and better grounded in the experience of stakeholders. For example, future survey and intervention research can be designed to investigate or address issues that are apparent to workers in a particular industry or work setting, and not rely solely on broader theory or indirect empirical evidence. While largely confirming findings regarding risks and hazards in the limited existing research literature on OHS in homecare, this study also identified new factors that warrant attention, including the organisation of the work (e.g. via agencies using self-employed workers), the type of service provided (e.g. aged care, disability support, youth services), the characteristics of different employment agencies (e.g. size, resources, focus), regional factors (e.g. transport, labour markets) and workforce composition (e.g. age and gender).

Homecare work is symptomatic of emerging trends in the service sector toward widespread precarious work, poorly understood and managed OHS hazards, and weak regulation of even basic OHS standards. These issues require more detailed investigation to guide the development of policy and regulation to secure healthy, productive and sustainable work environments for homecare workers.

Footnotes

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This study was partially funded by the South Australian Office of the Employee Ombudsman and an ARC Linkage Grant [LP110100021].

Acknowledgements

The authors thank the participants for their generous contributions. We are also grateful to Stephen Brennan and Andrew Farrell from the South Australian Office of the Employee Ombudsman for their support and assistance. We gratefully acknowledge contributions from Jessica Ang, James Finn and Vera Younis in data collection and analysis.

Biographical notes

Professor Michael Quinlan is a professor in industrial relations and director of the Industrial Relations Research Centre, Australian School of Business, The University of New South Wales, Australia; a visiting professor in the Work and Health Research Team, The University of Sydney, Australia; and an adjunct professor at Middlesex University, England. His research focuses on the regulation of OHS, the OHS effects of precarious employment and the OHS of vulnerable workers.

Professor Philip Bohle is leader of the Work and Health Research Team and co-convenor of the Ageing, Work and Health Research Unit, Faculty of Health Sciences, The University of Sydney, Australia. His research interests include the OHS of precarious workers; working hours, work-life conflict and health; the impact of workplace death on victims' families; and older workers, employment and OHS.

Dr Olivia Rawlings-Way is a research fellow in the Work and Health Research Team, Faculty of Health Sciences, The University of Sydney, Australia. Her research interests include OHS in the homecare industry; and the social, psychological and economic impact of workplace death on surviving families.

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