Abstract
Many healthcare workers are “on the road” traveling to and from fixed sites (eg, patients’/clients’ homes). Qualitative interviews with nine Nova Scotian managers of mobile healthcare workers explored the conditions of workers’ travel. Findings highlight challenges such as changing schedules, as well as positive features including flexibility over the travel schedule. Some managers noted worker mobility-related responsibilities including having to decide if travel is too dangerous due to poor weather. A few managers suggested that workers may not receive adequate economic reimbursement for travel costs (eg, wear and tear on vehicle), and in some instances, workers need to use a benefit (eg, vacation day) or are not paid if they cannot drive due to poor weather. Reported organizational supports for workers’ travel were variable. This research indicates a need for supportive mobility-related policies and practices across all organizations, including policies that cover economic costs related to travel for all workers.
Introduction
In many countries globally, it is expected that in the years ahead there will be an increasing demand for home and community healthcare largely due to an ageing population. 1 –3 In Canada and elsewhere, it is likely that more and more healthcare workers will be “on the road” traveling to provide care and services to this elderly population. In some places, there are policies supporting “aging in place,” 3 but a workforce is needed to provide home and community care. The recruitment and retention of healthcare workers is thus of critical importance to healthcare managers, 4 and the conditions of travel for workers is of interest given that these conditions may influence job satisfaction, which has been linked to retention. Retention is of concern, at least in part because high turnover can disrupt continuity of care. 5
The literature on geographically mobile healthcare workers tends to centre on the challenges of providing care and services in fixed sites such as patients’ or clients’ homes, with relatively little attention given to the conditions of travel. 6 –8 In our review of literature on mobile healthcare workers, we found studies highlighting the complex task of scheduling healthcare workers to meet the needs of homecare patients/clients at particular times and in specific locations, 1,9,10 but there was relatively little literature on the geographical mobility or conditions of travel for healthcare workers, particularly within the Canadian context. Many healthcare workers travel for long periods of time and great distances, using various modes of transportation (eg, buses, personal vehicles, walking), but we uncovered limited research specifically focused on Canadian healthcare workers’ mobility.
Various types of workers, including healthcare workers, can experience different forms and degrees of control over the conditions of their work, 6 –8,11 and research suggests that when workers operate remotely from each other and are physically separate from managers, they “will have more autonomy and responsibility than in traditional organizations….” 12 Mobile healthcare workers may, therefore, experience significant autonomy and responsibility, but at the same time, the organizational practices and policies where they work may influence travel experiences. As such, it is important to gain an understanding of the various conditions of their mobility, including mobility-related organizational practices and policies.
Study methodology and methods
We conducted a qualitative study to explore healthcare workers’ mobility from the perspective of managers of mobile healthcare workers in Nova Scotia, Canada. There are ongoing challenges with the recruitment and retention of healthcare workers in Nova Scotia, 13,14 and some of these challenges may be influenced by workers’ conditions of travel, so it is critical that we understand their mobility. Our previous research explored mobility from the perspective of mobile workers, 15 but we were also interested in the perspective of managers, given their knowledge of organizational practices and policies, and their potential role in developing practices and policies which may impact workers’ conditions of travel.
Prior to beginning this study, ethics approval was obtained from the relevant ethics research boards. Participants were recruited through public and private organizations employing mobile healthcare workers in Nova Scotia. Organizations were identified through various strategies (eg, community partners, review of relevant websites), and an e-mail about the study was sent to the organizations asking for interested participants to contact the study research coordinator.
Nine individuals volunteered to participate in a one-on-one interview, and all chose a telephone interview. Participants referred to themselves as either a manager (including senior manager) or a supervisor, but for the purposes of this article, we will speak about them collectively as managers. Verbal consent was obtained prior to conducting the interviews, and a small honorarium was provided. Eight participants were female and one male, and eight worked in the public sector and one in the private sector. Of the nine managers, eight worked in a unionized organization. The managers oversaw different types of mobile workers including continuing care assistants (eg, personal support workers), nurses (registered nurses and licensed practical nurses), social workers, and occupational therapists.
Managers were asked about workers’ mobility, including perceptions of the positives and/or challenges of mobility for workers, and organizational practices and policies related to travel. With permission, interviews were audiotaped, and the audiotapes transcribed verbatim and labelled with a participant number. Each transcript was read and re-read by two team members who discussed key concepts. Any discrepancies in the understanding of concepts were discussed until agreement. The data were coded for key concepts (eg, costs of travel) using the Atlas Ti qualitative management program and analyzed for themes and sub-themes. Three key themes are presented here: mobility and workers’ schedules; health, safety, and worker responsibilities related to mobility; and organizational supports related to mobility.
Findings
Mobility and workers’ schedules
A number of managers pointed to mobile workers’ schedules, and in particular changing schedules and the number of clients or patients, as a key challenge related to mobile work. As one manager explained, the scheduler’s task is to ensure that all clients have a worker “attached to them,” but workers sometimes question the number of clients they are given. One manager commented that staff meetings are where “scheduling issues [are] always a topic of discussion…” (#2), and according to another manager, “If they [workers] don’t like their schedule for whatever reason, we hear that a lot…” (#1).
At the same time as managers commented on challenges related to schedules, some discussed the flexibility of the schedule and workers’ control over the planning of the day. As one manager noted, “So we give them that opportunity to arrange their day that works best for them” (#3), and another commented, “They’re not on a strict schedule. That if they require a little bit more travel time…they need to make stops or whatever, they’re certainly free to do so in between the travel times from client to client” (#2). One manager indicated that the flexible schedule extends to carrying out small domestic errands between clients, commenting that, “A lot of them they love that they can pop into the grocery store and pick up supper between clients. They like having that bit of freedom” (#5). Many mobile healthcare workers are women, which might help to explain this comment about workers liking the “freedom” to accomplish domestic tasks given that women often have a number of domestic responsibilities that must be completed on a daily basis.
Health, safety, and worker responsibilities related to mobility
Some managers spoke about various health and safety issues related to mobility for healthcare workers, such as “slips on ice” when going to a patient’s/client’s home (#1), deer on the road, driving at night (#2), and going into the “ditch on a slippery road” when driving (#3). One manager commented that the environment in Nova Scotia creates concerns with black ice, and “when you’re working evenings in the wintertime, you’re spending probably 75% of the time driving in the dark” (#6). Another manager indicated that if the “roads are bad, we cancel programs, we cancel classes” and the workers can work from home (#8), thus pointing to the role of the organization in making the decision about when it is not safe to travel. However, a few managers stated that the organizational practice was for the worker to decide the extent of the safety risks and determine whether it was safe to be on the road (#2, #3). According to one manager, it is the worker’s decision whether or not to drive if there is poor weather, stating that, “…at the beginning of every winter season, we always re-share the policy with them [workers] and remind them that we want them to be safe on the roads, and that they should listen to, you know, road reports on the local radio station, and make informed decisions” (#1).
An organizational practice or policy that makes the worker responsible for deciding the risks related to driving is, according to one manager, a result of the fact that workers have different comfort levels with driving (#4). A few managers noted that workers are further responsible for letting clients know when they cannot travel, and one manager commented that, “So even if it’s raining and the worker thinks that she’s not safe on the road…then what she does is she calls the clients and she tells them…And then she will let me know” (#2). Reported practices or policies related to weather, mobility, and paying the worker were variable and in some instances depended on the context. According to one manager, for example, if the “whole province is shut down” due to poor weather, the worker would be paid (#6), and another indicated that in their organization if the client cancels there would be an attempt to reschedule the worker (#3) or the worker would be paid (#4). A couple of managers did note, however, that if the worker cancelled due to the weather, they had to use “banked time” (eg, hours that have been “banked” to be used in the future because they have worked more than the contracted hours) (#2, #3, #7). One manager commented that “…if she cancels because she feels unsafe, she uses it out of her banked time. But if the clients are calling in and they don’t want anybody on the road, or they cancel then [organization] pays them [the worker]” (#2).
Workers clearly have limited autonomy when they are making decisions about driving in poor weather in a context where they may have to use a vacation day, banked day, or perhaps not get paid. As one manager commented, “Yes, we have a storm policy. So, we don’t ever close the agency…So, our policy is, they [the workers] can have one of three options. They can take the day off without pay, they can take the day as a vacation day, or they can take the day and work together with staffing to make up those hours” (#5). An organization that does not close due to poor weather and yet recognizes that workers may not be able to travel and transfers the costs of immobility onto the worker is placing workers at potentially significant risk. Some workers reportedly travel if they do not have any vacation days or banked days left to use because as one manager explained, “The closer it gets to the end of March and the less vacation or entitlement banked time that people have left, the more likely they are to work when there’s a storm…Because people don’t like not to be paid…” (#7).
Organizational supports related to mobility
Organizational supports for mobility, and, in particular, supports for the economic costs for those who use their personal vehicles, were frequently discussed in terms of mileage or kilometer reimbursements. One manager noted that the cost of the vehicle insurance is reflected in the kilometer rate or the travel time rate provided to workers (#10), and another explained that the kilometer compensation is meant to cover incidentals such as winter tires and oil changes (#7). In a couple of instances, however, managers suggested that workers may experience some personal economic costs. One manager noted that if the workers had roadside assistance membership (ie, Canadian Automotive Association), it would not be covered by the organization (#1). According to another manager, the “wear and tear” on the car is not necessarily covered (#2) and yet another suggested that the financial impacts would probably depend on the type of vehicle one drives (#8).
Other organizational supports beyond kilometer per hour compensation were also referenced by a few managers, and although the supports varied across organizations, they included first aid kits (#3, #7), ice cleats (#4), and education sessions about “getting your car winter ready” (#3). These supports all center on workers taking personal responsibility for mobility, but a few managers did suggest that policies are needed to monitor workers to ensure that they all return home safely at the end of the day when the weather is poor. A couple of managers indicated that their organization is working on such a policy (#7, #8), and one manager stated that if there is bad weather, they monitor the workers to ensure everyone is home safely (#5). According to another manager, there should be “more specific funding for the travel piece of it,” (#5) although they did not elaborate on what the additional funding might cover.
Conclusions and discussion
Our interviews with managers of geographically mobile healthcare workers highlighted a number of conditions of mobility that may influence the recruitment and retention of workers. The travel schedule and traveling in unsafe weather conditions may, for example, negatively impact workers’ desire to engage in mobile work. At the same time, however, a flexible schedule means healthcare workers can utilize their break time when on the road to accomplish various tasks. Many women have a double day of work, engaging in both paid labour and domestic household responsibilities, 16 and mobile healthcare workers who have such dual responsibilities may experience this flexibility positively, which may in turn may play a role in retention.
The reported ability to have some control over one’s schedule is consistent with research suggesting that workers who are physically separate from managers have a certain degree of autonomy 12 and is also consistent with our research with mobile healthcare workers, some of whom commented on the “freedom” of mobility or freedom of the road. 15 The comments of some managers about mobile workers’ responsibilities (eg, decisions about travel in poor weather) are also consistent with our previous research with Nova Scotian mobile healthcare workers. 15 Such responsibilities may, however, negatively impact retention, as might economic costs related to mobility. The economic costs some managers commented on (eg, wear and tear on car) were also noted by some workers in our previous research, but additional research is needed to fully understand the extent of these economic costs, including how frequency of travel may impact costs and how the costs may have differential impacts depending on the worker’s income (eg, differences in income between professional and para-professional workers).
Our research does indicate that many managers are concerned about workers’ safety and that there are some organizational supports for mobile workers. In some instances, however, organizations are placing extensive responsibility for safety on the workers and are doing so in a context where at least some workers pay a cost for their safety (eg, must use a “banked day” if they do not travel). In essence, this means that these workers have to weigh their safety against the costs. Policies and practices could be implemented, however, so that no worker has to shoulder economic costs associated with their safety. As we have previously noted, 15 providing workers with a select number of “paid bad weather days” could reduce the economic pressure to engage in unsafe travel and could be used in a similar manner to paid sick days which are utilized only when necessary. A policy related to bad weather days may be especially important in the current context of climate change and the increasing frequency and intensity of storms. Implementing “paid bad weather day” policies would of course involve resources and therefore would require organizations and governments to collaborate. Health leaders can, however, play a critical role in advocating for such policies. Indeed, they are well situated to help put into place policies to ensure the safety of mobile healthcare workers.
Limitations
Our qualitative study highlights some key issues related to healthcare workers’ geographic mobility from the perspective of managers, but it is not without some limitations. One limitation is that although we recruited from both public and private agencies, only one manager was from a private institution, so we were unable to make any comparisons between these two types of agencies. Further research is needed to explore potential similarities and differences in policies and practices related to mobility between public and private agencies. There may also be differences between acute care agencies and long-term care agencies that need to be explored. A second limitation is that our study is a qualitative study that took place in one province in Canada, and we do not know about practices and policies in other places. Research in different provinces and regions across the country would help to further explore potentially different policies and practices. Further, although our research does point to variability in economic costs borne by geographically mobile workers, the various factors that may influence such variability are unclear, and research is needed to fully understand what underlies this variability.
Footnotes
Acknowledgements
The authors would like to acknowledge funding through the On the Move Partnership: Employment-Related Geographical Mobility in the Canadian Context. The On the Move Partnership is a project of the SafetyNet Centre for Occupational Health & Safety Research at Memorial University. On the Move is supported by the Social Sciences and Humanities Research Council through its Partnership Grants funding opportunity (895-2011-1019), the Research and Development Corporation of Newfoundland and Labrador, the Canada Foundation for Innovation, and numerous university and community partners in Canada and elsewhere. Author Bourgeault would also like to acknowledge funding provided by Canadian Institutes of Health Research Institute of Gender and Health Research Chair in Gender, Work and Health Human Resources. In addition, the authors would like to thank our community partners, the Nova Scotia Association of Social Workers, the Nova Scotia Government & General Employees Union, and the Nova Scotia Community College.
