In-home work environment for home care workers in Northern Sweden before and during the Covid-19 pandemic | BMC Health Services Research

The results from our two cross-sectional studies on the work environment among home care workers in northern Sweden showed that staff regularly experienced problems with the in-home work environment prior to the pandemic and that work environment problems were more frequently reported during the pandemic. On a daily basis, challenges with impractical bathrooms, non-ergonomic beds, indoor smoking, in-home temperature, and pets were most commonly reported, but also problems with verbal harassment were reported. Regional differences in the reporting of in-home work environment problems were seen, which implies that different priorities might be advisable for regions as well as for municipalities, at least under normal conditions such as before the pandemic. Our interpretation is that levels of problems both before and during the pandemic can be considered high for most occupational health challenges in all regions. Our study also presents pandemic-specific challenges that varied between regions. Worries about infections and the use of face masks were frequent problems among home care workers, as well as challenges with social interactions that might be connected to the use of safety equipment.

Little research has investigated the in-home work environment for home care workers. In a Norwegian study prior to the pandemic, inappropriate verbal interactions with the home care recipients and environmental hazards and unhealthy physical workloads were part of the key results [1]. Importantly, our reported challenges were not a consequence of the pandemic, but were common already prior to the pandemic. The pandemic brought attention to things that are particularly vulnerable when resources become scarcer. While our results are based on two cross sectional surveys, which limit the possibility to draw causal conclusions, our study suggests that with more strained working conditions the work situation becomes more challenging for home care workers.

However, it is not easy to interpret which in-home work environment problems are perceived as the most severe for the home care workers based on our survey because we only asked whether they experienced a problem and how often and not the burden of the problem on each occasion. Thus, the less frequently occurring harassments, which are a psychosocial problem for the home care workers, might overall be more demanding than the more frequently appearing ergonomic problems such as non-ergonomic beds and impractical bathrooms. We did not specify the type of harassments experienced by the staff. Challenges with sexual harassment among health care workers has been reported before and have been summarized in a recent review [30], but responses in our case could also relate to racism and other harassments. Despite harassment occurring in Swedish home care, the extent of such harassment is poorly documented. Future studies that can better explain the extent of in-home work environment problems and suggest improvements are important because such scientific information is lacking.

According to information we have received, we expect that among existing home care recipients, somewhere between 30 to 40% have received their first home care support during the year. During the pandemic, the municipalities likely updated the care recipients’ homes to a lesser extent, both to avoid the risk of an increased level of Covid-19 among them, but also due to less resources to make the necessary changes. We believe this is the main explanation for an increase in ergonomic problems during the pandemic.

There was also an increase in problems due to poor cleaning equipment during the pandemic. We expect that this is mainly because home care recipients did not update their equipment as much during the pandemic because they did not visit stores as often due to concerns about being infected. The home care workers also reported problems related to the behaviour of the home care recipient, as some were smoking, there were verbal harassments and there also was problems with the recipient being under the influence. These problems increased during the pandemic, which potentially might be explained by them being more isolated due to the risk of spreading Covid-19 increased.

Under certain circumstances it is possible to deny people home care and instead offer them nursing homes due to high costs according to the Social Services Act [3]. However, to our understanding people cannot be denied home care due to work environment problems for home care workers, despite the fact that Swedish work environment legislation demands that the employees have a suitable work environment [4]. To handle this, employers can redistribute the staff caring for home care recipients, such as having home care workers with allergies avoiding contact with pets, but can also try to have a dialogue with the home care recipient and their relatives. Dialogue models have been tested in the rehabilitation of patients with dementia in Sweden [31], and in such dialogues different professions collaborate with the care recipient and their relatives. Ways forward are needed to handle the conflicting challenge between the home care recipients’ autonomy and the home care workers’ work environment. For ergonomic problems, such as non-ergonomic beds and impractical bathrooms, potential solutions are likely simpler than for issues such as harassment, smoking, and pets. There are challenges in recruiting staff to the home care services, and it is common that staff want to leave the occupation [16, 17], and thus a well-working in-home work environment certainly must be of high importance [6].

During the pandemic, there were variations in the preparedness between different regions in Sweden [32], and the rates of infections and deaths varied [21]. We consider our results to well illustrate such differences between three northern regions, where Västernorrland was one of the regions with the greatest challenges during the pandemic and Västerbotten and Jämtland/Härjedalen were among the regions with the least challenges. For instance, the availability of and use of protective equipment was better in Västerbotten than in Västernorrland, and the least concern about being infected among home care workers and home care recipients was in Västerbotten. Interestingly, it appears that the regions with the lowest infection rates had as a side effect that social interactions with home care recipients were limited. In a previous study from our survey before the pandemic, more time for social support was asked for by home care workers [5]. Because social interaction is limited when the staff use protective equipment, such as face masks, better solutions for maintaining well-functioning social interaction with home care recipients despite the use of protective equipment can therefore be recommended.

Our point prevalences for both of the surveys should also be understood based on who responded to the surveys. Due to problems with recruiting staff, it is common among home care workers to have limited knowledge of Swedish, even though the Swedish language is a stated requirement for employment. The proportion of foreign-born responders in our study was much lower than the proportion of foreign-born home care workers reported by the Swedish Association of Local Authorities and Regions for Sweden [29]. Thus, we expect there to be a low response rate among foreign-born responders in our study. Translating the surveys into other languages to include their participation would have required more resources than we deemed reasonable, both for the research group and the home care organizations. If we would have been able to increase their participation in our surveys, our results likely would be affected. Thus, our results might mainly reflect the situation for Swedish-born home care workers, and a further follow-up of migrant workers would be valuable.

There was variation in the participating municipalities and a lower participation rate among home care workers during the pandemic. There was also a variation in terms of who answered the questionnaire, such as more night staff and more foreign-born responding during the pandemic. A lower participation rate during the pandemic might mean that there was a variation in who wanted to participate in the surveys. For instance, staff who had a less challenging situation during the pandemic, but also during “normal” circumstances, might have participated to a higher extent, as well as staff with a more negative view. Besides the limitations related to variation in the characteristics of who responded to the surveys, the low response rate in itself could also affect our overall conclusions. Even if the participants likely varied to some extent between the surveys, and there might be a bias in the prevalence of the extent of problems, we nevertheless expect the extent of the problems both before and during the pandemic to well represent the current situation.

The northern part of Sweden differs from the rest of the country, for instance in population density, which could limit the generalizability of our results to other parts of the country. However, despite some differences in challenges due to the colder climate and longer travel distances in the more sparsely populated Northern part of Sweden that we have included in our study, we do not expect the work environment-related problems we have investigated to differ notably in other regions in Sweden. Our study was limited to municipal home care providers. We expect similar challenges, but they may differ somewhat, among private providers and that study results would therefore be very valuable for them as well. In addition, the organization of home care in Sweden differs from many other countries, and there could therefore be limitations in the generalizability to other countries. However, the interaction between home care workers and home care recipients is inevitably part of the work in all countries, and we therefore expect our study results to also be of relevance outside Sweden, especially in countries with similar arrangements for their home care services.

In our studies for the WeWorC project we have also collected data about home care workers’ health, and it would have been valuable to investigate whether a poor working environment for home care workers is linked to health challenges. We have also collected narratives within the surveys from the home care workers about their work situation that could help with interpretations of the survey results. These are topics that we aim to evaluate in future research within the WeWorC project.

The pandemic challenged the organization within Swedish home care. The use of and availability of protective equipment have improved and a learning lesson from the pandemic is that staff are more aware of using them to protect home care recipients. Our study adds valuable knowledge about challenges that will be useful to the organizations even after the pandemic. To our knowledge, there are no studies that have investigated whether the use of and availability of protective equipment works well after the pandemic.