This is a qualitative study exploring the variation in work adjustments between different sized communities in response to home care restructuring. The study found different impacts of restructuring in the two communities: transfer of work to other workers, the imposition of time constraints on visits and provider stress.. Conclusions confirm that labor markets are locally constituted especially in medically under serviced regions.

Background: While altering the provision and organization of services, restructuring also changes the way activity is organized across communities, including the division of labor. The Long Term Care Act (1994) outlines the regulation of nursing and home support services and makes clear the type and amount of services that are covered by the provincial health plan. Non profit home care agencies have traditionally been funded mainly by public monies and operate much like public services. In order to be competitive in the restructured environment, these agencies have had to implement numerous cost saving strategies, most of which have impacted the labor process. Consequently, the work lives of home care providers are increasingly encumbered. This study evaluates the changes in the quality and distribution of work for home care providers resulting from health care restructuring in Ontario in the mid-nineties.

Methods: The labor process change of three categories of workers is examined: registered nurses (RNs), registered practical nurses (RPNs), and home support workers (HSWs). Part of a larger research study, this component included 27 interviews with home care practitioners living in Sault Ste. Marie ( a northern under serviced region, n=18) and Guelph ( a southern well serviced region, n=9). In depth, semistructured, audio taped face to face interviews were conducted with each of the three practitioner groups at both sites in the summer of 1995 and spring of 1996.

Results: Three major changes negatively impacted workers in both communities: work transfer, time constraints, and increased job stress. Work transfer refers to the transfer of responsibilities from one category of worker to others. Secondly, time constraints were implemented on all patient visits. Together, these two changes contributed to the third major change, increased job stress. The geographical analysis revealed that "size of place" impacted "work motivation and support", suggesting that characteristics of communities of various sizes affect practitioners' evaluations of work. In the two case studies, causal forces which appeared to be differentially impacting the labor process were (1) local service cultures, such as the timing and uptake of the new restructuring model between the cities; (2) local institutional practices such as the introduction of RPNs and amalgamation, and; (3) local practitioner advocacy, including union organization and job actions.

Conclusions: The process of long-term care sector reform in Ontario has had different impacts on homecare workers in the two communities. Size of place appears to be an important variable in this change. The degree to which other factors play a role varies based on local cultures, institutions and union organization. More broadly, these factors may result in continuing high rates of practitioner turnover and an overall decline in quality of care.

Reference: Williams, Allison W. "Restructuring Home Care in the 1990s: Geographical Differentiation in Ontario, Canada." Health and Place, 12 (2006) 222-238

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