There has been much recent discussion internationally about the emergence in modern society of a new class of workers – the precariat – with a common consciousness based on features such as low wages, insecurity, short-term jobs, minority status and restricted rights. This paper critically explores the extent to which the growing, large-scale group of personal support workers (PSWs) can be viewed as part of a new precariat in terms of their position in the healthcare labour market. Drawing on currently available empirical data, this issue is examined particularly with reference to PSWs in Canada – drawing out some of the implications for government health policy in this sphere.
The Precariat and Personal Support Work: An International Agenda
A new class has recently been argued to have emerged internationally in neo-liberal societies with the increasing privatization of the welfare state and developing New Public Management (Dent et al. 2004) – the "precariat." The precariat includes "a multitude of insecure people, living bits-and-pieces lives, in and out of short-term jobs, without a narrative of occupational development …" (Standing 2011: 14). The precariat is defined as an emerging class of workers and, as such, builds on, but is different from, precarious employment per se. Although both include many of the same principles (e.g., job insecurity and low wages) (Vosko 2006), they differ, as the precariat is defined as a collective group with a potential class consciousness and not simply as having similar precarious job characteristics. Precarious employment has therefore been common throughout history, whereas the new precariat class of workers is argued to have emerged following the rise of neo-liberalism in the 1970s (Standing 2011).
The recently defined precariat class includes a wide array of workers, in contrast to the contemporary proletariat of Marxist philosophy, as it does not have stable and predictable working conditions. To be sure, both classes lack ownership of the means of production, but the precariat does not have the same security as the proletariat in the labour market – with, among other things, laws regulating employers, greater upward social mobility, recognizable standards of workplace safety, stronger income streams and more workplace representation (Standing 2011). Part of the purpose of this identification is to consider whether such workers may become class conscious and politically active – in a similar way that the proletariat was felt to be a radical force in the nineteenth and twentieth centuries by Marxists – because of unfavourable work circumstances in national and international contexts. However, another key driver of the analysis has been to underline the precariousness of work widely carried out in modern societies, particularly with its gender and ethnic dimensions (Johnson 2015). Whatever the reasons for such precariousness and its potential political ramifications, there are clear implications for the health of the workers themselves and community well-being – locally, regionally, nationally and globally.
What has rarely been discussed explicitly in the literature (with the fleeting exception of Savage et al. 2013) is whether personal support workers (PSWs) in healthcare are a new and central element of the precariat. This is important because they now form the largest part of the healthcare workforce in neo-liberal societies, outnumbering professional groups such as nurses and doctors (see, for instance, Saks and Allsop 2007). Although this is debated, PSWs can be defined by three key features: they provide front-line support for clients and their carers in clinical, community or domiciliary healthcare settings; do not hold qualifications accredited by professional bodies and are not formally regulated by statutory bodies (Manthorpe and Martineau 2008). A large array of occupational titles represents PSW work, from "healthcare aides" to "nursing attendants" – where title varies across region and sector. PSWs have a broad scope of practice which lies between informal care by family and friends and formal medically oriented care in hospitals. In addition to such tasks, as Korczyk (2004) outlines, PSW work is often characterized by features like low wages, job insecurity, and short-term employment in many countries including Australia, Canada, Denmark, France, the Netherlands and the US. Internationally too, most PSWs are older women, and minority status is typically higher for PSWs than for other occupational groups within the same countries. Given their central role in healthcare delivery and service integration, they are therefore pivotal globally to well-being – not least in relation to the growing ageing population, which increasingly has multiple chronic conditions (United Nations Population Fund 2012). In this paper, we explore the extent to which PSWs are part of the precariat – a new concept in this literature – by presenting common characteristics of PSWs in the labour market, and examining the degree to which they align with features of the precariat using secondary sources as evidence. Having defined the precariat and its relationship to PSWs in modern societies, we now refer at greater length to PSWs in the US and UK, before addressing the example of PSWs in Canada.
In this regard, PSWs possess several of the characteristics covered by the analytical concept of the precariat. To illustrate this, in the US, Polson (2013) argues that home healthcare is a complex and ill-regulated area subject to the fraying of the welfare state, privatization and the externalization of costs to individual families. She claims the consequence has been the growth of a low-waged workforce between the formal and informal economy, operating in conditions akin to a precariat. This has only been partially addressed by government in that, with union support, there has been a drive towards a living wage and rationalization of the industry in places such as New York City. Such moves have, at least in the short term, assisted the largely female and ethnic minority workforce suffering from multiple dimensions of precariousness that has left it vulnerable in the recession – namely, labour market insecurity, lack of regulatory protection, lack of control of the labour process and low income (Black 2012).
Governments have also taken a greater interest in PSWs in the UK, where similar patterns are evident. Here, the independent review by Cavendish (2013) highlights not just concerns about public safety with a workforce with a relatively limited level of education, but also the lack of a progressive career – where low-paid employees are undertaking excessively long shifts and travel and other backfill costs are often not covered by employers. However, the ascription of the precariat to PSWs as a descriptor is not straightforward, in part because the PSW labour force has fewer common organizational structures allowing for uniformity in comparison to other healthcare workers, and some elements of it are better positioned than others, especially where labour substitution for employees of a higher standing is involved (McKee et al. 2006). A study of the regulation of PSWs undertaken for the UK Departments of Health by Saks et al. (2000) found that there were over three hundred different types of PSWs. At the top end of the scale, some workers, such as operating department practitioners, were in the process of professionalization. But if care is needed in seeing PSWs as a cohesive group of workers with the ability to mobilize as a class nationally and internationally, especially because they are currently largely politically unorganized, what of PSWs in Canada?
Personal Support Workers and the Precariat in Canada
These characteristics of the precariat internationally have been reflected in Canada, which has faced similar pressures to other neo-liberal countries with the rise of an ageing population – accentuating the increased proportion of users with chronic conditions and the associated shifts of healthcare from hospitals and other institutions to the home and community (HCC 2012). These larger shifts have led to increased dependence on PSWs (Fujisawa and Colombo 2009), who undertake a whole range of tasks from bathing, dressing, lifting and toileting to more clinically related roles, including reminding patients about medication and providing rehabilitation therapy. Although the definite number of PSWs working in Canada is as yet unknown, partly as a result of disorganization within this workforce, a nationwide study using 2001 data reported an estimate of 30,000 PSWs working in home care (HCSSC 2003). Health Canada's latest estimation in Ontario alone was of some 100,000 PSWs (HPRAC 2006) – suggesting that there may now be over a million such workers in Canada as a whole. Projections of PSW demand across Canadian provinces and territories indicate that the number is growing further, with greater anticipated future increases (Bloom et al. 2012; HCSSC 2003). Indeed, one province estimates that PSW hours in the home care sector will almost double by 2037 (Government of Manitoba 2016).
Canadian PSW literature to date has largely focused on specific provinces and/or is often restricted to the home and community care sector. Knowledge gained from this literature suggests that Canadian PSWs are primarily older women, with lower education levels in comparison to other paid front-line healthcare workers (HCSSC 2003), and higher proportions of visible minority and immigrant status in comparison to the general working population (Lum et al. 2010). All of these are also common features of PSWs elsewhere (Fujisawa and Colombo 2009; Korczyk 2004), as well as the precariat more generally (Standing 2011). The relatively low education levels most likely relate to the lack of mandatory standardized training and educational qualifications for PSWs across Canada in contrast to other paid healthcare providers, although varying PSW requirements exist in healthcare settings by province, region, sector and employer. This lack of consistent educational requirement and associated low education levels in comparison to other paid front-line healthcare providers contributes to the low human capital, market value and status of PSWs. However, the quality of education in Canada does not alone contribute to low PSW status, as key issues related to PSW status and market value remain even where there are robust PSW educational programs (Kelly 2017). The structure of Canada's neo-liberal healthcare system, with its related power dynamics in terms of occupational hierarchies and differences by sector, may play a major role in perpetuating the low status of PSWs (Lilly 2008). The gendered and ethnic nature of PSW work likely also contributes to the low human capital, market value and status of PSWs.
Commonalities between PSWs and typical precariat characteristics also exist in terms of workplace-related variables. PSWs are thought to regularly transition between this labour force and other work roles, low wages are commonplace and hours are mainly casual, contract-based or part-time (Zeytinoglu et al. 2009). Past research varies in the reported proportions of PSWs with full-time, part-time or casual status. Nonetheless, there are often high levels of part-time (52% of an Ontario sample [Zeytinoglu et al. 2014]) and casual (46% of a British Columbia, Ontario and Nova Scotia sample [Sims-Gould et al. 2010]) employment. PSW unionization varies by location – for instance, the proportions of PSWs in Canada's home care sector that were unionized ranged from 7.69% to 100% by province (Sims-Gould et al. 2010). Unions provide workers with a greater sense of unity, generally higher pay and job security (Long 1993) – thus, PSWs working without unionization are expected to be disadvantaged. The low upward mobility and high degree of unpaid labour for PSWs is commented on throughout the literature (Nugent 2007). Low wages are a common feature of PSW work, where pay tends to be focused around, and sometimes below, a living wage – with the lowest rates generally found in the home and community care sector (Lilly 2008) and the highest in Western provinces (Church et al. 2004; Parent et al. 2001). Across Canada, an average of $12.60 per hour was reported for PSWs working in home care in 2001; registered nurses received approximately double in the same year and sector (HCSSC 2003). Given low average wages, inconsistent unionization, non-guaranteed hours of work and the casual or part-time nature of PSW work, as in many other neo-liberal societies, a great number of PSWs in Canada can be considered part of the precariat. However, variations in wages, part-time or casual status and other elements of the picture indicate that blanket statements cannot be made; variance in the extent to which PSWs technically can be seen to belong to the precariat differs according to the spectrum of workplace characteristics, individual socio-demographic characteristics and location in terms of province and sector. But despite this range of features, past research indicates that general PSW workplace and other characteristics align this workforce with the precariat.
These findings about the generally precarious features of PSW activities are reinforced by other Canadian-based literature where there is added evidence of the potential consequences of precarious work. For instance, aspects of the existence of PSWs in Ontario such as part-time or casual hours, job insecurity, fear of job losses, heavy workloads and low workplace support have been found to contribute to high stress and/or lower job satisfaction (Denton et al. 2002). Furthermore, there is evidence for a link between job insecurity and musculoskeletal disorders (Zeytinoglu et al. 2015), implying that the precarious nature of PSW work is not only associated with psychological repercussions related to stress, but physical consequences too. PSWs generally have low health scores across all types of health measures, with PSWs in Canada reporting musculoskeletal injuries as the most common health issue (Alamgir et al. 2007; Ngan et al. 2010). The precariousness of the PSW labour market may also result in a backlash for employers and those receiving care. Zeytinoglu and colleagues (2009) show that in a sample of PSWs from Ontario home care, casual hours along with perceived employment and labour market insecurity are associated with higher turnover intention – with untoward implications for employers and users, not least in continuity of care.
Clearly, past Canadian literature that highlights aspects of socio-demography and employment for PSWs suggests precarity is a predominant feature of their situation. The potential dangers to PSWs – and, by extension, PSW employers and those receiving PSW care – have also been indicated. Many of the factors discussed in this section, including low full-time employment opportunities, poor opportunities for advancement, high job and employment insecurity and high levels of injury at work, associate PSWs with the previously given definition of the precariat including a lack of security related to the labour market, employment, skill reproduction, income and representation. Given rising reliance on PSWs and mounting evidence that suggests a precarious PSW labour force, more research is needed in Canada on such related issues as the stability of employment for PSWs and the labour supply outcomes for PSWs. Further research in these areas should also shed light on how far precarity itself is a new phenomenon in this sector of the labour market.
Conclusion: Policy Implications
This said, it should be stressed that in Canada there appears little sign of the development of a class-conscious group of PSWs in face of the widespread characteristics of precarity that many of these workers seem to share. This can be illustrated with reference to Ontario, where – while there has been some anger by workers at their precarious standing – there has been relatively limited sign up to the more politicized unions and associations for PSWs (Zlomislic 2016). Although Canadian workers overall tend not to be politically conscious, PSWs would benefit from becoming so considering their relatively low position in the labour market. This current general lack of politicization of PSWs is perhaps understandable given that – despite the size of the PSW workforce – resources and political power are limited for workers of generally low social, political and economic standing, in addition to their differentiation by role and sector. Defining PSWs as part of the precariat can have multiple implications. A positive implication for PSWs is that they may improve their situation in belonging to a larger group with shared disparities by becoming politically active and class conscious (Standing 2011). Although more research is necessary into the subjective perceptions of PSWs, one negative consequence could be that the development of a self-image of themselves as part of the precariat may reinforce their low status, until or unless there is a successful political movement to enhance their position.
The long-run sustainability of the Canadian health system also points to the need to improve the precarious conditions of many PSWs. There are several advantages to this from a policy viewpoint in healthcare. One of these is to make the PSW role sufficiently attractive to ensure that there is an adequate supply of suitable quality PSWs on the labour market to meet the rising demand for such workers – in a situation where there have already been reported shortages (Canadian Home Care Association 2008). Selective evidence-based attention to this group through government policy and other initiatives could also aid retention and improve the quality of this workforce, reducing risks to public health and safety. This is of course in addition to attending to the basic human rights of particularly disenfranchised PSWs in the precariat to combat social exclusion in Canada's fundamentally egalitarian and meritocratic society. Self-employment, part-time and casual employment, illicit working and other workplace features common to PSWs' precarious position impact their rights in a manner akin to that of the wider precariat – who are viewed as having a limited range of civil, cultural, social, economic and political rights (Standing 2011).
In this light, it should not be surprising that in Canada the government and the private sector have begun taking actions to counter the effects identified here of the newly identified precarity of PSWs in the provinces and territories. In Ontario, in fact, the Ministry has made several attempts to enhance the position of PSWs – not least through systematic wage increases for PSWs and increased investment in training through an envisaged standardized curriculum. This in turn brings financial advantage to PSWs in the market, even if a register of PSWs in Ontario has recently been closed down – despite enrolling approximately one-third of the relevant labour force (Zlomislic 2016). Other measures based on evidence that have been proposed for providers of services include task shifting for PSWs to make the role more interesting (Zeytinoglu et al. 2014). Such endeavours underline the importance of determining the precarious nature of the position of PSWs through proactive data gathering and analysis and finding the most appropriate ways to combat this from a policy viewpoint – whether through creating more systematic and relevant educational opportunities or other means. With limited financial resources and ever-expanding healthcare costs internationally, it is vital that governments and other players address the conspicuously disadvantaged position of many PSWs – a key element of the precarity of a workforce that is critical to future well-being in Canada and beyond.
Les préposés aux patients au Canada: un nouveau précariat?
Les débats internationaux récents évoquent souvent l'émergence, dans les sociétés modernes, d'une nouvelle classe de travailleurs – le précariat – dont les caractéristiques communes sont des bas salaires, l'insécurité, des emplois temporaires, un statut minoritaire et des droits limités. Cet article explore, de façon critique, dans quelle mesure l'important groupe grandissant de préposés aux patients (PAP) peut être considéré comme un nouveau précariat en raison de sa place sur le marché du travail de la santé. Au moyen des données empiriques actuellement disponibles, l'article examine la question relativement aux PAP au Canada et fait ressortir certaines répercussions pertinentes pour les politiques de santé gouvernementales dans ce domaine.
About the Author
Katherine Zagrodney, BA, PhD candidate, Health Services Research, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
Mike Saks, BA, MA, PHD, Research Professor in Health Policy, University of Suffolk and Visiting Professor, University of Lincoln, Lincoln, UK, Royal Veterinary College, University of London, London, UK, University of St Mark and St John, Plymouth, UK, University of Toronto, Toronto, ON
Correspondence may be directed to: Katherine Zagrodney; e-mail: firstname.lastname@example.org
The authors are grateful for comments on an earlier version of this paper by Professor Raisa Deber and Professor Audrey Laporte from the Institute of Health Policy, Management and Evaluation at the University of Toronto, Toronto, ON.
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