There are a variety of different health workers in home care services (see Box 1). The Canadian Home Care Human Resources Study (CHCHRS) (Home Care Sector Study Corporation, 2003b) estimated that in 2002 there were 9,241 registered nurses (RNs), 2854 licensed practical nurses (LPNs), and 32,300 home support/personal care workers (PCWs) working in Home Care in Canada. There were differences in the percentage of occupational groups working for different sectors. Government home care programs were more likely to employ professional occupations such as therapists and RNs, but fewer LPNs. The not-for-profit sector had a disproportionate share of LPNs, whereas the for-profit sector employed a higher proportion of home support workers (Canadian Home Care Sector Study Corporation, 2003, p.14). Home care work is also predominately a female occupation (3% to 9% across the occupational groups) with the majority of home care workers being over the age of 40 (Home Care Sector Study Corporation, 2003b).

There is little information on the extent of foreign born workers in this sector. Public use data from the 2001 Census reveals that in the categories childcare and home support workers and health care and social assistance workers, the proportion of foreign born workers is 4% and 5% respectively (see Table I.1) though this may not capture all older adult care workers. Based on a survey of home care workers, the CHCHRS found a small proportion of home care workers are members of visible minority groups (5-14%). In a 2002 survey of 1300 home support workers in Hamilton Ontario, Denton, Zeytinoglu and Davies (2003) found that 43% of home support workers were born outside Canada, a figure much higher than in the population for that city and the country as a whole (which is 16% according to the 2006 Census of Canada).

In terms of the registered nurse workforce, those who are internationally educated make up 16% of the workforce whereas they are generally around seven to eight percent across all nursing sectors, whereas internationally educated workers are much lower than the average at 4% (Table I.2). These data are limited in that an unknown number of foreign born workers may be educated in Canada so these numbers are likely underestimates of the extent of foreign born nurses in this sector.

Working conditions in home care are typically poor across Canada, no matter what model of service organization and delivery employed (Aronson, Denton and Zeytinoglu, 2004). Home care work is characterized by low levels of pay, few fringe benefits, job insecurity, and lack of career and training opportunities (Caplan, 2005; Home Care Sector Study Corporation, 2003a). Many workers are employed part-time or casual hours (i.e., are paid either by the hour or by the visit and hours are not guaranteed (Canadian Association of Retired Persons (CARP), 2001) and workers are expected to do weekend work and evening shifts. Job-specific factors such as high travel costs, occupational health and safety issues in clients’ homes, heavy client loads, limited time to care for clients and increasing acuity of sickness in patients are additional difficulties experienced by home care workers (CARP, 2001) Difficulties experienced in providing care in home settings include unsanitary conditions in houses, lack of cooperation from consumers, and informal care givers, physical or verbal abuse, sexual harassment and racial discrimination (Home Care Sector Study Corporation, 2003b.; Denton, Zeytinoglu & Davies, 2003). Other factors that contribute to job dissatisfaction are low wages and professional isolation, high levels of stress or burnout, lack of recognition, and injuries or disabilities of the care (Denton, Zeytinoglu, Davies & Lian, 2002).

The recruitment and retention of home care workers is an important issue (O’Brien-Pallas et. al., 2004b). Even though no national or even provincial statistics on turnover rates in home care exist, according the Ontario Community Support Association (OCSA 2000) estimates, “the average turnover rate for home care workers is double to triple the rate of other healthcare workers across Canada (that is, 25%-40% compared to 12%, respectively).” (as cited in Denton, Zeytinoglu, Davies & Hunter, 2006, p.108). The case study of the home care sector in a mid-sized city in Ontario done by Denton, Zeytinoglu, Davies & Hunter (2006) does more than to confirm the validity of such national statistics. This study reveals that in a five-year period, namely in the time range between spring 1996 and spring 2001, of the 620 visiting home care workers employed by the three non-profit agencies in 1996, 320, or 52%, had left the agency. During that time, as shown in table 1(below) taken from this study, “the turnover rate for nurses was 54% and for PSWs 50%”(Denton et al, 2006, p.113) . In a related study of the association between casualized employment and turnover intention in home care for elderly, Zeytinoglu, Denton, Davies and Millen (2008) find that controlling for variety of other factors, “casual hours and perceived employment insecurity and labour market insecurity are positively and on-call work is negatively associated with home care workers’ turnover intention”. Commenting on these results, researchers conclude that such findings represent evidence on the impact that casualized employment strategies have on home care workers’ turnover intention.

The Canadian home care human resources study conducted in 2003 finds that that between 10% and 20% of home care workers were intending to change their current employer in the next 12 months (The Home Care Sector Study Corporation, 2003). Home care workers who participated in this research cited the lack of job security as one of the first three reasons for leaving, after low wages and/or the lack of benefits. The CHCHRS shows that workers are leaving home care and taking better paying jobs in the institutional and acute care sectors (Home Care Sector Study Corporation, 2003a). It is estimated that workers in nursing homes and hospitals in Ontario earn up to 50% more wages than the average home care worker (OCSA, 2000). Additionally, many trained personal support workers (PSWs) may be leaving the health care sector altogether (Caplan 2005; Denton et al., 2007).

Recognizing issues arising with regard to retention and recruitment of health human resources in home care, governments have taken aim at addressing a shrinking workforce in this healthcare sector (CCAC/ Service Provider Association Committee, 2008). As evidence has demonstrated that being able to remain independent in their own homes improves the health outcomes for older adults, in 2007 the Ontario Ministry of Health and Long-Term Care dedicated $ 1.1 billion to its Aging at Home Strategy (CCAC/ Service Provider Association Committee, 2008). This strategy tries to aid matching the needs of seniors and their caregivers with the appropriate local community services and avoid the unnecessary loss of independence and dignity due to premature admission to long-term care homes or hospitals. Despite such provincial efforts, there are still many challenges to ensuring that home and community care, as a collective, are in position to attract, recruit and retain an adequate workforce to provide much needed care for Ontarians in their home and communities (CCAC/ Service Provider Association Committee, 2008). These, as identified by Joint CCSA/Service provider Association Committee are: a lack of recognition and image of home care as a place of care and as a workplace, inadequate education and training about the sector and for home care workers, underdevelopment of leadership which reflects collaboration and integration within home and community care at the local level, lack of research on identifying best leading and hiring practices, and lack of policy and guidelines that particularly address the unique characteristics and contribution of home and community health care.