September 26, 2018 Celeste Monforton, DrPH, MPH 1Comment

I respect and admire home care aides. It takes a skilled and compassionate person to work in someone’s home and provide personal assistance. From helping the elderly or a disabled person with toileting, bathing and dressing, to preparing meals, house cleaning, and laundering, there are nearly 2 million home care workers in the U.S.

A paper published this month in the Journal of Occupational and Environmental Medicine examines the experiences of home care aides (HCAs) with on-the-job slips, trips, and falls. The authors analyzed two sets of data: 741 written surveys and focus group interviews with 44 HCAs.

Fourteen percent of the HCAs (110 of the 785 participants) experienced at least one slip, trip, or fall in the past 12 months. Sixty-four of them indicated that they fell completely to the ground. The authors assembled rich data from a portion of the respondents who experienced the STFs. More often than not, the HCA’s said the incident occurred outside the client’s home, such as while taking out the client’s garbage or slipping on ice while leaving the client’s home. When the STF occurred inside the home, the culprits were wet floors, stairs, rugs, cords, medical equipment, and clutter.

Besides the physical hazards, some workers mentioned other factors related to the STF, including multitasking, lack of focus, and moving too fast. Some HCAs explained how their own health challenges play a role in STFs. One worker explained: “I got real bad arthritis. So I can’t really walk down the stairs.”

The mean age of the 741 HCA survey respondents was 45 years old, with 33 percent aged 50 or older. Their clients were adults aged 60 and older with disabilities and assets less than $17,500.

The authors found that very few of the HCAs reported the STF to their supervisor. The theme that emerged was that a supervisors was not likely to be able to do much about the situation. Instead, HCAs described their own efforts to cajole and negotiate with the client or the client’s family to assist in addressing STF hazards.

“I just had to tell her husband (of the client with cognitive impairment), ‘I am sorry but I’m not gonna be responsible for your wife falling because you won’t take this rug up.’ I said, ‘If you make the rug stationary where it will stay in one place, that’s fine….. I say you wouldn’t want her to fall and break a hip….'”

Another HCA said:

“I had to actually tell my client’s children, ‘I was not gonna be responsible and every day that I work I would take the rug up off the floor. Why? Because I can see it (an accident) waiting to happen….I’ve got to be here with her, and it’s just me and her, this is what I have to do not only to protect myself but to protect your mother.’’’

The researchers explored the HCAs’ experience with work-related injuries. A common theme was the inability to take time off despite being injured. Most HCAs do not have paid sick days or personal days. In a focus group, one HCA said:

“”I can’t afford to take off from work. So it is a choice. ….it’s what you call a double jeopardy. When you’re dealing with this, I‘m like up in the air. You have a lot to think about, even if you really hurt yourself. Some people take the route that their health is not important, unless it really bothers them…. But if you do it later, later detect it (a fall injury) and tell the company, they like, ‘Well, why didn’t you tell us the first day…..they’re looking at you like you want to sue them or something. So you know liability is very important.'”

The HCA’s shared ideas with the researchers on ways to prevent STFs. Their recommendations included more hands-on training about home injury prevention and greater involvement in the care plans for their clients. The authors conclude:

“Empowering HCAs with knowledge, training and involvement is critical for STF prevention given that their workplace cannot be easily accessed or intervened by external assessors. HCAs should be encouraged to report ‘‘near miss’’ STFs, or STFs that did not lead to injuries as an integral part of interventions that provide opportunities to prevent STFs in and outside home care clients’ homes. HCA safety promotion may also lead to clients’ safety, since the workplace environment coincides with clients’ life space.”

Given the prevalence of STFs outside clients’ homes, particularly those involving ice, the authors correctly note that community-based snow removal would address a serious hazard for both the disabled, low-income clients and the HCAs.

The very high demand for HCAs is expected to continue in the U.S. through 2026, according to the Bureau of Labor Statistics. The average growth rate for all occupations in the next eight years is 7 percent compared to 41 percent for HCAs. Studies like this one point to interventions that will make these jobs safer. My hats off to the public health researchers at the University of Illinois-Chicago School of Public Health, Georgetown University School of Nursing, and the University of Maryland who conducted the study.


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