Valuing the health of the support worker in the aged care sector

Abstract

This study explored aged care support workers’ perceptions of how their health was influenced by their job, highlighting similarities and differences of those working in community-based and institution-based care. Support workers working in two institution-based and three community-based aged care organisations were invited to participate. Semi-structured interviews were undertaken with ten participants. Open-ended questions probed participants’ perceptions of their health as it related to their work. Data were analysed with the General Inductive Approach. Four central themes were identified, many of which related to mental, as opposed to physical health. ‘Love of the job’ described various sources of satisfaction for participants. These factors commonly overrode the negative aspects. ‘Stress’ encompassed the negative influences on all aspects of health. ‘Support’ described the positive influences on health, which supported participants in their job. ‘Physicality’ described the physical nature of the job and the positive and negative impact this had on participants’ health. Support workers perform numerous tasks, which often impact upon their health. Aspects of the job that may impact the health of the worker are improved communication and support from management, as well as recognition for support workers’ contribution to society. These could be targeted to enhance support worker health. Additional training and reduced time pressure may also represent aspects for improvement, to optimise support workers’ physical health.

Introduction

Worldwide the proportion of the population aged over 60 years is increasing and is projected to continue to increase (Bloom, Canning and Fink 2010; United Nations 2009; World Health Organization 2014). New Zealand is no exception: a quarter of New Zealand's population is expected to be over 65 years old from the late 2030s (Dunstan and Thomson 2006).

Demand for care of this important group of society will consequently increase (Fujisawa and Colombo 2009). Support workers are vital members of the health workforce in the care of older adults (Hugo 2007). Two important groups in New Zealand are community-based and institution-based support workers. These support workers are also referred to as paid care-givers, home care aides, health-care assistants, home health aides, nurse aides or nursing assistants (Elwér, Aléx and Hammarström 2010; Jorgensen et al. 2009; New Zealand Human Rights Commission 2012). For this paper, the term support worker will be employed and refers to workers who are paid to provide assistance with a variety of tasks, including personal care and activities of daily living (Access 2012; Careers NZ 2014).

In New Zealand, aged care support workers are in the minimum wage bracket (Careers NZ 2014). The support worker role has predominantly been a female job and in New Zealand, 92 per cent of the support workforce are women (Badkar 2009; Statistics New Zealand 2006). There is concern over the future availability of support workers, with demand expected to exceed supply. As the current workforce ages, as a result of the demographic transition, the number of middle-aged female support workers currently in these roles will decline (Badkar 2009; Fujisawa and Colombo 2009; Hensen and Yeabsley 2013). Furthermore, as the educational level of women is increasing, it is improbable they will settle for employment with low wages and benefits, characteristic of support work (Hensen and Yeabsley 2013).

Recruiting and retaining support workers has been an ongoing challenge worldwide, and will continue to be problematic as the demand for care increases (Ashley, Butler and Fishwick 2010). Previous literature has identified several factors in this, including inadequate pay, lack of benefits, lack of respect and inconsistent hours (Ashley, Butler and Fishwick 2010; Butler et al. 2014; Stacey 2005). Poor working conditions, work overload, inadequate training and a lack of opportunity for advancement were also related to retention issues (Brannon et al. 2007; Jorgensen et al. 2009). Only two studies have explored influencers of recruitment and retention in New Zealand (Jorgensen et al. 2009; King, Parsons and Robinson 2012). These two studies reported the environment, training and wages as factors influencing retention (Jorgensen et al. 2009). King, Parsons and Robinson (2012) also discussed the influence on retention of changeable hours, supervision, communication and helping the client (King, Parsons and Robinson 2012).

One important aspect, not previously addressed in any detail, is the effect of the job on support workers’ health. Previous research has highlighted the high physical demands experienced by aged care support workers, with musculoskeletal injuries, particularly neck, shoulder and back pain being common complaints (Chang et al. 2013). Safety concerns for support workers have also been explored with potential back injuries related to lifting and transferring clients the primary physical safety concern identified (Craven et al. 2012).

Past research has highlighted the psychological reward of helping older adults as a factor motivating retention (Ashley, Butler and Fishwick 2010; Butler, Wardamasky and Brennan-Ing 2012). On the other hand, support workers can be subject to emotional strain (Stadnyk et al. 2011). Several studies also identified physical and emotional exhaustion as health concerns challenging retention (Butler, Wardamasky and Brennan-Ing 2012; Hsieh and Su 2007; Lindquist et al. 2012; Stacey 2005).

Two qualitative studies have explored health experiences. Elwér, Aléx and Hammarström (2010) reported that the health of 46 employees (38 women and eight men) in aged care in Sweden was affected by ‘structural stressors and relational health resources’ (Elwér, Aléx and Hammarström 2010: 1210). Support work was found to be exhausting, with stress arising from excessive demands, organisational changes and limited recognition. This study concluded that supportive environments might reduce relational stressors and provide protection from structural stressors (Elwér, Aléx and Hammarström 2010). Markkanen et al. (2007) investigated hazards for health experienced by seven home health aides and 17 nurses working in the United States of America. In terms of physical hazards, participants identified the following issues: safety concerns, rapid work pace, long distance driving, hygiene issues, limited workstations, heavy lifting and moving, limited supplies, and allergies (Markkanen et al. 2007). Neither of these studies focused specifically on support workers; other professions were also included.

Given the limited research on the health of support workers in general and in particular in New Zealand, this study explored the questions: How do New Zealand support workers perceive their jobs impact on their health? Are there perceived differences between community-based and institution-based care?

Design and methods

Design

A qualitative design was chosen using face-to-face semi-structured interviews to yield data. An open-ended question interview style was used allowing participants the freedom to express their own views (Ballou 2008). These questions were developed based on pertinent literature, and discussed and agreed upon by members of the research team. Prior to commencing the study, ethical approval was obtained from the University of Otago Human Ethics Committee (approval number 13/281).

Participants

Paid support workers providing community-based or institution-based care to older adults (over the age of 65 years) were purposively sampled for this study. Inclusion criteria included, requirement to speak English and a minimum of six months experience as a support worker. There were no exclusion criteria. The sampling method was chosen to recruit appropriate participants to meet the study aims (Tongco 2007). Participants were recruited via two institution-based and three community-based organisations providing aged care in Dunedin, New Zealand. Recruitment strategies included information sheets distributed by the organisations’ management, advertisements in the organisations’ newsletters, and presentation by the researchers at staff meetings. Interested participants were then asked to contact the Research Administrator directly to book an interview: disclosure of participation to their organisations was the participant's choice. The first ten potential participants who met the inclusion criteria and expressed an interest in taking part in the interviews were accepted into the study. Although gender was not an eligibility criterion, all individuals who agreed to participate were women. Pseudonyms were employed for all participants’ names, as well as assignment of participant numbers, to protect confidentiality.

Data collection

One or two members of the research team conducted the semi-structured interviews at a mutually convenient time and location. All interviews were audio-recorded with participants’ permission. A written information sheet outlining the study aims and procedure of the interview was provided for each participant, and participants signed informed consent prior to being interviewed. Participants initially completed a short demographic questionnaire which asked about name, date of birth, ethnicity, number of years living in New Zealand and area of support work. Key open-ended questions, covering relevant topics, were used to guide the interviews. Interviews generally began with, ‘Tell me what it's like to be a support worker’. The key questions for the interviews are listed in Table 1. The order of questioning depended on the flow of the discussion (Hardon, Hodgkin and Fresle 2004), and while probing questions were used when needed, every effort was made to maintain a natural discussion. The interviews were audio-recorded and transcribed verbatim by the researchers and professional transcribers. The first author checked for accuracy of transcription. On completion of the interview, field notes were made to record the main impressions gained during the interview and important observations.

Table 1. Interview guide (not all questions were asked)

Analysis

The General Inductive Approach, an approach frequently employed in health-related research (Thomas 2006), was chosen to analyse the data. This approach allows the analysis to be guided by the specific objectives of the study; clear links are established between the study objectives and the dominant themes emerging from the raw data (Thomas 2006). In this case, themes relating to how support workers perceived their job impacted upon their health were explicitly explored and identified.

Analysis began immediately after each interview, using field notes for each participant to capture the overarching ideas obtained in the interviews. If data saturation was not deemed to have been reached after ten interviews, it was planned that more participants would be recruited. The first five transcripts were initially read through to gain general impressions. Further readings were then used to generate codes, grouping the main themes from each interview relating to the impact on health. Following this, coded data from these five interviews were grouped into meaningful patterns so as to generate a coding framework of the major themes, sub-themes, categories of sub-themes and sub-categories that ran through the data. To address rigour and trustworthiness, the coding framework was discussed and agreed by the research team (EG, LH and JA) and then applied to all ten interviews. Slight modifications were made until all three researchers were in agreement. Reliability checking of the coding was achieved by having the three researchers apply the codes to interviews separately. Lastly, member checking of the results took place to enhance the credibility of the results (Goldblatt, Karnieli-Miller and Neumann 2011). This was achieved by asking a support worker who had worked in both community-based and institution-based care, but had not been interviewed, to comment on the findings and discuss whether they resonated with her experiences of working in the field. Overall, this support worker thought the results summarised her experience well; however, discussion from this meeting prompted several minor changes regarding the support in institution-based care and interaction with clients’ families. This support worker's comments also emphasised the significance of attachment to the clients, as well as the importance of common sense.

Results

Participants

Ten paid support workers, currently employed in community-based or institution-based care were interviewed. Data saturation was considered reached prior to the tenth interview, so further participant recruitment was not required. Among the participants, 80 per cent worked for a community-based organisation, 30 per cent in institution-based care and 10 per cent currently worked in both areas of care. One-third of the community-based support workers had previously worked in institution-based care. The ethnicity of all ten participants was New Zealand European, with one participant also of Māori descent. All participants had lived for the majority of their life in New Zealand. Ninety per cent worked part-time, with 20 hours the average number of hours in a typical week. Participants’ time spent in the support work industry ranged from six months to 28 years. Participants’ information is detailed in Table 2.

Table 2. Participant information

Notes: CB: community-based. IB: institution-based.

Support work had a perceived paradoxical effect on participants’ health. On the one hand, participants overwhelmingly spoke about the love they had for their work which fuelled their sense of wellbeing. Conversely, work could be extremely stressful, impacting on their health. A similar juxtaposition was offered by the physicality of the work; the work kept them physically fit, yet could also result in pain and fatigue. Good training and support enhanced their mental, emotional and physical health, a lack thereof left them feeling undervalued, anxious and stressed. These four themes – love of the job, stress, support and physicality – formed the core concepts that emerged and are described below, supported with quotes from the transcripts.

Theme 1: Love of the job

Most participants began the interview by declaring their love of the job; this appeared to be what primarily motivated them to do the job. Quite clearly a derived sense of satisfaction in making a difference in the lives of their clients gave them a mental health boost. It was often the simple act of helping clients, ‘making the client's day’, that several participants identified as overriding any negative aspects of the job. This was illustrated clearly by Diane:

I love helping people out and making life better for them … caring for others and like showering them and things like that, I don't really find it a chore … I'm making … those peoples’ lives a whole lot better by helping them shower. (Diane, community-based (CB))

Those who worked in the community acknowledged how the flexibility of the job gave them valuable time for other important aspects of their lives, such as family. Mary expressed it this way:

I do this job because I work around my son who's got the disability … it's a good job because you have your own family commitments and it just gives you a little bit of time outside the family to … do something for yourself … and help other people at the same time. (Mary, CB)

Particular to the community-based setting was the positive effect of the independence and one-on-one nature of the job on mental health; allowing freedom from management and avoidance of staff politics, as illustrated by Mary:

I love the job, I love the people that I work with, I also do like the fact … I know I'm working for the company but you're kind of working for yourself. (Mary, CB)

Theme 2: Stress

Stress, however, could counteract the pleasure participants derived from their work. Stress was a recurrent and dominating theme identified amongst all participants, which negatively influenced mental, physical and social health. Stress stemmed from many sources. In spite of the work been officially deemed ‘unskilled’, all participants talked about the mental demands their job placed on them, reflecting that the job was not as unskilled as it might superficially appear to be. Although there was seemingly a ‘sameness’ about the job, clients could vary considerably, requiring different approaches to how a task was undertaken, with some demanding clients placing added strain to what might be thought of as a simple job. For example, it was important to make connections with clients in a way that reflected their emotional and cognitive level as well as their personalities. Some patients always joked with participants while other patients wanted the participant to keep to the task at hand.

As Jenny describes: ‘Some of them [clients] it wouldn't matter what you did, how you did it, whether you did it their way, any other way, they would still moan’ (Jenny, CB). Several workers also identified the mental demand associated with seemingly constant time pressures, which potentially compromised client care, as well as the participants’ own safety.

Due to the nature of ageing, deteriorations in clients’ health were inevitable, and some participants spoke about having to be constantly alert to changes in the client. Further, client deterioration could be distressing to the worker. Mary's story below illustrates this:

I found a lady collapsed on the floor once and I rang work and they said ring an ambulance so that's what I did, she'd got out of bed in the night to go to the toilet and lost her balance and over she went and I think she hit her head on the corner of a cupboard or something and was just lying there sort of semi-conscious … Oh it's horrible to see somebody like that … it upsets me but you have to act accordingly, you can't just scream and run away … you know you've got to be positive and do something to assist, you don't just walk away. (Mary, CB)

Stress was also associated with management. Common issues included rushed communication, poor responses, limited face-to-face contact and lack of timely responses, particularly in community-based care; as Christine (CB) remarks ‘Not being able to speak to anybody when you need too … you just leave a message and hope like hell they get back to you’. Lack of support was further identified, often because management was busy. Limited supervision sessions and meetings were common complaints. Participants did not always feel listened to, or felt that their concerns were not addressed. Several participants mentioned a lack of organisation by management as stressful, most commonly in relation to scheduling. Those in community-based care commonly indicated inadequate time allocation for clients and travel time. Last-minute changes and large gaps in their rosters were also mentioned:

Sometimes like we finish at one client at 9 and we've gotta be at the next at 9 and we finish at 9:30 and we've gotta be at the next one at 9:30. (Angela, CB)

Lack of recognition also impacted on social and mental health, identified by 80 per cent of participants. Lack of appreciation was not only wanting from management, but the government, society, friends and other professions were also identified as being unappreciative.

I don't really have a lot to do with management … I hardly ever see them and there is one person I haven't even seen yet … and it would be quite nice to get around and meet those people and know that you are doing the right thing … rather than just every so often a person would complement you on like how valuable you are … I'd like to know it from a bit higher up. (Kate, institution-based (IB))

Participants often expressed experiencing a lack of power; despite spending a large amount of time with the client, they felt their opinions were not valued.

Well I know um, no they [physiotherapists, nurses, etc.] kind of look at us as if we're just cleaners as well, you know they come in, like I've got the white uniform, I've got the big badge and I've got the bag and I can do this, that and oh you've got the vacuum in your hand or the duster in your hand you know … I am a qualified teacher, I don't say that to them but I mean, let's be honest, I bet you there are a lot of older women who have qualifications behind them. (Mary, CB)

The majority of participants indicated situations where theory and practice did not match up, causing additional stress. Set procedures were often in place, in terms of window-cleaning height, caring for clients’ animals, using gloves for showering or assisting the client's spouse. However, participants identified instances where these procedures appeared inappropriate to follow. Frequently workers ‘went the extra mile’ for their clients, working overtime and beyond what was stated in the support plan.

Like you're looking after a client who has a husband and they might not share a room for whatever reason and so in theory because the husband is able and he's not the one getting support you are not meant to do anything in his room … but if you can see that it's dusty and the client wants you to dust and it's really getting them agitated that it's dusty and it you know you kinda just … dust it because it's their wellbeing. (Angela, CB)

Workers were responsible for numerous aspects such as medications, safety hazards and client health, and often this responsibility added to their mental stress. There were situations where management pushed workers to do things they were not qualified to do, such as administering medications or when involved parties had conflicting expectations.

Yeah, ’cause I have had some reasonably serious sort of situations really where I thought one client was mixing pills and alcohol … there was a couple of weeks there where they were really slurping into the alcohol and I'm thinking great … and so I immediately told them about that little problem when I saw it … ’cause I'm thinking no way, that's not good … doesn't matter what sort of pills you're on … incredibly dangerous really. (Jenny, CB)

The work environment contributed to stress, negatively influencing not only physical health but also mental health, especially for those in community-based care. Some clients’ houses were described as ‘filthy’, ‘unclean’, ‘untidy’ and ‘smelly’, and clients’ animals could add to this stress.

Whilst some workers acknowledged independence as a source of satisfaction, all community-based participants identified that independence could also result in stress, impacting on their social and mental health. Most workers kept to themselves, simply going in and doing their job.

Um, just feeling like you're not really uh joined together with other workmates as a workforce … ’cause you're going in there alone, you do your thing and then you go to the next place and you know, so all you're seeing is your client, you're not really seeing any workmates as such usually. (Jenny, CB)

Several participants expressed frustration by the limited ability for promotions and the inadequacy of pay and benefits.

Theme 3: Support

Although support workers faced stress as part of their job, they also experienced support, which positively influenced all aspects of health. Participants identified that people and the environment formed their support base. Whilst people could be a major source of stress, several support workers in both settings identified people as a main form of support, positively influencing mental and social health.

Clients were commonly identified as supportive, especially when they voiced appreciation. Their families also occasionally expressed their gratitude: ‘The families of the residents … they're really very helpful and very supportive towards us … ’cause they see what we do’ (Michelle, IB). Management was also identified as a major form of support, when communication was adequate and recognition and respect was provided, particularly if management came on to the ‘shop floor’ and interacted with the clients: ‘Um, so she's [co-ordinator] really, she's really good … I think we're pleased and quite you know sort of relieved that we've actually got somebody that understands our way of working’ (Patricia, CB).

Community-based workers mentioned the benefit associated with support plans provided by management, for the clear expectations they offered. Co-workers were another source of support, more commonly in institution-based care, but also in community-based care, as Gaye explains:

They're [co-workers] usually pretty good ’cause there's a couple of us that do the same houses because they're husband and wife … so it's easy to speak to each other and say ‘would you cover for the lunchtime ’cause I've got something’ and then we actually go to the boss and say ‘look, you know, Gaye will cover this’. (Gaye, CB)

Participants felt their jobs ran smoothly when team morale was high, and co-workers were prepared to cover for each other. A positive well-functioning work environment was enhancing for health. All institution-based support workers positively described most aspects of their work environment. However, due to the variable nature of the community-based work environment, only two participants described this aspect in a positive light.

Theme 4: Physical

All participants identified the physicality of support work and that this physicality could impact both positively and negatively on their health. Participants referred frequently to the job as ‘physically draining’. The need to be fit and strong was acknowledged, as well as the physical demands of long hours of heavy work in institution-based care. Bending down, getting on/off the floor, stairs, hoist work and physically assisting people occasionally led to musculoskeletal complaints. Diane clearly illustrates the physical demand:

It's physically pretty draining, you have got to do an awful lot of bending down and sitting on the ground to put people's shoes on … . so it's really hard on your knees. (Diane, IB and CB)

On the other hand, the physicality of the job was acknowledged by participants as improving their physical fitness and helping them lose weight.

Generally, adequate equipment was provided for physical health protection. Although in community-based care, equipment was not always available, something usually could be done about it: ‘Yeah like sometimes you don't but that is just when you have to identify that and then let somebody know … so far … I hadn't had any problems’ (Patricia, CB). Institution-based support workers identified several instances where equipment use was compromised by time: ‘We have the belts … but … sometimes, people are a bit pushed for time … so that they just don't get used’ (Kate, IB).

Physical safety was another aspect identified by all participants. Physical safety protection was acknowledged as provided by training, set procedures and common sense.

We're only allowed to do windows according to how high we can reach, we're not allowed to stand on stools or ladders now … I only do what I'm meant to do. (Mary, CB)

Most participants thought that they had adequate training for the job, either from the current employer or from previous experience, with regular options to up-skill. Areas of training included hand hygiene, lifting, hoist work, manoeuvring, shower assistance, medications, common health conditions, client safety and self-safety.

Although most participants (90%) acknowledged training was provided, half identified situations where training was inadequate. A few participants had received no training: ‘You get thrown in the deep end, because they didn't get you any training’ (Christine, CB). Several workers stated that they learnt a large amount of their practice simply ‘on the job’; this included efficient techniques involved in showering, dressing and drying someone, as well as identifying safety concerns of the client.

Discussion

This study explored New Zealand aged care support workers’ perceptions of how their work impacted their health. Participants identified four interconnecting themes of love of the job, stress, support and physicality, as influencing their health. These themes overlap to affect all aspects of health, as defined by the World Health Organisation, namely social, mental and physical health (World Health Organisation 1948).

Participants in this study loved their job, and this was the first thing that they stated in the interviews. Appreciation received from clients was something all participants considered to be a positive influence on social and mental health, a finding resonant to that of previous literature (Butler, Wardamasky and Brennan-Ing 2012; Faul et al. 2010; Sung, Chang and Tsai 2005). Surprisingly, remuneration was not referred to often and did not form a dominant theme, in contrast to previous literature (Ashley, Butler and Fishwick 2010; Butler et al. 2014; King, Parsons and Robinson 2012; Stacey 2005). Several participants identified that money was not their main motivation for work; instead the love of helping others and making a difference were their primary motivators. This was an unexpected finding given the low wages earned by support workers in New Zealand. Possible explanations may be that only those workers who viewed their job positively volunteered to participate in this study or that participants in this study received other sources of income, such as from partners or other jobs. Participants may have come into the study with low expectations of wages ever changing, and consequently focused on other aspects for the job in the interviews.

A dominant theme mentioned by all participants was the stress of the workplace. Inadequate communication and support from management negatively influenced participants’ social and mental health. These findings are similar to those of earlier studies in terms of communication issues (Butler, Wardamasky and Brennan-Ing 2012; King, Parsons and Robinson 2012) and the need for supportive supervision (Dill, Keefe and McGrath 2012; Fleming and Taylor 2007). Lack of recognition was commonly mentioned as a source of stress. In accordance with previous research, this lack of recognition was found to come from both society and management (Ashley, Butler and Fishwick 2010; Butler et al. 2014; Elwér, Aléx and Hammarström 2010). Participants studied by Elwér, Aléx and Hammarström (2010) mentioned feeling powerless; these authors attributed this to the undervalued nature of the support work, leading to difficulty managing stresses.

Most participants identified their work as physically demanding, confirming previous studies in which support work was described as exhausting, with high demands (Elwér, Aléx and Hammarström 2010; Kim et al. 2010; Larsson et al. 2013). On the other hand, several participants acknowledged the positive effects of the work on their physical health, such as fitness. Positive effects on physical health have not been discussed in previous literature.

Support (or lack of support) for the work participants were completing was noted by all participants. Training was mentioned as lacking and participants wanted more of it. Most participants received some form of training; however, half perceived this training to be inadequate in certain areas. This finding supports a previous New Zealand study that care providers perceived less than half of paid care-givers were adequately trained (Jorgensen et al. 2009). Participants perceived the training they received protected their safety, supporting previous research identifying training as an intervention limiting safety concerns (Craven et al. 2012). Physical safety concerns, commonly resulting from theory and practice not matching up, inadequate equipment and the environment, however, were identified by participants. Proper equipment, correct use of equipment, lifting techniques and applying common sense to difficult situations appeared to increase worker safety (Craven et al. 2012).

Of interest, only one community-based participant in the present study mentioned having back pain. This was surprising considering the high prevalence (58–75%) of low back pain among support workers reported in a recent systematic review (Chang et al. 2013). This difference may potentially be explained by improved handling and employment of safe lifting techniques.

The last dominant theme was physicality. Participants identified temporal concerns as sometimes compromising safety; these were similar to the findings of Craven et al. (2012). Not only was time pressure a safety concern for workers, several workers considered that it also compromised client care, a finding highlighted in previous research (Fleming and Taylor 2007). Safety was also sometimes compromised when participants went the extra mile for their clients. Mental health, in particular, was negatively influenced when participants took their clients’ problems home with them. On the other hand, mental health was positively influenced when participants were able to brighten someone's day.

This study also aimed to explore similarities and differences between the health experiences of those working in community-based and those in institution-based care. These differences were commonly expressed in terms of flexibility, environment and support.

All community-based workers identified the positive aspects to be job flexibility and independence; although they referred to the independence of the job in both positive and negative terms. Job flexibility has been identified in previous literature (King, Parsons and Robinson 2012). In some homes the participants had to work in unsanitary conditions or surrounded by noise. Inappropriate space, loud noises and unsanitary conditions have been previously identified as potential issues in clients’ homes (Craven et al. 2012; Sung, Chang and Tsai 2005). Institution-based support workers were able to modify their environment and they appreciated the comfortable ambient temperature of their environment.

Although institution-based participants had more support from management and co-workers, this increased contact sometimes negatively influenced health when the interaction focused negatively on staff politics. Hsieh and Su (2007) reported that positive work relationships increase retention rates.

Limitations and strengths of the study

A strength of this study was that participant demographics were reflective of those published for New Zealand. Participants in this study had a mean age of 51 years; New Zealand support workers are reported to be over-represented in the over-40 age group (Badkar 2009). All participants were female, reflecting the predominance of women (92%) in the care of older adults in New Zealand (Statistics New Zealand 2006) and also mirroring other New Zealand studies which reported 94 and 100 per cent (Jorgensen et al. 2009; King, Parsons and Robinson 2012). Participants were primarily of European descent, a finding that is also comparable with previous New Zealand studies (Jorgensen et al. 2009; King, Parsons and Robinson 2012). One participant was of Māori descent. In 2006, the percentage of Māori care-givers was 14.8 per cent (Badkar 2009) so further research may be required to enable recruitment of a representative sample of Māori and Pacific Island support workers. Previous research has shown that ethnic differences, along with language barriers between home care workers and their clients, can complicate relationships (Denton, Zeytinoğlu and Davies 2002).

The use of purposive sampling for participant recruitment may limit generalisability of the findings, although data saturation was considered to be reached. A limitation was the small number of institution-based support workers included in this study: only three of the participants were currently working in institution-based care as opposed to eight workers in community-based care. Furthermore, although the support worker workforce is primarily comprised of women, research including a male perspective would be of particular value to inform and enhance the recruitment of men into the support worker workforce. More effort is required to improve recruitment of institution-based workers and male workers into studies of this nature.

The credibility of the findings was assured in several ways. Investigator triangulation was achieved through agreement from three researchers on the coding framework (Letts et al. 2007). Reliability checking of the coding was achieved through three researchers coding the data separately. Lastly, member checking took place to enhance the credibility of results (Goldblatt, Karnieli-Miller and Neumann 2011).

Another potential limitation was that the main interviewer was an outsider to the profession, potentially limiting understanding of the topics of discussion. However, this could also help reduce researcher bias from pre-formed opinions.

Clinical implications

Although there were positive influences on health identified, potential areas were recognised that could be targeted to improve the health of support workers, potentially ensuring retention. Areas for development could include: improved communication with management, increased recognition by all of the importance of the job and the skilled nature of it, reduction in physical demands, increased training, and changes to timing of client interactions and travel.

Conclusion

From this study, there is no doubt that the nature of support work impacts workers’ health. Love of the job and good support facilitated mental and social health, whilst stress and poor support had the opposite effect. The physical nature of the job had its toll on physical health, but was also viewed as having a positive influence in terms of physical fitness. The major factors identified as influencing stress and poor support were communication and interactions with management, lack of recognition by the wider society for the work done, and availability of training. It is thus in these areas where potential changes could be instituted to improve the health of support workers. Differences were found between health experiences of community-based and institution-based support workers. Community-based workers valued the flexibility of the job and the absence of ‘staff politics’ which enhanced mental health, whereas institution-based workers valued the more readily available support and comfortable environment of the institution which facilitated physical health.