Home Health Care Services Quarterly, 33:229–243, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0162-1424 print/1545-0856 online DOI: 10.1080/01621424.2014.964897

Recruitment and Retention of Home Support Workers in Rural Communities ZENA SHARMAN, PhD Institute of Gender and Health, Canadian Institutes of Health Research, University of British Columbia, Vancouver, British Columbia, Canada

This qualitative study examined recruitment and retention of home support workers (HSWs) providing home support in rural communities. Thirty-two participants were recruited across four island-based communities located in British Columbia, Canada. Thematic analysis of interview data revealed several key themes: (a) how the rural context shapes HSWs’ employment decisions and opportunities; (b) why people become (and stay) HSWs in rural communities; and (c) how rurality influences the nature and scope of HSWs’ work. These findings suggest that health human resource policies and programs aimed at HSW recruitment and retention should be tailored to characteristics, strengths, and challenges of rural communities. KEYWORDS home health aide, home care services, health human resources, rural health

INTRODUCTION A car bounces down a rutted gravel road, the driver craning her neck to read house numbers through the trees. It is approaching dusk, prime time for deer to materialize out of the brush and run unexpectedly across the road. The driver—Kelly, a home support worker—simultaneously watches for animals, looks for her new client’s home, and keeps an eye on the clock. She is supposed to be at Mrs. Jensen’s house by a quarter past five, but she does not want to rush. The mobile phone signal is poor this far out in the country and she might not be able to phone for help

Address correspondence to Zena Sharman, PhD, Institute of Gender and Health, Canadian Institutes of Health Research, Room 305, 6190 Agronomy Road, University of British Columbia, Vancouver, BC V6T 1Z3, Canada. E-mail: [email protected] 229

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if she hits a deer. Kelly hopes Mrs. Jensen will be all right if she arrives late. When Kelly got this assignment, the scheduler told her Mrs. Jensen is frail and often gets confused, especially if she has forgotten to eat that day. Kelly accelerates a little as the clock approaches five-thirty.

Scenes like this one, based on a composite of experiences, play out every day in rural and remote communities. This vignette points to the complexities of delivering home health services like home care and home support outside of an urban setting. Home support workers (HSWs) working in rural contexts navigate varied and challenging weather and driving conditions. The communities they serve have limited access to health and social services—including long-term care, adult day care, or meal delivery. Professional and personal relationships overlap where workers and clients share direct and indirect community ties. Clients’ homes tend to be more geographically isolated than those of individuals living in densely populated urban areas. While many aspects of home support supersede geography— for example, the significance of continuity of care and positive worker-client relationships as key indicators of quality for both clients and workers—other dimensions are influenced and informed by the specificities of place. In their work on rural home support, Sims-Gould and Martin-Matthews (2008) call for attention to context—that is, “the dimensions of environment, relationships and person, from the perspectives of both providers and receivers of home care,” acknowledging that “home support is embedded within larger socioeconomic, cultural and political contexts” (p. 44). This article attends to context through an exploration of the drivers of recruitment and retention of rural HSWs. It focuses on how HSWs working in small cities, towns, and rural communities perceive their jobs, their working conditions, and their roles within the health care system and their experiences of, and motivations for, pursuing a career in the home support sector. It offers recommendations to inform the design of policies and programs for the recruitment and retention of HSWs in these communities. The findings presented here substantiate what is already known about the challenges of recruiting and retaining HSWs and add to our understanding of the specific ways these dynamics play out in rural communities. In so doing, this article seeks to address a key knowledge gap about the home support workforce— namely, “information about the kinds of people recruited into the sector, and how to respond to their needs and concerns” (Martin-Matthews, Sims-Gould, & Tong, 2013, p. 67).

LITERATURE REVIEW Home support involves help with daily activities (e.g., getting up and around, getting dressed, using the bathroom, preparing meals, and taking medications) as well as basic health care tasks, social support, and relational

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care. HSWs provide these services in clients’ homes in order to enable them to “live independently for as long as safely possible” (BC Ombudsperson, 2012a, p. 10). These services are critical to the health and independence of rural-dwelling seniors and people with disabilities and chronic diseases, as well as of individuals needing postacute or palliative care. Home support is integral to rural seniors’ capacity to age in place, and may play an increasingly significant role in communities already grappling with challenges accessing health services. Research on home support provision in small towns and rural places has tended to focus on client characteristics, health status, access to care, and health service utilization (McCann, Ryan, & McKenna, 2005; Nelson & Gingerich, 2010). McAuley, Spector, and Van Nostrand (2009) found that adults living in remote areas received fewer days of home care, suggesting a possible access problem. Vanderboom and Madigan (2008) reported that rural home care and home support agencies provided fewer visits per patient, which they speculate may be linked to the availability of human and financial resources. Forbes and Janzen (2004) found that rural home care and home support users are more likely than their urban counterparts to receive help with housework and less likely to receive help with personal care. The work of Allan and Cloutier-Fisher (2006) revealed that being older, female, and poor has greater influence than geographic location on access to and use of home support services, though Cloutier-Fisher and Kobayashi (2009) later reported that older men living in rural areas were most likely to report poor health yet least likely to use health services, which may be an indicator of unmet need. Rural HSWs must contend with place-specific factors such as poor road conditions; long distances between clients’ homes; inadequate compensation for travel time, mileage, or high fuel prices; and inclement weather (McCann et al., 2005). Bad weather may affect workers’ ability to get to and from work, or to travel between clients’ homes, particularly in regions with limited or no public transportation (Sims-Gould & Martin-Matthews, 2008). Weather and geography play a significant role in shaping rural HSWs’ working conditions, yet the policies governing community care often overlook “the contextual differences between institutional and non-institutional settings that include weather among other geographical and socioeconomic contingencies” (Skinner, Yantzi, & Rosenberg, 2009, p. 687). Such policies may also overlook the sociocultural particularities of rural communities—for example, the need for culturally competent home support and home care services for rural and remote-dwelling Aboriginal and Indigenous people (Lindeman & Pedler, 2008; Maranzan 2008). An early study about rural home support agencies by Martin-Matthews and Wakefield (1993) found that relationships with clients are very important to HSWs’ job satisfaction. This finding was echoed in McCann et al.’s (2005) work in rural Northern Ireland, in which care recipients emphasized the importance of continuity of care. Worker-client relationships in rural home

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support are shaped by their context. Relationships may be strengthened— or made more complicated—in communities with small populations where HSWs occupy the dual role of community member and caregiver, and may share social or family ties with their clients (Hunsberger, Baumann, Blythe, & Crea, 2009; Moules, MacLeod, Thirsk, & Hanlon, 2010). These close ties are stereotypical of rural communities, which are often characterized as having stronger social networks and offering greater access to informal supports (Forbes & Janzen 2004). However, Skinner et al. (2008) challenge this oversimplified conception of rural life, arguing that while rural residents tend to have a strong belief in community and confidence in the supports available to them, they recognize that there are substantial barriers to service provision including a lack of funding, infrastructure, professional and support services—all affecting the rural residents’ capacity to “age well” and to remain in their homes and communities. Some rural-dwelling older adults express a strong desire to be as independent as possible (Manthorpe, Malin, & Stubbs, 2004). Across rural and urban contexts, researchers estimate that 10% to 13% of HSW jobs in the home and community sector remain unfilled (Eaton, 2005; Hussein & Manthorpe, 2005; Castle, 2008). Estimates of annual turnover range from 25% to 170% (Denton, Zeytinoglu, Davies, & Hunter, 2006; Dill & Cagle, 2010). Other studies identify the limited number of new entrants to the field as the key issue, pointing to current HSWs’ relatively long average job tenures (Sims-Gould, Byrne, Craven, Martin-Matthews, & Keefe, 2010). The impacts of these labor force challenges may become more severe in the face of the increased demand for home support services likely to result from demographic and policy changes including population aging, shorter hospital stays, and a smaller supply of family caregivers (Keefe, Carrière, & Légaré, 2004). These challenges may have a greater impact on people living in rural communities, who tend to be older (a driver of demand for home support; Dandy & Bollman, 2008), experience more health disparities (Canadian Institute for Health Information, 2006; Nelson & Gingerich 2010), and have limited access to health services (Sibley & Weiner, 2011). The literature on HSW recruitment and retention suggests that workers leave their employment because they are dissatisfied with their compensation, have inconsistent schedules, feel isolated and overworked, and lack opportunities for training and advancement (Keefe, Knight, Martin-Matthews, & Légaré, 2011). In spite of these challenges, HSWs report fairly high levels of job satisfaction. Workers often report remaining in their positions primarily because of the intrinsic (nonmonetary) rewards of their caring relationships with clients, previous work in a “caring and sharing” profession, and previous involvement in and/or exposure to formal and informal care (Pfefferle & Weinberg, 2008; Mittal, Rosen, & Leana, 2009; Sims-Gould et al., 2010). Extrinsic drivers of HSW recruitment include wages, benefits, and flexible schedules (Sims-Gould et al., 2010). However, we know little about the

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ways in which these dynamics play out among HSWs in rural contexts—a knowledge gap the present study sought to address.

METHODS The study was carried out in British Columbia (BC), Canada, where at least 24,500 seniors received subsidized long-term home support services in 2009–2010 at a cost of C$339 million (BC Ombudsperson, 2012b). These services are provided by HSWs directly employed by the public health care system or by other organizations (nonprofit or for-profit) under contract to a regional health authority (BC Ombudsperson, 2012a). These workers are unregulated, though they are required to register in a provincial registry (the BC Care Aide and Community Health Worker Registry). In BC, as in the rest of Canada, the model of home support delivery has shifted from one focused on prevention and maintenance to “one focused more on shortterm post-acute care” (Martin-Matthews et al., 2013, p. 68). This has created challenges for workers and clients—including increasing complexity of client needs, gaps between HSW training and the services they are being asked to provide, and gaps between clients’ care plans and the services they require to maintain their health and independence. Research has pointed to related challenges with scheduling, discontinuity of care, and time compression (i.e., rushing; Sharman, Cohen, Ostry, & McLaren, 2008; Martin-Matthews et al., 2013). The exploratory qualitative research design for this study was informed by a commitment to informing policy development through collection and analysis of first-hand accounts of health care work from front-line workers such as HSWs whose perspectives may not be reflected at the upper echelons of decision-making (Mykhalovskiy et al., 2008). We conducted interviews with 32 participants. Interviews were conducted in four communities in central and northern Vancouver Island, an island off the west coast of BC which is accessible from the mainland only by air or water. The communities—Campbell River (pop. 31,771), Parksville (pop. 11,584), Port Alberni (pop. 17,836), and Port Hardy (pop. 3,917)—were selected in consultation with the regional health authority (the publicly funded body responsible for delivery health services on the island). They were chosen because their local home support systems all serve clients in nearby rural areas, yet the communities vary in size and sociodemographic characteristics. The communities were all at least 2-hours’ drive from the provincial capital, the island’s major urban center. For example, the smallest and most remote community was located on the northern tip of the island, 487 km from the capital. Road conditions could at times be poor in some of the mountainous, heavily forested, and coastal areas of the highway that connects the communities on Vancouver Island, rendering it difficult to travel

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between communities. All of the study communities relied to varying degrees on tourism and resource-based industries (forestry, fishing, mining, etc.) as their primary economic drivers. Three of the study communities—Campbell River (17%), Parksville (37.1%), and Port Alberni (20.7%)—had a higher-thanaverage proportion of residents over age 65. The provincial average is 15.7%; only Port Hardy fell below average at 11.1%. A convenience sample of 32 participants was recruited through distribution of a flyer to all home support staff members in the four study communities. The home support office in each community appended these fliers to staff members’ pay stubs. We chose this approach because HSWs tend to work alone, do not have work-related e-mail addresses, and rarely have the opportunity to attend team meetings. To be included in the study, participants had to be currently employed by the regional health authority and working in one of the four study communities. Because our recruitment was carried out through the local health authority, our sample did not include former HSWs. All participants were paid a C$25 honorarium for their participation. We received ethical approval for the study from the University of British Columbia Behavioural Research Ethics Board and the Joint University of Victoria/Vancouver Island Health Authority Ethics Subcommittee. Open-ended interviews based on an interview guide were conducted by the lead author and a research assistant in settings chosen by participants (e.g., their homes, restaurants, coffee shops, local home support offices). Interview questions focused on barriers to and facilitators of HSW recruitment and retention, as well as HSWs’ roles and responsibilities. Interviews ranged in length from 30 to 90 minutes; they were audio-taped and transcribed. All transcripts were checked against the original recordings for accuracy. There were two stages of thematic analysis of interview data. During the first stage, two researchers independently read the interview transcripts and identified recurring themes that formed the basis for the development of a data coding scheme focused on HSWs’ work (roles and work performed) and barriers to and facilitators of recruitment and retention. At the second stage, the interview data were reanalyzed using this coding scheme to further refine our understanding of the findings. Findings were later validated by study participants during an interactive workshop with HSWs.

RESULTS Sample The sample consisted of 32 participants, the majority of whom were HSWs (n = 17). The remainder of the sample consisted of home support leaders and managers (n = 8), community care coordinators (n = 3), nurses (n = 3), and a scheduler (n = 1). The characteristics of the HSW participant sample

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Rural Home Support Workers TABLE 1 HSW Study Participant Demographics Characteristic Gender Female Male Age Range Mean Employment status Permanent Casual Job Tenure Mean

Distribution (N = 17) 15 2 29–65 years 50 years 14 3 1–28 years 10.3 years

are described in Table 1. Most HSWs (n = 15) were female, with a mean age of 50. The majority of HSW participants (n = 14) were in permanent positions, with a mean job tenure of 10.3 years.

Key Themes A number of the themes that arose from the participant interviews were consistent with the literature on HSW recruitment and retention. Like their counterparts in other settings, they highlighted relationships with clients as being the primary source of job satisfaction. Participants expressed dissatisfaction with their compensation (in particular, the wage disparity that disadvantages community-based workers), their inconsistent schedules, and the economic burden of having to use their own vehicles and mobile phones on the job. They expressed concern about work and communication practices that create feelings of isolation and augment their risks of injury and violence on the job (e.g., working alone with little to no interaction with the home support team). These themes are not discussed in depth in this article, as they are somewhat “generic” to the literature on home support—evidence that there are commonalities that unite HSWs across diverse geographies. As such, my findings section is organized around three broad themes relating to recruitment and retention of HSWs in rural communities: (a) how the rural context shapes HSWs’ employment decisions and opportunities; (b) why people become (and stay) HSWs in rural communities; and (c) how rurality influences the nature and scope of HSWs’ work.

How the Rural Context Shapes HSWs’ Employment Decisions and Opportunities The socioeconomic and geographic contexts of rural communities influence the recruitment and retention of HSWs. This includes broader labor

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force trends and the local factors that influence individual training and employment decisions. Several of the study communities had long relied on resource-based industries (e.g., logging) as their main economic drivers. The communities experienced demographic shifts with the decline of these industries. Populations were shrinking and, in many cases, aging as young families left to find work or did not migrate to these communities. This in turn influenced the supply of potential HSWs; several of the study participants had partners who worked in local resource-based industries and chose home support for their employment because the flexible scheduling aligned well with their partners’ shift work. For example, one HSW explained that she was attracted to home support because the flexible schedule enabled her to share the care of her four young children with her husband, who also worked full-time. As she explained, “I could have gone into a facility and made more money, you know, but I chose this because it suited my family and it suited my lifestyle” (Participant A-4, HSW with 10-years’ experience). Rurality also mediates access to education and training. The 6-month college program (the Health Care Assistant program) required for many jobs in the home support sector is not offered in every community. Aspiring HSWs who leave their home communities to seek training may not return, choosing instead to go to larger, more geographically central communities to work. As one participant observed: I know that they ran a course, [it] must have been about a year ago, and we didn’t have anybody from Sointula that took the course. But the people that took the course in Port McNeil and Alert Bay and Port Hardy, they all went and worked in the city. They went to bigger centers to work. (Participant D-7, community health nurse)

The high cost of living in some rural, isolated, or remote communities (e.g., those accessible only by air or water) can be a barrier to recruitment and retention. Staples like food and fuel often cost more because they must be transported into rural, isolated, or remote areas, and these additional costs increase an individual or family’s overall cost of living. Since HSWs cannot always predict their take-home pay due to unpredictable and inconsistent schedules, working in home support may not provide a stable enough income to cover the costs that come with living in a smaller or more rural place. Communities with small populations may have few home support clients, which can exacerbate the challenges with unpredictable scheduling common to the home support sector. When a client dies or is moved to a long-term care facility, this can create a gap in the availability of home support work. One HSW noted that it was virtually impossible to get a permanent full-time posting in her community because there were so few home support clients (Participant D-5, HSW with 6-years’ experience). A scheduler

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reported that that they were unable to give shifts to aspiring HSWs who wanted to work in their nearby home community because, “right now, we don’t have any clients there” (Participant D-4, scheduler). Some communities have few HSWs, which creates a different set of challenges for workers seeking to book time off for holidays or needing to take leave for illness, and for schedulers trying to ensure that all clients are cared for.

Why People Become (and Stay) HSWs in Rural Communities When discussing what they enjoyed most about their work, participants emphasized the satisfaction they derived from enabling their fellow rural community members to age in place. As one worker explained, “I go home at the end of the day and I feel like I have helped to keep that person in their home, that they’re happy” (Participant C-6, HSW with 28-years’ experience). Helping their clients retain their independence and remain at home was of particular importance in smaller communities with less access to elder care resources such as long-term care facilities or adult day care. Home support has the capacity to support individuals to age in place, to remain at home with their partner or loved ones, and to die at home if that is their preference. Building and maintaining positive relationships with clients was integral to participants’ job satisfaction. They highlighted quality and continuity of care as key elements of effective home support. Participants believed that they were able to provide a higher quality of care when working in the community. They emphasized the importance of having control over the pace of their work and not rushing client care. They enjoyed the supported independence that came with working in clients’ homes. As one HSW noted, “I’m kind of working on my own. But I still have people to turn to if I need people” (Participant A-5, HSW with 5-years’ experience). The HSWs’ commitment to their clients may be due in part to their past work, volunteer and family caregiving experience. Participants identified several reasons for their attraction to the home support sector—including an affinity for seniors, past experience caring for relatives, and previous experience providing paid or unpaid caregiving to older adults. For example, one HSW had been the privately paid caregiver to an elderly woman living alone. She later provided similar assistance to some of her neighbors: “I always looked after neighbors and helped them shower and—when they didn’t feel safe, they always phoned me before I became a [home support worker]” (Participant C-1, HSW with 6-years’ experience). This same participant also mentioned that she had a history of working in the service industry (restaurants, bars, beauty salons). Other participants were frank about the economic constraints of working in a small community: “I need $15 an hour at least, and there aren’t a lot of other options here” (Participant D-5, HSW with 6-years’ experience).

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How Rurality Influences the Nature and Scope of HSWs’ Work Working in a small community shapes the worker-client relationship, as HSWs occupy the dual role of health care provider and community member. As one participant explained, “A lot of our clients know each other and they do communicate to each other through us. A lot of times I will go to clients where they’re members of my extended family or friends that I’ve known for years” (Participant A-4, HSW with 10-years’ experience). These dual relationships influence the nature and scope of HSWs’ work. Some HSWs reported doing extra work for their clients—on the job, by doing tasks in addition to those prescribed in the client’s care plan (e.g., vacuuming, mopping floors, and cleaning bathrooms); and off the job, by doing “favors” for clients during their off-hours (e.g., caring for pets; purchasing food, household items, or gifts for family members; home maintenance). At times these practices led to conflict among workers or between workers and managers because of disagreements about policies (what services the publicly funded home and community care system does and does not provide) and collective agreements (what tasks and responsibilities unionized HSWs are expected to perform). Having fewer health and social services available in communities created the conditions for innovation, as members of the health care team worked together to devise solutions to challenges. Close community ties, both professional and personal, facilitated this. As one manager put it: We’re small and we’re all sort of connected, you know, I work with the manager for acute care and I work with the manager for mental health. So if we’ve got shared clients like that, we can come up with a solution. (Participant D-6, manager)

Some participants enjoyed the broader range of duties that came with working in a rural community setting. As one participant noted, “We do things they don’t do in other areas” (Participant D-3, licensed practical nurse). For example, in one study community the home support system adapted to account for the fact that the local meal delivery service operated only 3 days a week. HSWs working in rural or remote communities must grapple with the challenges and additional costs associated with using their own vehicles to travel to and from these places. HSWs may be required to drive long distances in poor weather conditions to get to clients’ homes. This can result in wear and tear on vehicles. Although they were compensated at a rate of C$0.50 per kilometer driven, the participants felt that this compensation was inadequate. HSWs were not given additional compensation for the wear and tear of their vehicles—a cost to workers who might travel up to 300 kilometers in a given week. Additionally, some study participants reported serving

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clients living on an island only accessible by ferry, at times leaving HSWs stranded on the island overnight due to poor weather or ferry overcrowding. HSWs reported working or traveling through mobile phone “dead zones” where they were unable to use their telephones to call for help (Participant C-7, HSW with 20-years’ experience). One client reportedly joked to a HSW that one needed “a canoe and a rifle” to find his home (Participant C-1, HSW with 6-years’ experience), though this joke was not too far from one home support leader’s description of how difficult it was for the HSWs to find some of their clients’ residences: No city lights. Well, you know, the way we’re instructing some [HSWs] is, you know, “You go down this road and it’s—you’ll see a white mailbox and then you’ll see a gate on your right and the third unmarked driveway on your left after the white gate on the right is the home and it’s a long windy driveway.” And I mean, there are no lights, so it’s really hard to find directions. Often there are no markers, like a house number or whatever. They’re [HSWs] really out there on their own. (Participant C-8, home support leader)

The clients’ homes may be isolated from their neighbors’ homes, and some HSWs reported on-the-job encounters with animals both domestic (guard dogs) and wild (bears, cougars). These conditions underscore the risks inherent in working alone, as well as the importance of equipping HSWs with the right tools and information to do their jobs.

DISCUSSION My findings underscore the importance of attention to context and of developing policies that “attend to rural environmental circumstances” (SimsGould & Martin-Matthews, 2008, p. 51). On a broad level, this requires moving away from a “quick-fix” approach to home care policy (MartinMatthews et al., 2013). On a local level, it requires tailoring HSWs’ recruitment and retention efforts to the unique needs and priorities of each community. The rural context shapes HSWs’ employment decisions and opportunities. Economic boom/bust cycles and patterns of in- and outmigration in communities with resource-based economies will influence the supply of potential HSWs, as will the demographic changes associated with population aging. Access to training and employment opportunities at or near one’s home community will inform HSWs’ decisions to enter into and remain employed in the home support sector. The capacity to enable one’s fellow community members to age in place is an important dimension of the intrinsic rewards of HSW-client relationships. This should be prioritized,

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yet not at the expense of the economic realities of doing this work in communities that may offer fewer employment opportunities. The multifaceted nature of worker-client relationships in smaller communities holds with it the potential for connection and innovation as well as for exploitation and conflict. Participants’ descriptions of working in rural and isolated environments remind us of the physical realities and risks of working outside of urban settings. My study is limited in that includes only the voices of HSWs presently employed in the public health care system (a result of the employerfacilitated recruitment strategy). The absence of the voices of former HSWs is a limitation—there is much to learn from the workers who leave the home support sector. This represents a direction for future research. Future studies should also explore the replicability of innovative models of home support delivery that have been successfully implemented in other rural communities. For example, the team-based home support model that was successfully implemented in the BC communities of Kelowna and Sechelt, which both serve surrounding rural areas (Cohen, Hall, Murphy, & Priest, 2009). This model has several important features which include the implementation of HSW-level team leaders who lead daily HSW meetings, fixed schedules (so that HSWs know exactly when and how many hours they are going to work), cluster care (when feasible, client visits are grouped by geographic area), and employer-provided mobile phones. This model was found to improve HSW recruitment and retention, occupational health and safety, and job satisfaction (Groves, 2008). Ivanova (2009) estimated that provincewide implementation of this model would increase the average costs of home support delivery in BC by 7%, or C$19.3 million. Another model tailored to the needs of rural communities meriting further exploration is the 24-hour flexible in-home support pilot program described by Lum and Aikens (2009). The program was based around the question, “What do you need to stay at home today?” In this model, which was piloted in a small rural community in Ontario, home support clients were eligible for 24-hour emergency response, assistance from HSWs with mobility, bathing, housekeeping, and meal preparation, safety, security and reassurance checks, as well as links to a range of other services and supports (e.g., transportation, recreation, social services). HSWs on the night shift were paired with a community paramedic who provided specialized care to frail clients. These examples point to the importance and innovative potential of accounting for place, and for examining what is unique about home support in rural settings. As Kelly (2003) reminds us, ethical approaches to rural health account for the political, economic, social, geographic, and temporal characteristics of rural places and the lived experiences of the people who make up these communities. Ideally, health human resource policies and programs ought to be tailored to each community’s specific characteristics,

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capacities, and challenges. This may not always be feasible when dealing with system-wide issues, yet the need for a tailored approach ought to be kept in mind, particularly when delivering services outside of urban settings.

ACKNOWLEDGMENTS The author appreciates the support of the Vancouver Island Health Authority, as well as the contributions of Dr. Joy Johnson, Dr. Aleck Ostry, Dr. Pamela A. Ratner, and Dr. Jean Shoveller.

FUNDING This study was funded by the British Columbia Medical Services Foundation (Grant Number BCM07-0156). Dr. Sharman’s work was supported by doctoral awards from the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research.

REFERENCES Allan, D., & Cloutier-Fisher, D. (2006). Health service utilization among older adults in British Columbia: Making sense of geography. Canadian Journal on Aging, 25(2), 219–232. BC Ombudsperson. (2012a). The best of care: Getting it right for seniors in British Columbia (Part 2). Retrieved from http://www.ombudsman.bc.ca/images/pdf/ seniors/Seniors_Report_Overview.pdf BC Ombudsperson. (2012b). Home support backgrounder. Retrieved from http:// www.ombudsman.bc.ca/images/pdf/seniors/Home_Support_Backgrounder_ 2012.pdf Canadian Institute for Health Information. (2006). How healthy are rural Canadians? An assessment of their health status and health determinants. Ottawa, ON, Canada: Author. Castle, N. G. (2008). State differences and facility differences in nursing home staff turnover. Journal of Applied Gerontology, 27(5), 609–630. Cloutier-Fisher, D., & Kobayashi, K. M. (2009). Examining social isolation by gender and geography: Conceptual and operational challenges using population health data in Canada. Gender, Place and Culture, 16(2), 181–199. Cohen, M., Hall, N., Murphy, J., & Priest, A. (2009). Innovations in community care: From pilot project to system change. Vancouver, BC, Canada: Canadian Centre for Policy Alternatives. Dandy, K., & Bollman, R. D. (2008). Seniors in rural Canada. Rural and Small Town Canada Analysis Bulletin, 7(8), 1–56.

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Recruitment and retention of home support workers in rural communities.

This qualitative study examined recruitment and retention of home support workers (HSWs) providing home support in rural communities. Thirty-two parti...
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