Occupational stress in marginalized care workers and the implications for societal health

As more adults prefer to remain in their homes as they age, the demand for home care aides is projected to grow by more than 30% over the next decade, making it one of the fastest growing occupations in the United States. Despite the demand, low wages and challenging working conditions historically have made it difficult to attract and retain these essential workers, a dynamic made worse by the COVID-19 pandemic.

CUNY SPH Associate Professor Emma Tsui and colleagues have conducted a series of studies over the last two years to further understand occupational stress, particularly around patient death, among home health aides and its impact on worker well-being and employee retention, resulting in five recently published articles.

"It is well known that home health aides often form strong relationships with their patients, which benefits patient care," Professor Tsui says. "We found that aides often play a significant role in the end of a patient's life, providing both practical and existential support, but often without being adequately informed about their patient's health status or robustly trained for the emotional labor the end of life requires."

The team's research suggests that improved aide training on end-of-life issues, supervisor training for supporting aides, and dedicated paid time off following client death could meaningfully shift aides' work stress related to client death. Without significant training or more formal employer-based support, aides cope with the grief of losing their patients—and related job insecurity—by relying on their personal networks or an informal mix of employer and community-based support.

"Agencies who employ home health aides recognize the need to support aides, but face challenges in operationalizing this support," explains Tsui. "We studied one promising intervention in the form of group support calls at a NYC agency that arose during the COVID-19 pandemic, but considering the current limitations of agency support and that aides often are from already burdened communities, our research reveals the importance of extensive policy and community-based support solutions alongside job-based support."

The resulting published work includes: "Expanding the Conceptualization of Support in Low-Wage Carework: The Case of Home Care Aides and Client Death" published December 2021 in International Journal of Environmental Research and Public Health, Supplement: Work, Health, and Equity; "We want to hear your problems and fix them: A Case Study of Pandemic Support Calls for Home Health Aides" published February 2022 in Home Care Services Quarterly; and "Awareness, Acceptance, Avoidance: Home Care Aides' Approaches to Death and End-of-Life Care" published March 2022 in OMEGA—Journal of Death and Dying.

Furthering the impact of this work, Professor Tsui and her collaborators published both a recent commentary in New Solutions calling for a new model for societal health that recognizes care-workers of all kinds and an invited editorial in the American Journal of Public Health highlighting important directions for public health research on worker well being.

"Home care aides—whose work has historically had so little visibility—are critical to societal health at large," says Sherry Baron, an affiliated CUNY SPH faculty member, Professor at Queens College, and mentor to the project. "This breadth of research underscores the urgent need to reevaluate the sustainability of our current systems of care, reimagine care systems, and support the essential labor of home care aides."