Assessment of the occupational exposures within homes for home healthcare workers in the United Kingdom

Abstract

Many of the tasks being conducted by home healthcare workers are associated with significant complex demands. Each home is a unique work environment with potentially different exposures. The purpose of this study was to investigate the plethora of exposures for home healthcare workers in the United Kingdom. The study was a cross-sectional study that utilized a trained supervisor to complete the direct observation of the healthcare worker (nursing aide and nurse). Environmental hazards that were captured included mold/mildew (8.7%) and dogs (14.5%), and secondhand smoking (15.9% with smell in home and 8.7% with active smoking). Verbal abuse was prominent for nurse aides (31% experiencing it). Ergonomic hazards were observed through various tasks such as repositioning in bed (34.8%), transfer from bed to chair (30.4%), transfer from bed to chair (26.1%), and transfer from chair to chair (26.1%) and particularly for nursing aides. The results of the current observations indicated that home healthcare workers faced a multitude of exposures that could lead to injuries. This provides a rigid platform for occupational safety and ergonomics specialists to appreciate the occupational exposures and challenges that home health care workers face in the unique home care environment and proactively identify mitigation measures of the respective occupational hazards.

1. Introduction

The home healthcare sector refers to residential care for adults and the elderly (Ingham, Bamford & Johnes, 2015). In the United Kingdom, the homecare sector plays an important role in the country’s economy (Ingham et al., 2015). In the United Kingdom, the social care industry, which includes home healthcare, was 1.5 million in 2021 and is expected to increase by 29% to around 3.2 million in 2035 (Clarke, 2021). The current estimate of the number of caregivers in-home care in the United Kingdom is about 809,000 people (Berg, 2024). These in-home care workers are employed in 12,500 agencies and serve more than 950,000 clients (Berg, 2024). Thus, the need for in-home caregivers will continue to increase due to the aging population in the United Kingdom.

Home healthcare has been identified among the most hazardous industries in healthcare (Xu, Zhang & Hudson, 2021). According to Suarez, Agbonifo, Hittle, Davis and Freeman (2017) many of the tasks being conducted by home healthcare workers are associated with significant demands including physical demands such as mobility and repositioning activities as well as psychological demands which are attributed to dealing with a complex environment whilst administering medical and life-saving care to patients, and social demands that encompasses dealing with dying and grieving patients (Suarez et al., 2017). Based on previous work (Agbonifo et al., 20178, Chalupka, Markkanen, Galligan & Quinn, 2008, Hittle, Agbonifo, Suarez, Davis & Ballard, 2016, Suarez et al., 2017), home healthcare workers perceived that they are exposed to many of the exposures on a routine basis such as workplace violence, musculoskeletal disorders, automobile accidents, communicable disease transmissions, job stress, sharp injuries, and latex exposure. Many of the tasks being performed by home healthcare workers contain significant physical demands including mobility and repositioning of patients, moving furniture, and carrying medical equipment in and out of (Agbonifo et al. 2018, Hittle et al., 2016, Suarez et al., 2017). Home healthcare workers have an increased risk of injury from the plethora of exposure. According to the Bureau of Labor Statistics (BLS, 2014), the rate of injuries for home healthcare workers in the United States was twice the average for hospital workers and 3 times above the national average.

Home healthcare workers have limited or no control over the environment that they are working in as they go from house to house. Each home is a unique work environment with potentially different exposures such as poor lighting, uncomfortable and cramped workspaces, awkward work positions, cluttered or unclean environments, distractions from others in the home, unfamiliar surroundings, presence of small children and pets, working alone, and potential for violence (Hittle et al., 2016; Markkanen et al., 2007). Some exposures are known health occupational risks such as blood-borne pathogens as well as musculoskeletal disorders (MSDs) whilst others remain unknown hazards including secondhand smoke exposures, pest infestations, chemical exposures, aggressive pets, and motor vehicle crashes (Hittle et al., 2016). Furthermore, homes in the United Kingdom have potentially unique exposures due to the healthcare system and design of the homes such as multi-floors, smaller condensed rooms, and limited ventilation. As such, the objective of the current study was to investigate the exposures of home healthcare workers in the United Kingdom.

2. Methods

2.1. Study overview

This study was a cross-sectional design, that involved utilizing the validated Home Health Care Worker Observation tool (HHCWO) (Bien, Davis, Reutman & Gillespie, 2021). Data were collected between June 2023 and December 2023. The study was reviewed and approved by Loughborough University Ethical Online System (#10,650 issued on 6/16/2022). Participants were observed by a supervisor during their visit to the home of the patient using the HHCWO tool.

2.2. Participants

Sixty-nine home healthcare workers were observed during their visit to the home of a patient. Most (82.6% or 57) were females with an average age of 37.4 years (s.d. = 12.1) with 12 non-responses. Male participants constituted 17% (N = 12) of the study population/participants with an average age of 37.4 years (s.d. = 21.2). The average length of employment in home health care was 7.7 years (s.d. = 8.4). The race breakdown was 33 English (50%), 23 Asian (34.8%), 7 African (10.6%), 2 Pakistani (3%) and 1 Polish (1.5%). About 25% (17) of the participants were Muslim. Almost all were English-speaking (91%). Most of the participants (52 or 75%) were care workers (nursing aides) with the remaining being nurses (14 or 20.3%) with 3 not responding. All participants were in adult care with 39 in general adult care, 8 in mental or disabled care, 9 in acute and disabled care, and 5 in chronic care.

2.3. Observation tool

The observation tool used was developed and validated by Bien et al. (2021)). The Home Health Care Worker Observation tool (HHCWO) was designed to identify exposures for the workers in the homes of patients, including slips/trips/falls, risk factors, sharps, environmental, hand hygiene, egress/ingress, ergonomics, crime, medical procedures, cleaning, and injuries (Bien et al., 2021). Complete details of the specific items assessed can be found in the Bien et al. (2021)). The tool was found to have good reliability and high content validity.

2.4. Procedure

A home health care supervisor accompanied the home health care worker into the home of the patient. The entire time that the home healthcare worker was onsite at the patient’s home was observed. The observation started when the caregiver exited the vehicle and ingress the home and stopped when the caregiver returned to the vehicle. A total of 7 supervisors completed the observations. The completed HHCWO was sent to MF who scanned it digitally and sent it to AD who converted it into the Excel database for analysis. As part of their job, supervisors routinely assess the home health care workers in the homes. MF went over the HHCWO tool before the evaluation which included what and how to complete the form.

2.5. Statistical analysis

Descriptive statistics in frequencies, means, percentages, and standard deviations were computed for the characteristics of interest. Microsoft Excel was the software used for statistical analysis of the data obtained.

3. Results

3.1. Home and neighborhood concerns

Table 1 provides the breakdown of homes and neighborhood settings. This study involved observing home health care workers entering single-family (68.1%) and multi-family (17.4%). These homes were located mostly in suburban (42%) and rural (21.7%) neighborhoods. The patients in these homes were mostly covered by social care (63.7%) and secondary, primary NHS (14.5%).

Table 1.

Characteristics of homes visited by the participants.

Home and neighborhood characteristics	Number and percentage
Type of Neighborhood
Urban	15 (21.7%)
Suburban	29 (42.0%)
Rural	3 (4.3%)
No response	23 (33.3%)
Type of Home
Single-family	47 (68.1%)
Multi-Family	12 (17.4%)
No response	10 (14.5%)
Type of Healthcare Coverage
Social Care	44 (63.7%)
Primary NHS	10 (14.5%)
No Response	15 (21.7%)

3.2. Environmental hazards within the homes

It was observed that HHCWs (care workers and nurses) were exposed to various environmental hazards (Table 2). Mold or mildew and dust were the most observed environmental hazards (8.7% and 7.3%) respectively. Also, some homeowners had pets which are considered potentially allergens and infectious hazards for home health care workers. In this study, dogs were the most observed pets (14.5%) followed by cats (8.7%). Nursing aides encountered dogs more times (6 vs 3) but a lower percentage (11% vs. 21%). These animals could also be trip hazards to the HHCWs.

Table 2.

Number (percentage) of hazards observed for home healthcare providers during home visits.

	Overall (N = 69)	Nursing Aides (N = 52)	Nurses (N = 14)
Environmental Hazards
Mold/Mildew	6 (8.7%)	4 (7.7%)	1 (7.1%)
Dust	5 (7.3%)	2 (3.8%)	1 (7.1%)
Dog	10 (14.5%)	6 (11.5%)	3 (21.4%)
Cat	6 (8.7%)	4 (7.7%)	1 (7.1%)
Tobacco Smoke
Smell in Home	11 (15.9%)	7 (13.5%)	3 (31.4%)
Active Smoking	6 (8.7%)	5 (9.6%)	0 (0.%)
Smoking Allowed but Not Active	1 (1.5%)	0 (0.0%)	1 (7.1%)
Smoking Outside Home	1 (1.5%)	0 (0.0%)	1 (7.1%)
Hand Hygiene
Availability of Clean Water	68 (98.6%)	52 (100.0%)	13 (92.9%)
Hand Sanitizer	11 (15.9%)	8 (15.4%)	14 (100.0%)
Wash Hands with Soap and Water	28 (40.6%)	16 (30.8%)	9 (64.3%)
Community Surveillance
Unrestrained Animals	1 (1.5%)	0 (0.0%)	1 (7.1%)
No Safe Place to Park	4 (5.8%)	4 (7.7%)	0 (0.0%)
Clear Walking Path to Patients’ Home	11 (16.0%)	3 (5.8%)	8 (57.1%)
Safety Factors
Patient Confusion	1 (1.5%)	0 (0.0%)	1 (7.1%)
Alcohol Intoxication	2 (3.0%)	2 (3.8%)	0 (0.0%)
Drugs	0 (0.0%)	0 (0.0%)	0 (0.0%)
Verbal Abuse
Remarks about Employee Race or Ethnicity	1 (1.4%)	1 (1.9%)	0 (0.0%)
Yelling or Shouting at Employee	16 (23.2%)	16 (30.8%)	0 (0.0%)
Other Verbal Abuse	11 (15.9%)	11 (21.2%)	0 (0.0%)
Acts of Violence
Verbal Threats to Harm Employee	1 (1.5%)	1 (1.9%)	0 (0.0%)
Throwing Objects at the Worker	4 (5.8%)	4 (7.7%)	0 (0.0%)
Involved in Violence
Pets	1 (1.5%)	1 (1.9%)	0 (0.0%)
Family Member	6 (8.7%)	4 (7.7%)	2 (14.3%)
Patient	7 (10.1%)	4 (7.7%)	3 (21.4%)

Note: Total HHCWs include nurses, nursing aides, and no response (undeclared).

Tobacco smell (15.9%) was another environmental exposure that participants were exposed to in their homes. Observed homes with active smokers were about 9%, posing a direct hazard to the HHCWS through second-hand smoke exposure. No nurses were directly exposed with 5 nursing aides exposed. No sharps were reported to be used by the study participants during the home visits and observations.

3.3. Hand hygiene

Hand hygiene is a basic principle to prevent the transmission of germs amongst healthcare workers and patients and includes the use of hand sanitizer or soap and water. Almost everyone (98.6%) had access to clean and safe water (all the nursing aides and all but 1 nurse) but only 40.6% of the HHCWs reported washing their hands with soap and water before and after attending to patients (Table 2). Nursing aides utilized soap and water at a much lower rate than nurses (31% vs 64%).

3.4. Community surveillance and safety factors

Only one unrestrained animal was encountered (by a nurse) (Table 2). Four of the nursing aides (7.7%) were faced with unsafe parking. Few nursing aides were reported to have a clear walking path (6%) while many nurses had a clear path (57%).

3.5. Workplace violence

Being screamed at was observed in 16 (31%) of the nursing aides while no nurses experienced any verbal abuse (Table 2). Acts of violence also occurred toward nursing aides with actual verbal threats to one (2%) and four having objects thrown at them (7.7%). Both patients and family members were involved in initiating the violence toward the caregivers.

3.6. Patient handling tasks

A summary of the patient handling activities is in Table 3. Repositioning of the patient was the most prevalent patient-handling task (35% of visits) with nursing aides being involved in most of them (83%). There were many observed transfer tasks including transfer between chairs (26%), transfer from bed to chair (26%), and transfer from bed to wheelchair (17%). Two nursing aides had to assist patients from the floor to bed, indicating a potential fall of the patient. Nursing aides routinely changed the bedding (23%) and clothing of patients (17%) with nurses rarely doing either (less than 14%). Only nursing aides moved furniture (5 or 9.5%) while nurses were found to move medical equipment more (6 or 43%). Lifting hoists were only used 13 times (19%) and predominantly by nursing aides (12 of 13, 92%). A slip sheet or slide board was used 7 times (10.1%), all being nursing aides using them.

Table 3.

Number (percentage) of hazards observed ergonomic hazards for home healthcare providers during home visits.

Tasks	Overall (N = 69)	Nursing Aides (N = 52)	Nurses (N = 14)
Reposition in bed	24 (34.8%)	20 (38.5%)	2 (14.3%)
Transfer from chair to chair	18 (26.1%)	15 (28.9%)	3 (21.4%)
Transfer off bed/ back to bed	5 (7.25%)	4 (7.7%)	1 (7.1%)
Transfer from bed to chair	18 (26.1%)	18 (34.6%)	0 (0.0%)
Transfer chair to bed	11 (15.9%)	10 (19.2%)	0 (0.0%)
Transfer bed to a wheelchair	12 (17.4%)	10 (19.2%)	2 (14.3%)
Transfer wheelchair to bed	6 (8.7%)	4 (7.7%)	2 (14.3%)
Transfer bed to the bathroom	3 (4.4%)	2 (3.9%)	0 (0.0%)
Lift from floor to bed	2 (2.9%)	2 (3.9%)	0 (0.0%)
Transfer to/from the toilet	3 (4.4%)	3 (5.8%)	0 (0.0%)
Change bedding	17 (24.6%)	12 (23.1%)	2 (14;3%)
Change Clothes	10 (14.5%)	9 (17.3%)	1 (7.1%)
Move Furniture	6 (8.7%)	5 (9.6%)	0 (0.0%)
Move Medical Equipment	10 (14.5%)	4 (7.7%)	6 (42.9%)
Use of Lift Hoist	13 (18.8%)	12 (23.2%)	1 (7.1%)
Use of a Slip Sheet or Slide Board	7 (10.1%)	7 (13.5%)	0 (0.0%)

Note: Total HHCWs include nurses, nursing aides, and no response (undeclared).

4. Discussion

Recent research underscores the significant injury risk HHCWs face (Bien et al., 2021; Hittle et al., 2016). The current study has identified the most frequently performed activities by HHCWs in the United Kingdom. The demographic breakdown of the home healthcare workforce in the UK is like those in the United States with the majority being females and minorities (U.S. Bureau of Labor Statistics, 2020). The study also found that the demographic profile mostly HHCWs were female (83%).

The ergonomic injuries in HHCWs more frequently reported in other studies are back, neck, and shoulder injuries (Singleton et al., 2015, Davis & Kotowski, 2015). Analysis of workers’ compensation claims rates by injury event found that work-related musculoskeletal disorders (WMSDs) had the highest rates, followed by falls from the same level in HHCWs (Howard, Adams, Marcum & Cole, 2022; Kotowski & Davis, 2021). Overexertion while performing daily tasks has been a common cause of these injuries (Galinsky, Waters & Malit, 2001). Only a single individual reported a musculoskeletal injury during the observation in the current study, However, our study identified that repositioning a patient in bed and transporting clients to a chair or wheelchair were the most frequently performed tasks. Furthermore, nurse aides were mostly involved in the tasks of handling clients as compared to nurses. This study was able to show that nurse aides were more exposed to physical tasks including changing bedding and clothing as well as moving furniture. These findings align with Hittle et al. (2016)) who found nursing aides in the United States handled patients and furniture more than nurses.

Patients may be overweight, weak, and uncooperative, increasing the loads on the lower back and overall biomechanical stress (Choi & Brings, 2016). The United Kingdom has policies and regulations that ensure caregivers who need to lift patients are provided lifts to do it safely, under the Manual Handling Operations Regulations 1992 (HSE, 1992). Unfortunately, the current study as well as others (Holtermann et al., 2015; Koppelaar, Knibbe, Miedema & Burdorf, 2012) have shown the presence of lifting devices does not necessarily translate into actual usage. Thus, handling of patients by home healthcare workers poses a significant risk for low back injuries in the United Kingdom.

Slips, trips, and falls have been captured in previous studies both within and outside the home care in the United States (Hittle et al., 2016, Bien et al., 2021). However, in our study of home care in the U.K., no actual events of slips, trips, and falls were reported.

Verbal abuse from patients or their families was reported by 23% of HHCWs, signifying a prominent stressor. The results were able to show that nurse aides experience more verbal abuse (yelling or shouting at employees) as compared to nurses. Nurse aides also experienced more other forms of verbal abuse. These findings in terms of workplace violence agree with other studies that have ascertained that non-physical aggression or verbal abuse remains the dominant form of workplace violence experienced by home healthcare workers (Small, Gillespie, Hutton, Davis & Smith, 2023, 2022).

The number of visits with exposure to second-hand smoke was around 16% for HHCWs. The exposure to second-hand smoke highlights another significant challenge, potentially exacerbated by HHCWs’ reluctance to ask patients to refrain from smoking during visits. In the United States, second-hand smoke was potentially more prevalent (approximately 46 min for nurses and 15 min for nursing aides (Hittle et al., 2016).

In this study, 99% of the study participants acknowledged the presence of cleaning water in the homes. Further, 41% of the study participants responded to be compliant with washing their hands using soap and water. Hand hygiene remains the easiest way to prevent the spread of diseases in healthcare). Therefore, regular training about proper hand hygiene as well as the usage of client sinks or hand sanitizer will ensure infection control and disease control.

Another interesting finding of the study was the lack of certain hazards and exposures such as visible weapons, interactions with needles, completion of medical procedures, and use of personal protective equipment. It is extremely rare to have a weapon in the United Kingdom given the gun control laws, which are significantly different than seen in the United States. The lack of medical procedures and the use of needles may be more reflective of the limited number of nurses in the study. Limited resources may have resulted in the lack of use of personal protective equipment.

There are a few limitations that need to be considered when interpreting the results. First, the supervisors conducted the assessments, which meant there could be some variation in the observations and what was recorded among the multiple observers. The research team did provide a training video before the assessments and the supervisors regularly conducted evaluations of the HHCWs. Second, a total of 65 surveys were collected but could be considered a relatively small number of observations, particularly concerning the nurse and nursing aide breakdown. However, the observations provide insight into the types of exposures that HHCWs commonly face in the different homes during their shifts. The observations were predominantly for clients in adult care, with only a few in hospice or pediatrics. Future observations should expand to a more robust clientele. In addition, the assessment period was concentrated in the summer and early fall, potentially limiting some of the environmental conditions.

5. Conclusion

HHCWs are exposed to several occupational exposures in the unique environment of the homes in which they work. This study was able to capture a good number of occupational hazards that HHCWs are exposed to daily including biological hazards, ergonomic hazards, workplace violence particularly verbal abuse, and other physical hazards. Many of the results were like those captured in the United States such as routine patient handling activities with limited lift assist devices, verbal workplace violence happens often, and exposure to secondhand smoke. Future studies should continue to explore the exposures for all healthcare workers beyond nurses and nursing aides.