Unveiling the Strains: A Qualitative Study on Work Stress among Health Care Aides in Assisted Living Facilities

Introduction

One of the most important roles in providing care to older people in different settings is played by health care aides (HCAs), who work on the frontlines [1]. HCAs are also a more affordable option for the health care industry, which faces a shortage of skilled professionals [1]. However, finding and keeping qualified HCAs is a challenge, especially in the eldercare sector. Alberta is facing a health care worker shortage, especially for HCAs, who provide essential care to older people in different settings. The province has allocated $158 million in 2022 to address this issue and support the recruitment and retention of HCAs and other front-line staff [2]. This affects the residents of assisted living facilities (ALFs), who are very dependent on HCAs for their care because of their age and health conditions [3]. HCAs are the main and largest group of providers in ALFs, and they have to deal with a lot of stress as they interact with residents and meet their various needs. The aim of this research was to describe, understand, and examine the work stress that HCAs experience in ALFs.

Background

The world is witnessing a remarkable demographic transition, as people are living longer and healthier lives than ever before. The share of older people in the global population is increasing rapidly, especially in low- and middle-income countries. This trend reflects the success of improved sanitation, nutrition, medicine, and medical technology, as well as lower fertility rates, in enhancing human well-being across the world [4]. However, it also poses significant challenges for health and social systems in different countries. Canada is no exception to this global phenomenon. The country’s population is both growing and aging, as the first cohort of baby boomers turned 65 in 2011 [5]. The number of Canadians aged 65 and above in Alberta has more than tripled since 1974, reaching 385,241 in 2009 [6]. This growing segment of the population has implications for healthcare delivery and quality in ALFs and home care centers [7]. Moreover, the healthcare system and caregiving institutions face exceptional difficulties in meeting the rising expectations and the persistent shortage of healthcare professionals available to serve the elderly [3].

As people age, they often need more assistance with their daily activities. Some older adults also develop age-related conditions such as Parkinson’s disease and Alzheimer’s disease, which affect their functioning and independence [8]. With the growing number of older Canadians, especially in low- and middle-income countries [4], there is a rising demand for organized ALFs that can provide care, observation, and a home-like environment for this population [9]. ALFs are not the same as nursing homes, which provide more intensive medical care and supervision for older adults who need it. ALFs are designed for people who need some assistance with daily activities, such as bathing, dressing, eating, or taking medications, but who can still live independently in a safe environment [10]. ALFs may offer different levels of care depending on the needs and preferences of the residents, as well as the regulations of the state where they are located [11]. ALFs may also include settings such as personal care homes, residential care facilities, lodges, supportive housing, or congregate housing [11]. However, these terms are not interchangeable and may have different meanings in different states or countries. Therefore, it is important to research the specific services and standards of each facility before choosing one.

HCAs are essential in providing support and care to older adults living in ALFs. They are a key part of the continuing care sector in Alberta and other provinces in Canada. HCAs face immense pressure as they interact with residents, attend to their various needs and demands, and balance the expectations of management, staff members, and families. These competing demands add more responsibility and accountability to the role of HCAs.

Work stress is a common and serious problem that affects many aspects of life, especially for health care workers who face high demands and challenges in their daily interactions with patients and families. The World Health Organization (WHO) has declared work stress as a global epidemic, affecting individuals across different professions and regions [12]. Work stress can lead to various negative outcomes, such as reduced performance, increased absenteeism, turnover, burnout, and mental illness [12, 13, 14]. These outcomes can have substantial costs for both individuals and health systems [14]. Despite the importance of this issue, there is a lack of research on the specific experience of work stress among HCAs, who are a large and essential group of health care workers that provide direct care to elderly residents in ALFs [12]. There is limited documentation and understanding of the sources, manifestations, and consequences of work stress for HCAs in this setting [12]. Therefore, the question remains: What is the actual experience of work stress for HCAs? This study aims to investigate, explore, and gain a comprehensive understanding of the contemporary work stress experienced by HCAs in ALFs.

Methods

The purpose of employing a descriptive, exploratory, qualitative design is to gain a comprehensive understanding of a phenomenon that has not been extensively studied or requires further investigation. Descriptive, qualitative approaches involve a combination of sampling, data collection, analysis, and re-presentation methods [22]. The research questions in this type of design primarily focus on providing a detailed description of the phenomenon, with a particular emphasis on the “How and Who” aspects [22]. On the other hand, exploratory research questions are broader in nature and aim to explore areas that are not well understood, seeking answers to the “What and Why” questions [22].

A qualitative research design was adopted, utilizing purposive sampling followed by snowball sampling to recruit participants. The inclusion criteria ensured a focus on HCAs with significant experience in ALFs. A total of 14 HCAs from three ALFs were interviewed, with data collection continuing until data saturation was achieved. The interviews were conducted using a semi-structured approach to explore the participants’ experiences of work stress.

This study aimed to investigate the experience of work stress among HCAs in ALFs in two Southern Alberta communities. A purposive sampling technique followed by snowball sampling was employed to select 14 HCAs who had encountered work stress in their employment settings. Data collection ceased upon reaching data saturation, ensuring that no new insights were obtained. The inclusion criteria mandated that participants were currently employed as HCAs providing comprehensive care to ALF residents, proficient in assisting with activities of daily living, employed at the facility for at least twelve months, and English- speaking. The sample was derived from three sites of a Christian hospital-based, not-for-profit organization serving over 6,000 residents across Canada, encompassing a range of living suites, dementia care cottages, and geriatric mental health care beds.

Results

The demographic characteristics of the research participants provide significant insights into their age, experience, gender, and education. The study included a total of 14 participants, comprising two male HCAs and 12 female HCAs. Female participants exhibited an age range of 20 to 49 years, with an average age of 33 years, while male participants ranged in age from 36 to 38 years, with an average age of 37 years. Each participant had accumulated HCA experience ranging from 2 to 17 years. Most participants were Canadian born, with only two exceptions. Out of the 14 participants, ten held an HCA certificate from Canada, primarily obtained in Alberta. Additionally, one participant obtained their certificate in Ontario, and another in Saskatchewan. Moreover, two participants were nursing students, and two others had gained their nursing experience and education outside of Canada.

There was no standardized ratio across the three facilities. The average staff-resident ratio varied depending on factors such as floor, shift, and location. On the regular floor, the morning shift had an average ratio of one staff member to eight residents, while the evening shift had an average ratio of one staff member to 17 residents. Conversely, in the secure dementia care units known as cottages, the average morning ratio was one staff member to six residents, and the night shift had an average ratio of one staff member to 12 residents [12].

The thematic analysis of the qualitative interview data in this study was guided by established theories, namely, (a) the transactional model of stress and coping [23], and (b) the job demands-resources (JD-R) model [24]. These theoretical frameworks were employed to gain insights into the participants’ perspectives and experiences concerning work stress. To ensure participant confidentiality, pseudonyms were used throughout the study.

The research yielded five main themes, which provide valuable insights into the participants’ experiences. These themes are:

Theme 1: The Meaning of Work Stress: Participants discussed their understanding and interpretation of work stress. They shared their perceptions of the factors that contribute to stress in their work environment and how it manifests in their daily lives.

Two subthemes were identified: Identifying work stress and dissatisfaction. When asked to define work stress, participants faced difficulties in articulating their understanding of the concept. Two participants specifically struggled with the definition due to English not being their first language. However, most participants provided definitions of work stress from physical, psychological, and emotional perspectives, and they associated it with the experiences of staff, residents, and the work environment. The following quotes exemplify the participants’ descriptions of work stress: Jill described work stress as feeling physically and mentally drained, overwhelmed with emotions, and experiencing frustration and exhaustion. She also mentioned experiencing muscle tension in her shoulders and neck, illustrating the physical manifestations of stress.

Kat, on the other hand, discussed two types of stress: good stress and bad stress. She acknowledged that while good stress exists, bad stress tends to overpower it, making it challenging to leave work stress behind when returning home. She emphasized the time it takes for her body to relax and referred to the symptomatic nature of work stress as her body’s response to it.

Dissatisfaction emerged as a prevalent sentiment among the participants in their work as HCAs. Over one-third of the participants expressed discontentment with their job. Joyce and Judy specifically discussed the factors contributing to their dissatisfaction, highlighting the role of co-workers and education. Joyce expressed her lack of satisfaction, citing frustrations related to working with certain staff members and feeling voiceless as a healthcare aide. She also mentioned that dealing with residents could be challenging and sometimes lead to irritability.

These remarks shed light on the sources of dissatisfaction experienced by the participants, emphasizing the importance of interpersonal dynamics with colleagues and the impact it has on their overall job satisfaction. Additionally, Joyce’s mention of having limited influence as a healthcare aide suggests a potential frustration with the level of autonomy and decision-making power in their role.

Overall, the participant’s expressions of dissatisfaction underscore the need for addressing concerns related to work environment, interpersonal relationships, and professional development opportunities to enhance job satisfaction and overall well-being among HCAs. These responses and others highlight the multifaceted nature of work stress, encompassing both physical and psychological aspects. Participants emphasized the impact of stress on their overall well-being and the difficulty in separating work stress from their personal lives.

Theme 2: Genesis of Work Stress

Genesis of Work Stress: This theme explores the origins and triggers of work stress. Participants reflected on the specific job demands, organizational factors, and personal circumstances that contribute to their stress levels. They discussed the various stressors they encounter in their roles as HCAs.

This second main theme explores the sources and origins of work stress from the perspectives of HCAs. It is further divided into two sub-themes: (a) behaviors, attitudes, and situations; and (b) challenging work environment. Behaviors, Attitudes, and Situations, under this sub-theme, the participants identified three categories that contribute to work stress: (a) residents and families, (b) leadership stressors, and (c) other co-workers. Residents and families’ attitudes, behaviors, and situations were repeatedly mentioned by 13 participants as a significant source of work stress. Participants shared their challenges in dealing with residents, including coping with the fluctuating moods of residents, constant demands and calls for assistance, and accommodating individual preferences. Alayna described the stress she experienced when attending to a particular resident’s needs, where the tasks took longer than anticipated, resulting in a sense of time pressure and stress.

Furthermore, the participants highlighted instances of residents displaying aggressive or violent behavior towards others. Ten participants specifically mentioned violence from residents as a significant stressor. The types of violence identified included physical, verbal, and sexual aggression. It was acknowledged that these behaviors often stemmed from disease progression, misunderstandings, or communication breakdowns. More than half of the participants reported experiencing physical violence, such as scratching, pushing, throwing objects, grabbing, biting, and slapping from residents. These accounts highlight the significant impact of residents’ behaviors, attitudes, and situations on the work stress levels of HCAs. Challenges arise from managing various demands, accommodating preferences, and addressing violent or aggressive behaviors, which can contribute to heightened stress and a challenging work environment.

Verbal violence from residents was a shared experience among all participants, who considered it a regular part of their daily routine as HCAs. Verbal aggression encompassed behaviors such as yelling, screaming, degrading remarks, constant calling, and racial comments. Despite recognizing that these behaviors were a result of disease progression, HCAs still experienced significant stress. Kat expressed her thoughts on the matter, highlighting the impact of residents’ verbal aggression: “When you have residents yelling at you and degrading you, being verbally aggressive, it definitely triggers a reaction, but you can’t respond. If this behavior persists, it can cause stress because you want to avoid it. You don’t want to have to take care of them, but you have to. The things they say can be very personal and hurtful.” Furthermore, sexual violence was reported by six participants, all of whom were female. They shared experiences of inappropriate sexual behavior from residents. Mary recounted a sexually violent incident she had encountered: “[Name of one resident] would always try to hug you or touch your butt; he’s touched my butt many times. I tell him, ‘You can’t be doing this; you’re a grown man, and you have your life. That’s something that you don’t want to deal with. It’s uncomfortable.’ And then [name of one resident] ... I walked in at night because I wasn’t sure if we were supposed to check on him. It was like his first night here, and he was sitting on the toilet, and I said, ‘Did you need anything?’ And he’s like, ‘Oh no, I’m just sitting here masturbating.’ And he was telling me all about how his wife cut him off 20 years ago and so on. It was just really, really uncomfortable.” The participants expressed a range of emotions when confronted with violence from residents. Some described feeling uncomfortable, scared, or disrespected and degraded. Simultaneously, others demonstrated empathy towards the residents, understanding that their health conditions led to inappropriate behavior directed at others. Several participants mentioned that their self-esteem was negatively affected by the way they were treated, while others expressed concerns about potentially reacting inappropriately and losing their jobs if they were to retaliate. These accounts highlight the distressing experiences HCAs face when encountering verbal and sexual violence from residents. The emotional toll, as well as the internal struggle to maintain professionalism and prevent physical altercations, further contribute to the genesis of work stress in the HCA role.

Leadership stressors, encompassing interactions with Licensed Practical Nurses (LPNs) and managers, were consistently reported by all participants as significant sources of work stress. These stressors can be categorized into two sub-themes: direct supervisor stressors (LPNs) and manager stressors (unapproachable management).

Participants expressed dissatisfaction with LPNs’ behaviors and attitudes, perceiving a lack of control, limited involvement in decision-making, aversive behavior, specific leadership styles, lack of support, and absence of respect. Chloe shared her experience with an LPN who exhibited abrasive and rude behavior towards HCAs, which created a tense working relationship. Sue highlighted the need for mutual respect and collaboration between LPNs and HCAs, emphasizing the importance of recognizing the valuable contributions of all staff members. Additionally, some participants felt that LPNs were less helpful and incompetent, failing to provide adequate assistance or administer necessary medications when needed.

In terms of manager stressors, participants discussed behaviors, attitudes, and the resulting stressful situations associated with managers. They identified unapproachable management, poor relationships with managers, communication issues, and leadership styles as sources of work stress. Jill described her encounters with an unapproachable manager on her first day of work, highlighting the lack of friendliness and care displayed by the management team.

Furthermore, participants expressed frustration with a lack of support, lack of respect, and a disregard for their well- being by managers. This included managers not listening to HCAs’ ideas and suggestions and a general atmosphere of disrespect and unfairness. Kat shared her experience of feeling disrespected and unfairly treated by her manager.

These accounts demonstrate that both LPNs and managers contribute to work stress experienced by HCAs through their behaviors, attitudes, leadership styles, and lack of support. The strained relationships and negative interactions within the hierarchical structure of the healthcare team significantly impact the well-being and job satisfaction of HCAs.

Linda’s statement highlights a significant gap between staff and management, characterized by management’s unapproachability. The inconsistency in management’s behavior and attitudes, as described by Linda, creates a sense of uncertainty and difficulty in interacting with them.

Participants expressed the need to catch their managers at the right moment to have a productive conversation.

Participants also shared their feelings and emotions resulting from negative experiences with management. Five participants mentioned feeling afraid and scared of management, highlighting a sense of unease and anxiety when dealing with them. Alayna described her fear of management and the constant anticipation of something being wrong or a new directive being issued, which adds to her stress. She also expressed discontent with certain management decisions, such as the restriction on having coffee breaks at the nursing station.

Moreover, several participants discussed the lack of respect, appreciation, and recognition from management. Joe expressed frustration about working hard and not receiving acknowledgment for his efforts, feeling like he is putting in a lot of effort to make management look good while not receiving proper credit. This lack of appreciation and recognition contributes to feelings of stress and demotivation among HCAs.

However, it is important to note that two participants mentioned feeling appreciated and recognized by management, suggesting that not all participants had negative experiences with management. Mary specifically mentioned that she felt valued and supported by her manager, highlighting that positive relationships with management can mitigate work stress.

Overall, the lack of support, respect, and fairness from management, along with their unapproachability and inconsistent behaviors, contribute to work stress for HCAs. Addressing these leadership stressors and improving communication, recognition, and support from management can help alleviate workplace stress and enhance the overall well-being of HCAs.

Participants identified their co-workers as a significant source of work stress. They frequently mentioned negative attitudes and behaviors of co-workers, such as offensive remarks, degrading treatment, emotional abuse, bullying, and mobbing. These behaviors created a hostile work environment and added to the stress experienced by participants. Jordan shared an example of a co-worker confronting a casual staff member about the cost of a piece of toast, highlighting the stress caused by such interactions.

Incompetence among co-workers and poor work relationships were also mentioned as sources of stress. Participants expressed frustration when their co-workers did not fulfill their job responsibilities properly, leading to a sense of inefficiency and resentment. Lack of teamwork, communication issues, and co-workers refusing to collaborate further exacerbated the work stress. Iliana described the stress of working alone and feeling unsupported when co- workers were unwilling to help, creating a challenging and tense work environment. More than half of the participants reported that working with unqualified and incompetent casual co-workers was the most stressful aspect of their job. Instances of casual staff neglecting their duties or failing to provide proper care were cited as examples. Lena expressed her concerns about the younger generation of co-workers being inexperienced, making mistakes, and prioritizing personal gain over quality care. Participants also mentioned the negative impact of inadequate training or being trained by unqualified individuals, which contributed to the presence of incompetent staff.

These negative experiences with co-workers resulted in fear, anxiety, and animosity among participants. They felt worried and apprehensive about working with certain individuals and experienced ongoing stress as a result. The fear of potential consequences and the burden of responsibility added to their work stress. Casual workers specifically highlighted the challenges associated with their employment status. They felt excluded from important information and documentation, which affected their ability to perform their duties effectively. The stigma attached to being a casual worker and the pressure to adapt to different care styles also contributed to their stress levels. Overall, participants identified co-workers’ behaviors, attitudes, disrespect, and incompetence as significant sources of work stress. Addressing these issues through better communication, teamwork, training, and creating a supportive work environment can help alleviate stress and improve the overall well-being of the healthcare team.

Theme 3: The Impact of Stress on Workers’ Lives: Participants highlighted the effects and changes that work stress has on their lives. They shared personal anecdotes and experiences related to physical, emotional, and psychological well-being, as well as its impact on their relationships and overall quality of life.

The participants in the study identified a third subtheme related to the effects of stress on their lives. Within this theme, three subthemes emerged: (a) physical exhaustion, (b) mental and emotional strain, and (c) effects on personal and professional life.

1. Physical exhaustion: Over two-thirds of the participants reported experiencing physical symptoms because of frequent exposure to workplace stress. These included body pain (such as back, neck, shoulder, and foot pain), muscle aches, physical fatigue, indigestion, weight gain, and high blood pressure. Participants shared their experiences, highlighting the physical toll stress took on their bodies.
2. Mental and emotional strain: Participants described the mental and emotional challenges they faced due to stress. They expressed feeling mentally drained and emotionally exhausted. Stress manifested differently for each individual, but common effects included exhaustion, body pain, and injuries. Some participants even resorted to regular massages to manage their stress levels. The demanding nature of the job and constant disappointment contributed to their overall sense of physical and emotional strain.
3. Effects on personal and professional life: Participants discussed how stress affected various aspects of their lives.

Back pain and shoulder pain were particularly prevalent among participants, given the physically demanding nature of their work. Some mentioned weight gain and changes in their activity patterns, such as becoming less active and even resuming unhealthy habits like smoking. The physically demanding tasks involved in their roles, such as lifting, bending, grabbing, and pulling, contributed to their physical strain and injuries.

In conclusion, the participants recognized the physically draining and demanding nature of their job as a significant source of stress. This stress had detrimental effects on both their physical and mental well-being, as well as their personal and professional lives.

• Mental and Emotional Impact of Work stress: Participants in the study discussed the psychological and emotional consequences they experienced due to work stress, highlighting its effects on their psychological well-being. Several effects were identified, including emotional exhaustion, depression, anger, anxiety, restlessness, and changes in mental sharpness, sadness, unhappiness, sleep disturbances, and irritability. The participants shared their personal experiences of these consequences during and after stressful situations.

The participants described how work stress took a toll on their mental health, leading to emotional breakdowns and intense anxiety. One participant mentioned being brought to tears at home due to excessive stress caused by a sudden change in work conditions. Another participant emphasized that persistent stress could transition from a mental strain to a physical one, necessitating proactive measures for resolution.

Sleep disturbances were a common issue reported by participants, including difficulty falling asleep, insomnia, nightmares and excessive sleeping. Irregular sleep patterns disrupted their daily routines and further exacerbated their stress levels. These mental and emotional consequences highlighted the challenging nature of being a HCA in ALFs.

The theme also addressed how work stress affected both personal and professional aspects of the participants’ lives. The personal consequences included withdrawal from social life, increased irritability, and shouting, which strained their relationships and affected their ability to lead a normal life. Participants mentioned how their stress would often be directed towards their partners or family members. Additionally, participants admitted that work stress heavily impacted their personal lives, leaving them drained and unable to engage with their loved ones.

In terms of professional consequences, participants expressed concerns about the quality of resident care and their own performance. The stress they experienced interfered with their ability to focus on providing proper care, leading to mistakes and a diminished level of care. This further added to their stress and created a cycle of negative effects.

Overall, work stress had significant mental, emotional, personal, and professional ramifications for the participants, affecting their overall well-being and work productivity.

Theme 4: Coping Strategies for HCAs: This theme focuses on the coping mechanisms employed by HCAs to manage work stress. Participants shared their individual strategies, such as seeking social support, engaging in self-care activities, and utilizing resources within and outside the workplace.

The fourth theme regarding how HCAs cope with work stress reveals various coping mechanisms employed by the participants. Three subthemes emerged from this theme: venting and social support, chill out, and stress courses.

Venting and social support were identified as important coping strategies utilized by the participants. They described the act of talking about their stressors and sharing their feelings and opinions with trusted individuals. Seeking social support from co-workers, family members, friends, and even LPNs and management was deemed crucial in alleviating the negative effects of stress and fostering healthy work relationships. Participants believed that venting and receiving others’ opinions helped them process their stress and make decisions. Some participants also emphasized the importance of seeking social support from their spouses or partners. They found it helpful to discuss their work stress with their significant others, as it provided them with additional perspectives and ideas.

The second subtheme, chill out, involved participants engaging in activities that helped them get away from the stressful situation and relax. They described various methods such as taking short breaks, engaging in hobbies like reading or writing, participating in family activities, taking baths, getting massages, or watching movies. Some participants also mentioned the positive effects of exercise, such as walking, running, or playing sports like baseball, soccer, or tennis. Engaging in these activities allowed them to unwind and reduce work stress. However, it should be noted that one participant mentioned using sex to divert their attention from stressful situations, while another participant reported resorting to substance use, such as alcohol, tobacco, marijuana, or specific drugs like Percocet and Ativan, to cope with stress.

The third subtheme, stress courses, highlighted the participants’ lack of access to training or courses specifically focused on workplace stress or stress management at their workplaces. Although some participants received basic training on stress management during their PCA (Personal Care Assistant) course or at colleges, they expressed a desire for such courses to be provided at their workplace. Participants believed that attending courses or lectures on work stress would be beneficial in identifying stressors, learning coping mechanisms, and sharing experiences with others. They viewed these courses to prepare for the challenges of the workplace environment.

In conclusion, HCAs employed a variety of coping mechanisms to deal with work stress. Venting and seeking social support, engaging in relaxing activities, and expressing a desire for stress management courses were common strategies used by the participants to address their stress levels and mitigate the negative effects of their work-related experiences.

Theme 5: Training: During the interview, participants were asked about their participation in specific programs or training for their role as HCAs, revealing a diverse range of responses. Six participants completed a training program lasting three to six months, while three participants underwent a more extensive program lasting six months to one year. Among the remaining five participants, two were international Registered Nurses (RNs), and three were nursing students. Notably, seven participants received their training in Alberta from various institutions, while the other two received their training outside Alberta, specifically in Ontario or Saskatchewan.

The unanimous consensus among all participants was the importance of training for HCAs. However, two participants expressed concerns about the duration of the training program. Judy stated that while training is crucial, she believed it should be longer to ensure that individuals who enter this field possess the necessary qualifications. She believed that lengthier education would attract a more dedicated and qualified workforce.

Kat highlighted the need for standardized training programs to ensure that all HCAs deliver high-quality care consistently across the province. Other participants emphasized the advantages of such training programs, both for HCAs and residents. They believed that training enhances resident and staff safety, reduces medication errors, prevents infections, promotes quality care, and raises awareness of the rights and responsibilities of both residents and staff. Furthermore, participants recognized the importance of learning about work stress and acquiring coping mechanisms. Lena emphasized the significance of knowledge and proper procedures in healthcare, highlighting the need for HCAs to be well-informed to prevent infections, protect themselves, and provide effective and compassionate care to residents.

Overall, participants underscored the importance of comprehensive and standardized training programs that equip HCAs with the necessary skills, knowledge, and understanding to deliver exceptional care and ensure the well-being of both residents and staff.

These five main themes provide a comprehensive understanding of the participants’ perspectives on work stress, its origins, its impact on their lives, and the coping strategies employed, while also underscoring the value of training in their professional journey.

Participants emphasized the importance of management support and recognition in creating an ideal workplace. They expressed the need for managers to have a better understanding of the work HCAs do by spending time in the field and experiencing their workload firsthand. Regular meetings between management and staff were also suggested to address concerns and improve communication.

Teamwork and a sense of unity were highlighted as essential elements of an ideal workplace. Participants emphasized the importance of team building activities and eliminating hierarchical structures that hinder collaboration. They believed that fostering a healthy environment, free from gossip and negativity, would contribute to a positive work atmosphere.

Recognition and appreciation for the work of HCAs were considered crucial. Participants suggested providing incentives and rewards to show that employees are valued, and their efforts are acknowledged. They emphasized the need for managers to be approachable and supportive, creating a sense of trust and openness among the staff.

The physical space for staff was another aspect mentioned. Participants suggested having dedicated lounge rooms or areas where HCAs could relax and take breaks. Creating a comfortable and welcoming environment was seen as important for the well-being of employees.

Overall, an ideal workplace for HCAs would prioritize management support, teamwork, recognition, and provide a positive physical and social environment. These factors were seen as key to reducing stress levels and fostering a sense of joy and productivity among HCAs.

Discussion

The literature reviewed in the study identified inconsistencies in the titles, training, and job descriptions of HCAs in Canada and internationally. In Alberta specifically, HCAs were found to be unregulated and not recognized as a profession. There was no standardized educational requirement for HCAs, and training varied across provinces.

The participants in the study emphasized the importance of standardized education for HCAs to ensure the delivery of high-quality care to residents. They expressed the need for national standards and consistent training requirements for HCAs entering the workforce. These findings aligned with previous reports, such as the Workforce Strategy for Continuing Care in Alberta 2012 to 2017, which highlighted the need for standardized education and training for HCAs.

The study also revealed that assisted living facilities (ALFs) provided in-service education courses for HCAs, but less than half of the participants received instruction about work stress during their HCA training. This finding was consistent with previous reports from the Canadian Nurses Association (CNA) and the Health Professions Regulatory Advisory Council (HPRAC), which stated that many HCAs are trained by their employers, while others receive formal training in colleges. However, in the current study, no workplace-specific training on work stress was provided. Many participants recognized the potential value of such courses and expressed a desire for their inclusion in HCA training.

Overall, the study findings highlighted the need for standardized education, consistent training requirements, and inclusion of work stress instruction in the training curriculum for HCAs. These recommendations align with existing reports and emphasize the importance of providing comprehensive and standardized education to HCAs to enhance the quality of care they deliver.

Numerous studies have highlighted work stress as a significant source of overall stress, with its prevalence increasing globally. It affects approximately one-third of North American workers and is considered a substantial problem for both employees and employers. Work stress has been identified as a leading cause of worker ill health, disability, and turnover. In this research, four main themes emerged: the meaning of work stress, its genesis, coping strategies employed by HCAs, and the impact of stress on their lives.

Participants struggled to articulate their perception of work stress, possibly due to its subjective nature. Language barriers further complicated their ability to define and manage stress. Nevertheless, they associated stress with physical, psychological, and emotional perspectives, aligning with established definitions that describe it as the conflict between job demands and an employee’s control over meeting those demands. Participants reported high stress levels, rating them between 6 and 10 on a scale of 1 to 10.

Participants described various signs and symptoms of stress based on their beliefs, awareness, and personal experiences. These included headaches, muscle aches, insomnia, anxiety, and depression, which are consistent with findings from previous research. Interestingly, despite the identified factors contributing to work stress, only 40% of participants expressed job dissatisfaction. This dissatisfaction stemmed from organizational factors, such as leadership style and limited decision-making opportunities, as well as workload, lack of appreciation from management, supervisors, residents, and residents’ families. Contrary to expectations, participants were generally satisfied with their wages and considered HCA work financially rewarding compared to other jobs.

Overall, the study shed light on the subjective nature of work stress and its impact on HCAs. The findings emphasized the need for effective stress management strategies and highlighted the importance of addressing organizational factors to mitigate work stress. Furthermore, the study revealed the complex relationship between job satisfaction and specific factors affecting HCAs, challenging previously established assumptions.

The genesis of work stress involves various sources, as identified by the participants in the study. Two main categories of stress were identified. The first category encompassed stressors related to behaviors, attitudes, and situations involving residents, their families, leadership, and co-workers. This aligns with existing literature that highlights sources such as lack of appreciation, threat of violence, role conflict, and role ambiguity, among others. The second category focused on the challenging work environment, including factors such as working short- staffed, overworked, and underpaid, high resident-staff ratios, time constraints, and additional tasks not listed in the job description. These findings correlate with previous research on workload, shiftwork, lack of skills and training, work schedules, physical work environment, and workplace safety. Workplace violence was also identified as a significant source of stress, particularly for healthcare workers like HCAs who provide direct care to elderly residents, often with dementia. Participants reported experiencing physical, verbal, and sexual violence from residents. This aligns with research indicating high rates of workplace violence in the healthcare field. Inadequate training and negative experiences of violence further contributed to stress levels and job dissatisfaction among HCAs. Poor leadership and negative interactions with supervisors and managers were also identified as stressors. HCAs categorized stress sources as controllable (within their sphere of responsibility or manageable by employers) and uncontrollable (difficult to control, such as families’ attitudes and disease progression in residents with dementia). Overall, the study highlighted various sources of work stress faced by HCAs and emphasized the need for interventions and support to address these stressors effectively.

Work stress has significant effects on the lives of individuals, as revealed by the participants in the study. Three major consequences were identified. Firstly, there were physical consequences, including back pain, headache, neck pain, shoulder pain, and muscle aches. The nature of the work, which involves lifting, bending, and pulling, likely contributed to these physical symptoms. Secondly, participants experienced mental and emotional consequences, such as emotional exhaustion, depression, anger, anxiety, restlessness, irritability, and changes in sleep patterns. These findings align with existing literature on work stress in the healthcare field, which also highlights physical and psychological effects. Lastly, work stress had an impact on personal and professional life, leading to withdrawal from social activities, decreased focus, spread of stress to others, compromised resident care quality, and poor performance. These findings are consistent with previous research emphasizing the negative effects of work stress on employees, employers, and workplace productivity.

Participants employed various coping strategies to deal with work stress, recognizing it as an individual phenomenon. Coping mechanisms varied among participants, and researchers have identified several strategies to mitigate the negative effects of stress, including control, emotionality, social support, and individual coping mechanisms. Steps to reduce work stress involve taking responsibility for physical and psychological health, identifying negative attitudes and unhealthy habits, and improving communication skills. Coping strategies can be healthy or unhealthy, with examples such as seeking social support, avoiding stressful situations, engaging in leisure activities, and using behavioral mechanisms like substance use. HCAs in this study employed a combination of coping strategies to address work stress, reflecting the challenging nature of their work environment. These strategies included venting and seeking social support, avoiding stressful situations, absenteeism, engaging in leisure activities, and resorting to certain behaviors.

Overall, understanding the consequences of work stress and adopting effective coping strategies is crucial for managing stress levels and maintaining well-being in the workplace. The findings of this study have important implications for education and policy in the HCA sector, particularly in ALFs. The study sheds light on the experiences of HCAs in relation to work stress, its sources and consequences, coping mechanisms, and the implications of stress. It is the first study in Canada to specifically focus on HCAs in ALFs, using a descriptive and exploratory qualitative design, which adds valuable new insights and knowledge about their work life.

The study highlights the significance of training programs and in-service education for HCAs before they enter the field. Consistent and standardized programs are recommended to better prepare HCAs for the realities of their work and equip them with effective stress management strategies. Further research is needed to evaluate the effectiveness of such training programs and in-service education.

In terms of policy implications, the study suggests that policymakers and ALF managers should consider the criteria outlined by HCAs for an ideal workplace. These include factors like management support and recognition, regular meetings, and in-service education on work stress and stress management. Training programs for ALF managers, focusing on leadership positions and styles, are also recommended to foster proactive leadership and create a supportive work environment.

HCAs emphasized the importance of physical space for staff, teamwork, and appreciation among all levels of workers in reducing workplace stress. Therefore, additional in-service education is needed to promote these ideas and create a healthy work environment. Improving working conditions, such as staffing levels and workload, is crucial, as HCAs reported that poor working conditions contribute to work stress and impact their ability to provide safe and high- quality care. Interventions like increasing staff numbers and reducing long shifts could help alleviate stress, enhance safe practices, and improve the quality of care.

However, some factors that contribute to work stress, such as resource availability, hiring processes, staff- resident ratios, and resident placement, may be beyond the control of policymakers and managers. Nevertheless, it is recommended that efforts be made to address these factors as much as possible.

Lastly, the study suggests that the HCA profession should be regulated and incorporated into a regulatory body, like other healthcare professions. This would help standardize HCA training programs, certifications, and job titles across the country, ensuring consistency and quality in the field.

Overall, the study provides important insights and recommendations for educational and policy interventions to address work stress among HCAs in ALFs, ultimately aiming to improve their well-being, job satisfaction, and the quality of care provided to residents.

Recommendations for Future Research

Further research is recommended to delve deeper into the unique experiences of work stress among HCAs and their coping mechanisms. The complexities associated with ALFs and the nature of HCAs’ work pose challenges that warrant additional investigation. The study utilized two stress-related theories: the transactional model of stress and coping, and the job demands-resources model. Exploring these theories in different phases—stress appraisal, coping, and outcomes—among a larger population of HCAs would provide valuable insights.

Future research could expand the scope by including HCAs in various settings such as long-term care or hospitals and ensuring diverse participation, including more male participants. While the current qualitative study focused on work stress experiences of HCAs in ALFs in Southern Alberta, conducting studies in different geographical areas would help broaden our understanding of this issue. The present findings can serve as a foundation for future quantitative and qualitative research.

Given the limited knowledge about HCAs in Canada, further research at the provincial and national levels is necessary to investigate work stress among HCAs. A national survey of HCAs could offer insights into their demographic profiles and help shape policies and interventions. Additionally, addressing the issue of violence, particularly sexual violence, reported by HCAs in this study calls for further research to develop strategies for prevention and support.

Overall, future research should aim to deepen our understanding of work stress among HCAs, explore coping mechanisms, and investigate the prevalence and impact of violence within their work environments.

Limitations of the Research Study

The study had several limitations that should be acknowledged. One limitation was the selection of participants for interviews, as those who agreed to participate may have held stronger views on work stress, potentially leading to a biased sample. Additionally, the uses of inclusion criteria may have resulted in participants not fully represent the entire workforce.

Although this study yielded innovative findings and provided a detailed understanding of work stress and coping mechanisms, it is important to note that the findings cannot be generalized to the broader population. However, they may be transferable to similar settings. Furthermore, my own personal experience as an HCA may have inadvertently influenced the research process and interpretation of the findings.

While the findings may accurately reflect the knowledge and perspectives of the participating HCAs, they cannot be extended to encompass the experiences of other HCAs in different ALFs in Alberta or across Canada. Another limitation pertains to the study’s limited geographical scope, which may restrict the generalizability of the findings. Finally, the inclusion of more male participants could have provided additional insights and experiences not captured by the participants in this study.

Conclusion

This study offers valuable insights into the perception and coping of work stress among HCAs in ALFs. The themes and findings enhance the understanding of the challenges and coping mechanisms of HCAs. The results can help employers and service providers to identify stressors in the workplace and implement interventions to reduce work stress. Improving working conditions and supporting the well-being of HCAs will ultimately improve the quality of care provided to residents in ALFs.

Acknowledgements

I would like to express my gratitude to the participants who generously shared their experiences. Additionally, we extend our appreciation to the Christian hospital-based organization and ALFs for their support and cooperation throughout the research process. The author did not receive any financial support in relation to the research, authorship, or publication of this article.