Health Care Aides (HCAs) are of increasing importance to the delivery of care to older adults living in their own homes
[1, 2], and in nursing homes
. The term HCA is often used synonymously with Personal Support Worker (PSWs), along with other synonymous titles that are health care setting-dependent, including: home support workers, health care aide, hospital attendant, long-term care aide, nurse aide, nursing attendant, patient care aide, psychiatric aide, and resident care aide.
In Canada, HCAs constitute a significant component of the health care labor force, where these workers are concentrated in the long-term care (LTC) and home and community care (HCC) sectors and provide up to 80% of the direct care to elderly Canadians
. The exact size of this workforce at the national level is not known; however information is available for some Canadian Provinces through recent initiatives like provincial registries. Approximately 100,000 HCAs deliver care in the most populous Province, Ontario (13.5 million), where 57,000 work in long-term care facilities and 34,000 work for home health and social care service providers
. In British Columbia, the third most populous Province (4.6 million), over 44,000 HCAs have registered with the British Columbia Care Aide and Community Health Worker Registry since its inception in January 2010
. HCAs are unregulated in Canada, and are not recognized as a profession. In both home and community care (HCC) and long-term care (LTC) settings, HCAs work under the direction of a Registered Nurse (RN) or Registered Practical Nurse (RPN).
As the costs of health care escalate
, so do the challenges to policy makers and practitioners to provide efficient care without sacrificing effectiveness. One notable response to cost containment pressures relating to the delivery of care for older Canadians has been the introduction of new policies that support aging at home. These policies have effectively shifted care from ostensibly more costly acute care settings to the HCC and LTC sectors
. The consequent increase in demand for HCAs has been amplified by the concurrent trend to substitute higher cost regulated workers, like nurses, with lower cost unregulated workers
As recently as a decade ago, the role of HCAs in Canada was a purely supportive one involving assistance with daily living activities (ADLs), such as bathing, dressing, meal preparation and other ‘light’ household tasks. In the current environment, elderly clients living in their homes, and residents receiving care in nursing homes, require increasingly complex care
. The shifts in the workforce that have led to substitution have also led to role expansion, where the roles of some HCAs now include delegated acts for things such as catheterization and injection. Role expansion among these unregulated workers has prompted calls for standardized approaches to preparation/training, and to supervision
Increasingly, a number of jurisdictions in Canada have encountered recruitment and retention challenges relating to these increasingly important caregivers
. Keefe and colleagues have recently sought to initiate research and discourse to develop human resource strategies relating to these workers
. These are admirable efforts that underscore the importance to elder care of understanding this understudied workforce
[13–15] about which we ‘know’ very little with respect to fairly basic information including the nature of their preparation, their work motivations, their attitudes toward their work, and their aspirations. Work retention, for example, is an acknowledged problem among these workers
 that we do not yet know how to solve; there are differences in worker preparation and expectations
[4, 15] with unknown impacts on the quality of care delivered to older Canadians. A first step in developing informed human resources strategies, then, must be to endeavor to learn more about these workers. Specifically, we need to know more about the roles of HCAs in direct care to older Canadians; we need to know more about how and where they work; we need to gain an understanding of their work motivations, attitudes and aspirations; and we need to have a more comprehensive understanding of the variation, nature, and adequacy of their preparation. This can inform the development of recruitment programs, incentive systems, and retention and training strategies for these workers in the future.
The discussion that follows is one step toward addressing these knowledge gaps, and serves as a call for further work that stands to inform future human resource planning efforts relating to the delivery of care to older Canadians. We share and elaborate insights, regarding these workers and their work, which emerged from a focus group discussion that we recently led among industry experts actively engaged in long-term care delivery and policy decision making in Canada.