1. Physical work leading to bodily strain and injuries.

Workers are exposed to an elevated risk of physical harm due to manual handling, slips, trips and falls and excessive standing. Incidents commonly occur while cleaning, carrying groceries, moving or helping clients with bathing and dressing. Incidents often involve the performance of awkward (e.g., bending; maneuvering), high-force (e.g., lifting furniture; moving clients in and out of vehicles), tight spaces, repetitive (e.g., mopping; vacuuming), or sudden (e.g., catching clients when they fall) movements. Several providers noted that manual handling incidents were among the most common experienced by workers. Common injuries reported were musculoskeletal, including strains or sprains to the back, shoulders, knees, wrists and elbows. Several workers described ongoing soreness, with one worker noting that “aches and pains are part of the job”. This is supported by recent industry data showing that in the broader NSW healthcare and social assistance workforce, muscular stress and falls are among the top causes of workplace injuries, while soft tissue injuries and trauma to muscles, joints and ligaments are among the most common injuries [37].

Manual handling incidents sometimes occur due to improper technique [38]. Several workers described receiving no WHS training on manual handling techniques, while some providers noted that workers may often lift objects outside the scope of their work:

“The most common injuries we see are medium grade strains/sprains to shoulders and backs due to lifting people, instinctively catching someone instead of letting them fall, or using poor lifting techniques when picking up objects.” (WHS manager, disability care)

2. Unclear professional boundaries leading to inappropriate workplace relationships.

Standard and platform providers and labour hire agencies all noted the nature of the job can make it hard for workers to retain a healthy social distance from their clients. Workers can form strong bonds with their clients and be motivated to provide services outside their job description or performed after hours. This can result in injury or other personal costs. For instance, one worker described buying things for clients who would promise but fail to reimburse them. Workers on digital platforms encountered a unique challenge in maintaining professional boundaries. As one female platform worker explained, new and prospective clients have direct access to a worker’s personal information such as name and photo on their platform profile. This contrasted with standard provider and labour hire contexts, where a care coordinator mediated the initial engagement between workers and clients. More than one platform provider described incidents of excessive unsolicited messages from clients to workers, and one young female platform worker’s client found her social media account. Although platforms often had inbuilt messaging features that could be monitored, clients of all provider types frequently requested the worker’s phone number or email for convenience. One worker explained that such requests were difficult to turn down:

“[Clients] can latch onto you emotionally because of the nature of the work… They’re going to form an unhealthy attachment onto the support worker, and they do have contact details.” (Female, platform worker)

3. Demanding workloads leading to physical and emotional stress.

Some workers often felt rushed with insufficient time to complete all their tasks in a shift, consistent with United Workers Union [39] findings. This occurred when the employer allocated too many duties or when clients or family members pressured them to complete extra duties. King [40] reported that organizing care work according to the principles of market logic (e.g., competitiveness, outputs), can result in a focus on care tasks being completed efficiently rather than worker safety.

One provider said staff shortages lead to fatigue because workers took on extra shifts, and demanding workloads were more common in the aged than disability sector. One aged care provider reported their workers were asked by clients’ families to perform professional cleaning services despite being outside their job scope, while another reported not having time to use the restroom or eat between client appointments. Excessive workloads were physically and emotionally draining for workers:

“[I’ve] gone grey because of work and I’m losing hair. I’ve gone to my GP and he says [it’s] stress. And it is work stress, because I’m doing the best I can but I am a one-man army” (Female home aged care worker)

Adamson et al. [41] proposed that although migration is a potential solution to the workforce shortfall, it is not a prominent workforce building strategy. Given that visas are primarily skills-based, migration may contribute to building workforce numbers but is unlikely to address the skills shortage [42].

4. Driving-related hazards leading to potential accidents.

Driving was a regular feature of the job for many workers, who can spend substantial amounts of time on the road whether commuting to or between client homes, running errands for clients, or transporting clients to events, appointments or shops. One WHS manager described vehicles as the “workplace in between jobs”. Workers in rural or remote communities need to commute longer distances and travel on windier roads than urban workers who can experience stress and fatigue from traffic delays.

Several workers described incidents when transporting clients, such as clients attempting (sometimes successfully) to exit the car while still in motion, while another described a client attempting to grab the steering wheel during a trip. One worker described transporting clients as one of the more stressful job duties, echoing other findings (e.g., [39]).

“I had a dementia client who wanted to get out of the car while I was still driving. I now have to use child locks.” (Female, aged care worker)

5. Isolation leading to disconnection and professional loneliness.

Consistent with prior research [43], some workers said they experienced few, if any, interactions with colleagues while at work. With limited peer interactions, experienced workers past their initial training miss out on organisational support and contact with colleagues and supervisors that occurs elsewhere. One disability worker described having no one to debrief with after shifts, and another said they would like to visit a physical office to meet other workers from time to time. The submission to the Royal Commission into Aged Care Quality and Safety by the Accord on the Remote Aged Care Workforce [44] reported that remote and regional workers experience greater separation from colleagues and employers than metropolitan workers.

Some organisations provide buddy shifts, direct support and peer networking to address worker isolation, however beyond care manager or administrative client visits, clients tended to not pay for a second worker to attend a shift. Some workers said isolation was an increasingly prominent hazard, as previously there was more access to peer support.

“Peer support is a valuable thing in this field and it is really being destroyed.” (Male, disability care worker)

6. Physical aggression, verbal abuse leading to physical or psychological injury.

Many workers and providers described instances of physical aggression (i.e., grabbing, hitting, biting, throwing objects) and verbal abuse (i.e., threats of violence, being sworn at). Two workers reported that triggers of verbal abuse from clients or client families were how workers were doing their job (e.g., their cooking), or workers refusing tasks outside their job scope. Consistent with Overgaard et al. [45], stakeholders reported racially charged verbal abuse of some CALD workers. One described finding it difficult to form trust and build rapport with clients after a violent outburst that caused a physical injury:

“The accumulation of yelling and verbal aggression over time, as opposed to acute incidents, can lead to stress and compassion fatigue.” (WHS manager, disability care provider)

Several workers reported clients or their family members making sexual advances towards them. Platform-based work could expose workers to a heightened risk of sexual harassment as one digital platform WHS manager described people creating fake accounts to contact workers in whom they had a sexual interest.

Abuse and aggression including distress, exhaustion and compassion fatigue have caused physical and psychological harms to workers. One provider said 60% of home aged care workers have experienced workplace abuse and aggression from clients, while United Workers Union [39] reported around 70% have felt unsafe in a client’s home. The risk of abuse or aggression is higher when caring for clients with serious mental health or behavioral issues. One labour hire agency representative said these issues are more common for disability than aged care.

“Physical abuse… can just come from nowhere… all of a sudden something will set them off, something in their mind.” (Female aged care worker)

7. Distressing events leading to psychological injury.

Workers reported distressing events at work that can result in psychological harm. At an extreme, the death of a client and watching families grieve can lead to disenfranchised grief [46] when others do not recognise the nature of the workers’ relationship with the client. Other distressing events include deterioration in a client’s mental or physical health, seeing clients self-harm, seeing clients living in squalor and observing client elder abuse from family members. For example, an aged care worker described finding it hard to “switch off” when their client had died, and another witnessed their client’s husband not allowing his wife to leave the house or purchase necessary items.

Workers also experience distressing events secondhand through hearing of clients’ or colleagues’ distressing experiences (e.g., when clients disclose suicidal ideation or history of abuse and neglect).

“Witnessing the mental health deterioration of clients, or clients’ suicidal ideation, can lead to psychological harm [for the worker].” (CEO, disability labour hire company)

One disability worker who was neglected as a child was distressed after witnessing incidents of child neglect and made a WorkCover claim to recover.

8. Challenging client behaviours leading to stress or fatigue.

Clients sometimes behave in ways that are neither abusive nor aggressive but can nevertheless result in psychological harm to workers. These behaviours are typically associated with the client’s cognitive disabilities or mental health challenges and are not intentional. Situations that resulted in workers feeling stressed or fatigued included being hypervigilant for long periods to ensure clients do not wander off and put themselves in danger, having their opinions and actions repeatedly challenged by clients, being kept waiting at their client’s front door for extended periods and clients refusing to take their medication. Clients with obsessive-compulsive related disorders can assign meaningless tasks or set strict arbitrary rules for how a task should be performed (e.g., helping to hoard rubbish or being required to use a specific rag for all cleaning duties). Such tasks left workers feeling demoralized and wondering if they are reinforcing their client’s symptoms.

9. Unsafe client homes leading to physical injury.

Lucas and Elliott [47] stress that due to its own set of safety hazards, each home is essentially a new worksite. Similarly, interviewees noted that many homes were poorly laid out and not designed to safely accommodate workers (e.g., showers unable to fit two people, or lacking fittings such as handrails). Other contributing factors included confined or cluttered spaces, rubbish obstructions in hoarders’ homes, protruding or falling objects when opening cupboard doors and glass or needles stepping hazards. One provider noted that trips and falls caused by rugs, furniture or clutter were common. Another reported a spinal injury after tripping on a garden hose left on a client’s staircase.

10. Pathogens, poisons in uncontrolled workplaces leading to exposure, illness or disease.

Workers could be exposed to pathogens and poisons in an unfamiliar home. These included bodily secretions (e.g., blood, urine and faeces), drugs (e.g., cigarette smoke, marijuana and illicit injectables), diseases (e.g., COVID-19), allergens (e.g., animal fur), rubbish (e.g., dirty dishes), contaminated food offered by clients, pests (e.g., snakes and mice), mould and cleaning products (e.g., bleach), resulting in infections or asthma symptoms. Maddox [48] similarly reports on exposure to pathogens and poisons by Australian health and community workers.

Even when aware of the WHS hazards in a client’s home, workers or organisations have little power or agency to remove them. For instance, workers can find it challenging to tell a client not to smoke in their presence:

“Risks to workers include clients who smoke, which can exacerbate asthma.” (Workers’ compensation manager, aged care)

“In independent living, you’re always going into a work environment that’s a little bit unknown… You never know what’s happening at the house, it’s a little bit uncontrolled.” (WHS manager, disability care)

1. Taking shortcuts.

Some workers, training providers and standard providers said workers may not always follow correct WHS techniques or protocols on the job. Taking shortcuts could exacerbate several of the WHS hazards described above. For instance, workers could neglect to change gloves between duties or clients or could physically lift a client alone when a second worker or hoist is needed. Workers take these WHS shortcuts due to pressure from clients or their family, not having enough time to perform all assigned duties safely or complacency to take shortcuts after a long time in the industry. One worker said when clients or their family saw one worker “bend the WHS rules”, they expected others to be willing to do the same.

The lack of supervisory feedback and lack of consequences for unsafe behaviour can undermine their health and safety. One worker noted “I’m sure it is not WHS approved, but no one’s seeing me, so no one’s told me off for it.”

“To do things properly sometimes would take too long.” (Female aged care worker)

2. Prioritising client welfare over their own.

A strong desire to help their clients can put workers at risk of harm. One provider said the ‘patient always comes first’ mentality drove many risky behaviours. Workers “took shortcuts to be kind”, completing tasks they are not supposed to or deprioritizing their own WHS. Aged care interviewees spoke of prioritizing client needs more than those in the disability sector.

Several workers reported it challenging to distinguish between their own and their clients’ WHS needs. When asked about hazards or policies on worker health and safety, several described hazards or policies related to their client’s welfare, indicating they prioritized their client’s welfare potentially at the cost of their own welfare. Moreover, several providers also reported that client person-centered care was adhered to at the expense of worker safety. A managing director of an online platform provider said they are “…concerned with risks to our clients more than we are concerned to [sic] workers”, and it is the worker’s responsibility to look after WHS requirements, given they are contractors:

“The industry is very customer focused. We tend to get people putting the customer first. [Workers are] not as risk averse because… the customer needs are [seen as] greater than the risk to [themselves]… so they take on risky behaviours.” (WHS mgr, disability care)

“New reforms focus on client control and choice and we have lost the focus on workers.” (Rehabilitation organisation representative)

3. Unreasonable expectations.

While many workers have difficulty refusing pressure from clients and family to perform out-of-scope requests, several report they can effectively communicate their wants and needs with clients and managers and set reasonable expectations. For example, some workers decline shifts they do not feel qualified to perform, refuse manual handling shifts if they have an injury, or choose not to work with clients known to exhibit difficult behaviours.

Some workers seek written or verbal agreement from a client regarding the specific tasks they will perform and the client’s behaviour (e.g., not smoking or drinking during the shift). Some enforce boundaries by maintaining a physical or psychological distance from their clients. One worker described using a kitchen counter as a safety barrier when a client became aggressive, while another told us they leave a client’s residence if it is not in an appropriate state or the client refuses to comply with a request.

Organisational policies could assist to enforce boundaries with clients. For example, one online platform provider said they instruct workers not to share personal phone numbers with clients, and they monitor client-worker messages for excessive numbers of messages.

“[When] clients pressure me to do many tasks in a short time… I just say no with reasons given or explain my views with asking for extra time to be paid for chores to be done.” (Female, aged and disability care worker)

4. Distressed clients.

Some workers effectively use de-escalation techniques to mitigate the harms associated with abuse and aggression. One worker used music and talked to distressed clients about their interests. Another drew on background knowledge of a client living with dementia to calm them when distressed. At least two providers included de-escalation techniques in their training program. However, there are no de-escalation standard training techniques in the aged or disability care sectors:

“Knowing their history a bit really helps [with de-escalation]... I think that’s an important part that the industry doesn’t really recognize.” (Female, aged care worker)

5. Cultural and language barriers.

As a substantial proportion of the home care workforce was CALD, WHS materials and processes should be readily accessible to workers from different cultural backgrounds. Bilingual workers are especially beneficial for CALD clients living with dementia who reverted to their first language. However, one provider stressed that difference in cultural customs between workers and their clients could increase the likelihood or severity of harm associated with WHS hazards. For example, many African, Filipino and Nepalese workers found it hard to say “no” when asked to complete unreasonable tasks by clients. This could lead to workers bending rules or taking shortcuts.

6. Physical characteristics.

Workers’ gender, age, weight, fitness and length of service were all referred to as characteristics that could contribute to their risk of physical injuries on the job, particularly in relation to manual handling. These characteristics were linked to lower strength (e.g., being female, older, less fit, or lighter weight), lower agility, flexibility, stamina or balance (e.g., being older, less fit, or heavier weight) and more accumulated bodily wear-and-tear (e.g., being older, or longer service history). One female disability care worker (aged 56–65) described being asked to perform duties unsuitable for her back injury, despite having informed her employer she was unable to perform manual handling duties. The rehabilitation organisation interviewee added that older age, higher body mass index and lower strength were associated with poorer recovery outcomes following injury.

Even for workers with sound physical capabilities, there were risks for male and female workers when clients were bigger and aggressive:

“I’m about 45 kg myself, and having to help men shower sometimes, especially if they’re a lot bigger than you, it’s a bit weird, feels a bit awkward.” (Female, disability care worker)

7. Quality of WHS training.

Many workers considered they did not receive adequate WHS training and that they lacked the critical skills and knowledge needed to safely navigate workplace hazards such as de-escalating abuse or aggression, handling pathogens and poisons safely and using correct manual handling techniques and equipment.

8. Information provided by organisations.

Workers and providers all acknowledged that workers needed to know details of the client’s background including their behavioral history, criminal record, home environment and pets, and any medical and psychological conditions. However, multiple obstacles to information gathering existed. Care plans were often not updated as circumstances changed and information was not always conveyed clearly. Advertisements posted online by clients for platform workers were often inaccurate.

One worker and one training provider emphasized the importance of involving workers in developing in-person risk assessments and care plans when clients were first engaged:

“When you’re going into someone’s place… you wouldn’t know the place at all, or if it’s a client you’ve never dealt with before… you don’t know if they’ve got any sort of other illness, or confusion, or dementia or aggression… you don’t know if there are family pets onsite.” (Male, aged care worker)

9. Organisational support.

There were mixed reports about organisational support for workers. Some workers felt unsupported by their employer. Examples of inadequate support included a worker meeting their employer just once in two years of service, providers not being available for workers to make a report or debrief on weekends and providers not following up on reported incidents or hazards. One worker was offered shifts with a client after reporting that client made death threats towards them. Another said they no longer reported incidents because there was no or inadequate follow-up after an incident involving client violence. Further, some workers feared losing shifts if they refused work offered.

Lack of support could exacerbate many hazards including isolation, demanding workloads and psychological harms after witnessing distressing events. These findings accord with King [49], who found the primary reason for job dissatisfaction among 100 aged care workers was unsupportive management.

There were also positive reports of organisations supporting workers when they make requests or decline shifts. For example, one worker was given time off after a client passed away. Beyond the worker-organisation relationship, one labour hire interviewee said it was crucial to build strong collaborative relationships with their host employers as they had a shared duty of care and relied on information exchange to keep workers safe.

10. Non-standard employment contexts.

Workers in non-standard employment (i.e., those working for labour hire agencies or online platforms or who work independently from any organisation) could be exposed to additional factors that exacerbate WHS risks and harms. One worker said that as a contractor in an independent organisation, they were less likely to receive briefing information and broader organisational support than those employed by other types of organisations. This supports research that found training opportunities are largely unavailable to self-employed platform workers more generally [50]. Contracted workers could also experience more isolation and feelings of unfamiliarity if regularly switching between clients and home environments. The level of support offered by online platform providers can also vary between providers (e.g., in level of safeguarding or vetting clients and workers). One labour hire agency said they do not hire workers out to online platform providers due to the low organisational oversight of worker welfare.

11. Clients with complex needs.

Many workers and providers reported that workers had difficulty managing the behaviours of clients with a history of violence, were heavily medicated, or had psychological conditions such as dementia, psychosis, substance use disorder, autism spectrum disorder and attention-deficit/hyperactivity disorder. Worker risks and stress increased if they were not informed about these circumstances before entering the client’s home. Physical aggression and verbal abuse were more common in clients with dementia and certain psychological conditions. These clients required sustained and hypervigilant attention, which is tiring and stressful for workers. One worker said they use alcohol to relax after shifts with complex clients. Family members also can add to worker stress. For instance, a family member refused to give a client their medication, which led the client to engage in violent outbursts and self-harming behaviours.

12. Client homes lacking safety equipment.

Beyond client homes being unpredictable and uncontrolled workplaces, those homes can lack adequate equipment for the safe performance of domestic (e.g., vacuuming) and mobility (e.g., lifting obese clients) duties. Interviewees described bathrooms without slip mats or handrails, rooms that are too small to maneuver obese or wheelchair clients without hoist access. WHS risks of home care work without adequate equipment has been previously reported [39].

Limits on a client’s funding and lengthy approval processes often resulted in inadequate safety equipment and poor maintenance. Even if extra funding could be accessed, approvals for new equipment sometimes took months. One aged and disability provider reported that some care coordinators continued to transfer clients who lack appropriate equipment to different providers until one was willing to take them on.

13. Working solo.

All the risk factors described above are heightened because workers typically work alone. When an incident occurs (e.g., a physical injury or incidence of violence), working in isolation prevents or slows access to immediate support or intervention. One worker described feeling like they needed a security guard present while at work and others referred to their vulnerability of being falsely accused of abuse or aggression because they do not have any witnesses to come to their defense. Workers in rural or regional locations were further isolated when they had no mobile data or reception.

“In a sticky situation you only have your mobile phone.” (WHS manager, disability care)