Workers, workers, workers

The final report of the review of Australia’s National Disability Insurance Scheme (NDIS) will soon be published, and the disability workforce will be on its radar. In today’s post, Raelene West (@raelene_west) discusses disability support worker shortages and workforce churn. In 2022, she and colleagues Helen Dickinson and Sophie Yates conducted a study of the experiences and perceptions of people with disability purchasing supports from unregistered providers through the NDIS. Dr West argues that their findings suggest a need to look beyond traditional approaches to recruiting, training and retaining disability support workers to build a workforce capable of meeting the diverse needs and priorities of service users.

Ask anyone that works in a service industry in Australia and they’ll tell you about labour shortages - difficulties finding staff and issues with maintaining quality staff.

This very much includes workers required to support people with disability.

Traditionally, external training and in-house supervision of disability support workers (DSWs) has been viewed as the primary means to bring DSWs into the industry, and the means to ensure quality of service provision, including prevention of violence, abuse, neglect and exploitation of service users. Training policy focused on encouraging potential DSWs to obtain a minimum level qualification from Registered Training Organisations, and the on-going in-house professional development and supervision. These frameworks also provided the basis of efforts to professionalise the DSW workforce and progress it beyond perceptions of a lowly-paid, feminised care work role.

However, while DSW training is seen as important at the system level, it does not appear to be similarly prioritised by many people with disability using services. Research we undertook in late 2022 on experiences of service users purchasing supports from unregistered providers through the National Disability Insurance Scheme (NDIS) found that formal training and/or minimum level qualifications of DSWs did not always appear to be central elements in achieving quality, stability and safety for service users within their service interactions. Many interviewees described that being able to onboard, train, roster, supervise and even employ DSWs themselves achieved better support outcomes and reduced power differentials within their support interaction.

The NDIS offers three options for managing individual budgets - ‘Agency-managed’, ‘Plan-managed’ and ‘Self-managed’ (David and West, 2017). If a participant is agency-managed, they are required to purchase services only from NDIS registered service providers. Plan-managed and self-managed participants however have the option of purchasing services and/or equipment from non-NDIS registered providers, and these may or may not be disability specific services. Self-managed participants take-on provider payment responsibilities including having the choice of directly employing support workers and (David and West, 2017). These different types of funding management have significant implications for service users around provider choice, service flexibility, choice of staff, capacity to negotiate costs and levels of risk a service user is prepared to take on.

For workers, Cortis and Van Toorn (2020) surveyed 2,341 disability workers during March 2020. They noted that ‘many workers report a lack of access to training’ and that ‘a quarter of respondents (26%) received less than one day of training in the last 12 months’ (Cortis and Van Toorn, 2020: 9). Many workers highlighted feeling ‘under-supported through supervision and training’ and feeling they were ‘left to make decisions on their own about client care and support’ (Cortis and Van Toorn, 2020:10). Their research has also shown that there are increasingly high levels of casualisation in the industry, that workers perceive a level of deterioration in working conditions, and these elements were contributing to high turnover of DSWs across the industry (Cortis and Van Toorn, 2020:49).

Despite significant levels of capacity building around workforce development associated with the establishment of the NDIS, no mandatory minimum training level is currently required to work as a DSW in Australia – the only mandatory training modules are CPR and first aid (MacDonald 2021). In addition, inductions and professional development are often provided in-house to DSWs by larger disability service providers across Australia, however these are not recognised industry wide (MacDonald 2021). There have been significant calls for a minimum entry level qualification to be introduced for DSWs for decades, however regulators have resisted implementing any minimum entry level qualification due to chronic labour shortages across the industry. Advocates argue that establishing any minimum entry level qualifications would create barriers to employment for new workers seeking to enter the industry, or that mandating training would constrain service user choice and prevent some people with disability from working with their preferred DSWs (Taleporos, 2023)

In contrast, others in the sector claim that a minimum entry level qualification would at least provide a worker new to the industry some broad-based understanding of human rights and discrimination frameworks (such as the Convention of Rights of Persons with Disability (2006) and the Disability Discrimination Act (1992). In addition, it would provide a minimum understanding of social exclusion and inclusion informed by medicalised and social model discourses; basic Occupational Health and Safety guidelines; and awareness of regulatory and reporting requirements for serious incidents and mechanisms of prevention of violence, abuse, neglect and exploitation of both DSWs and service users.

Some participants prefer DSWs with no training

Our research examined the viewpoints of a cohort of 30 adult NDIS participants or plan nominees who are choosing to purchase some or all of their supports from unregistered providers. Our findings showed that some interviewees actually now avoided recruiting DSWs workers that have training and qualifications because of the perceived boxed-in approach to the style of support work they came with, preconditioned attitudes towards people with disability and power differentials that seemed to manifest within the support interaction with DSWs that arrived with training and qualifications. Interviewees also reported experiencing a high churn of DSWs from traditional providers (consistent with findings from Topping et al. (2022) and felt that just because a DSW was qualified, this did not mean they inherently provided safer and a better quality of support – especially with regard to reliability and consistency.

Some interviewees felt that training and professional development provided by RTOs and other service providers did not adequately provide the DSW with skills relevant to the reality of disability service provision. For example, Claire had trained as a DSW herself and found there was nothing in her training about how to support clients with low vision (which was her own specific requirement). Another interviewee noted that she found broader life experience much more useful than formal training.

Interviewees recalled instances where the previously trained but newly employed DSW gave them a false sense of security because they had received training. Some interviewees felt that harmful power dynamics could develop within the DSW support interaction where the DSW had undergone training. This was because a DSW with training could feel that a qualification provided them with a better knowledge of the needs of the participant then the NDIS participant themselves. Interviewees described this as manifesting in DSWs bringing a paternalistic attitude onto their shifts. Another interviewee noted that staff training is often about making sure staff conform to the organisation’s way of working (i.e. filling in the CTARS [the online incident reporting systems that providers use], not up-skilling them.

Interviewees reported that sometimes DSWs with provider professional development training felt the need to adhere to an ‘agency rule book’ while providing support in the home, such as documenting everything extensively and refusing to complete things out of their scope of practice, such as house cleaning.

Some participants prefer to train DSWs

Many interviewees described that they preferred to train up DSWs themselves. This way, DSWs could learn on the job the skills that they specifically needed, and learn that they, as a service user, was an individual disabled person with unique needs (as opposed to a one-size-fits-all disability template). Interviewees who had trained DSWs themselves often felt they had a better reciprocal work-relationship through this process. They noted having better and more direct communication, and valued being able to direct the support routine and also make changes where required.

Interviewees spoke of having a good relationship with their DSWs being crucial and of really needing to be able to trust the person who’s doing that support work. For interviewees such as Yasmin, this was more effectively achieved where they had had the opportunity to train up their own support workers and develop the support work relationship and support interactions from the start. Another interviewee felt that public discourse about training underestimated the capacity of people with disability to undertake their own DSW training. Interviewees also spoke of feeling empowered in being able to train people according to their or their family’s support needs. Several interviewees reflected that each DSW brings their own personality, their own gifts and their own strengths to the support interaction, and having the opportunity to select and train their own DSWs was key in obtaining a feeling of comfort, reassurance and safety in the support interaction.

Training and supervision mechanisms used by interviewees

Our findings showed that interviewees using unregistered providers used various mechanisms to induct, train and supervise their DSWs. Firstly, this included determining the initial suitability of the DSW to work in their home, and with them and their family. While each interviewee reported different processes, this could involve doing one or more meet-and-greets, reviewing CVs, verifying certificates and qualifications, and getting references checks from previous clients. This process sometimes included identifying any gaps that the potential DSW may have in their work history, whether the DSW needed any external units of training to do the role, or whether additional initial supervision might be required for the DSW to understand and complete tasks. Interviewees spoke of using the meet-and-greet to communicate expectations and boundaries to a new DSW. Some interviewees mentioned that the meet-and-greet was a paid hour so DSWs were paid for this time in addition to training time.

Other training mechanisms included using allied health staff to train DSWs, using online collaboration tools as resources, developing their own tik-tok videos to upskill DSWs on tasks and expectations (which meant they did not have to rely purely on conversation and verbal direction). Some interviewees detailed how they developed their own training tools, such as typing up lists of task details, giving firstly more broad and then more detailed directions during the first few shifts, and having both overview and detailed support plans. The latter took account of the reality that DSWs may only be able to take in a certain amount of information at the start, prioritising the most important things first and adding more detail later. Training and direction given by interviewees also included training in how to respond if something goes wrong. Several interviewees described utilising trial shifts or buddy/observation shifts with family members or more experienced DSWs, so that the new DSW could see for themselves and understand routines and how to use hoists and do transfers.

Interviewees also spoke of more abstract and intangible things that needed to be taught and communicated to newer DSWs, not just task descriptions. For example, if a DSW was supporting a client in community activities, learning when to step in and then step back around social interactions, and learning to anticipate if they needed some time out. Another element of self-training and managing DSWs was how to respond when there were issues with the DSW’s work or something did not feel right. Participants emphasised the need to have the confidence to speak up and trust their intuition. As Caleb mentioned, part of having this control over the employment of workers was also knowing how to cut ties when differences became irreconcilable.

Finally, interviewees spoke of the time and effort involved to train a new DSW, when they are ‘spending more time explaining it [tasks] than actually being able to just get on with it’ (Eugenie). However, this was generally considered preferable to needing to ‘untrain’ DSWs with unhelpful prior training and experience.

Discussion

Our findings have demonstrated that a DSW self-training framework taken on by participants themselves can produce good outcomes of quality, retention and safety within the service interaction. Some of our findings suggest the current DSW workforce training frameworks may not be fit for purpose, effective or meeting the needs of service users – the NDIS participants. As our findings highlight, the rationale of some interviewees in actively avoiding the recruitment of DSWs with training and qualifications in community support and disability is of concern. It is clear there is significant disconnect between the expectation of service users and the actual skills that trained DSWs bring to the job.

In training up a DSW, these interviewees reported that they were able to establish and build better, more balanced support interactions and establish a more equal power dynamic in the support interaction. The interviewees highlighted that they worked diligently in trying to keep themselves safe but were not averse to terminating the employment of a DSW where they felt their safety was threatened. This could occur even when there were not strong tangible reasons to terminate the DSW – experience had taught some participants that it was enough of a justification if the service user did not feel safe around the worker.

In undertaking training and ongoing supervision, a level of confidence and capacity in communicating needs and giving directions was an extremely important element. In these scenarios, it was vital that interviewees were able to communicate needs, establish strong and safe parameters around the work interaction, and communicate to the DSW why these support elements were important and needed to be maintained. As one interviewee noted, potentially more vulnerable or less capable NDIS participants may not have the confidence or capacity to conduct their own training and supervision, but for those that did they enjoy the empowerment and improved service outcomes that self training provided.

As noted above, a major issue in the disability support sector is that of worker churn. Our evidence seems to suggest that better training and ongoing supervision undertaken by the interviewees themselves can reduce turnover of DSWs because a) the interviewees felt more comfortable in their support interaction on an ongoing basis, and b) the DSWs had a better understanding of what was required in the role and were thus prepared to stay in the role for a longer period of time. This led to good working conditions where both the worker and the participant felt happier and more respected in the work relationship.

As I write this final paragraph, I am aware that the government response to the NDIS Review report is imminent. In reading the tea leaves, I imagine that there will be some changes and reform to how services in the unregistered service provider space will occur. Whatever these changes, it is vital that NDIS participants are given continued scope, choice and opportunity to undertake innovation and be flexible with how their services are provided, which self training of DSWs offers.

The government response to the NDIS Review report may have broad implications related to future capacity of service users to directly employ and/or train their own DSWs and conditions of the DSW workforce more broadly.

As the peak body for service providers - National Disability Services - has argued, any solutions to these DSW workforce issues must be developed in partnership and led by the sector to be effective (NDS 2022). However, it is clear from the above findings that some NDIS participants have already sidestepped existing formal workforce training frameworks, and with the flexibility enabled by the option to use unregistered providers, are constructing training and supervision mechanisms to meet their own service needs end achieve more improved service interaction outcomes.

Original Report

Dickinson, H., Yates, S., & West, R. (2022) Exercising meaningful choice and control in the NDIS: Why participants use unregistered providers. Canberra: UNSW, Canberra https://www.unsw.adfa.edu.au/sites/default/files/documents/Research-report-on-NDIS-unregistered-providers.pdf

References

Cortis, N and Van Toorn, G. (2020). Working in new disability markets: A survey of Australia’s disability workforce. Social Policy Research Centre, UNSW. https://doi.org/10.26190/5eb8b85e97714

David C and West R (2017) NDIS Self-Management Approaches: Opportunities for choice and control or an Uber-style wild west? Australian journal of social issues, vol 52, issue 4, December 2017, Pages 331-346

MacDonald F, (2021). Individualising Risk: Paid Care Work in the New Gig Economy, Palgrave, McMillan, Singapore Published: 18th May 2021ISBN: 9789813363656

National Disability Services – NDS (2022) State of the Disability Sector Report 2022. National Disability Services, Canberra. https://www.nds.org.au/images/State_of_the_Disability_Sector_Reports/SoTDS_2022.pdf

Taleporos, G. (2023) NDIS Minister National Press Club Address and what you might have missed (it's scary!) https://www.linkedin.com/pulse/ndis-minister-national-press-club-address-what-you-dr-george/?trackingId=gRhdE5PixeIV2BAFDFOGCg%3D%3D

Topping M, Jacinta Douglas & Di Winkler (2022) “They treat you like a person, they ask you what you want”: a grounded theory study of quality paid disability support for adults with acquired neurological disability, Disability and Rehabilitation, 2022 Vol. Published online: 21 Jun 2022; DOI: 10.1080/09638288.2022.2086636

Content moderator Sue Olney