Most of us will never do what a personal support worker does on an ordinary Tuesday. We won’t hold someone’s hand while they take their last breath, then finish the shift, clock out, and come back the next morning to do it again. PSWs do this routinely. It’s time we talked honestly about what that costs them.

(You’ll see PSWs called “care aides” in a lot of the research I’m drawing on here…. same job, different label depending on where the study was done.)

PSWs deliver somewhere between 70 and 90 percent of the hands-on care in long-term care homes. Sit with that for a second. That’s not a footnote, that’s the whole story. These are the people who actually shape what someone’s final days feel like. And yet the role comes with almost none of the structure you’d expect for work this heavy. No standardized training across the board. No legally defined scope of practice. No college, no conduct code, nothing holding the profession together the way we hold together nursing.

Most PSWs are women. A lot are over 40. In cities across high-income countries, a big share are migrant women, often speaking English as a second language, and Canada is no exception. That’s not incidental. It tells you something about whose labour we’ve quietly decided doesn’t need protecting.

What the Job Actually Asks of Them

Forget end-of-life care for a second and just look at an average shift. Verbal abuse, even violence, from residents isn’t rare…. it’s expected, almost baked in. Add bullying and incivility from coworkers on top of that. Time pressure means tasks get rushed or skipped, not because anyone’s cutting corners on purpose, but because there simply isn’t enough time built into the day. And the training meant to prepare people for all of this? By most accounts, it isn’t enough.

Here’s the part that actually stopped me. PSWs are often taught to keep emotional distance from residents. Not because distance is healthy, but because it’s the only coping strategy anyone’s handed them. Get close enough to give good care. Stay far enough away that it doesn’t wreck you. Nobody teaches you how to hold both of those at once, so people improvise. And improvising with something this heavy has a cost.

The Grief Nobody Names

Long-term care is becoming the place where people die. Projections suggest it’ll be the primary place of death for older adults by 2040. Which means the people working there aren’t occasionally brushing up against death…. they’re immersed in it, week after week, year after year.

And still, there’s almost no formal support for the grief that comes with that. Death gets folded into the job description, something you’re just supposed to absorb quietly. One study said it plainly: death is hidden within the culture of these homes, even while it’s happening constantly inside them. People have been naming this problem for years and very little has actually shifted. So PSWs lean on each other, and on whatever resilience they can scrape together on their own, because the institutions around them haven’t built anything sturdier to lean on instead.

You can guess what that produces. Burnout. High turnover. Something researchers call moral distress, which really just means knowing exactly what good care would look like and not having what you need to give it.

What COVID Made Impossible to Ignore

This particular research was collected before the pandemic, but it reads differently now, because we know what came after. Canadian long-term care homes saw the highest excess death rates in the world during COVID. PSWs who were already under-trained and under-supported for end-of-life care were suddenly living through death at a scale nobody had prepared them for.

That doesn’t make the pre-pandemic findings outdated. If anything, it shows you how thin the support already was before things got worse.

So What Do We Actually Do About This

I don’t think this needs another awareness campaign. It needs action at three levels, and honestly, all three matter.

For the individual PSW, training needs a real overhaul, not a tweak. The people doing this work described a mindset of “just keep going,” which is emotional labour wearing a different name. Some researchers call it surface acting, or “hiding behind your smile.” Worth saying plainly: PSWs are also expected to provide grief support to families after a death, a task nobody hired them for and nobody trained them for either. If that’s genuinely part of the job, it needs to be part of the training. And hiring should look for people who already have some grounding in what this environment demands, instead of handing untrained people the deep end and hoping they figure it out.

For the institutions, this takes an actual culture shift, not a memo circulated once and forgotten. Death needs to be acknowledged as central to the work, not hidden from it. Staff need real permission to grieve, without guilt attached, and without the quiet implication that grieving means you’re not cut out for this. The research keeps landing on the same point: good end-of-life care takes real effort from staff, and that effort falls apart without training and without genuine collaboration across the care team. Homes need actual bereavement policies, not just as a nice-to-have per facility, but built into how care systems operate at a broader level.

For the rest of us, we need to get more comfortable talking about death, period. Death Cafes, community conversations, university courses that actually engage with dying instead of skating past it…. these are steps in the right direction, but they need to widen enough to include the people who deal with death professionally and constantly. National dementia strategies especially should be building end-of-life preparedness into the workforce plan from day one, not tacking it on as an afterthought.

Where This Leaves Us

This study is one piece of a much larger, growing body of work trying to understand what it’s actually like to be a PSW sitting with dying residents. And it confirms what a lot of other research has already found: the trauma is real, the preparation is inadequate, and the support is close to nonexistent.

A couple of honest limitations worth naming. This was a case study on one floor within a larger facility, so while participants talked about experiences across different settings, the findings come from a narrower slice than the whole industry. And the participants were mostly white, while the PSW workforce in Canada, the US, and the UK is considerably more diverse than that. Future research needs to actually go find those voices, not just the ones easiest to reach.

None of that changes the core point. PSWs carry an enormous amount for very little institutional support, and it shows up in their bodies, their turnover, their burnout. If we want better end-of-life care in long-term care, and I think most of us do, we have to actually equip and support the people delivering it. That means real training in the emotional weight of the work, real permission to grieve, and enough cultural willingness to talk about death instead of tucking it out of sight. These are the people present at the end of someone’s life. They deserve to be trained for it, supported through it, and seen.

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