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Correspondence: Address correspondence to Peter Kemper, Department of Health Policy and Administration, The Pennsylvania State University, University Park, PA 16802. E-mail: pkemper{at}psu.edu
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Abstract |
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Key Words: Workforce • Long-term care • Skilled nursing facility • Assisted living facility • Home care • Culture change
Many believe that better management practices, implemented as part of a broader organizational "culture change," can improve the quality of the jobs, reduce turnover, and ultimately improve the quality of care provided (Stone, Dawson, & Harahan, 2003). Yet among the many options that exist, researchers do not know what changes would improve direct care workers' jobs.
We approached this question by analyzing direct care workers' own statements about what would improve their jobs and assessing the implications for management practice and public policy. Specifically, we address two questions: (a) What do direct care workers say is the most important thing that employers could do to improve their jobs? and (b) Do workers' recommendations vary across nursing facilities, assisted living facilities, and home care agencies?
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Background |
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A number of recent workforce initiatives have sought to improve the jobs of direct care workers in long-term care (Harris-Kojetin, Lipson, Fielding, Kiefer, & Stone, 2004; Stone et al., 2003). One of these initiatives was the Better Jobs Better Care (BJBC) demonstration (BJBC, 2002). It was designed to test innovative policies and management practices intended to improve the quality of direct care jobs and improve recruitment and retention of direct care workers.
In response to a competitive request for proposals, the demonstration selected nonprofit agencies leading coalitions of stakeholders in five states—Iowa, North Carolina, Oregon, Pennsylvania, and Vermont—to participate in a 3-year demonstration of a variety of policy initiatives and management practice interventions. The five BJBC projects selected provider organizations (including nursing facilities, assisted living facilities, home care agencies, and adult day service providers) to implement changes in management practices designed to improve direct care workers' jobs. (For additional background on the demonstration, see Kemper, Brannon, Barry, Stott, & Heier, this issue; Stone & Dawson, this issue.)
An evaluation of the demonstration analyzed the effects of the management practice interventions on direct care worker turnover, job satisfaction, and other measures of job quality. Data were collected at baseline and at follow-up at the end of the project. Data sources included an information system that collected hiring and termination data and surveys of clinical managers, supervisors, and direct care workers. This article analyzes the responses to an open-ended question in the baseline survey of direct care workers about what employers could do to improve their jobs.
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Previous Research |
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Direct Care Workers' Perspective
Three published studies asked direct care workers open-ended questions about their jobs. Bowers, Esmond, and Jacobson (2003) interviewed 41 direct care workers in nursing facilities about what their job was like and what led them to feel unappreciated. The authors classified direct care workers' responses as professional minimizing (devaluing their skill), personal minimizing (attacking their character), and professional and personal leveling (inability to distinguish workers based on their skills and their characters, respectively). Management practices identified as minimizing were rotation of direct care workers off of their usual floors, use of pool staff, low wages, and poor relationships with supervisors.
Eaton (1997) interviewed direct care workers in depth as part of her research on the link between quality of jobs and quality of care in nursing facilities. Workers in low-quality nursing facilities identified lack of recognition and respect as problems. They also felt that their jobs entailed too little teamwork, inadequate supplies, too much work, too many patients, and too much paperwork.
As part of a study on supervisor relationships in nursing facilities, McGilton, Hall, Pringle, O'Brien-Pallas, and Krejci (2004) also interviewed direct care workers. They identified personal and professional factors that affected whether supervisors displayed supportive behaviors. These factors included the supervisor's attitude and personality, teamwork, mutual support, breadth of knowledge, ability to delegate, and willingness to share information.
Three other studies were reported in four unpublished state reports. The Nursing Home Community Coalition of New York State (2003) used a combination of focus groups and questionnaires to ask direct care workers in nursing facilities what factors contributed to poor working conditions. The workers' most frequent responses were staff shortages, lack of teamwork among the staff, not being treated with respect, not having trusting relationships with residents and families, not having the tools to do the job, not having a good relationship with supervisors, and not being informed of changes before they are made. The Pennsylvania Intra-Governmental Council on Long-Term Care (2001, 2002) conducted focus groups with 167 direct care workers in a variety of long-term care settings. The factors direct care workers identified as leading to turnover included staff shortages, difficulty of the job, lack of appreciation by the organization, low wages, and lack of training. Finally, Mickus and colleagues (2004) reported on a mail survey of 1,100 current and former direct care workers in nursing facilities and home health agencies in Michigan. Workers at both nursing facilities and home health agencies mentioned low pay, not feeling valued, and personal health concerns as the top factors leading workers to leave direct care work. In addition, nursing facility workers were more likely to mention too many patients, the inability to provide quality care, and unsafe conditions, whereas home health workers were more likely to cite not being able to work enough hours and dissatisfaction with their work schedules.
This study extends previous research in two respects by analyzing a large sample of direct care workers from five states. First, to identify desired changes in management practices, we focused on workers' assessments of what changes employers could make to improve direct care jobs rather than on the problems in the jobs. Second, we extend research beyond nursing facilities by comparing responses of workers in nursing facilities, assisted living facilities, and home care agencies to identify possible differences in desired management practices across settings.
Theoretical Frameworks
Researchers have developed numerous management theories to explain what factors affect employee job satisfaction and performance (see Kreitner & Kinicki, 1998). Two of the most well known are those of Herzberg, Mausner, and Snyderman (1959) and Hackman and Oldham (1980). Although used widely in research, these theories have two limitations for this analysis: (a) They consider factors well beyond changes management can make; and (b) they are designed to apply across a wide range of skill levels and industries, not specifically to long-term care. The long-term care industry differs from many others in its dominant public financing, vulnerable frail or cognitively impaired "customers," and difficult-to-measure quality. However, Eaton (2000) and Hunter (2000) drew on existing management and industrial relations theories to develop frameworks specifically for nursing facilities. Both frameworks focus on management change from the organization's perspective rather than the worker's perspective as this analysis does. Although Eaton and Hunter conceptualized their frameworks quite differently, many of the specific factors they identified are the same.
Eaton (2000) conducted 20 case studies of human resource management practices and their relation to quality of care. Based on the case studies, she identified human resource practices (e.g., staffing, wages and benefits, hiring and selection, and training) and work organization (e.g., teams, work assignments, worker input) as factors affecting quality of care.
Hunter (2000) analyzed the determinants of job quality using data from a survey of Massachusetts nursing facilities. His framework identified three factors that define high-quality jobs: wages and benefits, opportunities for advancement (e.g., training, tuition reimbursement, and formal promotion programs), and new forms of work organization (e.g., teams and employee involvement).
A limitation of both frameworks for this study is their specific focus on nursing facilities. Nursing facilities, assisted living facilities, and home care providers differ in ways that affect the nature of direct care jobs. Understanding three fundamental differences is necessary to interpret differences across settings in workers' recommendations for management changes.
First, care provision in facilities differs from that in homes. Compared with home care, in facility-based care the facility is the center of responsibility for and control of care, interaction with supervisors and coworkers is frequent and in person, the work of one affects coworkers, workers care for multiple residents, and staffing levels affect all workers. Because home care is provided one-on-one to specific clients in their geographically dispersed homes, workers have greater autonomy; scheduling regular, full-time shifts is difficult; and responsibility for scheduling and clinical supervision can be split between two supervisors.
Second, the acuity of persons receiving care affects the intensity of direct care staffing and supervision needed, and the importance of clinical skills and supervision. Typically, the acuity of residents in nursing facilities is greater than in assisted living. Although resident care needs vary widely across individuals receiving home care, acuity is typically lower than in nursing facilities.
Finally, government payment and regulation affect settings in different ways. Most nursing facilities rely heavily on Medicaid reimbursements. Low Medicaid reimbursement rates constrain the financial resources of these facilities compared with: (a) many assisted living facilities, which typically rely more on private payments; and (b) home care, which relies on both Medicare and Medicaid. Nursing facilities also are more heavily regulated than other provider types, which can lead to more formal organizational structures, greater training requirements, and less flexibility to innovate.
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Methods |
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Sample
The population of interest for the study was all direct care workers at providers participating in BJBC. A direct care worker was defined as follows:
An individual who provides hands-on personal care (e.g., assistance with bathing, dressing, transferring and feeding) as a significant part of their job at a nursing facility, home health agency, assisted living organization, adult day center or other personal care organization. Although activities may sometimes overlap, we do not include licensed practical nurses or registered nurses in this definition. Also excluded are workers who help with cleaning, meal preparation and chores, but do not provide personal care. Typical job titles include nurse aide, home health aide, and personal care attendant. However, direct care workers are not limited to these job titles (Kemper, Brannon, & Barry, 2004, p. 1).
We identified workers from an information system developed to provide turnover information to participating providers (Barry, Kemper, & Brannon, in press). The information system tracks hiring, termination, and other information about direct care workers employed by participating providers. Upon enrollment in the demonstration, each provider submitted a list of all currently employed direct care workers. Each provider updated the information system at the end of each pay period with any changes that had occurred since the last update.
Once a provider enrolled, surveys were sent to a list of all of its direct care workers, which was extracted from the information system. Because the list was of current workers, the data do not reflect the perspectives of workers who quit or were fired. Because providers enrolled over time, baseline data collection extended from July 2004 through April 2006.
A total of 3,468 direct care workers completed the survey. Because the number of workers in adult day service providers (n = 54) was too small to analyze separately, we excluded them from the analysis, leaving a sample of 3,414 workers in 122 providers for this analysis. Reflecting differences in the number of providers participating in BJBC, sample sizes varied by state, with the largest being from North Carolina (n = 1,741), followed by Pennsylvania (n = 791), Oregon (n = 326), Iowa (n = 324), and Vermont (n = 232).
The providers included skilled nursing facilities (n = 53), assisted living facilities (n = 33), and home care agencies (n = 36). Because the study was based on providers that volunteered to participate in BJBC, it is not representative of all providers. For example, three fifths of BJBC providers were nonprofit organizations.
About a third of the home care providers were certified home health agencies, and the other two thirds were home care providers that typically provided nonskilled care (sometimes in combination with skilled care). Assisted living facilities as used here includes a range of types of residences that generally provide meals and personal care but not necessarily skilled care. Han, Sirrocco, and Remsburg (2003) referred to these as long-term care residential places. These facilities have different names depending on the state (e.g., assisted living facilities, personal care homes, adult care homes, and residential care). The BJBC providers in this category were diverse. They included, for example, assisted living residences that were part of continuing care retirement communities paid for privately, and adult care homes paid for largely through a combination of Supplemental Security Income and Medicaid.
As expected, the vast majority of direct care workers in our sample were high school educated women (see Table 1). Most other characteristics differed across settings. The median hourly wage was highest in nursing facilities ($10.34) and lowest in home care ($8.25). Health insurance benefits followed a similar pattern: Nursing facilities had the highest proportion of workers offered health insurance and the highest proportion enrolled, and home care agencies had the lowest proportions. Many workers in BJBC had long careers in direct caregiving: The median direct care worker in nursing facilities had spent 7.0 years as a direct care worker and 2.8 years at their current employer, compared with 5.7 and 2.0 years in home care, with assisted living falling in between. More than two fifths of the sample was older than age 45, with home care having the oldest workers and nursing facilities the youngest.
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Direct Care Worker Survey
The survey was an 8-page self-administered paper booklet. It included questions about length of employment, job satisfaction, job rewards and problems, supervision, perceptions of quality of care, job confidence, training, intent to quit, and demographic characteristics. Personalized packets including a survey, informed consent, a $2 bill, and a business reply envelope for all direct care workers were sent to the provider for distribution. The incentive was given up front to everyone because of evidence that it increases response rates more than incentives paid later only to respondents (Church, 1993; James & Bolstein, 1992).
Respondents returned the surveys in the business reply envelopes. Responses were tracked using identification numbers on each survey. To increase response rates, workers received a follow-up packet about a month after the initial packets were distributed. To ensure that the employer did not know who the nonrespondents were, everyone from the original list received a follow-up packet. For nonrespondents, the follow-up mailing included another copy of the survey and reply envelope. Those who had already responded received a thank you letter and a copy of a BJBC newsletter. The second administration increased the response rate by 10 to 15 percentage points.
Coding and Analysis
We obtained direct care workers' recommendations for improving their jobs from responses to the following open-ended question: "What is the single most important thing your employer could do to improve your job as a direct care worker?" The advantage of open-ended survey questions is that they allow respondents to fully express their response, providing more in-depth information than closed-ended questions (Bradburn, Sudman, & Wansink, 2004). Although the analysis of recommendations obtained by asking workers directly is a strength of this study, we should note that their recommendations may not have recognized constraints management faces or changes they are not familiar with. In addition, by asking for the single most important change, the question did not allow for the possibility of indirect or interactive effects or give any weight to secondary recommendations.
We reviewed the text responses to the question and identified themes based on recurring words (or synonyms) in the responses. For example, we identified a communication theme based on responses such as "better communication" and "keep communication open," but we also included responses like "keep us informed of changes" in that category (see Table 2). We then developed written criteria for 16 categories (including a left-blank category for nonresponse) and assigned responses to one of those categories.
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To assess reliability a second investigator coded the responses independently based on the written criteria. The second coder agreed on 90% of the detailed categories and 94% of the aggregate categories.
We estimated the weighted mean percentage of workers making each type of recommendation and compared the means across the three types of providers. When comparing settings, we tested the statistical significance of the difference for each pair of provider types using a t test with a Bonferroni correction for multiple testing.
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Results |
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Increased Compensation
Many workers called for increased compensation, including more pay, better benefits, or the opportunity to work more hours. Workers in home care (39%) and assisted living facilities (36%) were much more likely to say that increasing compensation was the single most important thing that employers could do to improve their jobs than workers in nursing facilities (23%). The differences were even more dramatic among workers who made a recommendation: 63% of home care workers identified compensation compared with 47% in assisted living and 29% in nursing facilities (data not shown).
In all three settings, most workers who mentioned compensation called for increased pay; much smaller percentages identified improved fringe benefits or the opportunity to work more hours. Consistent with their lower percentage with employer-sponsored insurance, home care workers stood out as more likely to call for better fringe benefits than workers in facilities. They also were more likely to identify being able to work more hours as important. This reflects the difficulty of scheduling consistent, full-time work given turnover among clients and the complexity of matching clients with workers within a reasonable distance of their home.
Improved Work Relationships
The work relationship category included a range of responses grouped into six subcategories. The language used more often was personalized and suggested greater intensity of personal concern in three subcategories: listening (e.g., "listen to what I say"), appreciation (e.g., "care about us"), and respect (e.g., "treat us with respect"). Although often not explicit, many of the responses appeared to refer to treatment by supervisors and may have reflected the culture of the organization. The language used in the other three subcategories—improved communication, better supervision, and more teamwork—tended to be less personalized.
Work relationships appeared to be of greatest concern in nursing facilities and of least concern in home care, with assisted living in between. In all, 24% of workers in nursing facilities mentioned work relationships compared with 19% in assisted living and 11% in home care. The high percentage in nursing facilities is consistent with the frequent interactions with peers and more intensive supervision in this setting. Of the six subcategories, direct care workers in nursing and assisted living facilities most often listed improving supervision. The three subcategories about how workers are treated (which, as indicated, at least partly reflect supervisory behavior) also were more often mentioned in nursing facilities: 11% of direct care workers in nursing facilities called for appreciation, respect, or being listened to, compared with only 7% of workers in assisted living and 4% in home care. Although workers in home care mentioned work relationships least often overall, they called for improved communication more often than other aspects of work relationships. This is consistent with the greater difficulty of communicating with workers not on site.
Improved Staffing
Workers in nursing facilities identified hiring more or better staff more often than any other major recommendation category and more often than workers in any other setting. In all, 25% of workers in nursing facilities identified staffing compared with 10% of workers in assisted living and almost none in home care. That home care workers do not identify increased staffing is not surprising given that their own work is largely unaffected by the aggregate staffing in the organization. The lower percentage in assisted living than nursing facilities may reflect the lower acuity of assisted living residents or the higher level of staffing relative to care needs.
Improved Management Systems
This category included recommendations concerning the purchase or maintenance of equipment, the availability of training and continuing education opportunities, the process of setting employees' work schedules, and a variety of miscellaneous changes in work processes. Improving management systems was suggested by a minority of direct care workers ranging from 8% in nursing facilities to 12% in home care. Within the broad category, workers in home care and assisted living called for increased training more often than nursing facility workers—likely due to regulatory requirements for training in nursing facilities. Compared with workers in facility-based settings, home care workers recommended improved scheduling more often, reflecting the greater difficulty of scheduling in home care.
Worker Recommendations in the Context of Theoretical Frameworks
In their theoretical frameworks, Eaton (2000) and Hunter (2000) identified many of the categories of management changes that workers identified. Both identified pay and benefits, worker input (which corresponds to listening), and training. However, they also identified changes that workers did not: organization in teams (both), work assignments (Eaton), formal promotion programs (Hunter), tuition reimbursement (Hunter), and selection (although a few workers identified hiring better workers) and recruitment (Eaton). Workers' failure to mention them is not surprising because workers are unlikely to have experienced such practices or, in the case of recruitment and selection, they may not feel that this affects their own jobs.
At the same time, workers identified some changes not identified in the two frameworks. Most important are the many dimensions of work relationships: respect, appreciation, listening, teamwork, communication, and supervision. The frameworks also did not identify working more hours (which home care workers called for). This is not surprising given that Eaton and Hunter developed the frameworks for nursing facilities.
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Discussion |
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It is the differences across the three settings, however, that stand out in what workers said. For example, although workers in all types of providers mentioned increased pay and improved work relationships as important, the fraction of workers doing so varied greatly across settings. Moreover, workers in different settings differed with respect to the specific subcategories of recommendations they emphasized. As a consequence, although some policies and management strategies for improving jobs apply across the board, some different ones will be needed depending on the setting.
Implications for Management
We base our discussion on averages across providers, focusing on recommendations made most often in each setting, under the assumption that they are most important for managers in general. However, what is relevant to a particular provider will differ depending on the provider's particular circumstances. Because what workers say generally may not apply to specific providers, a good place for managers to start in deciding how to improve jobs is by asking their own workers.
Our findings are also averages across workers. Because what is most important varies across workers, no one type of management change will improve every direct care worker's job. Thus, improving jobs is likely to require a multipronged strategy of management practice changes.
Nursing Facilities
Increasing staffing stands out as a priority for management change in nursing facilities—it was workers' most frequently mentioned change. Another priority should be improving work relationships—especially supervision and whether workers are appreciated, listened to, and treated with respect. Improving relationships through training in communication, supervision, and team building; peer mentoring; and greater involvement of direct care workers in care management decisions are promising management practices that were tested in BJBC. Increasing pay appears to be the third most important change that would improve workers' jobs.
Assisted Living Facilities
Increasing pay stands out as a change managers in assisted living should focus on—a third of workers said increasing pay is the most important change employers could make. Managers should also take steps to improve supervision, as well as other work relationships. Finally, providing more training and increasing staffing are additional changes workers identified that management should consider.
Home Care Agencies
Because care is delivered largely one-on-one in clients' homes, managers in home care face quite different challenges than managers of facility-based providers. Indeed, fewer factors that affect workers' jobs are under management's control. Reflecting this in part, direct care workers in home care were least likely to identify anything that employers could do to improve their jobs. Increasing compensation is by far the most important change that managers can make, as identified by workers. In addition, an important minority of home care workers called for better fringe benefits. Managers should also respond to home care workers' concerns about the number of hours they work, scheduling, and more training.
Implications for Public Policy
For public policy makers, our findings have two related implications. First, government policies that increase direct care workers' pay are important to improving jobs. Low Medicaid reimbursement rates are likely to lead to low pay and high turnover, especially in providers for whom Medicaid payments are a large share of revenue.
Second, policies that increase pay are not the only ones that can improve jobs. For example, government regulatory policies that lead to improved training of direct care workers and their supervisors have potential for improving jobs and reducing turnover. Pay-for-performance policies that emphasize turnover and retention (e.g., those in Iowa and Minnesota; Kane, Arling, Mueller, Held, & Cooke, 2007; Lipson, 2005) or other aspects of direct care workers' job quality in their performance criteria also may be effective. Another policy option is to undertake initiatives for assisted living and home care similar to the Centers for Medicare & Medicaid Services' Nursing Home Quality Improvement Initiative (Kissam, et al., 2003) to offer training opportunities for workers in these settings. In short, multiple policy options other than increasing workers' pay could help improve jobs and ultimately reduce turnover.
Implications for Research
This analysis has identified the management changes that workers say would improve their jobs. However, it has not provided evidence of the effectiveness of these changes in improving retention or quality of care. Managers and policy makers need this evidence to understand whether the management changes have benefits beyond improving jobs. Given the importance of work relationships to direct care workers, research on management practices that improve work relations also is needed. Research planned using the data generated by BJBC will analyze the effects on supervision, turnover, and worker perceptions of quality of care of the changes identified not only in Eaton's (2000) and Hunter's (2000) frameworks, but also by direct care workers themselves.
Finally, our findings have an important implication for researchers: Do not assume that findings from research on nursing facilities apply to other settings. Some findings from nursing facilities, where so-called culture change originated and where most of the research on improving direct care workers' jobs has been done, will apply to other types of providers, but not all findings will. Looking only through the lens of skilled nursing facilities may distort researchers' ability to see what changes are needed in assisted living and especially in home care.
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Footnotes |
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1 Department of Health Policy and Administration, The Pennsylvania State University, University Park.
2 Paraprofessional Healthcare Institute, Bronx, NY.
3 Survey, Statistics, and Psychometrics Core Facility, University of Nebraska, Lincoln.
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