Shining a Light: Examining Similarities and Differences in the Work Psychology of Health Support Workers Employed in Long-Term Care and Home and Community Care Settings

Abstract

Health Support Workers (HSWs) provide up to 80% of care to residents and clients in the long-term care (LTC) and home and community care (HCC) sectors but have received little research attention compared with the regulated professions. The authors explore similarities and differences in the work psychology of HSWs employed in LTC and HCC settings. Data were collected via survey from 276 LTC and 184 HCC HSWs. Descriptive statistics and path analyses were conducted. HSWs in LTC and HCC settings have significant, positive associations between organizational citizenship behaviors directed toward the organization (OCB-Os) and psychological empowerment, as well as intention to stay (ITS) and job satisfaction. For LTC sector HSWs, there are significant relationships between OCB-Os and quality of work life (QWL), ITS and work engagement, and individual performance and both job satisfaction and QWL. For the HCC sector, OCB-Os and ITS are significantly and directly related to organizational commitment. This study has implications for organizations interested in developing targeted interventions to improve the retention of HSWs.

Keywords

Health Support Worker long-term care home and community care work psychology

Introduction

System sustainability in the care of older adults is a growing concern (Spetz, Trupin, Bates, & Coffman, 2015). Health Support Workers (HSWs), also referred to as home care aides, health care aides, or personal support workers, administer a large proportion of care to older people in long-term care (LTC) homes and in the home and community care (HCC) sector. Employee retention of HSWs is recognized as an increasing problem (Faul et al., 2010).

HSWs are not a regulated profession in many jurisdictions, including Canada (Berta, Laporte, Deber, Baumann, & Gamble, 2013). Their role has traditionally been to deliver “supportive” care for basic daily living activities such as dressing, bathing, and light household tasks (Lum, Sladek, Ying, & Holloway Payne, 2010). This role has changed over time and become essential due to the increasing complexity of care required (Castle, 2008; Williams et al., 2009) and new policies encouraging aging at home that sustain older and frailer seniors in their homes longer (e.g., Commission on the Reform of Ontario’s Public Services, 2012). HSWs are essential to the increasing complexity of care required by the elderly (Castle, 2008). In Ontario, unregulated HSWs provide up to 80% of direct patient care to the elderly (Lum, Sladek, Ying, & Holloway Payne, 2010). This research seeks to examine whether differences in the work environment in these sectors in turn affect “work psychologies” and afford insights into ways in which to address issues of worker retention and concerns for system sustainability.

Background

Industrial and organizational (I-O) psychology refers to the science of human behavior relating to work, in which psychological theories and principles are applied to both organizations and individuals in their work environment (Truxillo, Bauer, & Erdogan, 2015). Work in the field of Industrial and Organizational (I-O) psychology has established a sequential relationship whereby features of the work environment impact the formation of work attitudes, which in turn influence work behaviors. Some of these relationships have been studied among regulated workers in health care (Tourangeau, Cummings, Cranley, Ferron, & Harvey, 2010) with a small number focusing on unregulated workers (Faul et al., 2010). Most studies simply examine dyadic relationships such as empowerment (a work attitude) and retention (a work outcome) (Berridge, Tyler, & Miller, 2016).

Whether conducted in health care or other settings, very few studies concurrently consider work environment, work attitudes, and work outcomes (i.e., work environment ←→ work attitudes ←→ work outcomes) (see Beecroft, Dorey, & Wenten, 2008).

Work psychology, which originated in I-O psychology, studies human behaviors in the workplace to create work environments that motivate workers and support positive work outcomes (Kurtessis et al., 2015). The theoretical foundation for work in this area is The Theory of Reasoned Action (Ajzen & Fishbein, 1980), suggesting that work outcomes (e.g., the act of staying with or leaving an organization) are directly related to behavior intentions and work attitudes, which are in turn influenced by perceptions of one’s work environment that are developed through interactions with coworkers, leadership (Kurtessis et al., 2015), and quality of work life (QWL; Sirgy, Efraty, Siegel, & Lee, 2001).

Research on work environments that support good work outcomes has been the focus of studies in other industries (Kurtessis et al., 2015) and in other health care settings (Tourangeau & Cranley, 2006). To our knowledge, no previous empirical studies have examined differences between LTC and HCC, simultaneously considering all the concepts included in this study. The findings of this study can help to further general knowledge of the complex dynamics of work psychology and provide insight into associations between the associations of work environments, work attitudes, and work behaviors for both LTC and HCC HSWs. This study provides new knowledge into the associations between work environment, work attitudes, and work outcomes for LTC and HCC HSWs. These insights can be leveraged to develop tailored health human resource interventions to make positive impacts on work attitudes and outcomes through alterations to work environments. This study is part of a larger program of research which aims to address the sustainability of human health resources as it relates to the care of the elderly and the role of Canada’s “invisible workforce” (Armstrong, Armstrong, & Scott-Dixon, 2008; Hollander, 2006; Hollander & Chappell, 2002; Keefe, Martin-Matthews, & Legare, 2011).

The aim of this work is to explore associations between work environment, work attitude, and work outcome variables.

Design and Method

This study used a cross-sectional research design. In 2015, data were collected on measures identified in Figure 1, via survey, from HSWs working in Ontario LTC institutions and HCC agencies. This study was approved by the University of Toronto’s Human Research Ethics Program Protocol Reference 30742.

Figure 1.

LTC and HCC final path analysis.

Measures

The well-established measures included in this study are presented in Table 1. These measures include QWL, organizational support-supervisor, perceptions of workplace safety, organizational commitment, and intention to stay. Measures for work engagement, psychological empowerment, OCB-Os, and job satisfaction were identical to those used in an earlier psychometric study of these measures for use in LTC and HCC (Ginsburg et al., 2016). A context-specific self-reported measure for individual work performance was developed and used (Zimmerman et al., 2005). Scales and question formats were retained from original instrument authors. Most of the scales ranged from 1 to 5, two scales ranged from 1 to 7, one scale ranged from 0 to 6, and one scale from 1 to 4.

Table 1.

Measures—Work Environment, Attitudes, and Outcomes.

Concept	Measure source
Work Environment
Quality of Work Life	Quality of Work Life Measure (13 items, Scale 1-5; Sirgy, Efraty, Siegel, & Lee, 2001)
Organizational Support-Supervisor	Two items (Scale 1-5) based on supervisor support from eight-item Survey of Perceived Organizational Support (SPOS; Eisenberger, Huntington, Hutchison, & Sowa, 1986)
Perceptions of Workplace Safety	Seven items (Scale 1-5) from the 29-item Western Health Risk Assessment Screening Tool (WHRAST; Lundrigan, Hutchings, Mathews, Lynch, & Goosney, 2010)
Work Attitudes
Work Engagement	Utrecht Work Engagement Survey–9 (UWES-9; nine items, Scale 0-6; Schaufeli, Bakker, & Salanova, 2006)
Organizational Commitment	Organizational Commitment Questionnaire (OCQ; nine items, Scale 1-5; Mowday, Steers, & Porter, 1979)
Job Satisfaction	Subscale from the Michigan Organizational Assessment Questionnaire (MOAQ-JSS; three items, Scale 1-5; Cammann, Fichman, Jenkins, & Klesh, 1983)
Psychological Empowerment	Psychological Empowerment Instrument (12 items, Scale 1-7; Spreitzer, Kizilos, & Nason, 1997)
Work Outcomes
Intention to Stay	Global measure (one item, Scale 1-4) modeled on Beecroft, Dorey, and Wenten (2008).
Organizational Citizenship Behaviors directed toward the Organization	Measures of OCB-O (four items, Scale 1-7; Choi, 2007)
Individual Work Performance	Context-specific; developed in consultation with collaborators (two items, Scale 1-5)

Work environment

Perceived organizational support (POS) refers to the degree to which an organization values employee contributions and cares about their well-being (Rhoades & Eisenberger, 2002). Perceived workplace safety reflects actions taken by organizations to ensure worker safety, which employees then interpret as evidence of the organization’s concern for their safety and well-being (Ayim Gyekye & Salminen, 2007). Although not measured in this study, patient/resident safety is important too and could also influence staff attitudes and behaviors. Perceived QWL stems from the satisfaction of workers’ needs through participation at work (Sirgy et al., 2001). Examples of workers’ needs include health and safety, economic and family needs, social needs, esteem needs, actualization needs, knowledge needs, and aesthetic needs (Sirgy et al., 2001).

Work attitudes

Organizational commitment refers to the positive affect and affiliation that workers develop for their organizations (Meyer, Stanley, Herscovitch, & Topolnytsky, 2002). Job satisfaction is defined as a worker’s positive feelings toward their job per se (Bowling & Hammond, 2008). Work engagement is described as a “positive, fulfilling work-related state of mind that is characterized by vigor, dedication, and absorption” (Schaufeli, Bakker, & Salanova, 2006, p. 702), where vigor refers to high energy levels applied to work and to mental resilience, dedication to work, enthusiasm and inspiration, and being engrossed in one’s work. Psychological empowerment refers to feeling capable of shaping one’s work context and work role (Spreitzer, Kizilos, & Nason, 1997) and comprised four factors: meaning associated with work tasks, feelings of competence and belief in one’s abilities to perform work activities, self-determination concerning control and choice over work behaviors, and observable positive impacts of one’s work behaviors.

Work outcomes

Work outcomes analyzed intention to stay, individual work performance, and organizational citizenship behaviors directed toward the organization. Intention to stay refers to one’s plan to remain with their organization. Individual work performance includes effectiveness and productivity (Koberg, Boss, Senjem, & Goodman, 1999; Spreitzer, 2008). Organizational citizenship behaviors (OCBs) are extra-role behaviors that “support the social and psychological environment in which task performance takes place” (Organ, 1997, p. 95). OCBs directed toward the organization, referred to as OCB-Os, include behaviors such as voice, constructive suggestions, and principled dissent. Often referred to as “challenge-oriented,” these behaviors are intended to benefit the organization (Podsakoff, MacKenzie, Paine, & Bachrach, 2000). Since LTC and HCC environments are often resource-constrained, OCB-Os may be of special interest to leadership since these behaviors are linked empirically to workplace proactivity, creativity, innovation, task performance, and job satisfaction (Van Dyne & LePine, 1998) while influencing organizational performance outcomes (Choi, 2007).

Sample and Survey Administration

Interested LTC home operators and HCC agencies responded to an invitational e-mail from collaborators and identified their preference for paper or electronic surveys. Paper surveys were mailed directly to LTC homes and HCC agencies which were then distributed to HSWs employed there. For electronic distribution of surveys, a message developed by researchers containing an embedded link to the e-survey was distributed via collaborators directly to interested agencies and operators who then forwarded the message to their HSWs. A modified Dillman approach was used (Blair, Czaja, & Blair, 2014; Dillman, 2000). Reminder e-messages were sent to agencies and 22 operators at 1, 3, and 4 weeks after the first invitational e-message. Upon completion of the survey, respondents were offered the opportunity to participate in a random draw for modest prizes (e.g., gift cards); contact information for the draw was collected and stored separately from completed surveys.

Data Collection

Paper survey respondents returned their forms anonymously by mail. Responses were double-entered upon receipt. Responses to the electronic survey were collected through FluidSurveys and were anonymous. Electronic responses had no missing data. Missing data for paper surveys ranged from 2.2% to 22.2% for response items. Pairwise deletion was used to preserve as many responses as possible.

Data Analysis

Descriptive statistics and Spearman correlations were generated using IBM SPSS Statistics 22. Path analysis was conducted using LISREL 9.1 to examine interrelationships among the constructs identified in Figure 1. Path analyses avoid the requirement for mediation analyses using separate regressions (Baron & Kenny, 1986). Normality assumptions of maximum likelihood estimation (the default estimation method used by LISREL) for all variables were met.

Goodness of fit for each model was evaluated by reviewing fit statistics. One test of model fit (chi-square [χ²]) and five goodness-of-fit indices were assessed: root mean square error of approximation (RMSEA); standardized root mean square residual (SRMR); goodness-of-fit index (GFI); comparative fit index (CFI); and normed fit index (NFI). These indices tend to be the most accurate reflection of model fit (Kline, 2013). Determination of goodness of fit was based on the accumulation of evidence across five of the statistics/indices. Although a nonsignificant chi-square test was preferred, this test is sample size sensitive, affected by the correlation size in the model, and often too powerful for most research studies (Meyers, Gamst, & Guarino, 2013). Less conservative approaches suggest that adequate fit is indicated by cutoff values of .08 for RMSEA, .08 for SRMR, and .90 for GFI (Byrne, 2014; Meyers et al., 2013). Since this is an exploratory study, modification indices were also examined to identify additional relationships not identified by our literature review.

Results

Response Rate

In total, 1,616 surveys were requested (paper surveys) or accessed (eSurveys). “Accessed” surveys reference instances where an individual clicked on the survey link provided in the e-mail. In total, 180 paper surveys sent to HCC agencies; survey link accessed by 170 HSWs employed by HCC agencies; 600 paper surveys sent to LTC homes; and survey link accessed by 666 HSWs employed by LTC homes. Of the total, 460 of the surveys were usable: 183 electronic surveys (88 from HCC and 95 from LTC) and 277 paper surveys (96 from HCC and 181 from LTC). This gave a 28.5% response rate.

This relatively low response rate was expected due to the indirect means of survey administration and communication, as well as the sensitive nature of the survey questions regarding one’s workplace.

Respondents

A summary of respondent characteristics is presented in the upper part of Table 2. For both the LTC and HCC samples, the majority of respondents were middle aged, college educated, and female. In Canada, Colleges offer full-time and part-time diploma and certificate programs. Many also offer bachelor’s degrees in applied areas of study. Colleges tend to be more directly career-oriented than universities. This means that they offer practical or hands-on training. Generally, a certificate program is 1 year or less, and a diploma program is 2 or 3 years. Universities are institutions that can grant degrees. All universities have undergraduate (bachelor’s) degrees, and many have graduate (master’s and doctoral) programs. Universities in Ontario are independent.

Table 2.

Respondent Characteristics, Scale Means, and Standard Deviations.

Respondent characteristic	LTC% sample	LTCn	HCC% sample	HCCn
Age (years)
≤29	15.1	265	9.4	181
30-39	14.7	265	18.2	181
40-49	30.9	265	21.5	181
50-59	32	265	38.7	181
≥60	7.2	265	12.2	181
Female	92.4	263	93.9	180
Immigrated to Canada	28	264	45.9	181
English First Language	81.3	272	61	182
Work experience as HSW (years)
≤2	10.7	272	15.3	183
3-10	32.8	272	47	183
11-20	37.5	272	26.2	183
>20	19.1	272	11.5	183
Highest education level
Grade school	1.1	273	2.7	183
High School	27.5	273	21.3	183
College	64.8	273	59.6	183
University	6.6	273	16.4	183
Employment status
Full-time	51.3	275	34.1	182
Part-time	42.1	275	38.5	182
Casual^a	6.5	275	27.5	182
Measures (Scale)	LTCM (SD)	LTCn	HCCM (SD)	HCCn
Intention to Stay (1-4)	1.28 (0.72)	272	1.27 (0.71)	181
Perceived Organizational Support (1-5)**	2.18 (1.02)	268	1.85 (0.80)	182
Perceptions of Safety (1-5)**	2.98 (0.78)	254	2.58 (0.55)	171
Quality of Work Life (1-5)	2.67 (0.66)	212	2.57 (0.65)	146
Work Engagement (0-6)**	1.07 (1.00)	265	0.70 (0.83)	180
Job Satisfaction (1-5)	1.93 (0.82)	273	1.84 (0.75)	177
Organizational Commitment (1-5)	2.13 (0.77)	255	2.03 (0.70)	170
Psychological Empowerment (1-7)	2.73 (1.16)	224	2.61(0.94)	142
OCB-O (1-7)	3.40 (1.09)	248	3.50 (0.93)	158
Individual Performance (1-5)	1.60 (0.62)	270	1.56 (0.48)	179

Note. Total LTC = 276; Total HCC = 184. LTC = long-term care; HCC = home and community care; HSW = Health Support Worker; OCB-O = Organizational Citizenship Behavior directed toward the Organization.

In Canada, “casual” workers are hired for specified periods that may not exceed 90 working days in one calendar year in a department or agency (Government of Canada, 2015).

p < .01.

Just under 30% of the LTC sample had immigrated to Canada, compared with almost 50% of HSWs had immigrated to Canada in the HCC sample. English was the first language for over 80% of the LTC sample, compared with just over 60% for those employed in HCC. Over 50% of the LTC sample worked full-time, compared with just over 30% for the HCC sample. It is also interesting to note that almost 30% of the HCC respondents were “casual” employees, compared with just over 5% for LTC.

Scale Reliabilities and Factor Analyses

All scales had acceptable reliability with Cronbach’s alpha >0.7. Factor analysis demonstrated that all measurement models met the fit criteria indicated by cutoff values of at least .08 for RMSEA or SRMR and .90 for GFI, NFI, and CFI (Byrne, 2014; Meyers et al., 2013).

Descriptive Statistics

Response means and standard deviations for each of the measures are presented in the lower part of Table 2. Low mean scores represent favorable responses (e.g., “Strongly Agree”).

There were no significant differences between HSWs employed in the LTC and HCC sectors on any of the three work outcome variables. For the individual performance outcome, the mean response is positive, whereby respondents “Strongly Agree” that they provide acceptable and high quality of care to residents/clients. The mean response for intention to stay suggests that most respondents “Strongly Agree” that they plan on remaining with their organization indefinitely. The mean response score for OCB-Os is slightly positive, that is, above neutral.

For work environment, significant differences were observed between the mean scores for LTC homes and HCC agencies for POS and perceptions of safety. HCC agency HSWs “Strongly Agree,” while HSWs in LTC homes “Agree,” that they receive strong supervisory support. HCC agency HSWs “Agree” they are comfortable with the current safety climate, whereas the mean response of HSWs employed in LTC homes tends toward “Neutral.” Both HCC and LTC workers “Agree” that they have good QWL.

Only one significant difference was found between the work attitudes of HCC agency HSWs and LTC home HSWs. On the Work Engagement scale, HCC workers appear to be “Always” engaged, or engaged daily, while LTC workers are engaged “Very Often,” referring to only a few times per week. Both HCC and LTC “Strongly Agree” that they are satisfied with their jobs and feel empowered. Both HCC and LTC workers “Agree” that they are committed to their organization.

The majority of the correlations between study variables are significant and positive (see Table 3) with a few exceptions. The exceptions for both LTC and HCC include the following nonsignificant correlations: intention to stay and psychological empowerment; intention to stay and OCB-O; and perceptions of safety and OCB-O. The exception for LTC homes, the correlation between OCB-O and performance, is also not significant, and for HCC, the correlations between intention to stay and performance, organizational support and OCB-O, and work engagement and OCB-O are all nonsignificant.

Table 3.

Spearman’s Rho Correlations.

		1	2	3	4	5	6	7	8	9	10
Long-term care
1. Intention to Stay	CC	1.000
1. Intention to Stay	n	272
2. Organizational Support	CC	.155*	1.000
2. Organizational Support	n	264	268
3. Perceptions of Safety	CC	.183**	.473**	1.000
3. Perceptions of Safety	n	250	248	254
4. Quality of Work Life	CC	.292**	.602**	.607**	1.000
4. Quality of Work Life	n	210	207	198	212
5. Work Engagement	CC	.256**	.419**	.352**	.590**	1.000
5. Work Engagement	n	261	260	245	205	265
6. Job Satisfaction	CC	.289**	.466**	.449**	.643**	.574**	1.000
6. Job Satisfaction	n	269	266	251	210	262	273
7. Organizational Commitment	CC	.317**	.578**	.453**	.611**	.537**	.696**	1.000
7. Organizational Commitment	n	251	251	241	201	246	253	255
8. Psychological Empowerment	CC	.110	.261**	.281**	.378**	.194**	.329**	.329**	1.000
8. Psychological Empowerment	n	220	218	210	177	217	221	207	224
9. OCB-O	CC	.104	.267**	.048	.292**	.310**	.198**	.226**	.469**	1.000
9. OCB-O	n	245	242	232	196	239	246	233	210	248
10. Performance	CC	.180**	.283**	.239**	.382**	.251**	.472**	.443**	.312**	.088	1.000
10. Performance	n	266	263	249	208	259	267	250	219	243	270
Home and community care
1. Intention to Stay	CC	1.000
1. Intention to Stay	n	181
2. Organizational Support	CC	.159*	1.000
2. Organizational Support	n	179	182
3. Perceptions of Safety	CC	.280**	.368**	1.000
3. Perceptions of Safety	n	168	169	171
4. Quality of Work Life	CC	.313**	.434**	.428**	1.000
4. Quality of Work Life	n	144	145	138	146
5. Work Engagement	CC	.208**	.290**	.232**	.485**	1.000
5. Work Engagement	n	177	178	167	145	180
6. Job Satisfaction	CC	.353**	.348**	.410**	.583**	.569**	1.000
6. Job Satisfaction	n	174	175	165	140	174	177
7. Organizational Commitment	CC	.380**	.524**	.518**	.657**	.366**	.673**	1.000
7. Organizational Commitment	n	168	169	161	139	167	166	170
8. Psychological Empowerment	CC	.038	.208*	.295**	.249**	.337**	.432**	.381**	1.000
8. Psychological Empowerment	n	139	140	135	116	141	137	136	142
9. OCB-O	CC	.053	.134	.154	.194*	.084	.208**	.305**	.409**	1.000
9. OCB-O	n	155	156	148	129	155	154	147	124	158
10. Performance	CC	.074	.304**	.258**	.246**	.303**	.442**	.579**	.433**	.220**	1.000
10. Performance	n	176	177	166	142	175	172	165	138	153	179

Note. CC = correlation coefficient; OCB-O = Organizational Citizenship Behavior directed toward the Organization.

Correlation significant at .05 level (two-tailed); **Correlation significant at .01 level (two-tailed).

Path Analyses

The path analyses output for both LTC and HCC, including standardized coefficients, are presented in Figure 1. Thick red lines indicate relationships identified in LTC survey respondents, while thick green lines represent relationships identified in HCC survey respondents.

Both models afford good fit to the data. For LTC, χ² = 58.987 (p = .0001, df = 24), RMSEA = 0.0727, SRMR = 0.0431, NFI = 0.964, CFI = 0.978, and GFI = 0.960. The LTC model accounts for 10.9% of the variance in intention to stay, 23.4% of the variance in OCB-O, and 20.5% of the variance in individual performance. For HCC, χ² = 31.123 (p = .0193, df = 17), RMSEA = 0.0672, SRMR = 0.0438, NFI = 0.967, CFI = 0.984, and GFI = 0.965. The HCC model accounts for 17.1% of the variance in intention to stay and 19.3% of the variance in OCB-O.

Work outcomes

For HSWs in both the LTC and HCC settings, OCB-Os are significantly and positively associated with psychological empowerment (.414, p < .001; .439, p < .001). For HSWs employed in LTC settings, OCB-Os are also significantly and positively associated with the variable QWL (.211, p < .001). For HSWs in HCC settings, OCB-Os are also significantly and positively associated with organizational commitment (.170, p < .001). In both the LTC and HCC settings, intention to stay among HSWs is significantly and positively associated with job satisfaction (.216, p = .002; .413, p < .001). In the LTC setting, intention to stay is also significantly and positively associated with work engagement (.155, p = .026). In the HCC setting, intention to stay is significantly and positively associated with organizational commitment (.160, p = .001). For HSWs in LTC settings, individual performance is significantly and positively associated with QWL (.273, p < .001) and job satisfaction (.236, p < .001). Several work attitudes of HSWs in both the LTC and HCC settings are associated with work environment. Organizational commitment is significantly and positively associated with QWL (.222, p < .001; .169, p < .005) and organizational support (.196, p < .001; .275, p < .001). Job satisfaction is significantly and positively associated with QWL (.271, p < .001; .260, p < .001) and perceptions of safety (.225, p < .001; .202, p = .001). Finally, work engagement is significantly and positively associated with QWL (.346, p < .001; .435, p < .001).

Work attitudes

In both the LTC and HCC settings, several work attitudes are interrelated. Organizational commitment is significantly and positively associated with job satisfaction (.508, p < .001; .407, p < .001). Job satisfaction is significantly and positively associated with work engagement (.344, p < .001; .416, p < .001).

Work environment

For HSWs in both the LTC and HCC settings, several characteristics of the work environment are interrelated. Perceptions of safety are significantly and positively associated with QWL (.294, p < .001; .248, p < .001). QWL is significantly and positively associated with organizational support (.288, p < .001; .238, p < .001).

Discussion

The work environment impacts the formation of work attitudes, which in turn influence work behaviors. The finding that no significant differences were found between HSWs employed in the LTC and HCC sectors on any of the three work outcome variables (i.e., intention to stay, individual work performance, and OCBs) is important for health care leadership in Ontario to note. Although the two samples have similar outcomes, their paths of getting there are quite different, or in other words, the drivers by which work outcomes are influenced are quite different. Thus these findings can help leadership determine where best to focus resources 1to achieve the outcomes they desire.

Significant Differences Between Mean Responses

Perceptions of support, safety, and work engagement were significantly poorer for HSWs in LTC compared with HCC.

Perceptions of support

The divide between regulated (e.g., nurses) and unregulated (e.g., HSWs) staff in LTC homes has been previously reported, with some nurses viewing HSWs as a threat to their roles (e.g., Workman, 1996). The lower perceived support identified by HSWs in LTC homes may be attributed to the tensions between nurses and HSWs working together or simply that the nature of the work may be more demanding in terms of greater complexity of care in relation to average patient cared for in HCC. In HCC, there is likely less of a power differential since HSWs do not work alongside nurses, and their supervisors are more likely to be experienced HSWs. This may be something worth examining for leadership in LTC homes, to better understand the cause of this and perhaps identify potential solutions to enhance POS.

Safety

The lower perceptions of safety identified by HSWs in LTC homes may be attributed to the increased complexity of residents that necessitates their placement in a LTC home. In addition to the greater acuity that is found in LTC, the Canadian Mental Health Association identified that between 80% and 90% of older adults living in LTC facilities have some form of mental disorder (Canadian Mental Health Association Ontario, 2007). LTC home leadership may want to consider this finding to better understand the situation and determine whether additional training and/or policies could improve perceptions of safety.

Work engagement

In LTC homes, working alongside nurses, there is low autonomy, an abundance of rules, and a narrow “scope of practice” for HSWs. Compared with HSWs in HCC, although rules exist, no one is necessarily “looking over their shoulder.” There is much higher autonomy and HSWs are more likely to have a slightly larger scope of practice.

Differences in Pathways Between LTC and HCC

Only in the LTC setting did the work environment of HSWs (specifically QWL) directly impact work outcomes (individual performance and OCB-O). Perhaps the differences in associations between HSWs working in LTC versus HCC are attributed to the constraints of working within a formal institution, the physical confines or “walls” of an organization, and its associated political landscape. In contrast, HCC workers are not restricted to a single institution, part of an immediate team, or under direct supervision at point of care. Further research is required to determine whether this also accounts for the differences identified when examining the direct impact of work attitudes on work outcomes; specifically, in the HCC setting, the association of HSW organizational commitment with intention to stay and OCB-O, and in the LTC setting, the association between HSW job satisfaction and individual performance and between HSW work engagement and intention to stay. Gaudenz, De Geest, Schwendimann, and Zúñiga (2017) also identified that intention to leave showed strong inverse relationships with affective organizational commitment. It is also worthwhile noting that Myers, Rogers, LeCrone, Kelley, and Scott (2016) identified key sources of stressors in nursing facilities which may not be the case out in the community.

Implications

Shared pathways

For both subsamples, QWL is associated with job satisfaction, which is associated with intention to stay. A generic health and human resource program (HHRP) aiming to combat turnover might focus on enhancing perceptions of QWL by engaging staff in discussions or inquiring about their aspirations and interests. Even implementing simple policies that demonstrate the organization is interested and cares about employee health and well-being can be beneficial since results demonstrate this is directly and positively associated with job satisfaction.

Also applicable to both samples, perceptions of safety are related to job satisfaction, which in turn is related to intention to stay. A generic HHRP might focus on simple, cost-effective solutions such as encouraging the reporting of safety concerns, ensuring appropriate training and education with respect to violence prevention, and improving communication strategies between staff about patients with a history of aggression or violence.

Different pathways

LTC leadership may want to consider focusing on the work environment, since it is likely easier to modify than work attitudes. Specifically focusing resources on improving QWL, our findings suggest, will impact individual performance and OCB-Os directly and intention to stay indirectly through work engagement. Focusing resources on safety initiatives and improving supervisor support may also be beneficial since both are directly associated with QWL. Initiatives to enhance supervisor support include providing training, giving advice, as well as providing feedback and assistance as needed.

HCC leadership, however, may want to consider a HHRP that focuses on enhancing organizational commitment, since this is shown to be directly associated with OCB and intention to stay. However, since work environment is likely more easily modified than work attitude, HCC leadership may want to focus resources on QWL and supervisor support, since these are directly associated with organizational commitment.

Limitations

HSW respondents were accessed indirectly which challenged recruitment, as reflected in the modest participation rate. There is the potential for common methods bias from the use of self-report survey data (Meade, Watson, & Kroustalis, 2007). Demographic differences exist between the two samples, which could influence study measures. The study was conducted in Ontario, Canada, thus findings may not necessarily be generalizable in other settings. Although confidential, the sensitive nature of the survey questions regarding one’s workplace should also be noted.

Future Research

Further exploration is required on the impact of demographic and geographical differences, financial compensation (e.g., wages, benefits, and expense reimbursement), job security, and scheduling on HSW attitudes and their potential impact on work outcomes. More objective outcome measures, such as actual staff turnover, should be considered. Finally, future research could explore whether findings for HSWs differ from other professions who work in LTC/HCC, such as nurses.

Conclusion

Novel insights are gained into the differences in work psychology of HSWs employed in LTC and HCC settings in Ontario, Canada. Generally, considered a homogeneous group of workers, this study helps to identify differences between these two groups of workers in Ontario. The study results can help LTC and HCC leadership determine where best to focus resources to help improve employee retention while driving system performance, enhancing patient safety, and improving the overall quality of care received by older adults.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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