The Association Between Psychosocial Work Environment and Satisfaction With Old Age Care Among Care Recipients

Abstract

This study examines the association between nursing assistants’ perceptions of their psychosocial work environment and satisfaction among older people receiving care in nursing homes and home care. Cross-sectional surveys were conducted among people receiving care (N = 1,535) and nursing assistants (N = 1,132) in 45 nursing homes and 21 home care units within municipal old-age care. Better psychosocial work environment was related to higher satisfaction in old-age care among the recipients. Significant and stronger associations were more common in nursing homes than in home care. Perception of mastery and positive challenges at work were associated with higher recipient satisfaction both in home care and in nursing homes: social climate, perception of group work, perception of mastery, and positive challenges at work only in nursing homes. Findings suggest that recipient satisfaction may be increased by improving the psychosocial work environment for nursing assistants, both in nursing homes and in home care.

Keywords

satisfaction with care psychosocial work environment old-age care staff nursing assistants nursing homes home care

Introduction

The Swedish population is aging, as in many other countries in the world. As the growing number of care-dependent older persons increases, the need for old-age health care services also increases (Blix, 2013). The number of persons 80 years and older will increase by 76% between the year 2015 and 2035 (Statistics Sweden, 2016). Consequently, there is a high demand for qualified staff to work with older people; however, nearly 50% of nursing assistants in Sweden have considered terminating their employment in old-age care because of poor working conditions in nursing homes and home care (Szebehely, Strantz, & Strandell, 2017).

High quality interactions between recipients of care and nursing assistants are likely to affect recipients’ perceptions of care. Nursing assistants are the frontline of care and as a result, their actions are often the primary focus of what recipients perceive as old-age care. According to Szebehely et al. (2017), nursing assistants’ work environment can be assumed to have an impact on their provision of care and social services and thus, in turn, on satisfaction among recipients of care. A healthy work environment might therefore be important both for those receiving old-age care and for nursing assistants. People who feel well, physically and mentally, also perform their jobs well.

Psychosocial Work Environment and Satisfaction With Old Age Care Among Recipients of Care

Sikorska-Simmons (2006) noted that a good working environment for staff contributes to better satisfaction among recipients of care in nursing homes and concluded that future studies should examine which work-related attitudes are the most relevant to resident care outcomes. The results of a nationwide survey about satisfaction among recipients of care in Sweden demonstrated that recipients’ satisfaction in old-age care was essentially based on interpersonal aspects of care, for example, influence, respect, and information (Kajonius & Kazemi, 2016). These interpersonal aspects are important due to their indirect effects on frontline workers (e.g., nursing assistants; Bishop et al., 2008). It has been shown that in nursing homes, there is a significant association between job satisfaction and quality of care as assessed by care professionals (Castle, Degenholtz, & Rosen, 2006). Regarding different aspects of perceived psychosocial work environment among staff, more role conflict, less job satisfaction, and exhaustion have been associated with lower satisfaction among recipients of care (Tzeng, Ketefian, & Redman, 2002). A higher level of job satisfaction in subordinates was found to have a significant positive relationship with satisfaction among recipients of care in both nursing homes and home care (Chou, Boldy, & Lee, 2003; Hasson & Arnetz, 2011; Sikorska-Simmons, 2006). Furthermore, Hasson and Arnetz (2011) suggested that “nursing staff behaviour and their competence are important factors influencing care recipients’ and relatives’ overall quality ratings, regardless of care setting” (p. 1432).

The relationships between psychosocial work environment of staff and satisfaction among recipients of care might be affected by the severity of health conditions among older persons. Over the past decades, hospitals in Sweden have decreased the number of available beds with nearly 30% between the year 2009 and 2016 (Statistics Sweden, 2014; Swedish Association of Local Authorities and Regions, 2017). This fact, combined with the increasing number of older people, has led to more seriously ill older people receiving nursing home and home care (Statistics Sweden, 2016; National Board of Health and Welfare, 2017b). Schön, Lagergren, and Kåreholt (2016) argued that these changes have reduced older adults’ length of stay in nursing homes (until death) by 22.1% between 2006 and 2012.

The Organizational Context: Nursing Homes and Home Care

The municipal social services provide old-age care in basically two different contexts: in the private home of the older person (home care) and in institutions (nursing homes). In Sweden, nursing assistants in home care and in nursing homes are recommended by the National Board of Health and Welfare (2011) to have an upper secondary (i.e., training in a vocational high school) or intermediate (i.e., junior college) education.

Nursing assistants in home care provide assistance through activities such as performing personal care, facilitating activities of daily life (ADL), treating wounds and administering prescribed drugs and injections (insulin) in the private homes of the older person (Szebehely & Trydegård, 2012). Because of the diversity of care needs, the work done by nursing assistants can vary from a quick visit (e.g., scheduled status check-up or delivering Meals-on-Wheels) to comprehensive health and social care of older adults with multiple chronic diagnoses (Hjalmarson, Norman, & Trydegård, 2004). Nursing assistants in home care generally work alone in large geographic areas, and the physical distance between recipients, their coworkers, and their first-line managers is large, resulting in more autonomy but also more isolation. Furthermore, nursing assistants in home care more often make quick visits to older people while nursing assistants in nursing homes have more continuous interactions with care recipients. Similar social and medical care is provided to older people by nursing assistants in nursing homes, but older individuals in nursing homes often have more ADL limitations, require more advanced care and have more morbidities than older people receiving home care (Ernsth Bravell, Berg, & Malmberg, 2008). Nursing assistants in nursing homes work together within a single building and, compared with those in home care, are physically closer to their work colleagues, their first-line manager and the older people in need of health care and services. These fundamental environmental differences (physical distance/proximity and working in nursing homes versus home care) play an important role in assistants’ daily work experience.

To improve satisfaction among recipients of old-age care, it is important to understand which work-related factors influence nursing assistants’ psychosocial work environment and whether there are differences and similarities between nursing homes and home care (Sikorska-Simmons, 2006).

The Present Study

Previous studies have shown the importance of a good psychosocial work environment for nursing assistants’ intention to do high quality work (Szebehely et al., 2017), and that recipients’ satisfaction in old-age care is based on interpersonal aspects of care (Bishop et al., 2008; Kajonius & Kazemi, 2016). However, there are environmental differences between the settings (e.g., nursing homes vs. home care; Szebehely & Trydegård, 2012; Lundgren, Ernsth Bravell, & Kåreholt, 2016). In the present study, we assessed the associations between psychosocial work environment factors and satisfaction among recipients in old-age care using a wide range of variables regarding both recipients’ satisfaction and nursing assistants’ psychological work environment. More specifically, we address the following questions: “Does nursing assistants’ psychosocial work environment have an impact on recipients’ satisfaction in old-age care?” and “Are there differences in such associations between nursing homes and home care?”

Method

Participants and Procedures

This study used a cross-sectional design, and the analyses were based on two validated questionnaires that were distributed to all nursing assistants and to all persons aged ≥65 years who received old-age care in a southern municipality in Sweden. In 2012, the questionnaires were mailed to 45 nursing homes and 21 home care units. Nursing homes and home care units that were located in the same building were excluded from the data (n = 4). This procedure was done to remove the impact of mixed settings in the analysis. First-line managers were instructed to provide one questionnaire to each nursing assistant (Questionnaire for Psychosocial and Social factors at work [QPS]) and one questionnaire (Recipient Satisfaction Questionnaire [RSQ]) to each older person who received care and/or services from the municipal old-age care system. Nursing assistants were instructed to return their completed questionnaires (QPS) to their work unit in an anonymized envelope. Older persons were instructed to return their completed questionnaires (RSQ) in an anonymized prepaid envelope. If the older person was unable to answer the questionnaire unaided, they were allowed to complete the survey with assistance from a relative or an acquaintance (called proxy interviews). The questionnaires based on proxy interviews were returned the same way in the anonymized prepaid envelopes that were provided to each older person. To maintain confidentiality, the responses to both the QPS and RSQ were then submitted to an external organization for data entry. For the QPS, the total sample consisted of 1,486 nursing assistants (n = 354 in home care and n = 1,132 in nursing homes). The total response rate was 76%. The response rate was 75% (n = 844) for nursing homes and 81% (n = 288) for home care. The RSQ was distributed to 2,802 persons (n = 1,267 in nursing homes and n = 1,535 in home care). The total response rate was 55%. The response rate was 52% (n = 655) for nursing homes and 57% (n = 880) for home care. Table 1 shows a description of the study sample.

Table 1.

Sample Characteristics.

Questionnaires for nursing assistants	Nursing home (n = 844)	Home care (n = 288)	Total (N = 1,132)
Psychosocial work environment (QPS)	%	%	%
Gender
Male	4	5	4
Female	91	89	91
Missing	5	6	5
Age
18-24	6	8	6
25-34	13	19	15
35-44	22	23	22
45-54	31	23	29
55-64	24	20	23
>65	1	2	1
Missing	3	5	4
Educational level
Compulsory	9	12	10
Upper secondary	51	48	50
Intermediate education	30	30	30
University	5	6	6
Missing	5	4	4
Number of employees at the unit
≤25	42	83	50
26-35	23	17	22
36-45	19	—	16
46-55	12	—	9
>56	4	—	3
Number of years at current unit
≤2	10	15	12
3-5	18	18	18
6-10	22	25	23
11-15	19	17	18
16-25	19	13	17
>25	8	8	8
Missing	4	4	4
Questionnaires for older people	Nursing home (n = 655)	Home care (n = 880)	Total (N = 1,535)
Recipient satisfaction (RSQ)	%	%	%
Gender
Male	31	28	30
Female	63	66	64
Missing	6	6	6
Age
Mean age	84	82	83
Marital status
Married	19	22	21
Widow/widower	54	51	52
Divorced	8	11	10
Unmarried	12	11	11
Missing	7	5	6

Note. QPS = Questionnaire for Psychosocial and Social Factors at Work; RSQ = Recipient Satisfaction Questionnaire.

The sample description (Table 1) showed that a majority of the nursing assistants (QPS) were women (91%) and that 74% of the respondents were between 35 and 65 years of age. The data indicate that nursing assistants in nursing homes and home care had the same education. Most of the sample (80%) had an upper secondary or intermediate level of education. The sample distributions are equivalent with the population of nursing assistants in Sweden. For example, 92% of nursing assistants in Sweden were women, 76% were between 30 and 59 years old, and 85% had an upper secondary or intermediate level of education. The professional training to become a nursing assistant in Sweden is 3 years for students between 16 and 19 years old. It is possible for persons older than 19 years to become a nursing assistant. Older students with an earlier exam from upper secondary school are able to validate subjects by checking their previous credentials. Then the training is approximately 1.5 years, and the supplemental education focuses on health and social care (Swedish National Agency for Education, 2011). In Sweden, registered nurses (RN) can delegate some medical tasks to nursing assistants. In these cases, the RN is responsible for determining that nursing assistants have the right prerequisites to perform the delegated tasks, and the nursing assistants have the responsibility for how they perform the delegated work tasks (National Board of Health and Welfare, 1997, 2017a).

None of the home care units had more than 35 employees. In the survey on satisfaction among recipients of care (RSQ), 64% of the respondents were women. Among recipients of old-age care in Sweden, there are 67% women. For persons ≥80 years in Sweden, approximately 23% receive support in home care, and nearly 15% live in nursing homes (National Board of Health and Welfare, 2013). In fact, this is comparable with the studied municipality.

Measures/Questionnaire

This study used two questionnaires:

The QPS, developed by the National Institute for Working Life (Lindström et al., 2000), was used to measure employees’ perceptions of the psychosocial work environment in nursing homes and home care. In this study, the QPS consisted of a total of 16 items divided into five factors (“support from coworkers,” “social climate,” “perception of group work,” “perception of mastery,” and “positive challenge at work”). Each factor consist of two to five items, and each item was rated on a Likert-type scale that ranged from 1 (very seldom or never) to 5 (very often or always).

The RSQ was developed by the municipal development unit for older age care with guidelines from the National Board of Health and Welfare (2012). The RSQ consisted of two separate surveys: one for nursing homes (35 items) and one for home care (32 items). Eight items and one index (containing three items) were consistent across both surveys and provided the comparison data between the nursing home and home care used in the current analyses. The items were as follows: (a) To what extent do you feel that you are involved in decisions made regarding your situation? (“Participation in decision making”); (b) How do you assess your opportunities to contact social care staff? (“Contact with staff”); (c) To what extent do you feel that your individual needs are taken into consideration? (“Consideration”); (d) To what extent do you feel that the social service staff show you respect? (“Respect”); (e) To what extent do you feel that the social service staff show interest in you and your situation? (“Interest”); (f) Do you feel safe in your everyday life? (“Security in everyday life”); (g) To what extent do you feel that the social care staff you interact with have sufficient knowledge of their work? (“Staff knowledge”); (h) To what extent do you feel confident in your social care staff? (“Trust in staff”); and (i) the three-item index, which assessed overall satisfaction with care, expectations of received care, and the extent to which the received care was ideal (“Overall satisfaction”). Each item was rated on a Likert-type scale that ranged from 1 to 6, with higher numbers indicating more positive answers.

Both questionnaires had variables indicating organizational setting (e.g., nursing homes and home care) and which unit respondents came from.

Data Analyses

Based on the structure of the questionnaire (Lindström et al., 2000), straightforward summary indexes were created for each factor. The response scores were summed and divided by the number of items. The distribution of all factors in the QPS and RSQ was positively skewed, and thus the responses had to be normalized. Zero skewness ln-transformation using the STATA (StataCorp LP., Texas) command LNSKEW0 was performed to generate nonskewed variables. Each variable was standardized to range from 1 to 5 (QPS) and 0 to 5 (RSQ). As a constant was added before the ln-transformation, there was no straightforward interpretation of the beta coefficient except that a positive value indicated a positive association and a negative coefficient, a negative association.

Regarding data from QPS, for each unit, all different variables were aggregated into means for numeric variables and proportions for discrete variables. The average at the unit level for staff data was then correlated with individual data for each care recipient Therefore, unit-level data were used for nursing assistant responses and individual-level data were use for patient responses. With this procedure, it is possible to measure the association between aggregated data on nursing assistants’ perceived psychosocial work environment and recipients’ assessments of their satisfaction with the old-age care in nursing homes and home care. Data aggregated in this way commonly results in erroneously low standard errors. To control for this, cluster-correlated robust estimates of variance were used (Rogers, 1993). This procedure recalculates the standard errors of observations correlated within each work unit.

Linear regressions controlling for factors associated with both the recipients of care and with the work unit were performed. The recipient factors included gender, age (linear representation), marital status, self-rated health, and whether the interviews were direct or with a proxy. Factors associated with each work unit included gender, age distribution (categorized as 18-24, 25-34, 35-44, 45-54, and 55-64 years), number of staff at the unit (≤25, 26-35, 36-45, 46-55, or ≥56), number of years at current work unit (<22, 5,6-10, 11-15, 16-25, and ≥26 years), and educational level (compulsory, upper secondary, intermediate, and university) all in a linear presentation.

Variables

The following dependent variables from the RSQ were used: “participation in decision making,” “contact with staff,” “consideration,” “respect,” “interest,” “security in everyday life,” “staff knowledge,” “trust in staff,” and “overall satisfaction index.”

The following independent variables from the QPS were used: “Support from coworkers,” “social climate,” “perception of group work,” “perception of mastery,” and “positive challenge at work.”

Ethics

This study was approved by the Ethical Committee in Jönköping, Sweden (DNR: 2013-3).

Results

Table 2 includes descriptions of the items, indexes, Cronbach’s α coefficients, means, and p values for the differences between nursing homes and home care according to employees (QPS) and to older persons receiving care and services in nursing homes and home care (RSQ). The QPS included questions regarding gender, age, number of staff in the unit, number of years at current work unit, and educational level, and the RSQ assessed gender, age, marital status, respondent or proxy, and perceived health.

Table 2.

Psychosocial Work Environment Factors and Satisfaction Items/Factors in Nursing Homes and Home Care.

Factors	Number of questions in index (α)	Nursing homes	Home care	p values for difference between nursing homes and home care
Independent (psychosocial work environment factors from the QPS)		n = 844	n = 288	p
		M	M	p
Support from coworkers	2 (.89)	3.68	3.40	.028
Social climate	3 (.93)	3.72	3.77	.794
Perception of group work	3 (.81)	3.51	3.48	.758
Perception of mastery	4 (.77)	3.68	3.66	.730
Positive challenge at work	3 (.70)	3.69	3.57	.092
Dependent (recipient satisfaction factors and items from the RSQ)		n = 655	n = 880	p
		M	M	p
Participation in decision making	—	4.30	4.68	<.001
Contact with staff	—	5.06	4.90	.011
Consideration	—	4.61	4.87	<.001
Respect	—	4.88	5.21	<.001
Interest	—	4.62	4.94	<.001
Security in everyday life	—	5.07	5.02	.631
Staff knowledge	—	4.78	4.68	.270
Trust in staff	—	4.94	5.08	.022
Overall satisfaction	3 (.93)	4.71	4.92	.001

Note. The p values are based on binary logistic regression with nursing homes/home care as the dependent variable. The figures presented are based on nontransformed values (psychosocial work environment = 1-5 and recipient satisfaction = 1-6). QPS = Questionnaire for Psychosocial and Social factors at work; RSQ = Recipient Satisfaction Questionnaire.

Nursing assistants’ assessment of their psychosocial work environment showed one significant difference between nursing homes and home care (support from coworkers). The means indicate that nursing assistants in nursing homes perceived more support from coworkers compared with nursing assistants in home care. For the dependent variables, recipients in home care rated participation in decision making, consideration, respect, interest, trust in staff, and overall satisfaction significantly higher compared with recipients in nursing homes. Nursing homes recipients rated contact with staff significantly higher than recipients in home care.

The Pearson correlations between psychosocial work environment factors are presented in Table 3.

Table 3.

Correlations Coefficients Between Independent Variables.

Psychosocial work environment factors	1	2	3	4
1. Support from coworkers	—
2. Social climate	.68***	—
3. Perception of group work	.78***	.73***	—
4. Perception of mastery	.49***	.41***	.62***	—
5. Positive challenge at work	.37***	.32***	.32***	.49***

Note. Pearson’s correlations are used.

***

p < .001.

We studied the interaction between different measures regarding the psychosocial work environment and other independent variables on the measures of satisfaction among recipients of old-age care. Several significant interactions between nursing homes/home care and the measures of psychosocial work environment were found (i.e., differences between nursing homes and home care in the associations between psychosocial work environment with satisfaction among recipients of old-age care). The results are therefore presented separately for nursing homes and home care. These results were obtained by including interaction terms and shifting reference categories for the nursing home/home care variable. The interaction terms are not presented, just the p values that show if the β-coefficients (associations) differed significantly between nursing homes and home care. We also identified significant interactions between direct/proxy interviews and “positive challenge at work.” The results for the associations between “positive challenge at work” and satisfaction among recipients of old-age care are thus presented separately for direct and proxy interviews.

No significant interactions were found between psychosocial work environment factors and age or gender of nursing assistants.

Table 4 summarizes the associations between the assessed psychosocial work environment and variables measuring satisfaction among recipients of old-age care and how the associations differed between nursing homes and home care. Only associations, presented as β-coefficients (from linear regressions), and interactions with p < .05 are presented.

Table 4.

Association Between Psychosocial Work Factors and Recipient Satisfaction in NH and HC.

Dependent variables	Participation in decision making		Contact with staff		Consideration		Respect		Interest		Security in everyday life		Staff knowledge		Trust in staff		Overall satisfaction
Independent variables	β (p)	p ¹	β (p)	p ¹	β (p)	p ¹	β (p)	p ¹	β (p)	p ¹	β (p)	p ¹	β (p)	p ¹	β (p)	p ¹	β (p)	p ¹
Support from coworkers
NH	0.71 (.063)		0.72 (.131)		0.41 (.469)		1.26 (.004)	*	0.90 (.053)		−0.11 (.813)		−0.51 (.222)		0.40 (.367)		−0.19 (.626)
HC	−0.06 (.876)		0.23 (.437)		0.39 (.476)		0.13 (.699)	*	0.13 (.672)		0.02 (.954)		−0.44 (.062)		0.29 (.249)		0.09 (.739)
Social climate
NH	0.95 (.001)	**	1.54 (<.001)	**	1.24 (.004)	**	1.53 (<.001)	***	1.26 (<.001)	***	1.17 (.001)	**	−1.07 (<.001)	*	1.15 (<.001)	**	0.88 (<.001)	**
HC	−0.29 (.275)	**	−0.41 (.064)	**	−0.41 (.291)	**	−0.13 (.667)	***	−0.62 (.065)	***	−0.39 (.205)	**	−0.11 (.671)	*	−0.14 (.565)	**	−0.27 (.373)	**
Perception of group work
NH	1.27 (.001)	**	1.10 (.049)		0.71 (.263)		1.25 (.005)		0.88 (.047)		0.44 (.340)		−0.91 (.054)		0.87 (.038)		0.10 (.818)
HC	−0.06 (.890)	**	0.07 (.885)		0.69 (.220)		0.49 (.371)		0.38 (.458)		0.76 (.175)		−0.45 (.245)		0.64 (.091)		0.13 (.750)
Perception of mastery
NH	1.86 (.017)		1.91 (.057)		2.69 (.007)		2.45 (.021)		1.71 (.041)		2.58 (.019)		−1.23 (.173)		1.62 (.070)		0.48 (.664)
HC	0.39 (.574)		1.38 (.035)		1.28 (.131)		1.63 (.134)		1.52 (.056)		1.16 (.283)		−0.89 (.140)		1.24 (.081)		0.82 (.226)
Positive challenge at work
NH direct^a	−1.16 (.180)		2.53 (.001)		3.02 (.001)		0.84 (.073)		1.65 (.031)		2.74 (.002)		−2.18 (.003)		2.29 (.003)		3.31 (<.001)	*
HC direct	1.16 (.414)		0.67 (.506)		−0.49 (.777)		0.86 (.626)		0.49 (.635)		1.44 (.296)		−0.95 (.407)		1.55 (.184)		−0.43 (.712)	*
NH proxy^b	1.13 (.110)		2.96 (.001)	*	4.59 (<.001)	***	2.83 (.002)		3.63 (<.001)	**	2.04 (.045)		−2.34 (<.001)	*	2.19 (.003)		3.26 (<.001)	**
HC proxy	0.40 (.409)		0.74 (.046)	*	−0.15 (.772)	***	0.99 (.095)		0.33 (.427)	**	1.10 (.065)		0.33 (.427)	*	0.91 (.049)		−0.06 (.878)	**

Note. Results are from linear regressions with β-coefficients showing the strength of the associations. Bold values indicate significant associations (p < .05). The p¹ = p value for significant differences between NH and HC. NH = nursing homes; HC = home care.

p < .05. **p < .01. *** p < .001.

Direct corresponds to questionnaires completed by respondents.

Proxy corresponds to questionnaires completed by relatives or an acquaintance (if the older person had help or if someone else completed the questionnaire). In all instances, direct and proxy answers were analyzed together, but the analyses controlled for direct versus proxy, as the associations between dependent and independent variables were similar for direct and proxy interviews.

In general, a better psychosocial work environment was associated with higher satisfaction among recipients of old-age care, with the exception of the recipient satisfaction item “staff knowledge,” for which the association was negative (Table 4). Stronger associations were observed in nursing homes than in home care for all individual associations of psychosocial work environment with satisfaction among recipients of old-age care. There were 35 significant associations in nursing homes and three significant associations in home care.

In nursing homes, a better “social climate” at the work place was significantly associated with positive outcomes in all dependent variables except “staff knowledge.” In other words, if nursing assistants perceived the psychosocial work environment to include supportive and encouraging coworkers, older persons in need of care reported higher satisfaction with old-age care. Similarly, if nursing assistants experienced “positive challenge at work” and perceived that they were able to use their competencies and skills at work, all variables measuring satisfaction among of old-age care recipients variables were significantly higher, with the exception of “participation in decision making” and “respect” (significant only in proxy interviews). Furthermore, “perception of mastery” was associated with several variables measuring recipients’ satisfaction in nursing homes, demonstrating that when nursing assistants in nursing homes are content with their work (e.g., quality of their work, ability to solve problems at work), older persons are more likely to be satisfied with the “consideration,” “respect,” and “interest” shown by nursing assistants. Older persons also perceived greater “participation in decision making” and “security in everyday life” if nursing assistants were content with their amount of work, ability to solve problems at work, and the quality of their work.

In home care, older persons perceived more satisfaction in staff contact and more trust in staff when nursing assistants had higher mastery.

Overall, these results indicated that high assessments of “social climate,” “positive challenge at work,” “perception of mastery,” and “perceptions of group work” were related to many different aspects of satisfaction among old-age care recipients in nursing homes and to some extent in home care.

Some of the associations between psychosocial work environment and recipients’ satisfaction differed significantly between nursing homes and home care. In all such cases, the associations were stronger and significant in nursing homes and weaker and nonsignificant in home care. All associations between “social climate” and recipient satisfaction variables differed significantly between nursing homes and home care. Significant differences between nursing homes and home care were also found for the following associations:

Among proxy interviews, there were significant differences in the associations between “positive challenge at work” and the following factors measuring satisfaction among of old-age care recipients: “contact with staff” (p < .05), “consideration” (p < .001), “interest” (p < .01), “staff knowledge” (p < .05), and “overall satisfaction” (p < .01).

Among direct interviews, there were significant differences in the association between “positive challenge at work” and “overall satisfaction” (p < .05).

For the psychosocial work environment factor “support from coworkers,” there was a significant difference in its association with “respect” (p < .05).

For the psychosocial work environment factor “perception of group work,” there was a significant difference in its association with “participation in decision making” (p < .01).

No significant interactions were found between psychosocial work environment and age or gender in terms of satisfaction among of old-age care recipients.

Discussion

In this study, we examined the associations between nursing assistants’ perceptions of the psychosocial work environment and satisfaction among older people receiving care in nursing homes and home care in Sweden. To our knowledge, few studies have simultaneously examined these associations in different old-age care settings. Therefore, it is essential to gain a greater understanding of how nursing assistants’ psychosocial work environment affects satisfaction among care recipients in these different contexts.

When nursing assistants had high perceptions of their psychosocial work environment, older people reported better satisfaction with care. These findings are consistent with research in home care and nursing homes, which indicated that higher job satisfaction is associated with higher satisfaction among recipients in old-age care (Barry, Brannon, & Mor, 2005; Chou et al., 2003; Kajonius & Kazemi, 2016; Ott & Van Dijk, 2005; Sikorska-Simmons, 2006).In other words, improving nursing assistants’ psychosocial environment has broader implications. However, prior research has indicated that changes to the work environment in old-age care in Sweden have contributed to a decline in working conditions for nursing assistants over the past 10 years. This situation has declined to the point that nearly 50% of nursing assistants have considered terminating their employment because of the poor working conditions (Szebehely et al., 2017).

Several psychosocial work environment factors (i.e., “social climate,” “perception of group work,” “perception of mastery,” and “positive challenge at work”) played an important role in older persons’ satisfaction with old-age care. Significant associations were primarily found in nursing homes. These patterns suggest that nursing assistants’ assessments of the psychosocial work environment play a greater role in satisfaction among care recipients in nursing homes than in home care. One explanation could be that nursing assistants in home care more often have quick visits (e.g., scheduled status check-up or delivering Meals-on-Wheels) to older people while nursing assistants in nursing homes have more continuous interactions with care recipients. This seems likely as the recipients of care assessed contact with staff higher in nursing homes than in home care. Home care is based on different tasks, which are adapted to each individual’s need of health care and services. It is common for these tasks to be scheduled and for units to receive economic compensation for their scheduled time. Thus, the scheduled time does not encourage interaction between nursing assistants and older persons in home care. In fact, it might lead to higher work demands in these settings due to the higher expectations of effectiveness in home care than in nursing homes. Furthermore, nursing assistants in home care work alone in a wide geographic area and must commute between people in need of health care and services. In previous research, we found that nursing assistants in home care experience less support from coworkers, have less control over their work pace, and perceive less positive challenges at work than nursing assistants in nursing homes. We have also found fewer significant associations between leadership and psychosocial work environment factors in home care than in nursing homes (Lundgren et al., 2016).

The results of this study showed that the associations between “positive challenge at work” and variables measuring satisfaction among care recipients differed between nursing homes and home care. Specifically, the associations were stronger in nursing homes than in home care. “Positive challenge at work” showed only two significant associations in home care (“contact with staff” and “trust in staff”). This finding suggests that perceiving a “positive challenge at work” may primarily be positively associated with assessments of satisfaction among people in need of health and care services in nursing homes and their relatives.

Sweden has conducted an annual national elderly survey every year since 2008 (2016, N ≈ 220,000); this survey is completed by all municipalities in Sweden (National Board of Health and Welfare, 2016). It is common for these municipalities to report “overall satisfaction” as a collective description of satisfaction with old-age care. The present study identified only three significant associations between psychosocial work environment factors and “overall satisfaction.” Previous research has shown that overall satisfaction in nursing homes and home care is difficult to measure because older people receive different combinations of services and might be satisfied with some specific services but not all (Corrigan, 1990; Geron et al., 2000). The current results indicate that “overall satisfaction” is less important than a good composite assessment of satisfaction in old-age care and that it is important to study individual variables measuring satisfaction among old-age care recipients.

Limitations and Strengths

This study used a cross-sectional design, and the subjects were selected from a single municipality in southern Sweden; these factors can be considered a limitation. The characteristics of the samples may affect the generalisability of the results, as although the organizational assumptions are largely the same, we do not know whether other municipalities share these characteristics. The nonresponse rate was 22% for the psychosocial work environment survey and 45% for the survey measuring satisfaction among old-age care recipients. Selection bias due to nonresponse may have affected the results. However, this study included a large sample and surveys that tapped multiple dimensions of satisfaction and the psychosocial work environment.

Conclusion

In summary, nursing assistant’s perceptions of the work environment appears to be related to satisfaction among old-age care recipients. This study identified a positive relationship between nursing assistants’ assessments of their psychosocial work environment and satisfaction among care recipients primarily in nursing homes but also in home care. One way of increasing recipients’ satisfaction in general could be for policy makers, directors of social services and other leaders in old-age care to focus on improving the psychosocial work environment overall. In addition, first-line managers should concentrate on improving the “social climate,” “perception of group work,” “perception of mastery,” and “positive challenge at work” for nursing assistants. Old-age care managers and first-line managers should also consider the differences in associations between nursing homes and home care.

Footnotes

Declaration of Conflicting Interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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