Abstract
Recruiting and retaining a quality care staff are increasingly viewed as significant challenges for aging countries across the globe that are facing increased demand for long-term services and supports. Nurses and, even more importantly, nursing assistants, home health and home care aides, and other health support workers, are the major care providers to older adults and younger people with disabilities in nursing homes, assisted living facilities, other residential care settings, and individual homes. They are the eyes and ears of the system and, next to families, have developed the closest relationships with residents and clients and have the greatest potential for influencing quality of care and quality of life. In this issue of Journal of Applied Gerontology, researchers from the United States, Canada, and Switzerland use a range of quantitative and qualitative methodologies to explore individual, organizational, and policy-level factors that influence the development of a stable care staff.
The first two articles explore various aspects of the decision made by care staff (registered nurses [RNs], licensed practical nurses [LPNs], and frontline nursing staff as a group) to leave the job. In their case-control, longitudinal study of care staff employed in 18 for-profit nursing homes operating in Maryland and New England, Zhang and colleagues find that evening shift work and shift length of greater than 8 hours are significantly associated with nursing staff’s voluntary termination—two aspects of job design that are within providers’ ability to control and modify. Using secondary data analysis of almost 3,000 care staff working in 156 Swiss nursing homes, researchers find that more than half of the sample report intention to leave the job. Not surprisingly, their results confirm findings from previous research (including studies conducted by the author of this editorial and authors of other articles in this issue) that a perceived lack of supportive leadership and recognition contributes to greater intent to quit. At the same time, this study fails to show a relationship between several factors identified by others as associated with intent to leave, including teamwork, perceptions of staffing and resource adequacy, and work stress related to workload or lack of preparation. These contradictory findings underscore the difficulty in consistently measuring aspects of job design and organizational culture and translating an evidence base into practice.
The next two articles focus more specifically on the direct care worker in the nursing home. Using cross-sectional data from a sample of aides in four Canadian nursing homes, Caspar and colleagues find that supervisory support is an important mediator in enabling aides’ self-determination and ultimately their ability to provide person-centered care. Noting the critical role that leadership plays in helping to cultivate autonomous motivation through supportive supervision, the authors recommend that stakeholders—including administrators and regulators—challenge the rigid policies and practices that disempower supervisors, aide the residents, and hinder the provision of person-centered care. Researchers from the University of Wisconsin-Madison use raw staffing data collected form 30 nursing homes reflecting three levels of culture change adoption to calculate and describe variation in consistent assignment of aides—a practice identified in the literature as positively affecting aide turnover and quality of care. They find tremendous variation and overlap across the three models, raising questions about the most important measure of quality of assignments from a resident perspective—averages or stability over time. The authors call for further research to determine the quality threshold distinguishing a level of consistency that results in positive resident experiences.
Another Canadian research team from Toronto reports on findings from one of the few studies to compare similarities and differences in work psychology and employee outcomes between nursing home and community care aides. For both groups, quality of worklife and perceptions of safety are associated with job satisfaction, ultimately influencing intent to stay. However, perceptions of support, safety, and work engagement are significantly poorer for nursing home aides than their peers employed in community care. Furthermore, only in the nursing home setting, does the work environment directly impact individual performance (effectiveness and productivity) and organizational citizenship behaviors such as having a “voice” and principled dissent. The authors note that workers in community care are not tied to an institution, team or supervisor at point of care, and call for more research on which organizational and job-related factors are key to successful outcomes in this setting.
In the final article, Nisbet and Morgan shift the unit of analysis to New York-based home care agencies to gather insights into how the competing influences of health care, labor, and employment policy shape scheduling of staff, including hours shortfall and instability. They report that agency employers are struggling to find practical solutions to problems associated with an ever-changing policy landscape. Agencies primarily reliant on public payers generally feel forced to make changes to scheduling and assignment practices because of concerns about reimbursement not covering overtime and wage or benefit increases. While New York is in the vanguard of implementing policies that support the home care workforce, lessons learned may be limited to the uniqueness of the policy environment, including the fact that the state’s home care sector is more heavily unionized than most other states. Nevertheless, the findings underscore the need to understand the complex interrelationship between various policy actions, agency practices, and hours available to workers.
Taken together, these articles form an issue that confirms findings from previous studies, challenges other findings that have emerged from the public literature, provides new insights into the role of policy and practice in affecting the quality of worklife, productivity, and turnover among care staff across a range of settings and occupations, and raises questions for further quantitative and qualitative research. This special issue highlights the range of methodologies that can be used to explore how to strengthen care staff, underscores the importance of this research for practice and policy and demonstrates that the future of the long-term care workforce is, indeed, a global issue.