Organizational Factors Associated with Certified Nursing Assistants’ Job Satisfaction during COVID-19

Abstract

Given the instability of the nursing home (NH) certified nursing assistant (CNA) workforce and the challenging demands during COVID-19, it is important to understand the organizational factors that are correlated with job satisfaction which is a major predictor of CNA turnover. The purpose of this study was to determine the associations between quality of supervisor relationships, organizational supports, COVID-19 work-related stressors, and job satisfaction among CNAs in NHs. The results indicate that CNAs who reported a more optimal relationship with their supervisors, felt appreciated for the job they do and worked in NHs with lower COVID-19 resident infection rates tended to report higher rates of job satisfaction. The COVID-19 work-related stressors of increased workload demands and understaffing were associated with lower rates of job satisfaction. The study has practical implications for employers regarding how to support CNAs to improve job satisfaction especially during a crisis.

Keywords

COVID-19 nursing homes caregiving certified nursing assistants job satisfaction nurse supervisor

What this paper adds

• The study expands on previous research investigating factors associated with job satisfaction—a major predictor of CNA turnover—by demonstrating the importance of good quality supervisor relationships and organizational supports for job satisfaction in the highly stressful work environment of the COVID-19 pandemic.

• The research also provides insights into the COVID-19-specific work-related stressors impacting job satisfaction.

Applications of study findings

• To enhance quality of relationship with supervisors, which can improve job satisfaction among CNAs, nurse managers in nursing homes need to be trained as effective supervisors.

• To counteract staff shortages and its stressful effects on CNAs and, therefore, to improve job satisfaction among CNAs, nursing home providers need to explore avenues to strengthen the pipeline of workers to fill vacant positions.

Introduction

Certified nursing assistants (CNA) provide the majority of hands-on care to older adults and younger people with disabilities in nursing homes. In the nursing home setting, 527,480 CNAs deliver personal care, assistance with daily activities, and clinical support to 1.5 million nursing home residents in the United States (PHI, 2022). The median age of the nursing home CNA is 37. Certified nursing assistants are predominately female (90%) and people of color (58%), with 21% who are foreign-born. About 50% have a high school education or less and their socioeconomic status is fairly low, making an hourly wage of $14.41 with approximately one-third relying on some form of public assistance (PHI, 2022).

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected nursing home residents and staff, including CNAs. As of August 2022, 154,856 residents and 2,573 staff have died due to COVID-19 (Centers for Medicare and Medicaid Services, 2022). The pandemic has added significant stress, physical exhaustion, and has adversely impacted mental health and emotional well-being in an already vulnerable nursing home workforce (KFF, 2021; Kirzinger et al., 2020; Tomlin et al., 2020; White et al., 2021). Certified nursing assistants in nursing homes faced additional work-related and external challenges, including increased workload demands, understaffing and staffing shortages, emotional burden of caring for residents facing significant isolation, distress, illness, and death, new responsibilities, separation from family members, managing personal needs and family demands, and experiencing financial hardship (Cimarolli et al., 2022; White et al., 2021).

At the same time, COVID-19 has generated awareness of the value of and reliance on the CNA workforce to provide care in places for those most at risk from the disease. The pandemic shed new light on existing workforce shortages and high turnover in the long-term services and supports (LTSS) sector that has continued throughout the pandemic due to low wages, inadequate training, lack of opportunities for career advancement, and the physical and emotionally demanding nature of the work (Spetz et al., 2019; White et al., 2021). Several studies have demonstrated workforce shortages. The turnover rate of 129% among CNAs was already high prior to the pandemic (Gandhi et al., 2021). According to the U.S. Bureau of Labor Statistics, about 420,000 nursing home employees, many of them CNAs, left the nursing home workforce since February 2020 (Bernstein & Van Dam, 2022). A June 2021 survey by the American Health Care Association and the National Center for Assisted Living found that 94% of nursing home providers reported a shortage of staff (AHCA and NCSL, 2021). Further, an analysis by the Kaiser Family Foundation suggests that the LTSS sector has continued to have problems employing people while other health services sectors have recovered in the past year (Wager et al., 2021).

Employee well-being and job satisfaction are critical to retaining the CNA nursing home workforce. A significant factor impacting intent to leave the job and turnover is job satisfaction (Castle et al., 2007; Choi & Johantgen, 2012; Decker et al., 2009). Research conducted during the COVID-19 pandemic found that CNAs in nursing homes who report higher job satisfaction are more likely to report their intent to stay on the job (Cimarolli et al., 2022), which confirms the pre-COVID-19 established relationship between job satisfaction and turnover intent. High turnover and job vacancies not only influence worker outcomes but also negatively impact the quality of care delivered to residents (Barry et al., 2005; Bostick et al., 2006; Castle & Engberg, 2005). Given the instability of the workforce and the challenging demands experienced during COVID-19, it is important to understand the organizational supports that are correlated with job satisfaction. Knowledge of these factors can help to maintain workforce stability and improve well-being in CNAs, and subsequently enhance the quality of care provided to residents.

Conceptual Framework

Castle et al. (2007) developed a conceptual framework proposing a multitude of factors associated with a CNA’s decision to leave the job. The model identified job characteristics (e.g., work schedule, work content, coworkers, and workplace supports) that contributed to job satisfaction, which in turn predicted a CNA’s intention to quit or leave the job. Studies conducted prior to the pandemic identified several organizational supports associated with job satisfaction. One key factor is supervisor support (Bethell et al., 2018; Bowers et al., 2003; Decker et al., 2009; McGilton et al., 2016; Schwendimann et al., 2016). Decker et al. (2009) assessed factors that contributed to intrinsic and extrinsic job satisfaction. They found that a more positive assessment of the supervisor’s behavior was the best predictor of intrinsic job satisfaction. A systematic review by McGilton et al. (2016) found that effective nurse supervision was associated with CNAs’ enhanced job satisfaction, lower turnover and intent to leave, greater job effectiveness, improved decision making, lower job stress, as well as increased resident satisfaction.

In addition, teamwork and safety climate, staffing and resource adequacy, time to provide assistance with activities of daily living, and feeling valued by one’s employer have also been found to be associated with higher job satisfaction (Castle et al., 2007; Choi & Johantgen, 2012; Decker et al., 2009; Schwendimann et al., 2016). However, limited research has examined how organizational factors impact job satisfaction during COVID-19 when CNAs experienced additional stressors due to the pandemic. Therefore, the purpose of this study was to determine the associations between quality of relationships with supervisors, organizational supports (e.g., feeling appreciated), COVID-19 work-related stressors, and job satisfaction among CNAs in nursing homes. Ascertaining these factors that can be addressed by nursing home employers will increase job satisfaction, and likely reduce turnover, among their workforce particularly during times of crisis like a pandemic. Based on this study’s conceptual model and prior research, we hypothesized that higher levels of organizational supports and quality of supervisor relationship will be associated with increased job satisfaction, whereas COVID-19 work-related stressors will be associated with decreased job satisfaction.

Methods

Study Participants

Study participants were 402 CNAs who were employed at 59 nursing homes run by 31 organizations across 21 states in May 2020. CNAs were employed in nursing homes for an average of 1.92 years (SD = 4.31). The nursing homes were located primarily in suburban (n = 35, 60.3%) and urban (n = 16, 27.6%) geographical areas, and were medium (n = 26,46.4%) and large sized (n = 23, 41.1%) nursing homes. Approximately two-thirds (74.6%) of the nursing homes were not-for-profit. Because the nursing homes from which our study sample was drawn are predominately located in metropolitan areas and are largely not-for-profit organizations, we created Table 1 to illustrate how these nursing homes compare to nursing homes nationally along these two characteristics.

Table 1.

Comparison of Nursing Home Sample and Nursing Homes Nationally.

	Nursing Home Sample (N = 59)	National Nursing Homes^a (N = 15,600)
Not-for-profit	68.4%	18.8%
Geographical location
Metropolitan (urban and suburban)	89.4%	71.9%
Micropolitan (rural)	10.6%	13.5%

^aSource: Sengupta M, Lendon JP, Caffrey C, Melekin A, Singh P. Post-acute and Long-Term Care Providers and Services Users in the United States, 2017–2018. Vital Health Stat 3.2022 May; (47):1–93. PMID: 35604771.

Procedures

Study data were obtained from WeCare Connect^™, which is an employee engagement and management system used by 165 organizations in the United States to solicit regular feedback from their employees. Employee responses to an online battery of questions help employers better understand staff challenges with onboarding, training, supervisor relationships, job fit, job satisfaction, expectations, and the physical and organizational environment. During May 2020, WeCare Connect^™ added several pandemic-related questions, created by the researchers of this study, to its employee interview battery. The WeCare Connect^™ surveys are active for 30 days. The recipients receive an email and text to complete the survey and if it is not completed within 7 days, the employees are called and the survey is conducted via phone. The overall response rate is 85% and above across all employees. This study analyzed data from the sub-sample of the CNAs of the nursing home data file. The study was approved by the Internal Review Board of the researchers’ institution (IRB# 2020174).

Measures

Relationship with Supervisor

Perceived quality of CNAs’ relationship with their supervisor was assessed with a 4-item scale asking participants to rate aspects of quality of their relationship with their supervisor on a 5-point scale (1 = Worst; 5 = Best). The four items include: “How would you rate the frequency of feedback from your supervisor?”, “How would you rate the quality of guidance/leadership your supervisor provides?”, “How would you rate your level of comfort going to your supervisor with a problem?”, and “How well does your supervisor assist you with questions or concerns?”. Items were summed to form a total score which can range between four and 20 with higher scores indicating more optimal quality of perceived supervisory relationship. Cronbach’s Alpha of the scale was α = .93.

Organizational Supports

We utilized two indicators assessing organizational supports. Participants were asked whether they feel appreciated for the job they do (Yes = 1; No = 0) and whether they feel safe and comfortable at work (Yes = 1; No = 0).

COVID-19 Work-Related Stressors

To assess work-related stressors, participants were presented with a list of five challenges asking them to indicate which COVID-19-related work challenges caused them stress when caring for residents, including lack of personal protective equipment (i.e., N95 masks and gowns), lack of organizational protocols/guidance to care for residents, increased workload demands, increased risk of transmission to and from residents, and understaffing.

Outcome

Job Satisfaction

Job satisfaction was measured with a one-item indicator asking participants to rate how satisfied they were with their current job (1 = Not at all satisfied; 5 = Very satisfied).

Covariates

For an indicator of resident COVID-19 infection rates, we obtained the total number of confirmed resident COVID-19 cases per 1,000 residents from the Nursing Home COVID-19 Public File which is comprised of data reported by nursing homes to the CDC’s National Healthcare Safety Network (NHSN) Long Term Care Facility (LTCF) COVID-19 Module: Surveillance Reporting Pathways and COVID-19 Vaccinations. Number of beds in the nursing homes that CNAs worked at was used as an indicator of nursing home size. Job tenure was measured by length of employment in years. Ownership status (for-profit or not-for-profit) and geographical location (rural, urban, or suburban) were also included as covariates. We used the National Area Deprivation Index (ADI), a publicly available measure created by the Health Resources and Services Administration, to characterize neighborhood socioeconomic disadvantage. The ADI is a weighted, factor-based index comprised of 17 poverty, education, and housing variables drawn from data of the United States Census and the American Community Survey.

Data Analysis Plan

Descriptive statistics and frequency distributions were examined for all key study variables to screen for missing data and normality. Pearson’s correlations were then conducted to determine the bivariate associations among the independent variables, as well as between the independent variables, and our outcome variable measuring job satisfaction. Nursing home size, geographical location, ownership status, neighborhood socioeconomic disadvantage (ADI), resident COVID-19 infection rates, and job tenure were examined as potential covariates. To obtain a more parsimonious model, only independent variables and covariates significantly correlated with job satisfaction were included in subsequent analysis. Potential collinearity between variables was assessed via inspection of bivariate associations and the variance inflation factor (VIF), which indicates if inflated variance is due to collinearity among independent variables. VIFs for each of the variables ranged from 1.12 to 1.64, indicating no violation of collinearity (see Appendix, Table A in Supplementary Materials).

Intraclass correlations (ICC) were calculated to examine differences in variance among the 59 nursing homes included in the analysis. A random-facility level mean intercept model was fit to estimate the ICC of facilities, which indicated that 11% of the variance in job satisfaction was attributed to facility level characteristics. Because of the natural clustering of CNAs within nursing homes, linear mixed models with a random effect were utilized to account for nesting at the facility level. Specifically, a random intercept model which included a random facility level effect term, as well as fixed facility- and individual-level predictors, was used to estimate both nursing home and individual factors on job satisfaction. This approach accounts for underlying systematic differences in job satisfaction among the nursing home facilities. Model fit was examined via inspection of −2 Log Likelihood.

Maximum Likelihood Estimation was used to deal with missing data. A p-value of < .05 was used to assess statistical significance. IBM SPSS Statistics 27 was used for all data analyses.

Results

Table 2 provides facility- and individual-level descriptive statistics for our key study variables. Inspection of Table 2 shows that the majority of CNAs reported that they feel appreciated for the job they do (76.1%) and feel comfortable and safe at work (92%). The mean score on the quality of the relationship with supervisor scale was 16.79 (SD = 3.90). CNAs primarily reported understaffing (40.3%), increased risk of COVID-19 transmission to and from residents (28.2%), and increased workload demands (27.5%) as the top work-related challenges. Participants’ mean job satisfaction score was 4.17 (SD = .96).

Table 2.

Descriptive Statistics for Key Study Variables at Individual (N = 402) and Nursing Home/Facility Level (N = 59).

	Nursing Home/Facility Level			Individual Level
Study variables	N (%)	M	SD	n (%)	M	SD
Relationship with Supervisor
Overall quality of relationship with supervisor	N/A	N/A	N/A	402	16.79	3.90
Organizational Supports
Feeling appreciated (yes)				216 (76.1)
Feeling comfortable and safe (yes)	N/A			366 (92.0)
COVID-19 Work-Related Stressors
Lack of personal protective equipment (yes)	N/A			85 (21.1)
Lack of guidance/protocols to care for residents (yes)	N/A			34 (8.6)
Increased workload demands (yes)	N/A			109 (27.5)
Increased risk of COVID-19 transmission (yes)	N/A			112 (28.2)
Understaffing (yes)	N/A			160 (40.3)
Covariates
Resident COVID-19 infection rate^a	56	61.93	142.66	394	44.97	111.63
Job tenure	56	2.02	2.63	367	1.92	4.31
Geographic location
Rural	7 (12.1)			42 (10.6)
Urban	16 (27.6)			145 (36.5)
Suburban	35 (60.3)			210 (52.9)
NH size
Small	7 (12.5)			29 (7.4)
Medium	26 (46.4)			203 (51.5)
Large	23 (41.1)			162 (41.1)
Ownership status
Profit	15 (25.4)			127 (31.6)
Non-profit	44 (74.6)			275 (68.4)
Area deprivation index
State	58	4.81	2.94		4.48	2.62
National	58	50.34	23.40		49.74	21.40
Outcome
Job satisfaction	59	4.12	.57		4.17	.96

^aNote. Resident COVID-19 infection rates are calculated by dividing the total number of confirmed COVID-19 cases by total number of occupied beds multiplied by 1,000.

Pearson’s correlations examining the bivariate associations between quality of supervisor relationship, organizational supports, COVID-19 work-related stressors, and job satisfaction showed that perceived higher quality of supervisor relationship (r = .56), feeling appreciated for the job they do (r = .54), and feeling comfortable and safe at work (r = .36) were significantly positively associated with job satisfaction. We also found that COVID-19 work-related stressors related to lack of protocols and guidance from the organization to care for residents, increased workload demands, increased risk of transmission to and from residents, and understaffing were significantly associated with lower job satisfaction (rs range from −.11 to −.39). Three covariates were significantly associated with job satisfaction: employment at for-profit NHs, shorter job tenure, and higher resident COVID-19 infections rates were associated with lower job satisfaction and thus, were included as control variables in subsequent analyses. (see Appendix, Table A in Supplementary Materials for Pearson’s Correlations and variable collinearity diagnostics).

COVID-19 Work-Stressors and Organizational Factors on Job Satisfaction

To examine the associations between quality of supervisor relationship, nursing home organizational supports, and COVID-19 work-related stressors on job satisfaction, while controlling for facility-level characteristics, a full model was fit with random intercept, facility, and CNA-level fixed effects to determine the individual and facility-level factors significantly associated with job satisfaction. Final multilevel model results are shown in Table 3. In this model, the variance in nursing home characteristics did not significantly differ between facilities (Estimate = −.02, SE = .02, p = .268, 95% CI [.004–.144]). Results in Table 3 show that while controlling for clustering at the facility-level, overall quality of supervisory relationship, feeling appreciated, and lower resident COVID-19 infection rates were significantly associated with higher ratings of job satisfaction. Feeling comfortable and safe in one’s work environment (Estimate = .30) was trending significance (p = .074). Alternatively, stressors related to increased workload demands and understaffing were significantly associated with lower ratings of job satisfaction.

Table 3.

Multilevel Model Predictors for Job Satisfaction in Nursing Home CNAs.

	95% CI
Predictors	Estimate	SE	Lower	Upper	p
Intercept	2.60	.23	2.14	3.06	<.001
Quality of Supervision
Overall quality of relationship with supervisor	.06	.01	.03	.09	<.001
Perceptions of Support
Feeling appreciated	.68	.13	.42	.94	<.001
Feeling comfortable and safe	.30	.17	−.03	.63	.074*
COVID-19 Work-Related Stressors
Lack of personal protective equipment	.11	.12	−.12	.34	.453
Lack of protocols/guidance to care for residents	.26	.18	−.10	.61	.160
Increased workload demands	−.32	.11	−.52	−.11	.003
Increased risk of COVID-19 transmission	−.05	.10	−.25	.14	.603
Understaffing	−.37	.10	−.56	−.17	<.001
Covariates
Ownership status NH (for profit)	.09	.10	−.13	.31	.404
Job tenure	−.01	.01	−.03	.01	.212
Resident COVID-19 infections	−.001	.00	−.002	−.00004	.004

Note. * = trending significance. −2 Log Likelihood = 537.142. NH = Nursing Home.

Discussion

The purpose of this study was to assess the relationship between job characteristics, including the quality of the relationship with supervisors, organizational supports, COVID-19 work-related stressors, and job satisfaction among CNAs in nursing homes. We found that CNAs who reported more optimal relationships with their supervisors, felt appreciated for the job they do by their employer, and worked at nursing homes with lower COVID-19 resident infection rates reported higher rates of job satisfaction. Alternatively, the COVID-19 work-related stressors of increased workload demands and understaffing were associated with lower rates of job satisfaction.

These findings are consistent with other pre-COVID-19 era studies that have found a positive relationship between high quality supervision, which includes good communication during interactions with CNAs, supportive supervision, supervisors who respect and coach staff, and job satisfaction (Bishop et al., 2009; Castle et al., 2007; Choi & Johantgen, 2012; Decker et al., 2009; Escrig-Pinol et al., 2019; McGilton et al., 2016; Schwendimann et al., 2016). Studies have found that nurse supervisors lack adequate preparation to help them navigate the challenges of their management roles and do not have the resources they need to carry out their supervisory positions (Bryant & Stone, 2022). One clear implication is the need to develop and train nurse supervisors to be effective communicators, coaches and leaders, problem-solvers, and able to assist CNAs with questions and concerns.

The study also demonstrated that understaffing and high workload can negatively impact CNAs’ job satisfaction. These demands can exacerbate stress in CNAs and influence how they perceive their jobs. Studies have found that work overload is associated with higher intentions to quit and actual turnover (Castle et al., 2007; Gray & Muramatsu, 2013). This is an important finding as nursing homes continue to experience workforce shortages. These staffing shortages have a wide-ranging impact and make it more challenging to provide basic care, monitor residents, and follow protocols. They also result in more staff leaving the job (McGilton et al., 2020). Interestingly, the remaining work-related demands specific to COVID-19—such as lack of personal protective equipment, lack of protocols or guidance to protect residents, and the increased risk of transmission to and from residents—were not significantly associated with job satisfaction. We would have expected these stressors to show associations with job satisfaction as they specifically relate to experiencing the negative health consequences of the virus. It appears that under the exceptional work circumstances of the pandemic that CNAs can cope with stressful work challenges that may impact their health, if they feel supported by their supervisor and appreciated for the work they do. This implies that if a nursing home organizational culture is supportive of CNAs and if they perceive that the organization cares about them overall, they can feel satisfied with their job and will likely remain in their job even during an extreme emergency such as a pandemic.

Limitations

One limitation of this research is that the study sample is not a random sample of nursing home CNAs but a convenience sample of CNAs whose organizations use the WeCare Connect^™ employee management system. For example, the WeCare Connect^™ sample was more representative of CNAs at not-for-profit nursing homes and at nursing homes located in metropolitan areas. It is also likely that nursing homes that use WeCare Connect^™ are those where leadership is more committed to quality improvement. Therefore, generalizability of the study findings is limited to the CNAs at nursing homes who use the WeCare Connect^™ employee management system. In addition, the WeCare Connect^™ interview battery does not assess sociodemographic characteristics of employees and additional variables such as wages and benefits, training, career mobility, and teamwork. It is possible that these variables could contribute to job satisfaction since, for example, other studies have found these variables are associated with job satisfaction and commitment to the job (Bishop et al., 2009; Ejaz et al., 2008; Choi & Johantgen; Decker et al., 2009). Finally, the study was a cross-sectional study, therefore, we cannot assume causal relationships among study variables and draw predictive conclusions based on the significant differences.

Implications

Despite its limitations, our study has practical implications for employer practices in nursing homes that can support CNAs, particularly during crises such as a pandemic. Study findings point to the important role of the quality of the CNA—nurse supervisor relationship for improving job satisfaction among CNAs and underscore the need for nurse manager training in supervision of CNAs. In our study, quality of relationship with one’s supervisor was conceptualized as CNAs receiving feedback often enough by their nurse manager, the quality of guidance/leadership the nurse manager provides, level of comfort in approaching the nurse manager when a problem arises, and quality of the nurse manager’s response to questions/concerns by the CNA. Training programs for nurse supervisors designed to enhance these specific supervisory skills among nurse managers could be developed, implemented, and evaluated in nursing homes. Research also suggests that nurse managers lack adequate preparation and that many LTSS providers do not have structured processes and formalized systems in place to help nurse managers effectively carry out supportive supervisory relationships (Dwyer, 2011; Siegel et al., 2008; Warshawsky & Cramer, 2019). Leadership training programs can help develop effective supervisors and stabilize the workforce (Harvath, 2008). Another area to address is understaffing and increased workload due to staffing shortages. To accomplish this, nursing homes can stagger shifts and allow CNAs to work flexible shifts. Nursing homes may also consider how to strengthen the pipeline of workers to fill vacant positions.

Supplemental Material

Supplemental Material - Organizational Factors Associated with Certified Nursing Assistants’ Job Satisfaction during COVID-19

Supplemental Material for Organizational Factors Associated with Certified Nursing Assistants’ Job Satisfaction during COVID-19 by Natasha S. Bryant, Verena R. Cimarolli, Francesca Falzarano and Robyn Stone in Journal of Applied Gerontology

Footnotes

Acknowledgments

We would like to thank David Gehm, president and CEO of Wellspring Lutheran Services and Jon Golm, president of WeCare Connect^TM and his team for their collaboration on this study.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Patrick and Catherine Weldon Donaghue Medical Research Foundation.

Author’s Note

Institutional Review Board and Approval Number: UMass Boston; #2020174

ORCID iDs

Natasha S. Bryant

Verena R. Cimarolli

Francesca Falzarano

Supplemental Material

Supplemental material for this article is available online.

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