Determinants of staff job satisfaction of caregivers in two nursing homes in Pennsylvania

Job satisfaction is defined as "the favorableness or unfavorableness with which employees view their work" [1]. Determinants of these views include the work environment and the personality of workers. In operationalizing the work environment, it is most often split into multiple factors (or domains) such as supervisors, pay, and promotion opportunities. In this investigation, we use a large sample of data from caregivers (i.e., nurse aides (NAs); Licensed Practical Nurses (LPNs); Registered Nurses (RNs)) working in nursing homes to examine: (1) their job satisfaction scores on 13 questions; and, (2) what characteristics of these caregivers are associated with job satisfaction domains.

Participation rates were similar at both facilities. About 75% of eligible staff completed surveys at each wave. There were a total of 717 surveys returned from a possible total of 953, however only 573 had complete data for all items, representing 251 unique individuals (average of 2.3 surveys per person). A descriptive profile of the caregivers with completed surveys for each wave of data collection at the two facilities is shown in Table 2.

The means and standard deviations for each of the questions in the Job Description Index are shown in Table 3 along with the results of the EFA. The overall mean ratings for each question ranged from 2.80 ("Salary and wage increases are given to those who do a good job") to 5.39 ("After a day's work, I really feel like I have accomplished something"). It should be noted that no ceiling or basement effects were identified for any item [33], and most mean scores were centered around the middle of the response scale. These results provide information to address our first question of what job satisfaction items are ranked highest by nursing home staff. That is, at least from the items we used, a relative picture of staff opinions of these items is shown. The third column of Table 3 has the overall rank of each item. In the EFA no reverse coding was used, however, to ease interpretation of the rankings we reverse coded the negatively worded items.

Regression coefficients from the GEE models examining job satisfaction are presented in Table 4. This information was used to examine our second question of what characteristics of caregivers are associated with job satisfaction. We found that males were less satisfied with work than females. Older workers were slightly more satisfied with pay (p < .001) but married caregivers were less satisfied with both pay (p = .020) and work (p = .040). NAs were less satisfied with pay than nurses (p = .090), however they were relatively more satisfied with the work (p < .001). Fulltime caregivers were less satisfied with pay than part-time workers (p < .001), but more satisfied with the work (p = .010). Caregivers who have been on the job for 1 to 5 years were generally less satisfied than those who have been there for either less than one year or more than 5 years. Finally, caregiver's perceptions of the quality of care (measured with the question that caregivers would recommend the nursing home for a relative or friend) was associated with all three job satisfaction domains (i.e., pay (p < .001), management (p < .001), and work (p < .001)).

Job satisfaction has important implications for nursing home staff, the nursing home industry, and quality of care. Nursing homes already employ more workers than steel producers and auto makers combined [12], yet we know little about factors associated with job satisfaction and dissatisfaction for these workers. In this research we find that, overall, caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation (shown in Table 3).

Although not examining all of the same areas of job satisfaction, our results for many individual job satisfaction questions (see Table 3) are somewhat similar to those recently reported by Parsons and associates [3] and Will [33]. These authors also found most satisfaction with work and least satisfaction with pay. Studies with RNs and LPNs in nursing homes have also found dissatisfaction with pay [29]. It is not surprising that pay should be of concern. It is widely acknowledged that nursing home staff are underpaid relative to other areas of health care [34]. Moreover, NAs are often the working poor, many consisting of women, single-family, and/or minorities [35]. Yet, it is surprising that NAs seem to enjoy their work even more than nurses do. Given the often-reported poor quality of care in nursing homes, and difficult work undertaken by caregivers [36], one would assume that staff would have poor job satisfaction. Clearly, this is not the case. NAs would appear to enjoy working with residents and their coworkers. Other job satisfaction studies have highlighted the enjoyment staff receive from relationships with residents [3]. Others have also noted that work attitudes of stayers and leavers differ, with stayers valuing relationships with residents [35].

We speculate that if staff have higher job satisfaction ratings from forming relationships with residents, then facility management could promote such relationships. This could include permanent assignment to residents and teams (often called care pairs), but also more social activities. This may also benefit residents, for as Eaton [12] describes a "typical resident spends at least ninety-one of 112 waking hours a week doing nothing whatsoever." However, given the often chronic understaffing found in many nursing homes, encouraging caregivers to become involved in more social activities with residents will likely be difficult. It may also be difficult to make the case that this type of work is productive [12].

Also, it may be instructive to examine satisfaction with work over time. On the one hand, as more residents in nursing homes are admitted with terminal illness or severe dementia, then the time for staff to build relationships with residents and the ability of residents to form such relationships will likely decrease. If this influences work satisfaction, we may see even fewer staff willing to work in nursing homes. To the extent that the work in nursing homes was described as "emotional labour" [37], this may increase when residents are unresponsive. On the other hand, family members will likely remain to build relationships with caregivers.

Using the three job satisfaction domains (i.e., pay, management, and work), one robust finding is that we see workers with a tenure of more than one year are less likely to be satisfied with the pay. Katz [38] developed a model of employee turnover whereby he identified that workers perceptions of the work environment varied according to their tenure. He used three stages of perceptions of the work environment, socialization, innovation, and adaptation. In this study, we clearly see that satisfaction with pay declines after one year of employment.

The results from the three job satisfaction domains (see Table 4), also show that staff who perceived the quality of care to be high (agree with the statement that they would recommend the nursing home for a relative or friend) have higher job satisfaction than those who do not. Poor levels of satisfaction are linked to high rates of turnover [2, 3]. The typical managerial response to high endemic rates of turnover among caregivers is to modify the conditions of employment (e.g., pay, promotion, communication). However, if satisfaction can be modified as a result of efforts to improve the quality of care, those efforts may also have the beneficial 'win-win' effect of reducing turnover.

This finding for quality is important. We could not find any other studies in the literature that have examined this relationship. This finding, if it holds up in further research, suggests that quality improvement projects may have an impact on caregiver morale. However, the opposite may also be true: unhappy staff may provide poor quality of care, thus placing residents at risk and also increasing the likelihood of turnover.

One further observation from our results using the three job satisfaction domains is that there is variability in the association between some caregiver characteristics and job satisfaction domains. For example, fulltime workers are less satisfied with pay but more satisfied with work than part time workers. Also, NAs are more satisfied with work, however they are less satisfied with pay than are nurses (although this finding did not reach statistical significance at conventional levels). By contrast, the association with tenure and perceived quality are consistent across domains. Researchers and others who focus on staff satisfaction need to be alert to important differences between subgroups of workers.

Clearly, we need to be careful in interpreting our findings. Although our sample size of caregivers was relatively large, this information only came from two facilities. This limits somewhat the generalizability of our findings.

In summary, we find that overall nursing home caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation. NAs appear particularly sensitive to pay, whereas other staff appear more sensitive to work. Of significance, we also find that caregivers who perceived the quality of care to be high have higher job satisfaction than those who do not.