Individual and organizational predictors of allied healthcare providers’ job satisfaction in residential long-term care

Within healthcare, Kanter’s theory has historically most often been applied to the study of nurses [26, 31‐34]. More recently, studies have begun using Kanter’s theory to examine the effects of structural empowerment on job commitment, job satisfaction, burnout, and turnover intention in allied health professionals [35‐40]. For instance, Gilbert, Laschinger, and Leiter [35] used Kanter’s theory to examine how structural empowerment affects healthcare professionals’ use of “organizational citizenship behaviours” [35] in different hospital units. Similarly, in a study including nursing assistants, nurses’ aides, registered nurses, physiotherapists, and occupational therapists employed in nursing homes or home-help services in Sweden, Hagerman et al. [36] used Kanter’s theory to examine the relationship between empowerment, stress, and performance. Kanter’s theory has also been applied to examine structural empowerment on job commitment and turnover intention among pharmacists [37], and physical therapists [38, 40], physiotherapists, and occupational therapists [40]. Miller, Goddard, and Laschinger [38] found evidence in support of Kanter’s theory as a framework to examine factors important in empowering physical therapists. However, these studies have not directly examined whether structural empowerment enhances job satisfaction among allied health workers.

In the Theory of Psychological Empowerment, Spreitzer [21, 22] was concerned with how employees interpret their work environment psychologically. Psychological empowerment refers to a state experienced by employees that is required for employers’ interventions to succeed [21, 22]. There are four components of psychological empowerment: 1) competence (employee’s confidence in their ability to do their job); 2) meaning (compatibility between an employee’s value and beliefs and the requirements of the job); 3) self-determination (feelings of control over their place of employment); and 4) impact (a sense that one’s contributions are important and meaningful to the organization) [21, 22]. According to Spreitzer, high levels of psychological empowerment promote job satisfaction.

Each of the four dimensions of Spreitzer’s theoretical framework have been studied and found to be associated with job satisfaction; however, as with Kanter’s theory, most of the research on this area has examined the applicability of Spreitzer’s theory in a nursing context [31‐33, 41, 42]. In nursing studies, organizational empowerment predicted job satisfaction among nurse educators [33], hospital nursing staff [42], and staff nurses in critical care, med-surgical, and maternal-child units [41]. Among nurse educators, Sarmiento et al. [33] found that opportunity for advancement, access to information, access to resources, support, and formal and informal power were significantly related to overall job satisfaction.

Spreitzer’s theory has also been applied to health care contexts more broadly. For instance, a study by Wagner et al. [39] of over 5000 health organization employees found that psychological empowerment predicts job satisfaction (and turnover intention). Wagner et al. [39] concluded that their findings provide strong support for the role of psychological empowerment as a mediator between organizational context factors and job satisfaction.

More recently, researchers have begun integrating theories of structural and psychological empowerment to gain a more comprehensive understanding of the factors affecting job satisfaction [43]. Researchers have found that both structural and psychological empowerment correlate with job satisfaction in nurses [29, 30] but that the combination of both theories more strongly predicts job satisfaction than when used alone [27]. In nurses, psychological empowerment has also been shown to mediate the relationship between structural empowerment [26] and job satisfaction, as well as workplace environment and job satisfaction [28]. These studies provide support for the notion that organizational empowerment affects employees’ job satisfaction by promoting psychological empowerment [26‐30]. Though in nurses, this conclusion was reached in a recent review by Cicolini, Comparcini, and Simonetti [44], who found that psychological empowerment mediated the relationship between structural empowerment and job satisfaction [44]. More recently, studies have begun examining the relationship between these theories and job satisfaction among allied health workers. For example, Wagner et al. [40] investigated the role of structural empowerment and psychological empowerment on job satisfaction among physical therapy and occupational therapy practitioners’ perceptions of resonant leadership [40]. Taken together, these findings provide support for the role of structural and psychological empowerment in employees’ job satisfaction.

Job satisfaction was defined as a holistic measure of a person’s attitude and feelings toward work. Job satisfaction was measured using the Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale [47], which is a three-item scale, scaled on a five-point Likert scale (1, strongly disagree; 5, strongly agree). An overall score for job satisfaction was produced by taking a mean of the three items (score range 1–5), with higher values representing higher job satisfaction.

Independent variables were chosen based on their availability in the TREC allied healthcare provider survey, balanced by the presence of empirical and/or theoretical support in relation to allied healthcare provider job satisfaction. We assessed demographic, individual-level, and organizational context variables.

Demographic variables included: gender, age group, highest education, primary role, current enrolment, hours worked in two weeks, years worked in current role, and years worked in facility. Although previous research studies did not identify demographic factors as predictors of job satisfaction [16‐19], we included demographic variables in our bivariate analysis because very few studies have assessed these variables among allied health staff. Thus, we wanted to know if these variables were significant in our population.

Individual-level variables included: three dimensions of burnout (exhaustion, cynicism, efficacy), measured using the Maslach Burnout Inventory-Short Form [48]; three dimensions of work engagement (vigor, dedication, absorption), measured using the Utrecht Work Engagement Scale [49]; four dimensions of psychological empowerment (competence, meaning, self-determination, impact), measured using Spreitzer’s Psychological Empowerment Scale [23]; problem solving, measured using an abbreviated version of Heppner’s Problem Solving Inventory [50]; and physical and mental health, measured using the SF-8 Health Survey [51].

Contextual variables investigated were: adequate orientation (single item on the TREC survey), dementia-related responsive behaviours (six items on the TREC survey), and the 10 scales of the 53-item Alberta Context Tool (ACT). The ACT is a survey designed to measure modifiable elements of organizational context [45]. It is comprised of 10 concepts: leadership, culture, evaluation (feedback of data), social capital, organizational slack (composed of 3 concepts: staff, time, space), formal interactions, informal interactions, and structural and electronic resources. The ACT, originally developed for use in acute care hospitals [52], was modified for and produced reliable and valid scores when used with healthcare aides and registered nurses in residential LTC [53, 54].

Largely consistent with Spreitzer’s Theory of Psychological Empowerment [21‐23], which suggests that high levels of psychological empowerment promote job satisfaction, higher scores on three subscales of Spreitzer’s Psychological Empowerment Scale [23] predicted higher levels of job satisfaction among allied healthcare providers. These findings are in line with previous research on allied health provider job satisfaction in LTC. Greater autonomy [16, 18] and ability to contribute to decision making [17] have long been shown to promote job satisfaction among allied health professionals. For example, Tourangeau and colleagues [60] found that higher job satisfaction among allied healthcare providers was associated with higher psychological empowerment and higher sense of personal accomplishment, and that lower levels of autonomy on the job were positively correlated with intention to leave. As well, studies in diverse workers in varied settings have reliably found that meaning is positively associated with job satisfaction [23, 32, 61, 62]. In the present study, meaning had the largest predictor coefficient among the psychological empowerment components.

Our findings also reflect research on allied healthcare providers working in non-LTC settings. In a study examining aspects of allied healthcare providers’ jobs that contribute to job satisfaction and intention to leave a metropolitan hospital, Wilson and colleagues [63] found a significant negative correlation between factors related to psychological empowerment, including autonomy and accomplishment, and their intention to leave their job. Similarly, in a literature review of factors promoting retention of rural and remote allied health professionals, Campbell and colleagues [64] found that autonomy was a positive intrinsic incentive promoting retention, while not same, is nonetheless related to job satisfaction. These findings support the notion that autonomy to make decisions about how to do one’s work results in a sense of ownership, which may explain why higher psychological empowerment is predictive of higher job satisfaction among allied healthcare providers in the present study.

We found a negative relationship between competence and job satisfaction among allied health staff. These results are surprising, as competence was positively predictive of job satisfaction in the bivariate analysis. Although general suppressor effects, suggested by the negative beta coefficient, are difficult to interpret [65], previous studies have found mixed results for the role of competence in job satisfaction. Among nurses, low levels of competence have been associated with work stress [66], whereas higher levels of competence have been shown to predict job satisfaction [67]. Among nurse aides, training has been shown to improve competence in managing dementia-related behavioral problems, improving job satisfaction [68]. On the other hand, Li and colleagues [32] found that among nurses, competence was not associated with job satisfaction in the bivariate analysis, and only the self-determination subscale of psychological empowerment was predictive of job satisfaction in multivariate analysis. In a different study, only meaning and impact, not competence, were significant predictors of work stress among nurses [31].

Outside of the nursing field, studies examining the relationship between job satisfaction and competence have also been inconclusive. In a study of 174 customer service employees, Carless [61] found that competence was a negative predictor of job satisfaction, whereas meaning and impact were positively predictors of job satisfaction (self-determination was not significant). Spreitzer et al. [23] found that competence was positively correlated with job satisfaction among subordinates but did not affect job satisfaction among supervisors. Since our sample included both registered professionals (i.e., therapists, social workers, dieticians) and their assistants/aides, we examined whether the association between competence and job satisfaction differed between these two groups. We found that opposite relationship to that of Spreitzer et al. [23]: competence was positively correlated with job satisfaction among registered professionals (r = .155, p = .036, N = 184), but had no effect among assistants and aides (r = .098, p = .282, N = 118). Because competence includes the perceived similarity or mismatch between the skills possessed and the skills required for a particular job [62], it may be that significant incongruence in either direction (i.e., underqualified or overqualified) may lead to job dissatisfaction. In our sample, it may be that assistants and aides felt overqualified for their positions, resulting in the negative association between competence and job satisfaction, whereas regulated professionals felt “just right” for the job, leading to a positive relationship.

Conversely, it may be that there are complex interactions between dimensions of psychological empowerment, leading to enhancement of suppression of job satisfaction. For instance, Wang and Lee [62] found that, when examined separately, dimensions of psychological empowerment had positive effects on job satisfaction; however, when examined together, individual dimensions enhanced or suppressed the influence of other dimensions on job satisfaction. These findings suggest that the notion that each component of psychological empowerment has an additive effect on job satisfaction is too simplistic and incomplete.

Given these findings and the findings of the current study, further research exploring the causal pathway between empowerment and job satisfaction is needed. Specifically, a quantitative study with a large sample of both regulated professionals and assistants/aides would permit researchers to develop two separate models of job satisfaction to untangle differences and similarities between regulated professionals and their assistants/aides. As well, there is a need to conduct qualitative studies to further examine the relationship between perception of one’s competence for the job and job satisfaction among allied health staff in LTC facilities.

Leaders and managers within facilities can empower staff, thereby enhancing their job satisfaction. According to Gleasonwynn and Mindel [16], allied health professionals who know their role responsibilities and how to accomplish their duties should be given freedom and flexibility when making decisions regarding how to do their job. Organizations should provide information about their mission and values to provide staff with a sense of purpose and meaning in their work [23]. In addition, a program that fosters communication and feedback to staff may help staff feel valued and supported [23]. LTC facilities could also provide incentives for taking part in the decision-making process to empower employees to take control of their work [69]. For example, allowing allied health staff to take part in flexible scheduling would also provide employees with more control and autonomy over their work life, thereby likely enhancing their job satisfaction [70]. Managers who provide staff with a sense of autonomy could also promote empowerment, making staff more likely to stay on the job [70]. As the meaning dimension of empowerment appears to have a consistent positive effect on job satisfaction [62], managers should emphasize programs that increase staff’s sense of meaning. However, given the potential complex interactions between dimensions of psychological empowerment and job satisfaction, managers should be careful to ensure that their policies do not inadvertently work against employees’ job satisfaction.

In the present study, the cynicism dimension of burnout predicted lower job satisfaction. Cynicism measures the indifference or a distant attitude that individuals may feel toward their work. To the best of our knowledge, this is the first study to identify cynicism as a factor affecting job satisfaction among allied health professionals in LTC facilities. However, studies have found that other dimensions of burnout are associated with reduced job satisfaction among allied health professionals. In a study of factors affecting job satisfaction in LTC facilities among allied health workers, Tourangeau et al. [60] found that higher burnout-exhaustion, which measures overextended and exhausted by one’s work, and higher burnout-depersonalization, which measures an impersonal response toward recipients of one’s service, care treatment, or instruction, were associated with lower job satisfaction.

The relatively limited time allied healthcare providers spend with residents in LTC may contribute to their perception of cynicism regarding their ability to effectively meet patients’ needs. In addition, allied health professionals in LTC facilities tend to focus on delaying onset of immobility and easing discomfort as opposed to therapeutic progress for physical therapy and related concerns, which may further contribute to allied healthcare providers sense that they may not be putting in enough time [71]. Indeed, Balogun et al. [71] argued that poor treatment outcomes in working with individuals with chronic conditions, lack of organizational slack time, lack of peer and supervisors’ support, inadequate resources, and interprofessional conflicts contribute to burnout among allied health professionals. Balogun et al. [71] found significant relationships between allied healthcare providers relationships with peers and supervisors and burnout. They found that support from supervisors explained 7% of the variance in emotional exhaustion and support from colleagues accounted for 9.6% of the variance in cynicism. Thus, the requirements for emotional labour may be lower for allied healthcare providers but frustration and cynicism due to prolonged and poor treatment outcomes may be higher, reducing the impact of emotional exhaustion on their job satisfaction while increasing the impact of cynicism. Taken together, these findings suggest that burnout-cynicism is an important factor affecting job satisfaction among allied healthcare providers in LTC facilities that needs addressing.

Consistent with previous studies [72, 73], work engagement was correlated with job satisfaction in the present study. In a study of health care professionals employed in a community setting, Noblet et al. [72] found a significant correlation between work satisfaction and work engagement. In the current study, all components of work engagement were likewise correlated with job satisfaction in the bivariate analysis. In the final model, however, work engagement was not a significant predictor of job satisfaction. Given the significant negative correlation between each component of work engagement and the exhaustion and cynicism components of burnout, which is consistent with the conceptualization of work engagement as being the “opposite” of burnout [74], it is possible that some of the predicted variance attribute to work engagement components becoming attributed to burnout-cynicism, reducing the overall significance of work engagement in the final model. However, we were unable to identify studies that examined the relationship between work engagement and job satisfaction among allied health professionals in LTC facilities. Thus, further research to examine the role of work engagement in job satisfaction among allied health staff in LTC facilities is warranted.

The present study identified social capital as significant positive predictor of job satisfaction among allied health professionals. This is in line with Kanter’s [20] theory of structural conditions necessary for job empowerment and job satisfaction, which proposes that informal power derived from relationships with superiors, peers, and subordinates promotes job satisfaction. In addition, these findings are consistent with previous studies. For instance, Wilson et al. [63] and Rodwell, Noblet, Demire, and Steane [75] found that communication and support from the manager were significantly correlated with intention to stay and job satisfaction among allied healthcare providers; and Gleasonwynn and Mindel [16] who found that peer support, emotional support, and morale enhancement improved job satisfaction among LTC allied healthcare providers. Finally, Stagnitti, Schoo, Dunbar, and Reid [76] also found that when allied healthcare providers felt supported in the workplace, they expressed higher intention to stay.

The importance of communication among colleagues may be particularly salient for allied healthcare providers, given that there are relatively few allied health professionals employed in a single LTC facility compared to other care provider groups and that allied healthcare providers tend to move around units or floors in a facility more than other care providers, leaving limited opportunity for peer support [16]. Consistent with this, Collins et al. [69] found that job satisfaction depended on participants’ integration within their own professional group and with colleagues in other fields.

The concept of esprit de corp, defined as “feelings of group belonging and solidarity derived from a sense of the position nurses occupy as a subordinate collective within the healthcare system” [77], may also explain the importance of social capital for allied healthcare providers. Miller et al. [77] found that feelings of professional solidarity among nurses were interpreted negatively by other professionals. As a result, social capital, which may indicate the extent to which allied healthcare providers are integrated into the facility and the extent of interprofessional collegiality, may be more important than unit or facility culture for this population. For allied healthcare providers, who may be excluded from the esprit de corps of the nursing groups [77], integration and interprofessional communication may play a particularly important role in job satisfaction. Taken together, the present findings suggest that support provided through social connections and social capital among allied healthcare providers and between allied healthcare providers and nursing staff may enable the former to receive better emotional support, boosting morale and job satisfaction.

In the present study, social capital was defined as the stock of active connections among colleagues. Social capital has also been defined as including “the norms and networks that enable people to act collectively” as well as “how people interact with each other (and on what terms)” [78]. A concept analysis of social capital identified “networks of social relationships at work,” “shared assets,” and “shared ways of knowing,” which includes an organization’s culture based on values, beliefs, and understandings, as key features of social capital [79, 80]. Given these broad definitions of social capital, it is not surprising that social capital was also correlated with culture and informal interactions, which may be categorized under “social integration” (i.e., “connectedness with or caring about fellow workers”) [81]. Social capital was also positively correlated with leadership. While these variables were significantly correlated with job satisfaction in the bivariate analysis, only social capital was found to be a significantly predictive of job satisfaction in the final model. It may be that social capital explains more of the variance in job satisfaction than either culture, leadership, and informal interactions [82]. McColskey [81] argued that good leaders create a general ambience on a unit through interactions of many factors that in turn increase social capital. Thus, it may be that good leadership promotes a positive work culture, which then contributes to an environment where allied health staff experience a positive social capital, to which they then attribute their job satisfaction. From the perspective of employees, social capital may be the most proximal factor affecting job satisfaction.

In the present study, perceptions of a lack of organizational slack - time, which refers to the perceived availability of time to provide resident care and share best practice knowledge, was a predictor of lower job satisfaction among allied healthcare providers. While, to the best of our knowledge, organizational slack-time has not been assessed in any of the previous studies on allied healthcare provider job satisfaction, it may be that limited time with each patient contributes to job dissatisfaction by increasing burnout-cynicism resulting from insufficient time to complete job duties, particularly given the long timescales that may be required for treatment among this population [71]. Kanter [20] argues that access to resources, including time to accomplish organizational goals, is an important component of job satisfaction. Our results with respect to slack-time are also consistent with research showing that insufficient time with residents increases stress, which may contribute to poorer job satisfaction. For instance, in a qualitative study of retention among allied health workers in rural areas, O’Toole, Schoo, and Hernan [83] found limited time to do administrative work reduced healthcare providers’ intention to stay. Our findings, in conjunction with past research in the field, suggests increasing allied health care providers organizational slack-time as a means of promoting their job satisfaction.

The present study also identified adequate orientation as a significant predictor of allied healthcare provider job satisfaction. Adequate job orientation refers to an individual’s perception of whether they have had enough on-the-job orientation and training to carry out their job safely and effectively. Kanter [20], in the Theory of Structural Empowerment, posits that access to information (e.g., technical knowledge, data, expertise) to function effectively in one’s position is important to job satisfaction. Though not directly assessing job satisfaction, Stagnitti et al. [76] found that allied health professionals who were given orientation to their primary position were more likely to express intention to stay longer in the job. It is possible that the lack of adequate job orientation contributed to lower job satisfaction by increasing stress and time required to work out proper protocols. We recently conducted a similar analysis on nurses (Aloisio et al. :Individual and organizational predictors of nurses' job satisfaction in residential long term care, submitted) and found that adequate orientation was also a significant predictor of job satisfaction among regulated nurses. Among nurses, perception of inadequate training leaves nurses feeling unprepared and overwhelmed about their responsibilities [84, 85], and lack of clarity about one’s role contributes to confusion [86], adversely affecting job satisfaction. Among allied health professionals, adequate orientation is associated with intention to stay employed in the current facility [70]. Likewise, lack of adequate orientation is associated with increased stress, as staff are forced to spend more time identifying appropriate contacts and proper protocols for organizational procedures [87].

Given the relationship between adequate orientation and job satisfaction identified in this and previous studies, orientation and training programs need to be developed that address the needs of allied health professionals employed in LTC facilities. In a systematic review of the effectiveness of training program aimed at health professionals working with older individuals with dementia, McCabe et al. [84] found that training and education programs reduced staff stress levels, improved employees’ sense of self-worth and satisfaction with work, and reduced turnover. Training has also been shown to reduce staff members’ perception of the severity and frequency of dementia-related behaviors among staff [88], reducing job strain and enhancing job satisfaction. In a study of factors affecting job satisfaction among nurses and allied health professionals, Collins and colleagues [69] found that respondents who felt adequately trained and prepared for their roles reported higher job satisfaction. The authors posited that training made staff feel more capable and comfortable at their jobs.

Summarizing the literature on education and training programs for staff employed in LTC facilities, Moyle et al. [89] provided recommendations for orientation and training programs based on their findings. Among the recommendations, Moyle et al. [89] suggest involving the target audience in planning and design of the information to ensure that the information provided matches the needs of the audience. Input from staff would allow the organization to empower staff to gain the resources they feel are most important to them. Therefore, a needs assessment by individual LTC facilities could provide clarity into what may be missing from the current orientation provided. This is particularly important as the design of the program plays a key role in program success [90]. Moreover, to ensure success, the curricula of the training and orientation programs should also be embedded in the culture of the LTC facility [91]. As well, effective leaders that are supportive of training and education initiatives are crucial to program success [89]. To promote job satisfaction among staff, leaders and change agents within the organization need to ensure consistent and ongoing commitment to developing and implementing orientation and training programs that meet the needs of the staff [89]. By providing adequate orientation, facilities can address multiple factors shown to influence job satisfaction in the present study.

The study has important strengths. It is the first study to evaluate, using multivariate analysis, a large variety of factors, individual and organizational, affecting job satisfaction among a relatively large sample of allied health care providers in residential LTC settings. Data was collected from a random stratified sample of LTC facilities using well-validated responses with a high degree of quality assurance processes [92]. Additionally, secondary analyses, such as this one, are time- and cost-effective, as resources do not need to be expended on collecting data. They also serve as a useful exploratory tool.

The cross-sectional nature of our analysis limits ability to assess whether temporal changes in organizational context affect allied healthcare providers’ job satisfaction. Further, as this was a secondary analysis, the data did not contain all of the variables of interest identified in the literature, e.g., levels of administrative duties [17], contextual variables such as less routinization [18], satisfaction with residents and residents’ families [16], pay and benefits (particularly as compared to those working in other sectors) [93‐95], and opportunities for promotion and career advancement [18, 96]. Additionally, some of the scales used in the original study with established reliability, when administered to healthcare aides [54] and nurses [53] in LTC, displayed lower alpha scores of <.70 when administered to allied healthcare providers in our study. Thus, future research refining the TREC survey for allied healthcare providers is warranted. Additional limitations include the self-reported nature of all the data, including contextual factors.