Compared with home care, in facility-based care the facility is the center of responsibility for and control of care, interaction with supervisors and coworkers is frequent and in person, the work of one affects coworkers, workers care for multiple residents, and staffing levels affect all workers. Because home care is provided one-on-one to specific clients in their geographically dispersed homes, workers have greater autonomy; scheduling regular, full-time shifts is difficult; and responsibility for scheduling and clinical supervision can be split between two supervisors.
Second, the acuity of persons receiving care affects the intensity of direct care staffing and supervision needed, and the importance of clinical skills and supervision.
Typically, the acuity of residents in nursing facilities is greater than in assisted living. Although resident care needs vary widely across individuals receiving home care, acuity is typically lower than in nursing facilities. Finally, government payment and regulation affect settings in different ways.
Most nursing facilities rely heavily on Medicaid reimbursements. Low Medicaid reimbursement rates constrain the financial resources of these facilities compared with: a many assisted living facilities, which typically rely more on private payments; and b home care, which relies on both Medicare and Medicaid. Nursing facilities also are more heavily regulated than other provider types, which can lead to more formal organizational structures, greater training requirements, and less flexibility to innovate.
Using the baseline survey of direct care workers in BJBC, we coded responses to an open-ended question about employer changes that would improve workers' jobs and grouped these responses into categories. We then compared the percentages of workers recommending changes in these categories across types of providers.
The population of interest for the study was all direct care workers at providers participating in BJBC. A direct care worker was defined as follows: An individual who provides hands-on personal care e. Although activities may sometimes overlap, we do not include licensed practical nurses or registered nurses in this definition. Also excluded are workers who help with cleaning, meal preparation and chores, but do not provide personal care.
Typical job titles include nurse aide, home health aide, and personal care attendant. The information system tracks hiring, termination, and other information about direct care workers employed by participating providers. Upon enrollment in the demonstration, each provider submitted a list of all currently employed direct care workers.
Each provider updated the information system at the end of each pay period with any changes that had occurred since the last update. Once a provider enrolled, surveys were sent to a list of all of its direct care workers, which was extracted from the information system. Because the list was of current workers, the data do not reflect the perspectives of workers who quit or were fired. Because providers enrolled over time, baseline data collection extended from July through April A total of 3, direct care workers completed the survey.
Because the study was based on providers that volunteered to participate in BJBC, it is not representative of all providers. For example, three fifths of BJBC providers were nonprofit organizations. About a third of the home care providers were certified home health agencies, and the other two thirds were home care providers that typically provided nonskilled care sometimes in combination with skilled care.
Assisted living facilities as used here includes a range of types of residences that generally provide meals and personal care but not necessarily skilled care.
Han, Sirrocco, and Remsburg referred to these as long-term care residential places. These facilities have different names depending on the state e. The BJBC providers in this category were diverse. They included, for example, assisted living residences that were part of continuing care retirement communities paid for privately, and adult care homes paid for largely through a combination of Supplemental Security Income and Medicaid.
As expected, the vast majority of direct care workers in our sample were high school educated women see Table 1. Most other characteristics differed across settings. Health insurance benefits followed a similar pattern: Nursing facilities had the highest proportion of workers offered health insurance and the highest proportion enrolled, and home care agencies had the lowest proportions.
Many workers in BJBC had long careers in direct caregiving: The median direct care worker in nursing facilities had spent 7. More than two fifths of the sample was older than age 45, with home care having the oldest workers and nursing facilities the youngest. Response rates were higher among workers who had worked at the provider longer, in smaller organizations, in Vermont and Oregon, and in home care agencies and adult day service providers.
To adjust for these differences, we reweighted the respondent sample so that the distribution of the sample matched the population distribution on these characteristics. The survey was an 8-page self-administered paper booklet. It included questions about length of employment, job satisfaction, job rewards and problems, supervision, perceptions of quality of care, job confidence, training, intent to quit, and demographic characteristics. Respondents returned the surveys in the business reply envelopes.
Responses were tracked using identification numbers on each survey. To increase response rates, workers received a follow-up packet about a month after the initial packets were distributed. To ensure that the employer did not know who the nonrespondents were, everyone from the original list received a follow-up packet.
For nonrespondents, the follow-up mailing included another copy of the survey and reply envelope. Those who had already responded received a thank you letter and a copy of a BJBC newsletter. The second administration increased the response rate by 10 to 15 percentage points. Although the analysis of recommendations obtained by asking workers directly is a strength of this study, we should note that their recommendations may not have recognized constraints management faces or changes they are not familiar with.
In addition, by asking for the single most important change, the question did not allow for the possibility of indirect or interactive effects or give any weight to secondary recommendations.
We reviewed the text responses to the question and identified themes based on recurring words or synonyms in the responses. We then developed written criteria for 16 categories including a left-blank category for nonresponse and assigned responses to one of those categories.
We also aggregated the detailed categories into five major categories of related responses. When a respondent provided more than one recommendation, we coded the first one, recognizing that this may not have been the most important in all cases.
To assess reliability a second investigator coded the responses independently based on the written criteria. We estimated the weighted mean percentage of workers making each type of recommendation and compared the means across the three types of providers. When comparing settings, we tested the statistical significance of the difference for each pair of provider types using a t test with a Bonferroni correction for multiple testing.
Not all workers made a recommendation for improving their jobs. This group had two subcategories: a smaller group whose responses indicated that they were satisfied with their jobs, and a larger group that did not respond to the question.
Those not making a recommendation presumably either did not take time to respond, were happy with their job, or were unable to identify a change that would improve their jobs.
As a group, those not making a recommendation were more satisfied with their job than those making a recommendation. Many workers called for increased compensation, including more pay, better benefits, or the opportunity to work more hours.
In all three settings, most workers who mentioned compensation called for increased pay; much smaller percentages identified improved fringe benefits or the opportunity to work more hours.
Consistent with their lower percentage with employer-sponsored insurance, home care workers stood out as more likely to call for better fringe benefits than workers in facilities. They also were more likely to identify being able to work more hours as important. This reflects the difficulty of scheduling consistent, full-time work given turnover among clients and the complexity of matching clients with workers within a reasonable distance of their home.
The work relationship category included a range of responses grouped into six subcategories. The language used more often was personalized and suggested greater intensity of personal concern in three subcategories: listening e. Although often not explicit, many of the responses appeared to refer to treatment by supervisors and may have reflected the culture of the organization.
The language used in the other three subcategories—improved communication, better supervision, and more teamwork—tended to be less personalized.
Work relationships appeared to be of greatest concern in nursing facilities and of least concern in home care, with assisted living in between. The high percentage in nursing facilities is consistent with the frequent interactions with peers and more intensive supervision in this setting. Of the six subcategories, direct care workers in nursing and assisted living facilities most often listed improving supervision.
Although workers in home care mentioned work relationships least often overall, they called for improved communication more often than other aspects of work relationships. This is consistent with the greater difficulty of communicating with workers not on site. Workers in nursing facilities identified hiring more or better staff more often than any other major recommendation category and more often than workers in any other setting.
That home care workers do not identify increased staffing is not surprising given that their own work is largely unaffected by the aggregate staffing in the organization. The lower percentage in assisted living than nursing facilities may reflect the lower acuity of assisted living residents or the higher level of staffing relative to care needs.
This category included recommendations concerning the purchase or maintenance of equipment, the availability of training and continuing education opportunities, the process of setting employees' work schedules, and a variety of miscellaneous changes in work processes. Within the broad category, workers in home care and assisted living called for increased training more often than nursing facility workers—likely due to regulatory requirements for training in nursing facilities.
Compared with workers in facility-based settings, home care workers recommended improved scheduling more often, reflecting the greater difficulty of scheduling in home care. In their theoretical frameworks, Eaton and Hunter identified many of the categories of management changes that workers identified. Both identified pay and benefits, worker input which corresponds to listening , and training. However, they also identified changes that workers did not: organization in teams both , work assignments Eaton , formal promotion programs Hunter , tuition reimbursement Hunter , and selection although a few workers identified hiring better workers and recruitment Eaton.
Workers' failure to mention them is not surprising because workers are unlikely to have experienced such practices or, in the case of recruitment and selection, they may not feel that this affects their own jobs. At the same time, workers identified some changes not identified in the two frameworks. Most important are the many dimensions of work relationships: respect, appreciation, listening, teamwork, communication, and supervision. The frameworks also did not identify working more hours which home care workers called for.
This is not surprising given that Eaton and Hunter developed the frameworks for nursing facilities. Two changes that direct care workers identified as the single most important thing their employers could do to improve their jobs were common across nursing facilities, assisted living, and home care.
Workers in all three settings called for two changes: a more pay and b improved work relationships. It is the differences across the three settings, however, that stand out in what workers said. For example, although workers in all types of providers mentioned increased pay and improved work relationships as important, the fraction of workers doing so varied greatly across settings.
Moreover, workers in different settings differed with respect to the specific subcategories of recommendations they emphasized. As a consequence, although some policies and management strategies for improving jobs apply across the board, some different ones will be needed depending on the setting.
We base our discussion on averages across providers, focusing on recommendations made most often in each setting, under the assumption that they are most important for managers in general. However, what is relevant to a particular provider will differ depending on the provider's particular circumstances. Because what workers say generally may not apply to specific providers, a good place for managers to start in deciding how to improve jobs is by asking their own workers.
Our findings are also averages across workers. Because what is most important varies across workers, no one type of management change will improve every direct care worker's job.
Thus, improving jobs is likely to require a multipronged strategy of management practice changes. Increasing staffing stands out as a priority for management change in nursing facilities—it was workers' most frequently mentioned change. Another priority should be improving work relationships—especially supervision and whether workers are appreciated, listened to, and treated with respect. Improving relationships through training in communication, supervision, and team building; peer mentoring; and greater involvement of direct care workers in care management decisions are promising management practices that were tested in BJBC.
Increasing pay appears to be the third most important change that would improve workers' jobs. Increasing pay stands out as a change managers in assisted living should focus on—a third of workers said increasing pay is the most important change employers could make. Managers should also take steps to improve supervision, as well as other work relationships. Finally, providing more training and increasing staffing are additional changes workers identified that management should consider.
Because care is delivered largely one-on-one in clients' homes, managers in home care face quite different challenges than managers of facility-based providers.
Indeed, fewer factors that affect workers' jobs are under management's control. Reflecting this in part, direct care workers in home care were least likely to identify anything that employers could do to improve their jobs. Increasing compensation is by far the most important change that managers can make, as identified by workers.
In addition, an important minority of home care workers called for better fringe benefits. Managers should also respond to home care workers' concerns about the number of hours they work, scheduling, and more training. For public policy makers, our findings have two related implications.
First, government policies that increase direct care workers' pay are important to improving jobs. Low Medicaid reimbursement rates are likely to lead to low pay and high turnover, especially in providers for whom Medicaid payments are a large share of revenue. Second, policies that increase pay are not the only ones that can improve jobs. For example, government regulatory policies that lead to improved training of direct care workers and their supervisors have potential for improving jobs and reducing turnover.
Pay-for-performance policies that emphasize turnover and retention e. In short, multiple policy options other than increasing workers' pay could help improve jobs and ultimately reduce turnover. This analysis has identified the management changes that workers say would improve their jobs. However, it has not provided evidence of the effectiveness of these changes in improving retention or quality of care. Managers and policy makers need this evidence to understand whether the management changes have benefits beyond improving jobs.
Given the importance of work relationships to direct care workers, research on management practices that improve work relations also is needed. Research planned using the data generated by BJBC will analyze the effects on supervision, turnover, and worker perceptions of quality of care of the changes identified not only in Eaton's and Hunter's frameworks, but also by direct care workers themselves. Finally, our findings have an important implication for researchers: Do not assume that findings from research on nursing facilities apply to other settings.
Some findings from nursing facilities, where so-called culture change originated and where most of the research on improving direct care workers' jobs has been done, will apply to other types of providers, but not all findings will. Looking only through the lens of skilled nursing facilities may distort researchers' ability to see what changes are needed in assisted living and especially in home care. We are grateful to the foundations for their support; to Maureen Michael for suggesting this analysis; and to Sarah Ayers, Nancy Fishman, Jackie Williams Kaye, Andrea Schreiner, and Amy Stott for helpful input on an earlier draft of this article.
Notes : Sample sizes differ slightly across characteristics because we excluded missing data from our analyses. The maximum percentage of cases excluded was 2. Notes : We performed a Bonferroni correction and used an adjusted p value of. Barry, T. The Gerontologist. Better Jobs Better Care.
Call for proposals - demonstration program. Retrieved September 12, , from www. Bowers, B. Turnover reinterpreted: CNAs talk about why they leave. Journal of Gerontological Nursing, 29, , 3 , 36 Bradburn, N. Asking questions: The definitive guide to questionnaire design for market research, political polls, and social and health questionnaires.
San Francisco: Wiley. Castle, N. Staff turnover and quality of care in nursing homes. Medical Care, 43, , Church, A. Estimating the effect of incentives on mail survey response rates: A meta-analysis. Public Opinion Quarterly, 57, , 1 , 62 Dawson, S. Direct-care health workers: The unnecessary crisis in long-term care. Eaton, S. Pennsylvania's nursing homes: Promoting quality care and quality jobs. International Journal of Human Resource Management, 11, , Rule Direct care worker means a paid caregiver who provides direct , hands on personal care services to persons with disabilities or the elderly requiring long - term care.
Sample 1. Sample 2. Sample 3. Direct care worker means an individual who by virtue of employment generally provides to individuals direct contact assistance with personal care or activities of daily living or has direct access to provide care and services to clients , patients or residents regardless of setting.
Examples of Direct care worker in a sentence June 8, Direct care worker means those individuals aide , assistant , caregiver , technician or other designation used employed by or under contract to a personal assistance services agency to provide personal care services , companion services , homemaker services , transportation services and those services as permitted in 24 Del.
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