THANKS SO MUCH FOR INVITING ME TO YOUR CONFERENCE!

Strategies for Empowering

Direct Care Workers and Improving Job Outcomes

Linda S. Noelker, Ph.DSenior Vice President

Director, Katz Policy Institute Benjamin Rose Institute Presented at the North Carolina

Conference on Aging, September 10, 2007, Winston-Salem, NC.This research was supported by a grant from the Institute for the Future of Aging

Services under the Better Jobs Better Care initiative funded by the Robert Wood Johnson Foundation and Atlantic Philanthropies.

Benjamin Rose Institute (BRI) Established in 1908

Endowment (currently 120 million)

Mission: To advance the health, independence, and dignity of older adults by raising the standards for quality of care

A non-profit agency that includes Home & Community-based Services(HCBS), Applied Aging Research, and Public Policy Institutes

What changed at BRI? 1961: BRI’s first 115-bed nursing

home opened

1997: BRI’s new 184-bed nursing home opened

2006: BRI got out of the nursing home business

Kethley House @ Benjamin Rose Place

What does it reflect about Long Term Care?

Inadequate reimbursement under Medicaid

Shift to HCBS (“rebalancing”) Liability issues (threat to BRI’s

endowment) Licensed nursing shortage Direct care workforce (DCW) issues

(e.g., increasing health insurance costs, projected shortages)

Today’s Objectives Further understanding of the touch points

between Rosabeth M. Kanter’s theory of worker empowerment and the stress and social support model as they affect DCW job satisfaction

Present findings on factors affecting DCW job satisfaction with a focus on education and training

Promote improved DCW training based on their recommendations

What is empowerment?A process by which the

characteristics of the organization and the job

create an environment in which the employee feels in control

and has the power and ability to affect the achievement of organizational goals (Kanter, 1993)

Key Elements of Empowerment

Training and education so workers can learn and grow

Supportive leadership and work environment

Information sharing

Access to needed resources

DCW Training and Education

Competencies are developed broadly

Include interpersonal and group process skills, problem-solving and decision-making skills, leadership, customer relations skills, and technical skills

Comments Reflecting a Lack of Empowerment around Education

“You can’t expect them to learn that.”

“Continuing education is the same old thing over and over.”

“I can’t leave the unit to attend.”

“They get to go to the Marriott for their continuing education.”

Empowerment Outcomes Higher job satisfaction

Greater job commitment

Reduced job-related stress & burnout

Higher retention

Better Education = Better Jobs

BRI’s Survey of DCWs

Employed stress & support conceptual model to guide the research

Both DCW-level and organization-level analyses conducted to address issue of nested data

DCWs from nursing homes, assisted living and home health agencies included

Study Design and Methods

Cross-sectional survey; in-person/phone DCW interviews

Questionnaires for data on organizational characteristics and management practices

Study sites drawn using proportionate random sampling from all Nursing Homes (NHs), Assisted Livings (ALs) and Home Health Agencies (HHAs) in five counties in NE Ohio

90 sites chosen/49 agreed (41% participation rate)

27 NHs, 14 ALs, and 8 HHAs

DCW Sample

Proportionate random sampling of DCWs within the 49 sites

Targeted 900, 1058 contacted, 644 participated (61% participation rate)

Over time & over budget on sample recruitment and data collection

Is is possible to obtain a representative sample of DCWs?

LTC Stress and Support Model Predicting Direct Care Workers’ Job Satisfaction

A. Background Characteristics

Direct Care Workers• Age• Marital Status• Race

B. Stressors:

Direct Care WorkersPersonal• Family & Financial• Health ChangesJob-Related• Training• Pay & Benefits• Scheduling Changes• Permanent Assignment

C: Workplace Support:

Direct Care WorkersPositive & Negative Relationships• With Residents/Clients• With Staff

E: Outcomes:

Direct Care Workers• Job Satisfaction

D. Organizational Variables:

Characteristics• Types of LTC Setting• Profit Status• % of Minorities Served• % of Medicaid ReimbursementManagement Issues• Turnover of DCWs• Minimum Pay

Analytic Approach

Multiple Linear Regression Analysis: using individual-level DCW data to predict job satisfaction

Hierarchical Linear Modeling: using organizational-level data to predict average job satisfaction score in study sites after controlling for individual-level variables

Perceived Adequacy of Training Entry-level

Job orientation

Continuing Education

Recommendations for improvement

Positive and Negative Support in the Workplace

Positive interaction with peers and residents/clients (e.g., feelings of respect, affection)

Negative interaction with peers and residents/clients (e.g., feelings of anger, frustration)

Frequency of hearing racist remarks from residents, families and other staff

Findings: DCW characteristics Age (average) 39 years

Minorities 59%

Female 95%

Unmarried 63%

Work in LTC (average) 8.7 years

Multiple Linear Regression Results

for DCW Job Satisfaction

Adj. R2 .51 (p<.01)

Background characteristics: Non-minority

*Personal Stressors: + Physical health & emotional health change; lower depression scores

*Job-related Stressors: adequacy of job orientation & continuing education; fewer scheduling changes; fair pay & more benefits (health insurance, retirement)

Workplace Support: less negative interaction; fewer racist remarks

Racist RemarksHeard make remarks: To be

hurtful:

Clients/Residents 70% 4%

Families 15% 38%

Other staff 21% 65%

Quotes from Workers “I want to leave because I cannot take

the racial comments anymore. I am training to go into medical billing.”

“There seems to be a ‘white’ standard and a ‘colored’ standard. The white workers are expected to do more and be more responsible which makes them feel discriminated against and angry.”

Results from HLM Analysis of Factors Affecting DCW Job

Satisfaction

Adjusted average DCW job satisfaction scores were higher for:

DCWs in Assisted Living and Home Health Agencies

Sites reporting less difficulty with DCWs quitting and being fired

Sites with a higher rate of starting pay

DCW Reports about Training

NH DCWs AL DCWs HHA DCWs

Initial training made

me well prepared 55% 59% 71%

Job orientation was

very helpful 49% 47% 63%

Very useful to have

a mentor 74% 77% 79%

Continuing education is

very useful 53% 51% 70%

CEU Topics Most Frequently Covered

Preventing injuries at work (not as helpful for NH/ALF DCWs)

Caring for those with dementia

Communicating with residents/clients

Resident/client care skills such as bathing (need more in ALFs)

How to deal with difficult coworkers

CEU Topics Needing More Attention

DCW Teamwork (especially in NHs)

Organizing tasks so everything gets done (especially in HHA)

CPR (especially in NHs)

Problem solving on the job (especially in ALFs)

Managing job stress (especially in NHs)

End-of-life issues/grief (especially in ALFs)

Recommendations for Improving Entry-Level Training

Longer/more hours

More clinical time

More one-on-one instruction (peer mentoring)

Cover teamwork, respect, communication, dementia care, lifts/transfers, vital signs

Recommendations for Improving Continuing Education

More frequent, shorter sessions

Offer on all shifts/all days of the week

Interactive training (e.g., role plays)

Obtain DCW input on content and design

Ensure coverage to foster attendance

Cover teamwork, respect, communication, mental illness, vital signs, and CPR

References Ejaz, F., Noelker, L.S., Menne, H.L. & Bagaka’s, J.

G. (in press) The impact of stress and support on direct care workers’ job satisfaction, The Gerontologist.

Kanter, R. M. (1993) Men and Women of the Corporation. N.Y.: Basic Books.

Noelker, L.S., Ejaz, F.K. & Menne, H.L. (in press) Knowledge as empowerment: Improving nursing assistants’ education and training, in Empowering Work Teams in Long Term Care: Why and How to Create Self-directed Teams, Yeatts, D., Noelker, L.S. & Cready, C.M. (eds.), Health Professions Press.

Today, Tomorrow, Together! Working collaboratively to

improve the size and quality of the Direct Care Workforce

Ensuring quality jobs and quality care for older and younger disabled citizens