Frontline Supervisor Survey Data Collection Report

Brigitt Heier, Diane Brannon and Peter Kemper

Pennsylvania State University, Center for Health Care and Policy Research

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This report was prepared under contract #HHSP23320044303EC between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Pennsylvania State University. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Marie Squillace, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Marie.Squillace@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

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INTRODUCTION

In long-term care, frontline supervisors play a central role in direct care workers’ (DCWs’) job quality and turnover and are critical to the implementation of management changes. To better understand supervisors' perceptions of management practices, the quality of supervision, and the effect on DCW turnover and job quality, the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services contracted with Penn State to conduct a survey of supervisors participating in the Better Jobs Better Care demonstration (BJBC). The BJBC demonstration took place in five states and tested innovative policy and practice models designed to improve the quality of DCW jobs in an effort to improve retention of these workers (Kemper, Brannon, Barry, Stott, and Heier, in press; http://www.bjbc.org).

The Frontline Supervisor Survey project was designed to address several questions:

1. What are supervisors’ job responsibilities?

2. What are the characteristics of supervisors?

3. How do supervisors assess their jobs?

4. Do supervisors and clinical managers agree about management practices where they work?

The data collected from this project will be made available to other researchers and policy analysts through the University of Michigan’s Interuniversity Consortium for Political and Social Research (http://www.icpsr.umich.edu/) under restricted use agreements that ensure confidentiality. The survey instrument and data collected laid the foundation for a subsequent report entitled the Frontline Supervisor Survey Report (Kemper, Brannon, Heier, Kim, Warner, Vasey, and Stott, http://aspe.hhs.gov/daltcp/reports/2008/FSSrpt.htm), which analyzes supervision of DCWs across long-term care settings.

DEFINITION AND IDENTIFICATION OF THE POPULATION

The population of interest for the survey is all supervisors who provided ongoing supervision through daily contact with DCWs in the skilled nursing facilities, assisted living facilities, home care agencies, and adult day service providers participating in BJBC. Because job titles and roles of frontline supervisors vary across settings, it was important to clearly define the population of interest. To do this we identified responsibilities specific to frontline supervision, developed an instrument to identify the supervisors based on these responsibilities, and asked the clinical manager at each provider to use this instrument to list supervisors who performed these responsibilities.

Defining the Population

To begin with, we conducted a series of open-ended telephone interviews with either an administrator or director of nursing from four skilled nursing facilities, one assisted living facility, two home care agencies, and one adult day service provider to gain a better understanding of supervisory structures in each type of organization. These organizations represented all five states participating in the BJBC demonstration. We also spoke with home health care trade associations. The phone calls allowed us to explore the concept of “supervisory function” with the respondents.

From the information collected during both the telephone interviews discussed above and subsequent cognitive testing of procedures with clinical managers from local long-term care organizations, we developed a Supervisor Identification Instrument. This identification instrument included nine tasks, or supervisory responsibilities, which were divided into primary and secondary responsibilities. A person qualified as a supervisor if he or she performed one or more of the following primary responsibilities:

• Ensure that DCWs are giving proper care to clients/residents;
• Initiate disciplinary action;
• Document DCW performance problems;
• Provide feedback to DCWs on job performance;
• Directly respond to job concerns raised by DCWs.

or if they performed at least two of the following secondary responsibilities:

• Act as a mentor to DCWs;
• Schedule DCWs;
• Recommend training for DCWs;
• Conduct on-the-job training.

The Supervisor Identification Instrument (task list) is included as Appendix A.

Identifying the Population

Once finalized, the Penn State Survey Research Center sent a recruitment e-mail (Appendix B) and Supervisor Identification Instrument via e-mail to the clinical manager at each BJBC provider organization. Those without e-mail were contacted by phone and sent the task list by fax. The recruitment letter explained that we were planning to survey staff “who have a role in supervising direct care workers” and were asked to “indicate the staff member(s) responsible for each task listed.” Clinical managers then were asked to return the identification instrument via e-mail or fax to the project manager at the Survey Research Center. The project manager used the screening criteria to determine if individuals listed on the identification instrument met our definition of a supervisor. If an individual did not meet the criteria, the project manager contacted the clinical manager to clarify the role of the individual and to verify the tasks reported to determine whether or not he or she was a supervisor. To obtain identification instruments from as many providers as possible, the project manager made anywhere from three to ten follow-up attempts using a variety of different methods including phone, fax, e-mail, regular mail, and express mail.

The Survey Research Center developed and programmed a secure Web tool to manage the survey process and track responses. Supervisors who met the definition were entered into the database. To ensure confidentiality, only the Survey Research Center staff had access to the names of respondents included on the identification instrument. Supervisors in the database received an internal identification number for tracking non-respondents to the Supervisor Survey so that follow-up procedures could be carried out when the survey was administered.

DEVELOPMENT OF THE SURVEY INSTRUMENT AND PROCEDURES

The Supervisor Survey is an 11-page, paper-and-pencil survey with 132 items related to supervisory responsibilities; provider management practices; and job quality, satisfaction, problems, and rewards. We chose a paper-and-pencil survey over a telephone survey for two reasons: (1) a telephone survey is costlier; and (2) obtaining individual supervisor telephone numbers is difficult. The survey is based on items adapted from the BJBC Clinical Manager Survey and BJBC Direct Care Worker Survey that were administered as part of the broader BJBC evaluation. So that comparisons could be made across surveys, we kept question wording consistent.

Prior to fielding, the Survey Research Center cognitively tested the survey by interviewing five frontline supervisors from local long-term care providers. Three were supervisors in skilled nursing facilities, one was in a home care agency, and another was in an adult day service provider. Respondents were asked to describe their thought processes out loud as they answered the survey questions. The interviewers solicited feedback on wording, placement, and flow of questions within the survey. These interviews identified items that were not clear to respondents or were not interpreted as intended. As a result, we made minor changes in the wording and placement of these items.

We anticipated that in smaller organizations clinical managers also might qualify as supervisors. Because the Clinical Manager and Supervisor Surveys contained many common items, the Survey Research Center prepared a shorter version of the survey instrument that included only the items on the Supervisor Survey that were not in the Clinical Manager Survey.

For the survey and survey procedures, we obtained Institutional Review Board (IRB) approval at the Pennsylvania State University (IRB #16989) and clearance from the Office of Management and Budget (OMB # 0990-0295). In addition, we obtained a National Institutes of Health Certificate on Confidentiality to strengthen respondent privacy.

In addition to testing the survey instrument, the Survey Research Center staff reviewed internal procedures to ensure that all technical aspects of the data collection methodology functioned properly. Procedures for administering the survey were the same as those successfully used in the BJBC evaluation to survey DCWs. Therefore, it was not necessary to field test the administration of the Supervisor Survey.

SURVEY ADMINISTRATION

Once the survey was developed, the population was taken from the information system database. The Survey Research Center identified clinical managers who also were supervisors by comparing the names of the clinical managers with the names of the supervisors. Each supervisor in the study received a packet that included: (1) a cover letter explaining the survey and providing the information for informed consent (Appendix C); (2) a survey (Appendix D); (3) a $2 cash incentive; and (4) a postage paid business reply envelope addressed to the Survey Research Center. We considered a higher incentive but decided to offer the same amount as that given for the Direct Care Worker Survey, so as not to adversely affect the DCW response rate. Prior research has shown that incentives given upfront to all potential participants are more effective in increasing response rates than incentives paid later only to respondents (Church, 1993; James and Bolstein, 1992).

The Survey Research Center alerted its contact at each provider before sending survey packets for distribution. The contact chose one of three ways to distribute the surveys -- at staff meetings, with paychecks, or in worker mailboxes at the organization.

The cover letter informed respondents that their participation was voluntary and that their responses would be kept confidential. Respondents provided passive consent by completing and returning the survey. Respondents returned completed surveys directly to the Survey Research Center to ensure that respondents’ employers would not see their responses. The Survey Research Center tracked survey responses using identification numbers on each survey.

Prior research has shown that multiple mailings increase response rates (Dillman, 2000). Therefore, approximately a month after the first survey administration, follow-up packets were sent to each organization. Supervisors who had not completed a survey received a packet containing a follow-up cover letter (Appendix E), another copy of the survey, and another business reply envelope. To ensure that employers could not distinguish non-respondents from previous respondents, packets also were sent to supervisors who had completed the survey. These packets contained a cover letter expressing our thanks for completing the survey, along with a copy of the BJBC newsletter.

As the surveys were returned, they were logged and scanned into the system using the identification number printed on the surveys. At the end of the fielding period, the Survey Research Center verified and cleaned the data and removed all identifying information before providing the data files to the research team.

The original Supervisor Survey project was designed to be cross-sectional, with a one-time administration scheduled toward the end of the BJBC demonstration. After approval of this project, the Robert Wood Johnson Foundation and the Atlantic Philanthropies, the funding agencies for the evaluation of the BJBC demonstration, authorized the Penn State Survey Research Center to use funding from the evaluation for a baseline (Time 1) administration of the survey. However, at this point in the project it was too late for four of the states to receive a baseline survey. Therefore, the Time 1 administration was conducted only in North Carolina, which had experienced delays in starting the demonstration.

The Time 1 administration in North Carolina occurred from November 2005 through March 2006. The second administration in North Carolina and the originally-planned administration in the other four BJBC states (Time 2) took place from July 2006 through June 2007. Because of the larger sample size, most analyses were conducted using the cross-sectional data from the Time 2 administration. However, when appropriate, analyses employed the baseline data from North Carolina, including a small panel of supervisors who responded to the survey in both time periods.

SAMPLE SIZE AND RESPONSE RATES

Providers

The Survey Research Center was able to identify the population of supervisors at almost all providers. Provider response rates to the Supervisor Identification Instrument that identified the population were high. Sixty-two out of 65 providers returned the identification instrument at Time 1, and 120 out of 124 providers returned the identification instrument at Time 2 (Table 1). Thus, the Supervisor Survey sample is nested in 62 providers in Time 1 and 120 providers in Time 2. The overall response rates were 95 percent and 97 percent in Time 1 and Time 2, respectively. The vast majority of identified supervisors performed either primary supervisory responsibilities or a combination of primary and secondary responsibilities; only about 3 percent qualified solely on the performance of secondary responsibilities.

At Time 2 there was some variation by state with Iowa, North Carolina, and Oregon having provider response rates of 100 percent, followed by Pennsylvania at 94 percent, and Vermont at 86 percent.

TABLE 1. Provider Sample Size and Response Rates by State
State	Number of Identification Instruments		Response Rates   (percent)
	Administered	Returned
Time 1
North Carolina	65	62	95
Time 2
Iowa	12	12	100
North Carolina	55	55	100
Oregon	10	10	100
Pennsylvania	33	31	94
Vermont	14	12	86
Total	124	120	97

Provider response rates differed little by provider type at Time 1, with all provider types having a 95 percent or 96 percent response rate (Table 2). Response rates differed more at Time 2, with skilled nursing facilities having the highest response rate (100 percent) followed by assisted living facilities (97 percent), home care agencies (94 percent), and adult day service providers (88 percent).

TABLE 2. Provider Sample Size and Response Rates by Provider Type
State	Number of Identification Instruments		Response Rates   (percent)
	Administered	Returned
Time 1
Skilled Nursing Facilities	21	20	95
Assisted Living Facilities	23	22	96
Home Care Agencies	21	20	95
Total	65	62	95
Time 2
Skilled Nursing Facilities	46	46	100
Assisted Living Facilities	36	35	97
Home Care Agencies	34	32	94
Adult Day Service Providers	8	7	88
Total	124	120	97

Supervisors

A total of 1,126 supervisors were identified using the identification instrument: 421 at Time 1 and 705 at Time 2. From this population, 257 supervisors responded to the survey at Time 1, and 424 responded at Time 2 (Table 3).

The survey response rates were relatively high for a paper-and-pencil survey, especially since the Survey Research Center was unable to follow up directly with specific, individual supervisors. The overall response rate for Time 1 was 61 percent and for Time 2 it was 60 percent. At Time 2, Vermont had the highest response rate at 75 percent, while Oregon had the lowest at 52 percent.

TABLE 3. Supervisor Survey Sample Size and Response Rates by State
State	Number of Surveys		Response Rates   (percent)
	Administered	Returned
Time 1
North Carolina	421	257	61
Time 2
Iowa	82	52	63
North Carolina	344	206	60
Oregon	104	54	52
Pennsylvania	132	79	60
Vermont	44	33	75
Total	705	424	60
NOTE: The Supervisor Survey data file contains 7 more observations than the Supervisor Identification Instrument data file (6 more at Time 1 and 1 more at Time 2); therefore, the detail of the number of surveys administered does not sum to the total, and the response rates by state at Time 2 may be slightly understated. The reason for this discrepancy was respondents removed identification numbers from their survey, which required the assignment of a new identification number when the survey was received and made it impossible to link that Supervisor Survey with the corresponding record in the Supervisor Identification file.

Table 4 shows response rates by provider type. At Time 1, home care agencies had the highest response rate (71 percent), while skilled nursing facilities had the lowest (53 percent), with assisted living facilities falling in between.

TABLE 4. Supervisor Survey Sample Size and Response Rates by Provider Type
State	Number of Surveys		Response Rates   (percent)
	Administered	Returned
Time 1
Skilled Nursing Facilities	189	101	53
Assisted Living Facilities	148	92	62
Home Care Agencies	90	64	71
Total	421	257	61
Time 2
Skilled Nursing Facilities	359	204	57
Assisted Living Facilities	178	93	52
Home Care Agencies	149	114	77
Adult Day Service Providers	20	13	65
Total	705	424	60
NOTE: The detail of the number of surveys administered does not sum to the total and the response rates by provider type may be slightly understated. See note to Table 3 for further detail.

A slightly different pattern was observed at Time 2: home care agencies still had the highest response rate (77 percent), but assisted living facilities had a slightly lower response rate (52 percent) than skilled nursing facilities (57 percent).

Response rates at individual providers ranged from 0 percent to 100 percent at both time periods, with a median response rate across providers of 67 percent at Time 1 and 75 percent at Time 2 (data not shown). Response rates varied within provider type at both time periods. At Time 1, the greatest variation occurred within skilled nursing facilities, with an interquartile range of 22-100 followed by home care agencies (53-100), and assisted living facilities (44-85). This pattern changed at Time 2, with the greatest variation in response rates occurring in assisted living facilities (40-100), followed by adult day service providers (50-100), skilled nursing facilities (46-84), and home care agencies (75-100).

Item non-response in the Supervisor Survey was generally low, with most items having missing values in less than 5 percent of the cases. The total number of missing items in each survey also was low. Only 21 supervisors were missing 30 percent or more of their items.

REFERENCES

Better Jobs Better Care: Building a Strong Long Term Care Workforce. http://www.bjbc.org/.

Church, A. (1993). “Estimating the effect of incentives on mail survey response rates: A meta-analysis.” Public Opinion Quarterly, 57(1): 62-79.

Dillman, D. (2000). Mail and Internet Surveys: The Tailored Design Method. New York, NY: John Wiley & Sons.

Inter-University Consortium for Political and Social Research. http://www.icpsr.umich.edu/.

James, J., and Bolstein, R. (1992). “Large monetary incentives and their effect on mail survey response rates.” Public Opinion Quarterly, 56(4): 442-453.

Kemper, P., Brannon, D., Barry, T., Stott, A., and Heier, B. (in press). “Implementation of the Better Jobs Better Care Demonstration: Lessons for Long Term Care Workforce Initiatives.” The Gerontologist.

Kemper, P., Brannon, D., Heier, B., Kim, J., Warner, C., Vasey, J., and Stott, A. (2008). Frontline Supervisor Survey Report. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Available at http://aspe.hhs.gov/daltcp/reports/2008/FSSrpt.htm.

APPENDIX A: Supervisor Task List

Supervisory Tasks List
Provider Organization Name:
Under the name of each staff member listed, please put an X next to the tasks they perform. If you need more space to write in the staff members who are responsible for these tasks, you can copy this form.
Tasks	Staff Member Responsible for Tasks Name: Title:	Staff Member Responsible for Tasks Name: Title:	Staff Member Responsible for Tasks Name: Title:	Staff Member Responsible for Tasks Name: Title:
Act as a mentor to DCWs
Ensure that DCWs are giving proper care to clients/residents
Schedule DCWs
Initiate disciplinary action
Document DCW performance problems
Provide feedback (positive or negative) to DCWs on job performance
Recommend training for DCWs
Conduct on-the-job clinical training activities
Directly respond to job concerns raised to DCWs
Comments:

APPENDIX B: Survey Research Center E-mail to Clinical Manager Contact

Email Contact Provider Organization for Supervisor Information

Dear [clinical manager],

As part of the data collection for the Better Jobs, Better Care Demonstration evaluation, we are preparing to survey staff members who have a role in supervising direct care workers at participating provider organizations. I would like to ask for your help in identifying staff at [name of provider organization] who are responsible for carrying out specific tasks. Attached is a form that will take about 5 minutes to complete. On this form, please indicate the staff member(s) responsible for each task listed.

As you complete the form, keep in mind that the definition of a direct care worker for the Better Jobs, Better Care Demonstration is an individual who provides hands-on personal care as a significant part of their job. Although activities may sometimes overlap, we do not include LPNs or RNs in this definition. Also excluded are workers who help with cleaning, meal preparation and chores, but do not provide personal care.

Once you’ve identified the staff member(s) who performs these tasks for your organization, please send a reply email and include the completed form as an attachment or fax the completed form to my attention at (814) 865-3098. If necessary, you may make copies of the form in order to include all relevant staff. Space is also provided for comments if you would like to further clarify how the tasks on the list are carried out at your organization.

If you have any questions or would like additional information regarding this request, do not hesitate to contact me at (800) 648-3617. Thank you again for your time and assistance.

Jennifer Sheaffer
BJBC MIS and Survey Coordinator
SSRI, Survey Research Center
The Pennsylvania State University
327 Pond Lab
University Park, PA 16802-6201
Tel: 1(800) 648-3617
Fax: 1(814) 865-3098

APPENDIX C: Supervisor Survey Cover Letter

Date

Greetings!

As you may be aware, your employer is participating in the Better Jobs, Better Care Demonstration Project (IRB# 16989). In order to evaluate the effects of the resulting changes in your workplace on direct care worker job quality and retention, our team of researchers here at Penn State is conducting a survey and would very much appreciate your participation.

In the enclosed survey, you will be asked to answer several questions about your job, which will take approximately 15-20 minutes. Your answers to the survey questions will be kept confidential by the Survey Research Center. If this research is published, no information that would identify you will be written. You do not have to answer any questions you feel uncomfortable answering. There are no risks in participating in this research beyond those experienced in everyday life. Some of the benefits from participating in this survey are that you may gain a better understanding of how you view your current job and how changes in your workplace affect how you feel about your job. Overall, this information may help to improve the quality of your job, which will ultimately affect the quality of care your patients/residents/clients receive.

You may ask questions about this research by contacting David Johnson at (814) 863-0170. If you have questions about your rights as a research participant, contact Penn State’s Office for Research Protections at (814) 865-1775. Your participation in this research is completely voluntary and you may end your participation at any time by not completing the survey. The Office for Research Protections and the Social Science Institutional Review Board (IRB) may review records related to this project.

By completing and returning the survey, you are acknowledging that you are at least 18 years of age and consent to participate in this study. Please keep this form for your records or future reference.

To help us protect your privacy, we have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you. The Certificate cannot be used to resist a demand for information from personnel of the United States Government that is used for auditing or evaluation of Federally funded projects or for information that must be disclosed in order to meet the requirements of the federal Food and Drug Administration (FDA). You should understand that a Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer, or other person obtains your written consent to receive research information, then the researchers may not use the Certificate to withhold that information.

After completing the survey, please return it in the postage paid envelope provided. Please accept the enclosed two-dollars as a token of appreciation for your help with this important study. We greatly appreciate your input.

Sincerely,

The Penn State Research Team

An Equal Opportunity University

APPENDIX D: BJBC Supervisor Survey

This appendix is a recreation of the questions asked on the survey.
See the PDF version at http://aspe.hhs.gov/daltcp/reports/2008/FSSdata.pdf for a copy of the actual survey.

Better Jobs Better Care
Building a Strong Long-Term Care Workforce

Tell Us About Your Job

Your employer is one of over 130 that are part of the Better Jobs, Better Care Demonstration -- People like you in the state of Iowa, North Carolina, Oregon, Pennsylvania, and Vermont are being asked to complete this important survey. Your answers to these questions are very important to the success of this project. Please answer them as honestly as you can. Remember that your answers will be kept completely confidential. Your employer will not see any of your responses. Your answers will go directly to the Penn State Survey Research Center and you will not be identified.

A Confidential Survey
Conducted by the Survey Research Center at Penn State

Paperwork Reduction Act Statement A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to be 30 minutes per response.

INSTRUCTIONS: If circles are provided, please completely fill in the circle next to your answer (example: Yes No). If boxes are provided, write your numeric answer in the boxes (example: ). If you are asked to specify an answer, please clearly print your response in the space provided.

1. How long have you worked as a supervisor of direct care workers? _______years _______months

2. Have you ever worked as a direct care worker? _______Yes _______No

3. How long have you worked for this employer? _______years _______months

4. How long have you worked as a supervisor for this employer? _______years _______months

5. How many direct care workers do you typically supervise? _______

6. Do any direct care worker supervisors report to you? _______Yes _______No

7. Please indicate the extent of your responsibility as a direct care worker supervisor to perform the following tasks.

   	My responsibility alone	My responsibility but others do this too	Not my responsibility but I sometimes do this	I never do this
   a. Act as a mentor to direct care workers.
   b. Ensure that direct care workers are giving proper care to clients/residents.
   c. Interview direct care worker applicants.
   d. Schedule direct care workers.
   e. Provide feedback to direct care workers on job performance.
   f. Document direct care worker performance problems.
   g. Initiate disciplinary action.
   h. Recommend training for direct care workers.
   i. Conduct on-the-job clinical training
   j. Directly respond to job concerns raised by direct care workers.

8. For each statement below, please indicate if you strongly disagree, somewhat disagree, somewhat agree, or strongly agree.

   	Strongly disagree	Somewhat disagree	Somewhat agree	Strongly agree
   a. I have learned the skills necessary to do my job well.
   b. I have the opportunity to work in teams.
   c. I am confident in my ability to do my job.
   d. I could get a job that paid more than this job.

9. Overall, how satisfied are you with your job?
   _______Extremely satisfied
   _______Somewhat satisfied
   _______Somewhat dissatisfied
   _______Extremely dissatisfied
   _______Don't know

10. During the past year, did you receive any formal training (inservice, workshop, etc.) on ...

    Training		If yes, how useful was it?
    		Not At All Useful	Somewhat Useful	Very Useful	Extremely Useful
    a. Communicating effectively with other employees	_______Yes --> _______No
    b. Communicating effectively with patients/residents/clients	_______Yes --> _______No
    c. Diversity or cultural issues	_______Yes --> _______No
    d. Effective disciplinary procedures	_______Yes --> _______No
    e. Skills for managing people	_______Yes --> _______No

11. How often are the following management practices used for the direct care workers you supervise?

    	Never	Seldom	Occasionally	Frequently	Always
    a. Permanent assignment to patients/residents/clients.
    b. Rotation of assignments to different services or units.
    c. Cross-training (learning new skills not traditionally used by direct care workers, such as medication administration or assisting with physical therapy).
    d. Self-managed work groups that include direct care workers.
    e. Flex time for direct care workers.

12. What mechanisms are used in your organization to handle employee concerns? (Mark all that apply)
    _______Talk with supervisor
    _______Toll-free "hotline"
    _______Organizational ombudsman
    _______Mediation
    _______Arbitration
    _______Other:_________________________
    _______Don't use any specific method

13. What approaches are used to handle poor performance or negative behaviors at your organization? Mark all that apply)
    _______Counseling by supervisor in the work unit
    _______Counseling by senior manager
    _______Written documentation
    _______Final warning conference
    _______Probation
    _______Suspension
    _______Termination
    _______Other:_________________________
    _______Don't use any specific method

14. How often do direct care workers in your organization ...

    	Never	Seldom	Occasionally	Frequently	Always
    a. Have input into changes in patient/resident/client care plans
    b. Actively participate in developing patient/resident/client care plans
    c. Write in patient/resident/client care charts
    d. Communicate in writing with other direct care workers to rely information about residents/patients/clients
    e. Communicate verbally with other direct care workers to relay information about residents/patients/clients
    f. Communicare information either in writing or verbally about residents/patients/clients by reporting to their supervisors
    g. Meet formally or informally with a supervisor to discuss patient/resident/client care issues
    h. Receive verbal feedback about their everyday job performance
    i. Receive written feedback about their everyday job performance

15. Please estiamte the overall competency level of direct care workers you supervise using the following benchmark:
    _______0 = All require constant supervision and guidance
    _______1
    _______2
    _______3
    _______4
    _______5 = All have an average level of competency for the position
    _______6
    _______7
    _______8
    _______9
    _______10 = All perform their jobs well with minimal guidance

16. Approximately what percentage of the direct care workers you supervise ...

    	None	1-25%	26-50%	50-75%	76-100%
    a. Currently participate in a career ladder program for the direct care worker to advance to a higher level of direct care worker (for example, team leader or dementia care specialist)
    b. Currently participate in a career ladder program for the direct care worker to become a Licensed Practical Nurse
    c. Currently have a designated peer mentor
    d. Participate in formal inservice programs beyond those required for certification

17. During the past year, approximately what percentage of the direct care workers you supervise ...

    	None	1-25%	26-50%	50-75%	76-100%
    a. Have completed a self-directed educational video or computer-based training program while at work
    b. Have attended a conference or workshop away from work
    c. Received formal training (inservice, workshop, etc.) on communicating effectively with other employees
    d. Received formal training (inservice, workshop, etc.) on communicating effectively with patients/residents/clients
    e. Received formal training (inservice, workshop, etc.) on diversity or cultural issues

18. If a friend or family member asked your advice about taking a job as a direct care worker at the place where you work, would you ...
    _______Definitely recommend it
    _______Probably recommend it
    _______Probably not recommend it
    _______Definitely not recommend it

19. If a friend or family member needs care and asked your advice about getting care from the place where you work, would you ...
    _______Definitely recommend it
    _______Probably recommend it
    _______Probably not recommend it
    _______Definitely not recommend it

20. Now, we'd like to ask if you agree or disagree with the following statements about your organization. It is important that your confidential responses to these questions be honest and accurate.

    	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
    a. Employees take personal responsibility for their behavior.
    b.The organizational culture encourages risk-taking.
    c. The organizational culture encourages continuous improvement.
    d. Senior management has presented a clear vision of the future of the organization.
    e. The organization rewards staff for being innovative.
    f. Management communicates effectively with staff in all levels of the organization.
    g. Management solicits input from all levels of staff when deciding on purchases related to care delivery.
    h. Management solicits input from all levels of the organization when deciding on policies and protocols.

21. Think about your job right now. Fill in the circle that best indicates how much, if at all, each of the following is a rewarding part of your job. Is it not at all rewarding, somewhat rewarding, very rewarding, or extremely rewarding?

    	Does not apply to my job	Not at all rewarding	Somewhat rewarding	Very rewarding	Extremely rewarding
    a. Helping others is ...
    b. Being able to work on your own is ...
    c. Getting credit for your work is ...
    d. Finding your work interesting is ...
    e. Liking your coworkers is ...
    f. Making a difference in other people's lifes is ...
    g. Feeling a sense of accomplishment and competence from doing your job is ...
    h. Having your job fit your skills is ...
    i. Having the chance to learn new things is ...
    j. Being valued by supervisors and management is ...
    k. Being needed by others is ...
    l. Having the power you need to get your job done without getting permission from someone else is ...
    m. Having a lot of different things to do is ...
    n. Getting support from coworkers is ...
    o. Having your job fit your interests is ...
    p. The income you earn is ...
    q. Being valued by residents or clients and their families is ...
    r. Having the freedom to decide how to do your work is ...
    s. The team spirit in your work group is ...

22. Continue thinking about your job right now. Indicate how much, if at all, each of the following is a problem or concern in your job. Is it not at all a problem, somewhat a problem, a big problem, or an extremely big problem?

    	Not at all a problem	Somewhat a problem	A big problem	An extremely big problem
    a. Having too much work to do is ...
    b. Having to deal with emotionally hard situations is ...
    c. Not having support from your supervisor in your job is ...
    d. Finding your job boring or doing too much of the same thing is ...
    e. Having your job take too much out of you is ...
    f. Having little chance to get promoted is ...
    g. Dealing with unrealistic expectations from your supervisor for your work is ...
    h. Not having the job use your skills is ...
    i. Catching an illness is ...
    j. Not having the chance to develop job skills is ...
    k. Not being valued by your supervisor for your work is ...
    l. Being on your own too much is ...
    m. Getting hurt is ...
    n. The physical conditions (equipment, temperature, smell, etc.) at your job is ...
    o. Not having enough help when you need it is ...
    p. That your supervisor is not good at her/his job is ...
    q. That the job is physically hard is ...
    r. The time it takes to get to work is ...

23. Please indicate the degree to which you agree with the following statements about how you are respected as a part of your organization's health care team (those who provide clinical services) by filling in the appropriate circle.

    	Not at all a problem	Agree somewhat	Agree a great deal
    a. Residents' or clients' families respect me as part of the health care team.
    b. Residents or clients respect me as part of the health care team.
    c. Direct care workers respect me as part of the health care team.
    d. My supervisor respects me as part of the health care team.

24. Please indicated the degree to which you agree with the following statements about how you are respected as a part of your organization's management team (those who establish and maintain work-related policies) by filling in the appropriate circle.

    	Not at all a problem	Agree somewhat	Agree a great deal
    a. Residents' or clients' families respect me as part of the management team.
    b. Residents or clients respect me as part of the management team.
    c. Direct care workers respect me as part of the management team.
    d. My supervisor respects me as part of the management team.

25. How likely is it that you will leave this job in the next year?
    _______Very likely
    _______Somewhat likely
    _______Not at all likely

26. How often do you think about quitting?
    _______All of the time
    _______Some of the time
    _______Rarely
    _______Never

27. Now, we'd like to ask if you agree or disagree with the following statements about your organization in the context of the Better Jobs, Better Care project.

    	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
    a. The Better Jobs, Better Care project is being supported by a senior level executive in your organization.
    b. All levels of management are committed to the Better Jobs, Better Care project.
    c. Senior management has clearly articulated the need for the Better Jobs, Better Care project.
    d. The Better Jobs, Better Care project conflicts with other major activities going on in the organization.
    e. The programs that are part of the Better Jobs, Better Care project have been well executed.
    f. The Better Jobs, Better Care project's overall impact on this organization will be positive.

28. What is the single most important thing your employer could do to improve the job of direct care workers? _________________________

29. What is the single most important thing your employer could do to improve your ability to do your job as a supervisor of direct care workers? _________________________

30. In your current job with this employer, what is your hourly wage? $_______ per hour

31. Do you receive health insurance through this employer?
    _______Yes, I receive health insurance through my employer.
    _______My employer offers health insurance to me, but I am not enrolled.
    _______My employer does not offer health insurance to me.

32. What is your gender?
    _______Male
    _______Female

33. What is your age?
    _______Less than 25 years old
    _______25-34
    _______35-44
    _______45-54
    _______55-64
    _______65 or older

34. Did you earn a high school diploma or GED?
    _______No
    _______Yes ––>

    34a. If yes, what is your highest level of education?    _______High School or GED    _______Some college/trade school    _______College graduate or post-college

35. Are you a nurse?
    _______No
    _______Yes ––>

    35a. If yes, are you a ...    _______LPN    _______RN    _______Diploma RN    _______BSN    _______MSN    _______Advanced Practice Nurse

36. Are you of Hispanic or Latino origin?
    _______No
    _______Yes

37. Please indicate your race. (Please select one or more)
    _______American Indian or Alaska Native
    _______Asian
    _______Black or African American
    _______Native Hawaiian or Other Pacific Islander
    _______White

APPENDIX E: Follow-up Cover Letter

Date

Greetings!

A few weeks ago, you should have received a survey regarding the Better Jobs, Better Care project. To the best of our knowledge, it’s not yet been returned. If you have already completed and returned the survey to us, thank you. We appreciate your willingness to be a part of this important project.

We are writing again because of the importance your survey has for helping us to get accurate results. We’re enclosing another copy of the survey in case you misplaced the copy we sent you before. There is no need to respond at this time if you have already returned the survey you received a few weeks ago.

To remind you, the purpose of this study is to evaluate the effects of changes in your workplace on direct care worker job quality and retention. We have received responses from a number of staff, but need to hear from everyone to ensure that the results are representative of all long-term care provider organizations. Information that you provide in this survey will help us to better understand issues concerning the direct care workforce in long-term care. Overall, this information may help to improve the quality of the direct care workforce, which can ultimately affect the quality of care received by long term care consumers.

The survey should take approximately 15-20 minutes to complete, and your answers to the survey questions will be kept confidential by the Survey Research Center. If this research is published, no information that would identify you will be written. You do not have to answer any questions you feel uncomfortable answering. There are no risks in participating in this research beyond those experienced in everyday life. Some of the benefits from participating in this survey are that you may gain a better understanding of how you view your current job and how changes in your workplace affect how you feel about your job. Overall, this information may help to improve the quality of your job, which will ultimately affect the quality of care your patients/residents/clients receive.

To help us protect your privacy, we have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you. The Certificate cannot be used to resist a demand for information from personnel of the United States Government that is used for auditing or evaluation of Federally funded projects or for information that must be disclosed in order to meet the requirements of the federal Food and Drug Administration (FDA). You should understand that a Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer, or other person obtains your written consent to receive research information, then the researchers may not use the Certificate to withhold that information.

You may ask questions about this research by contacting David Johnson at (814) 863-0170. If you have questions about your rights as a research participant, contact Penn State’s Office for Research Protections at (814) 865-1775. Your participation in this research is completely voluntary and you may end your participation at any time by not completing the survey. The Office for Research Protections and the Social Science Institutional Review Board may review records related to this project. By completing and returning the survey, you are acknowledging that you are at least 18 years of age and consent to participate in this study. Please keep this form for your records or future reference.

After completing the survey, please return it in the postage paid envelope provided. We greatly appreciate your input.

Sincerely,

The Penn State Research Team

An Equal Opportunity University