This study adapts the job demand control/support model and social, economic, and geo-political conceptual framework to examine dimensions of the job, agency, worker characteristics, and economic and sociopolitical factors and their impact on job satisfaction and intent to leave the job (Karasek, 1979; Delp, Wallace, Geiger-Brown, & Muntaner, 2010). Figure 1 outlines the model, which conceptualizes influencers on job satisfaction and intent to leave from a multilevel perspective--dyadic care interactions and controls set within home care structure and policies, economic and sociopolitical factors, compensation, and workplace characteristics together influence job satisfaction. The dyadic care relationship encompasses the physical and emotional interaction between workers and consumers, peers and supervisors, and the demands and rewards of that interaction as well as controls. Workplace characteristics include decision latitude and relationship with supervisors and clients. These workplace characteristics may exert direct positive effects on job satisfaction and indirectly positively influence intent to stay. Policies frame the setting within which interactions occur. Policies of interest include compensation, provision of benefits, efforts to prevent injuries, and meeting employees’ preferences for hours. Job stressors and demands, compensation, home care structure and policies, and economic and sociopolitical factors (labor market alternatives) may also directly influence intent to leave the job--or these factors may act through job satisfaction to affect intent to leave.
Findings from several studies have served to provide empirical support for the relationship between the factors identified in the model shown in Figure 1, job satisfaction, and intent to leave.
Worker Characteristics: Most of the studies examining home health workers have found that older workers have greater job satisfaction than their younger peers (McCaughey et al., 2012; Delp et al., 2010; Denton, Zeytinoglu, Davies, & Lian, 2002; Benijamali, Jacoby, & Hagopian, 2014). However, in a study of the consumer-directed model in California, older age was correlated with lower job satisfaction (Kietzman, Benjamin, & Matthias, 2008). The literature indicates that older workers are less likely to intend to leave their jobs and have longer job tenure compared with their younger counterparts (McCaughey et al., 2012; Butler et al., 2013; Butler, Wardamasky, & Brennan-Ing, 2012; Morris, 2009).
Only one study assessed household income in a multivariate model of job satisfaction, where it was found that higher income was correlated with higher job satisfaction (McCaughey et al., 2012). The findings from studies examining household income and its correlation with intent to leave the job and/or turnover have been mixed. A study of former home care workers in Washington State found leavers were wealthier than current home care workers, with one in four leavers having a household income at or above $55,000, compared with only 13 percent of stayers (Banijamali, Jacoby, & Hagopian, 2014). McCaughey and colleagues (2012) also found that home health workers with higher incomes were less likely to intend to leave their jobs. However, Butler and colleagues (2012) did not find a significant effect on household income and termination among home health workers in Maine.
Home Care Structure and Policies: Home health workers’ job satisfaction was found to be lower in for-profit home health agencies (McCaughey et al., 2012). Two studies among nursing home assistants, however, did not find a significant association between overall job satisfaction and nursing home ownership status (for-profit versus not-for-profit) (Decker et al., 2009; Bishop et al., 2009). Study findings also show intention to leave the job and turnover may be greater in for-profit nursing homes and home health agencies (McCaughey et al., 2012; Jobs with a Future Partnership, 2003; Castle & Engberg, 2006; Donoghue & Castle, 2006). Brannon and colleagues found that for-profit nursing homes are associated with high turnover organizations (Brannon, Zinn, Mor, & Davis, 2002). Banazak-Holl and Hines (1996) reported turnover rates were 1.7 times higher in for-profit nursing homes compared to not-for-profit nursing homes.
A meta-analysis found a strong association between advancement opportunity and job satisfaction in nursing homes (Karsh, Booske, & Sainfort, 2005) and a study of nursing homes found a positive relationship between career advancement and job satisfaction (Parsons, Simmons, Penn, & Furlough, 2003). The association between career advancement opportunities and aide turnover or turnover intention is mixed. Career advancement opportunities for nursing assistants and home care workers have been found to be negatively correlated with turnover intentions and positively related to intent to stay on the job (Morris, 2009; Brannon, Barry, Kemper, Schreiner, & Vasey, 2007; Luo, Lin, & Castle, 2011; Parson et al., 2003). However, one study did not find a significant effect between turnover intentions and career ladder positions in home health agencies (McCaughey et al., 2012).
Workplace Characteristics: The direct care worker’s assessment of the quality of the relationship between the supervisor and the aide as well as having supportive leadership have been shown over a large number of studies to be a strong indicator of job satisfaction in nursing home and home care settings (Karantzas et al., 2012; Gerstner & Day, 1997; Decker et al., 2009; Beulow, Winburn, & Hutcherson, 1999; Bishop et al., 2008; McGilton, Hall, Wodchis, & Petroz, 2007; DeLoach & Monroe, 2004; Castle et al., 2006; Dawson, 2007; Parson et al., 2003; Karshe et al., 2005; Bishop, Squillace, Meagher, Anderson, & Wiener, 2009). Research also supports that the perceived quality of the supervisor influences an aide’s intention to stay or leave the job, with aides who have a more positive relationship less likely to intend to leave or actually leave the job (Karantzas et al., 2012; Eisenberger, Stinglhamber, Vandenberghe, Sucharski, & Rhoads, 2002; Bowers, Esmond, & Jacobson, 2003; Stearns & D’Arcy, 2008; Brannon et al., 2007; Choi & Johantgen, 2012; Banazak-Holl & Hines, 1996; Bishop et al., 2008; Mittal et al., 2009; Parson et al., 2003; Barborotta, 2010; Straker et al., 2014). Dill et al. (2012) found the opposite--that nursing assistants who reported a higher degree of supervisor support were less likely to intend to stay on their job.
A positive workplace environment can improve job satisfaction and reduce the turnover intentions of direct care workers. Previous research has found that home health workers and nursing assistants who feel empowered--listened to, involved in decision-making, teamwork, have control over work, and experience autonomy--are more likely to be satisfied with their job and less likely to want to leave the job (Seavey & Marquand, 2011; Karsh et al., 2005; Parsons et al., 2003; Bishop et al., 2009; Denton et al., 2002; Sikorska-Simmons, 2005; Butler et al., 2013). Zhang, Punnett and Gore’s (2014) study showed that nursing assistants’ positive perceptions of their workplace conditions (e.g., coworker support, supervisor support, respect received at work, and decision authority) were negatively correlated with intent to leave the job within the next two years. In fact, nursing assistants who reported four positive features of their working condition were 77 percent less likely to indicate strong intention to leave the job. Providing challenging work and respecting aides for the work they do can also improve job satisfaction and turnover (Bishop et al., 2009; Butler et al., 2012; Bowers et al., 2003). Several studies have found non-significant associations between workplace environment variables and turnover (Wiener et al., 2009; Butler et al., 2013).
Job Stressors or Demands: Increased pay or satisfaction with pay is a strong predictor of job satisfaction or retention and can reduce turnover (Bishop et al., 2009; Decker et al., 2009; Mittal et al., 2009; Ejaz, Noelker, & Menne, 2008; Wiener et al., 2009; Morris, 2009; Jobs with a Partnership, 2003; Butler et al., 2013). Rosen, however, found that pay was not a predictor of turnover intent or turnover (Rosen, Stiehl, Mittal, & Leana, 2011).
Studies have found inconsistent findings on the relationship between benefits or health insurance and direct care worker job satisfaction. Ejaz and colleagues (2008) found a positive relationship between the availability of retirement/pension benefits and health insurance coverage with job satisfaction. They did not find a significant relationship between paid sick time and paid holidays with job satisfaction. However, Bishop and colleagues (2009) reported a positive significant relationship between paid sick time and job satisfaction, but did not find a significant relationship between retirement/pension benefits and health insurance with job satisfaction. Delp and colleagues (2010) also found a positive significant association between health care access and job satisfaction.
The majority of research studies on the correlation between health insurance and turnover among direct care workers find that offering health insurance can reduce turnover and/or turnover intentions (Butler et al., 2014; Luo et al., 2013; Decker et al., 2009; Mittal et al., 2009; Howes, 2005; Rosen et al., 2012; Dill et al., 2012). Other studies have found that health insurance is not related to tenure or turnover intentions, while other benefits, such as paid time off, availability of a pension, paid personal, vacation days, and holidays have a positive effect on job tenure (Wiener et al., 2009; Rosen et al., 2011).
Finally, a balanced workload and sufficient time for tasks contributes to job satisfaction (Seavey & Marquand, 2011; Bishop et al., 2009). In addition, direct care workers who perceive a heavy workload are more likely to intend to leave the job, particularly among those working in nursing homes or assisted living facilities compared to home care workers (Brannon et al., 2007). Higher nurse staff levels can decrease HHA turnover (Butler et al., 2012). Injuries, potential for violence, and threats or verbal and physical abuse contribute to lower job satisfaction and job retention and increase turnover intention (McCaughey et al., 2012; Sherman et al., 2008). Dill and colleagues (2013), on the other hand, found workload was not a significant predictor of actual retention.
FIGURE 1. Conceptual Model: Social, Cultural, Economic, and Political Factors that Shape Care Work and Influence Job Satisfaction and Intent to Leave Job