Studies of the nursing home environment have long suggested that leadership and communication are related to performance,10, 31
although few have actually tested these relationships empirically. This study presents a tool for measuring multiple domains of nursing home work environment and examines their association with organizational and structural facility attributes, and perceived work effectiveness.
Theory-based, reliable and valid measures of the long-term care work environment are much needed as workplace attributes may be key factors in improving organizational performance, including resident care.10, 32
Based on a large sample of respondents and facilities in NYS we demonstrated the reliability of the survey instrument for measuring work environment and performance, and established its face, content, and construct validity.
Our second objective, to examine individual and facility-level predictors of perceived work effectiveness, identified several potentially modifiable factors that may offer insights for improving nursing home performance.
Compared with paraprofessionals, professionals assess their work environment as being better on all four attributes. At the same time, paraprofessionals report higher perceived work effectiveness, compared to professionals. Our finding with regard to work environment is consistent with findings from other nursing home studies14
and with our prior work in community-based long-term care.16
Many reasons for dissatisfaction among the CNAs, who comprise the majority of paraprofessionals, have been identified, e.g.: managers' disregard for their input into residents' care plans; lack of trust between the CNAs and their supervisors; inadequate communication between CNAs and licensed staff; and general incongruence of goals and values between CNAs and management.32-34
The CNAs are the backbone of resident care, providing 80% to 90% of nursing care, yet nursing homes nationally experience extraordinarily high turnover rates among them.35
This very likely has a negative impact on the quality of care provided to residents. As nursing home leaders address issues of quality and staff turnover within their institutions, they may want to pay particular attention to the work environment of the CNAs. Nursing home managers should take advantage and build on the higher sense of fulfillment with work among the CNAs, because it is that perceived satisfaction with work that likely translates into better organizational performance.
Several individual and facility characteristics appear important in influencing work effectiveness. Minority paraprofessionals credit their facilities with significantly greater work effectiveness compared both to white paraprofessionals and to professionals of either race. While we have no a priori
reasons to expect that staff of different socio-demographic characteristics will perceive work effectiveness differently, it is interesting to note that such differences do exist. Some support for this finding comes from other studies, which demonstrated significantly greater satisfaction with work among African-American (compared to white) nursing home workers, and among the CNAs compared to RNs and LPNs.36
Future research could examine whether the quality of care provided by minority paraprofessionals is in fact better than that provided by those of the majority race.
Other characteristics that influence the perception of work effectiveness are years in the profession and years worked at a facility. Workers with more years in the profession tend to have a worse perception of work effectiveness than those with fewer years. However, more years of work experience in a facility brings about higher perceived work effectiveness. Studies have shown that experienced CNAs, those who have learned to more effectively integrate the of their work, are more efficient and more responsive to the needs of their residents.34
CNAs with longer in facility tenure are also likely to be those with greater commitment to the residents and to caregiving as an occupation.32
Management's attention to and continuous investment in these experienced workers may be an important strategy for improving organizational performance.
Four modifiable facility characteristics are significantly associated with work effectiveness. Facilities characterized as autocratic/custodial, i.e. in which management exhibits little receptivity for input from workers or openness to new ideas, are associated with worse performance. Furthermore, good management is dependent on the stability of the leadership. The administrator and the DON are the key people in the chain of organizational and practice. Castle showed the association between higher turnover among the administrators and worse resident outcomes.37
Our study extends this finding by suggesting that it is the administrator's and not the DON's turnover that matters with regard to work effectiveness. In addition, better workplace conditions and more nursing hours are significant predictors of performance. Of the six items comprising the measure of workplace conditions, three deal with pay, benefits, and promotion opportunities. Improvements with regard to these factors, as well as higher nursing staffing, are costly and are not likely to be voluntarily implemented by nursing homes, particularly the for-profits. Early results from the recently implemented nursing home payment incentive programs in Florida and California have shown that additional payments to nursing homes did increase staff wages and resulted in some increases in staffing, but had no substantial impact on improving resident outcomes.38, 39
Our model recognizes the multidimensionality of nursing home work environments. The results suggest that efforts at improving work effectiveness must also be multifaceted, i.e. focusing on multiple work environment domains and organizational and structural attributes of the facilities.
A few caveats should be noted. First, our analysis is limited to nursing homes in NYS. Variables affected by state-specific industry regulations or environmental factors could make insights from this study not generalizable. However, neither quality of care40
nor workforce issues faced by the study facilities are substantially different from other areas of the US.30, 41
Second, assessments of the work environment and performance are based on single point in time estimates. Over longer periods of time, point estimates are not likely to accurately reflect organizational performance as individual and facility-level characteristics change.
Although perceived work effectiveness may be an important indirect measure of organizational performance, ultimately what counts is the ability to bring about good resident outcomes. The next step is to examine if facilities with better organizational performance produce better risk-adjusted outcomes for their residents. Being able to identify better performing facilities will allow for subsequent, focused assessment of their practice patterns in order to understand how good work environment brings about better quality of care.