The cohort used in this analysis comprised 393 men and women who completed the surveys and clinical assessments in the four extended care facilities. They had a mean age of 41 years, and 84.5% were women. They were predominantly low-wage employees, with a mean hourly wage of $15.73. The employees were from diverse racial and ethnic backgrounds, with about 60% from Black, Hispanic, or another minority groups. In Boston, many recent immigrants working in nursing care are from Haiti, Brazil, and the Dominican Republic. About 8% of the interviews were conducted in Haitian Creole. Just over half of employees had a child under 18 in the household. Over a quarter had two or more CVD risk factors.
Association Between Manager Score and Employee Characteristics
Manager score was associated with several socio-demographic and occupational characteristics in bivariate analyses (see ). It is of particular concern that employees in health care occupations who were largely direct patient care workers, such as certified nursing assistants and licensed practical nurses, tended to have managers with the lowest scores on openness and creativity with regard to work–family issues. Manager score was also significantly associated with CVD risk. Among employees with managers who scored low on the scale, 28.57% had two or more risk factors, whereas only 18.49% of employees whose managers scored high had two or more risk factors (p = .02).
Employee Sociodemographic, Work, and Health Characteristics According to Manager Work–Family Balance Score
We also examined correlations between the manager score and employee reports of job demands, job control, social support at work, work–family spill-over, and workplace flexibility. The manager score was not significantly correlated with any of these measures (data available on request), nor were other dimensions of the job, including demands, control, support, or flexibility, strongly related to manager scores. Thus, the manager score developed from semistructured interviews with managers adds a unique dimension of job exposure to the domains of the occupational health literature.
Association Between Manager Score and Employee CVD Risk and Sleep Duration
In the next set of analyses, we used multilevel models to assess the association between manager score and employee CVD risk and sleep outcomes while controlling for potentially confounding factors. It is important to recall in these analyses that the manager score was derived from information from interviews with the managers, whereas employee data were from interviews and physical examinations of employees. For this reason, it is unlikely that employee characteristics bias the association between manager score and employee health outcomes. displays odds ratios for two or more CVD risk factors associated with low and middle, compared with high, manager scores, controlling for age, gender, hourly wage, educational level, race/ethnicity, work site, hours worked per week, and night work. Overall, employees with managers who had low or middle scores had odds ratios of 2.11 (95% CI [0.90, 4.90]) and 2.03 (95% CI [1.02, 4.02]), respectively, of having two or more CVD risk factors compared with employees whose managers had high scores on work–family balance.
Results of Multilevel Model Predicting Two or More Cardiovascular Risk Factors (n = 393)
In our next set of analyses, we fit the same multilevel models for each of the five risk factors we included in the modified Framingham risk factor score. summarizes these odds ratios in a bar graph. In these analyses, we controlled for the same set of factors that we controlled for in the first analysis (age, gender, hourly wage, educational attainment, race/ethnicity, work site, hours worked per week, and night work). Although these differences were not statistically significant, the trend was for employees of managers with low scores to have higher risks. This was especially apparent for employees with diabetes (OR for low manager score = 1.64; 95% CI [0.49, 5.47]), high blood pressure (OR for low manager score = 1.89; 95% CI [0.73, 4.89]), and obesity (OR for low manager score = 1.44; 95% CI [0.67, 3.05]).
Figure 1 Odds ratio for each cardiovascular risk factor for employees with managers with low, middle, or high work–family balance scores. Because of missing data, the number of subjects available for each outcome differs: n = 393 for diabetes, high blood (more ...)
Turning our attention to our second outcome of interest, sleep duration as assessed by the actigraphy monitor, we found a very strong association between sleep duration and manager score. In fully adjusted multilevel models, employees whose managers scored low slept almost 29 min less per day than employees whose managers scored high (p = .03; see ). In these analyses, we controlled for all the same confounders we included in the earlier models. In these analyses, our sample size dropped to 320 because not all respondents provided actigraphy data. Subjects with actigraphy data (n = 320), compared with those without actigraphy data (n = 73), had a slightly lower mean hourly wage ($15.40 compared with $17.17, p = .06), worked, on average, more hours per week (34.9 compared with 32.8, p = .11), had slightly lower mean household income adjusted for household size ($27,883 compared with $31,663, p = .04), were less likely to have a college degree or more (13.8% compared with 30.1%, p = .01), and were more likely to work full time at the extended care facility (76.3% compared with 63.0%, p = .02).
Results of Multilevel Model Predicting Mean Minutes of Sleep Per Day (n = 320)
Employees in Direct Patient Care Occupations Had Higher CVD Risk in Relation to Manager Score
We were particularly concerned that employees in direct patient care occupations might be at elevated risk because of low levels of job flexibility, whether due to job characteristics themselves or to managers’ practices. In our bivariate data shown in Table 1, it is evident that health care workers generally have managers who score lower on the work–family scale of openness and creativity than employees working in other occupations within long-term care settings. This association may be the result of the job classifications themselves given that nursing care is traditionally a job that has limited flexibility (Kleinman, 2004
; McGilton, Hall, Wodchis, & Petroz, 2007
). On the other hand, managers of direct patient care occupations tend to be nurses who are selected into management positions on the basis of their excellent clinical skills (Care & Udod, 2003
; Kleinman, 2003
; Morrison, Jones, & Fuller, 1997
); it may be that they have limited management training, resulting in fewer resources or knowledge about how to consider work–family balance in employees. Although we cannot evaluate that issue, we tested whether the risks associated with having managers with low levels of openness and creativity vis-à-vis work–family demands were elevated among health care workers in direct patient care.
show the odds ratios for health care workers in direct care positions (mostly certified nursing assistants and licensed practical nurses) compared with employees in other occupations for cardiovascular risks (see ) and sleep duration (see ). shows that the odds ratio for two or more CVD risk factors associated with low manager score is greatly increased (OR = 6.33; 95% CI [1.39, 28.83]) compared with non– health care workers. For sleep duration, the patterns of sleep duration did not differ for health care and non– health care workers although both occupational groups show clearly elevated risks for employees working with managers who score low.
Figure 2 (a) Odds ratios of having two or more cardiovascular risk factors among employees whose managers have low, middle, or high work–family scores stratified by occupation. (b) Mean hours of sleep per day among employees whose managers have low or (more ...)
We found no increased risks among employees who had children under the age of 18 living at home (data not shown). Unfortunately, we lacked finer grained data to test hypotheses related to the effects among those who had very young children in the household or for those who had children who did not reside in their household (these children may reside in other countries for some immigrants or in other households for those who are divorced or separated). It may also be that virtually all employees in this sample had caregiving responsibilities related to care of parents or other family members, including partners, siblings, and other close friends, so that our question about children in the household did not capture the myriad family care responsibilities experienced by this cohort. Finally, our hypothesis that supervisor support for work–family balance and CVD risk is mediated by employees’ perceptions of work–family spillover was not supported with these data.
In summary, manager attitudes and practices that reflect openness and creativity to work–family balance were an important resource for low-wage workers in long-term care settings. Employees who worked for managers with low work–family openness and creativity were more likely to have elevated CVD risks based on both biomarker assessments and reports of doctor diagnoses. They also sleep almost half an hour less per night than employees with managers with high levels of openness and creativity in relation to work–family issues. The CVD risks for health care workers involved in direct patient care, including nursing assistants and nurses, are particularly elevated.