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International Journal for Quality in Health Care 14:207-217 (2002)
© 2002 International Society for Quality in Health Care

Staff satisfaction and its components in residential aged care

SHU-CHIUNG CHOU1,2, DUNCAN P. BOLDY1,3 and ANDY H. LEE1

1School of Public Health and
3Freemasons Centre for Research into Aged Care Services, Division of Health Sciences, Curtin University of Technology, Perth, Western Australia, Australia and
2Center for Quality of Care Research and Education, Harvard School of Public Health, Boston, MA, USA

Objectives. The purpose of this study was to assess the direction and magnitude of the effects among the components of staff satisfaction in residential aged care and to examine whether the relationships among satisfaction components vary according to facility type (i.e. nursing homes and hostels). A hostel is a low care facility in which residents are more independent, have a lower level of care needs, and receive personal but not nursing care.

Design. A cross-sectional survey design was adopted to collect the required information, and a stratified random sampling approach was utilized to select facilities. Structural equation modeling was used to examine relationships among satisfaction components.

Setting. Seventy residential aged care facilities in Western Australia.

Study participants. The sample includes 610 nursing home and 373 hostel care staff.

Results. The relationships among satisfaction components are different for nursing home and hostel staff. Professional support is found to have a strong and positive effect on all other aspects of staff satisfaction.

Conclusion. The findings lead to an improved understanding of the interrelationship among staff satisfaction components, which has important implications through enhancing professional support. This needs to be recognized and emphasized by managers, care providers, and policy makers so as to maintain stable personnel and continuity of care.

Keywords: hostel, long-term care, nursing home, professional support, quality

Accepted for publication February 6, 2002.

The proportion of the Australian population aged over 65 years is predicted to grow from 12% at the turn of the century to over 24% by 2051 [1]. Owing to the growing percentage of elderly citizens, the demand for quality care facilities is likely to increase in Australia, both for elderly people with relatively low levels of need as well as for those with relatively high levels of need. Residential care will continue to play an important and necessary role in the overall provision of aged care services. This it is important to understand what contributes to staff satisfaction if present staff are to be retained and new staff attracted to residential aged care.

Residential aged care facilities provide long-term nursing home or hostel care to frail older people. In Australia, nursing homes (high care facilities: for residents with higher levels of care needs) provide support in daily living activities and nursing care. Hostels (low care facilities. residents with lower levels of care needs) provide similar personal support to more independent residents, but not nursing care services [2]. Within this context, care staff have long-term relationship with residents and play a significant role in delivery of services to them.

Concerns about quality and standards of long-term care for older people have received considerable attention. It has been noted that staff attitudes have a significant impac. on the quality of life of residents in the labor-intensive long-term care sector [3]. The importance of staff satisfaction is well documented in the literature. For example, lower job satisfaction has been linked o higher mortality [4]. Job satisfaction has also been shown to be positively associated with staff retention [5], intention to stay [6], organizational commitment [7, 8], staff-perceived quality of care [9], and patient satisfaction [10]. Higher job satisfaction is also found to be inversely related to intention to leave [8, 11, 12], absence [6, 8, 13], and turnover [6, 7, 13]. Specifically, various studies have established the link between job satisfaction and turnover among nurses [14, 15], social workers [16], and administrators/managers [17] in long-term care.

Indeed, whilst staff turnover is difficult to quantify, it is considered a serious problem in the residential aged care industry [18]. In Australia, many facilities have already experienced difficulties in staff recruitment and retention, and in maintaining a desirable staff mix [19]. The inability to attract and retain quality staff may be detrimental to both staff and residents. The extra workload has to be absorbed by the remaining staff [12], while residents are more prone to disrupted social ties and altered care regimens [18].

Although staff satisfaction has a direct impact on staff retention, service quality and costs associated with recruitment and training [18, 20], limited research has been conducted on the components underlying staff satisfaction. A thorough understanding of the relationship among satisfaction components will provide useful information for enhancing staff satisfaction. This is particularly pertinent in residential aged care settings, where residents are vulnerable to poorer quality of care due to their vulnerability and frailty caused by limited finances, infirmity, lack of advocates among family and friends [21], increased dependency on staff, fear of retribution if they complain, etc. This may be more likely to happen in the nursing home setting, where a majority of residents are cognitively impaired and cannot voice their opinion.

By assessing staff satisfaction and examining the relationships among satisfaction components, important aspects can be identified and targeted for improvement from the staff members' perspective.

In an earlier paper, we assessed the factor structure, reliability, and validity of an existing Measure of Job Satisfaction (MJS) [22]. Staff satisfaction was confirmed to be a multidimensional construct composing of five factors: personal job satisfaction, satisfaction with workload, satisfaction with team spirit (co-workers), satisfaction with training, and satisfaction with professional support. The purpose of this paper is to assess the direction and magnitude of the relationships between various staff satisfaction components in residential aged care services in Australia.

As mentioned previously, there are two types of residential aged care facilities in Australia, namely nursing homes (high care) and hostels (low care). Residents are classified and allocated according to their care needs. A hostel is a low care facility for frail but semi-independent residents who have lower levels of care needs and receive personal care such as group meals, housekeeping, and other support service, but not nursing care. Most hostels broadly fit the definition of 'congregate care' in the US. In contrast, a nursing home is a high care facility for more dependent residents who have higher levels of care needs and receive personal and nursing care. Generally, nursing homes employ more qualified staff who have received less formal training.

In view of the different environment, resident characteristics, care needs, and staff requirements, it is also anticipated that nursing home and hostel staff will have different patterns of relationships between satisfaction components. Consequently, two research questions are addressed in this study.

Research question 1. What is the relationship among the components of staff satisfaction in residential aged care?

Research question 2. Do the relationships among staff satisfaction components vary according to facility type (i.e., hostel and nursing home)?

The primary purpose of this paper is to investigate the relationships among staff satisfaction components. Consideration of the link between staff satisfaction and quality of care (e.g. resident satisfaction) is the subject of a subsequent investigation, which will be reported elsewhere.


   Methods
Top
 Methods
Results
 Discussion
 Conclusion
 Acknowledgements
 References
 
Research design and participants
As described in Chou et al. [22], a cross-sectional survey design was used to collect the required data. In order to select a variety of residential aged care facilities in Western Australia, a stratified random sampling approach was utilized to select facilities by taking the following factors into consideration: size (small, medium, or large), location (metro and non-metro), and type of facility (nursing home or hostel). Dementia-specific and aboriginal-specific facilities were excluded from the study because of their special needs. All staff involved in direct resident care, including the Director of Nursing, manager, registered nurses, enrolled nurses, nursing assistants, and therapists within a selected facility, were invited to participate. Further details regarding the sampling strategy are given in Chou et al. [22]. The study sample of 983 staff was recruited from a wide variety of residential aged care facilities between April 1998 and April 1999.

Ethical approval
This study was approved by the Human Research Ethics Committee at Curtin University of Technology.

Measure of job satisfaction
Staff satisfaction was assessed through the self-complete MJS questionnaire [22]. Twenty-two items covering five aspects (factors) of staff satisfaction (i.e. personal job satisfaction, satisfaction with workload, team spirit/co-workers, training, and professional support) were used for this study. These five factors were obtained via exploratory and confirmatory factor analysis; details are given in a previous paper [22]. Items are on a five-point Likert scale from 1 (very dissatisfied) to 5 (very satisfied). A satisfaction score for each factor was obtained by proportionally weighted factor score regression to combine individual items. A higher score would indicate a greater satisfaction with respect to that factor.

Statistical analysis
Structural equation modeling (SEM) of staff satisfaction was undertaken in two stages, measurement model and structural model fitting [23, 24]. Since the five staff satisfaction scores were slightly skewed with non-zero kurtosis, a weighted least squares procedure was considered appropriate for parameter estimation. In addition, when the items are ordinal, a polychoric matrix should be used for SEM analysis [24, 25]. The SEM approach is considered appropriate for the present study because the procedure permits the assessment of measurement properties of the satisfaction constructs. SEM permits specification and simultaneous estimation among multiple dependent and independent latent variables [26] and provides a better understanding of the complex relationships among satisfaction components.

Measurement model
A one-factor congeneric measurement model was first fitted to each of the five constructs to assess their validity and reliability, using LISREL [23]. A fitted congeneric model allows large numbers of observed variables to be reduced to a single composite scale and subsequently reduces the number of variables to be included in the SEM [27]. In order to keep the measurement models simple, it was aimed to retain only four or five items per factor. The composite scale reliability was determined for each latent factor [27-29]. The estimated regression coefficients and measurement error variances for the five satisfaction factors were then fixed in the measurement part of the SEM.

Structural model
The relationships among the five key staff satisfaction components were then investigated through the structural part of the SEM. A conceptual model was formulated, representing the expected relationships among the five satisfaction components: personal job satisfaction (n1), satisfaction with workload (n2), satisfaction with team spirit/co-workers (n3), satisfaction with training (n4), and satisfaction with professional support (n5). The hypothesized relationships, graphically presented in Figure 1, have been identified based on our review of the literature and informal discussions with relevant care staff, stakeholders, and other researchers (see ref. [2] for details).



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  		Fig. 1. Hypothesized structural relationships among staff satisfaction components.

 

For example, in human resources management it has been suggested that job satisfaction is positively associated with peer and supervisor support, but negatively related to routinization and workload [30]. Similarly, work support, such as supportive social interaction from supervisors, management and co-workers, can have a positive effect on employee well-being in terms of job satisfaction [31]. On the other hand , stress related to poor support (e.g. lack of human resources or senior support) and overload were found to be associated with reduced job satisfaction, whereas satisfaction from 'working with people' and 'management' appeared to be correlated with high job satisfaction [32]. The importance of interpersonal relationships was also evident in another study, where professional respect from other disciplines was shown to be a significant determinant of overall job satisfaction [33]. The (alternative) hypotheses are stated below.

H1. Satisfaction with professional support (PSUP, n5) has a positive effect on personal job satisfaction. (PSAT, n1), satisfaction with workload (WKLOAD, n2), team spirit/co-workers (TEAMSP. n3), and training (TRAINING, n4).

H2. Satisfaction with team spirit has a positive effect on personal job satisfaction and satisfaction with workload.

H3. Satisfaction with training has a positive effect on satisfaction with workload.

H4. Satisfaction with workload has a positive effect on personal job satisfaction.

H5. The relationships among staff satisfaction components depends on facility type (nursing or hostel).

These hypotheses were tested via SEM using the LISREL package [34]. The parameters estimated were the regression coefficients in this structural equation part of the SEM. Some of the above relationships were modified in view of the model fitting results. In addition to theoretical and practical considerations, the assessment of model adequacy was based on the following goodness-of-fit criteria: Normed chi-square (x2/df)<3, root mean square error of approximation (RMSEA) <0.05, non-normed fit index (NNFI) >0.90, comparative fit index (CFI) >0.90, goodness of fit index (GFI)>0.90 and adjusted goodness of fit index (ADFI)>0.90 [23, 24, 35, 36].


   Results
Top
 Methods
 Results
Discussion
 Conclusion
 Acknowledgements
 References
 
Staff characteristics, educational background and work condition
A total of 983 care staff from 70 facilities returned their completed questionnaires, representing an overall response rate of 57%. Response bias at the facility level was addressed through implementing a rigorous stratified random sampling procedure. Every effort was also made to recruit a 'reasonable' number of facilities within each stratum, resulting in an adequate coverage of a variety of staff from a variety of aged care facilities. The response rate for nursing homes was 54% (range 20-81%) and for hostels 66% (range 14-100%). Only three nursing homes and three hostels had a response rate less than 30%. Unfortunately, no demographic information is available about non-responders due to confidentiality assurances; therefore, it is not known if they differed in any systematic way from participants. Survey details are given in Chou et al. [22].

Information on staff demographic characteristics, educational background, and opportunities are represented in Table 1. Ninety four percent of respondents were female and their mean age was 44 years. Forty-three percent of respondents carers of nursing assistants, with 16% being registered nurses, mainly in nursing homes. Only 2% of the respondents in hostels were registered nurses.



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  		Table 1. Staff characteristics, educational background, and opportunities by facility type

 

Staff were asked to indicate their highest level of schooling or training. Approximately 32% had left school before year 12 and less than 5% of respondents had a postgraduate qualification. More than half the respondents had completed at least one aged care-related course, with significantly more hostel staff (67% having completed such a course than nursing home staff (505) (P<0.001).

Interestingly, a significantly lower proportion of nursing home staff had attended ongoing education during work time. Moreover, a higher proportion of nursing home staff (59%) were in fact interested in more professional development activities relevant to their current work, suggesting a higher desire for training, compared with hostel staff (52%).

Measurement properties
Weightings of staff satisfaction items provided by the factor score regression are given in Table 2. Each of the five measurement models fitted satisfactorily. The high composite reliabilities for the staff satisfaction constructs suggest that all observed variables (items) were valid and reliable measures of the underlying latent constructs (satisfaction factors). Moreover, all observed variables have a good item reliability (above 0.5) and were significant a the 1% level, implying a high level of convergent validity. Convergent and discriminant validities, which support the appropriateness of collapsing the 22 MJS items into five domains, are also demonstrated and discussed in Chou et al. [22].



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  		Table 2. Staff satisfaction component reliability and items (n = 983)

 

Staff satisfaction levels
Table 3 presents the means and standard deviations of the five staff satisfaction variables. The nursing home staff had lower scores on all aspects of satisfaction than the hostel staff. A series of independent sample t-tests confirmed such differences as significant, with P<0.01 in each domain except team sprit (see Table 3). Consequently, it was judged necessary to examine whether or not the hypothesized structural regression paths vary according to nursing home and hostel staff.



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  		Table 3. Staff satisfaction component scores for nursing home and hostel groups

 

Structural regression paths by facility type
In testing the equality of structural regression paths across nursing home and hostel, a multi-group model with the coefficients constrained to be equal between the groups (i.e. the groups are expected to behave similarly) was estimated first. The model with coefficients unconstrained (i.e. expected to behave differently) was then estimated. The hypothesis of invariant structural regression paths can be assessed by a likelihood ratio test between the constrained and unconstrained models [37]. A non-significant difference supports an invariant pattern of structural regression paths.

The sample of staff was split into nursing home (n=610) and hostel (n=373) groups. The result indicated a significant difference in fit between the constrained and unconstrained models. It may therefore be concluded that the structural regression paths did vary between the two groups (H5). This provided support for the separate modeling of nursing home and hostel staff satisfaction components.

Hostel model
Tests of the initially hypothesized structural model for hostel staff identified that path B24 (training - workload) was not statistically significant at the 5% level, indicating that H3 was not supported by the data. All other paths were significant at the 1% level, thus confirming H1, H2, and H4. A post hoc analysis suggested an additional structural path B41 (personal job satisfaction - training). The model was re-specified and re-estimated (see Table 4).



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  		Table 4. Goodness-of-fit summary for staff satisfaction models

 

The fitted hostel staff satisfaction model presented in Figure 2 illustrates the fundamental relationships among the five satisfaction domains. In order to keep the diagram simple, only the structural part of the SEM is shown. A summary of the direct, indirect, and total effect sizes for the final hostel model is given in Table 5. The total effect size of 'professional support' on all other aspects of staff satisfaction ranged from 0.442 to 0.658. This suggests that professional support can play a central role in driving all other aspects of staff satisfaction.



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  		Fig. 2 Fitted hostel staff satisfaction structural model. Key as for Figure 1.

 

Nursing home model
For the nursing home group, path B23 (team spirit - work-load) was not statistically significant at the 5% level. All other paths were significant at the 1% level. The SEM results thus confirmed H1, H3, and H4, but not H2. A post hoc analysis again suggested an additional structural path B41 (personal job satisfaction - training). The model was subsequently revised and re-estimated. Table 5 shows that the fit of the revised nursing home model is satisfactory.



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  		Table 5. Decomposition of standardized effects for hostel staff satisfaction

 
The fitted nursing home model is graphically presented in Figure 3. Table 6 provides the direct, indirect, and total effect sizes derived from the SEM. Similar to hostels, (satisfaction with) professional support has a strong and positive effect on all other aspects of staff satisfaction (total effect sizes ranging from 0.479 to 0.653).



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  		Fig. 3 Fitted nursing home staff satisfaction structural model. Key as for Figure 1.

 


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  		Table 6. Decomposition of standardized effects for nursing home staff satisfaction

 

Comparison between nursing home and hostel staff satisfaction
The main difference between nursing home and hostel models relates to the non-significant path B23 (team spirit - workload) and the significant path B24 (training - workload) in the nursing home model.

Professional support is more strongly related to other aspects of staff satisfaction in the nursing home group except for the workload aspect. The magnitude of the two paths, B12 (workload - personal job satisfaction) and B13 (team spirit - personal job satisfaction), is larger in the hostel group than the nursing home group. The effect of personal job satisfaction on training is also stronger for hostel staff.


   Discussion
Top
 Methods
 Results
 Discussion
Conclusion
 Acknowledgements
 References
 
Personal job satisfaction
Personal job satisfaction is directly influenced by workload, team spirit, and professional support for both nursing home and hostel groups. Staff are likely to feel good about their job if they are satisfied with these aspects. This is consistent with literature findings [7, 32, 33].

Team Spirit (co-workers)
Satisfaction with team spirit (co-workers) can be affected directly by professional support. Facility management should therefore take an active role in establishing a positive and supportive working environment. Incidentally, it has been suggested that the director of nursing or senior nurse is pivotal to team cohesiveness, as well as offering a stable, satisfied, and friendly environment for staff [19].

Training
The training items address satisfaction with training opportunity and perceptions of its adequacy. Satisfaction with training is directly influenced by personal job satisfaction and professional support. Staff will perceive to have adequate training opportunity if their needs are met through on-site job support directly from their supervisor or indirectly from their co-workers and feel content with their job. This has implications on creating a learning environment for staff rather than just a place for daily routine work.

Professional support
That professional support has a strong and positive effect on all other aspects of staff satisfaction is consistent with other studies [30, 31, 38]. Care staff should be provided with sufficient support, enabling them to express their concerns, receive proper guidance and supervision, as well as obtain fair treatment from their bosses. Once again, facility management can play a key role in assisting staff to perform their duties successfully [39].

Although professional support, referring to support from supervisors/managers (see Table 2), appears to be a major component driving staff satisfaction, further investigation is needed to develop appropriate policy or practices for supporting staff adequately, perhaps through focus group meetings, the use of a suggestion box, or a regular staff survey. Furthermore, policies prescribed to increase professional support in a facility may affect staff differently, depending on their job level. Facility managers who intend to enhance professional support by particular interventions should monitor their effects on satisfaction on all levels of staff.

Variation by facility type
Several notable differences were observed between nursing homes (high care) and hostels (low care). Firstly, the mean composite scores for personal job satisfaction, workload, training, and professional support were significantly lower for nursing home staff compared with hostel staff. Secondly, the structural regression paths varied between the two groups. The main difference related to the effect of training on workload, which was insignificant in the hostel group, and the effect of team spirit on workload, which was absent in the nursing home group. Such differences must be taken into consideration when developing effective strategies to improve staff satisfaction in each setting.

Training and workload
Education and training are important approaches for preparing, updating, and enriching staff, with the expectation that they will then manage and perform their job better. The absence of a training effect on workload in the hostel group might be due to the fact that hostel staff had a better educational background and opportunities. For example, a significantly higher proportion of hostel than nursing home staff had already completed an aged care-related course (67% versus 50%) and had adequate opportunities to attend ongoing education during work time (76% versus 65%). L If staff are well trained and satisfied with their training opportunities they will be better equipped to manage their work.

For nursing homes, the significant effect of training on workload may simply reflect the lack of training opportunities during work time and the high workload of staff. Often, nursing home staff have to struggle to finish their daily routine with more dependent residents who require extra care. Such heavy workload is evident from the fact that, after adjusting for resident dependency, relatively fewer care hours (about one-third less) were provided compared with hostels (t=4.52, df=39.44, P<0.001). Workload is thus more of an issue in nursing homes. While staff may have difficulty finding time to engage in training activities, training can enhance their professional development and in turn enable them to better manage their work.

It has been suggested that commitment to in-service training can have a greater impact on quality outcomes than the initial training of staff [3]. The sample statistics revealed that 59% of nursing home staff were interested in further training relevant to their work. Moreover, the lack of opportunities to attend in-service training during work time, and the fact that only half of the respondents had completed an aged care-related course, indicate that nursing home staff do need additional training to support their work.

Team spirit and workload
In general, nursing home staff were quire satisfied with their colleagues (team spirit mean score = 4.2). However, this does not appear to enhance their satisfaction with workload. It is a common practice for nursing home facilities to employ a large proportion of casual or agency staff, who work short or split shifts, to supplement the limited number of regular staff. Within such an environment, where staff come and go on a regular basis, there is little time or commitment to build up cooperative relationships, and/or to facilitate team spirit.

Indeed, some nursing home respondents remarked that the use of casual staff sometimes create additional workload for permanent staff, which has ramifications and possible detrimental effect on the quality of care.

Limitations
As discussed previously, this research has some limitations. First of all, findings were based on Western Australia data only, although Western Australia does have a full range of staffing arrangements. In addition, the moderate response rate may weaken our conclusions about relationships among satisfaction components. Lack of information about non-responders is another limitation.

Recommendations
The results confirm the findings in the literature that management and leadership are pivotal to staff satisfaction. Facility managers should consider implementing strategies and policies designed to enhance staff job satisfaction, particularly in long-term care settings, where turnover is a problem. The following strategies are suggested as examples that we believe will probably strengthen professional support and promote staff satisfaction in residential aged care settings.

  1. Organizing regular in-service training program that provide opportunities for staff to update their practice, skills, and knowledge, especially in nursing home settings.
  2. Arranging regular staff meetings that allow staff at all levels to discus concerns and difficult issues, exchange information and ideas, and support each other to solve encountered problems.
  3. Educating facility managers and senior staff about the important role that they play and encouraging them to make changes when necessary and to have a close and supportive relationship with staff.
  4. Establishing a resource centre at the facility level, providing education and training materials such as textbooks and videos, for staff to access as required for encouraging self-initiated learning.
  5. Sharing information, such as research reports, quality improvement tools, and education and training materials, at regional, state or national level by establishing an aged care support and resource center.

Overall it is important for facility managers to discuss with staff about how they might best provide professional support.


   Conclusion
Top
 Methods
 Results
 Discussion
 Conclusion
Acknowledgements
 References
 
This study has shown that by increasing professional support all aspects of staff satisfaction can be enhanced. Since staff satisfaction has a positive impact on staff retention [5, 6, 11], this finding is significant in terms of maintaining a stable staff and hence continuity of quality care. Finally, effective strategies to improve staff satisfaction need to be formulated separately for nursing homes and hostels, taking into account the different relationships among satisfaction components in each setting.


   Acknowledgements
Top
 Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
References
 
The authors wish to express their gratitude to the staff and administrators of the 70 residential aged care facilities who participated in this study. Without their cooperation and assistance this research could not have been completed. The authors also wish to thank two anonymous references for their thoughtful and constructive suggestions.


   References
Top
 Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
 References
 

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