THANKS SO MUCH FOR INVITING ME TO YOUR CONFERENCE!

1. THANKS SO MUCH FOR INVITING ME TO YOUR CONFERENCE!

2. Strategies for Empowering Direct Care Workers and Improving Job Outcomes Linda S. Noelker, Ph.D Senior Vice President Director, Katz Policy Institute Benjamin Rose Institute Presented at the North Carolina Conference on Aging, September 10, 2007, Winston-Salem, NC. This research was supported by a grant from the Institute for the Future of Aging Services under the Better Jobs Better Care initiative funded by the Robert Wood Johnson Foundation and Atlantic Philanthropies.

3. Benjamin Rose Institute (BRI) • Established in 1908 • Endowment (currently 120 million) • Mission: To advance the health, independence, and dignity of older adults by raising the standards for quality of care • A non-profit agency that includes Home & Community-based Services(HCBS), Applied Aging Research, and Public Policy Institutes

4. What changed at BRI? • 1961: BRI’s first 115-bed nursing home opened • 1997: BRI’s new 184-bed nursing home opened • 2006: BRI got out of the nursing home business

5. Kethley House @ Benjamin Rose Place

6. What does it reflect about Long Term Care? • Inadequate reimbursement under Medicaid • Shift to HCBS (“rebalancing”) • Liability issues (threat to BRI’s endowment) • Licensed nursing shortage • Direct care workforce (DCW) issues (e.g., increasing health insurance costs, projected shortages)

7. Today’s Objectives • Further understanding of the touch points between Rosabeth M. Kanter’s theory of worker empowerment and the stress and social support model as they affect DCW job satisfaction • Present findings on factors affecting DCW job satisfaction with a focus on education and training • Promote improved DCW training based on their recommendations

8. What is empowerment? A process by which the characteristics of the organization and the job create an environment in which the employee feels in control and has the power and ability to affect the achievement of organizational goals (Kanter, 1993)

9. Key Elements of Empowerment • Training and education so workers can learn and grow • Supportive leadership and work environment • Information sharing • Access to needed resources

10. DCW Training and Education • Competencies are developed broadly • Include interpersonal and group process skills, problem-solving and decision-making skills, leadership, customer relations skills, and technical skills

11. Comments Reflecting aLack of Empowerment around Education “You can’t expect them to learn that.” “Continuing education is the same old thing over and over.” “I can’t leave the unit to attend.” “They get to go to the Marriott for their continuing education.”

12. Empowerment Outcomes • Higher job satisfaction • Greater job commitment • Reduced job-related stress & burnout • Higher retention

13. Better Education = Better Jobs BRI’s Survey of DCWs • Employed stress & support conceptual model to guide the research • Both DCW-level and organization-level analyses conducted to address issue of nested data • DCWs from nursing homes, assisted living and home health agencies included

14. Study Design and Methods • Cross-sectional survey; in-person/phone DCW interviews • Questionnaires for data on organizational characteristics and management practices • Study sites drawn using proportionate random sampling from all Nursing Homes (NHs), Assisted Livings (ALs) and Home Health Agencies (HHAs) in five counties in NE Ohio • 90 sites chosen/49 agreed (41% participation rate) • 27 NHs, 14 ALs, and 8 HHAs

15. DCW Sample • Proportionate random sampling of DCWs within the 49 sites • Targeted 900, 1058 contacted, 644 participated (61% participation rate) • Over time & over budget on sample recruitment and data collection • Is is possible to obtain a representative sample of DCWs?

16. LTC Stress and Support Model Predicting Direct Care Workers’ Job Satisfaction A. Background Characteristics C: Workplace Support: E: Outcomes: B. Stressors: • Direct Care Workers • Age • Marital Status • Race • Direct Care Workers • Positive & Negative Relationships • With Residents/Clients • With Staff • Direct Care Workers • Job Satisfaction • Direct Care Workers • Personal • Family & Financial • Health Changes • Job-Related • Training • Pay & Benefits • Scheduling Changes • Permanent Assignment D. Organizational Variables: • Characteristics • Types of LTC Setting • Profit Status • % of Minorities Served • % of Medicaid Reimbursement • Management Issues • Turnover of DCWs • Minimum Pay

17. Analytic Approach Multiple Linear Regression Analysis: using individual-level DCW data to predict job satisfaction Hierarchical Linear Modeling: using organizational-level data to predict average job satisfaction score in study sites after controlling for individual-level variables

18. Perceived Adequacy of Training • Entry-level • Job orientation • Continuing Education • Recommendations for improvement

19. Positive and Negative Support in the Workplace • Positive interaction with peers and residents/clients (e.g., feelings of respect, affection) • Negative interaction with peers and residents/clients (e.g., feelings of anger, frustration) • Frequency of hearing racist remarks from residents, families and other staff

20. Findings: DCW characteristics • Age (average) 39 years • Minorities 59% • Female 95% • Unmarried 63% • Work in LTC (average) 8.7 years

21. Multiple Linear Regression Results for DCW Job Satisfaction Adj. R2 .51 (p<.01) Background characteristics: Non-minority *Personal Stressors: + Physical health & emotional health change; lower depression scores *Job-related Stressors: adequacy of job orientation & continuing education; fewer scheduling changes; fair pay & more benefits (health insurance, retirement) Workplace Support: less negative interaction; fewer racist remarks

22. Racist Remarks Heard make remarks: To be hurtful: Clients/Residents 70% 4% Families 15% 38% Other staff 21% 65%

23. Quotes from Workers • “I want to leave because I cannot take the racial comments anymore. I am training to go into medical billing.” • “There seems to be a ‘white’ standard and a ‘colored’ standard. The white workers are expected to do more and be more responsible which makes them feel discriminated against and angry.”

24. Results from HLM Analysis of Factors Affecting DCW Job Satisfaction Adjusted average DCW job satisfaction scores were higher for: • DCWs in Assisted Living and Home Health Agencies • Sites reporting less difficulty with DCWs quitting and being fired • Sites with a higher rate of starting pay

25. DCW Reports about Training NH DCWsAL DCWs HHA DCWs Initial training made me well prepared 55% 59% 71% Job orientation was very helpful 49% 47% 63% Very useful to have a mentor 74% 77% 79% Continuing education is very useful 53% 51% 70%

26. CEU Topics Most Frequently Covered • Preventing injuries at work (not as helpful for NH/ALF DCWs) • Caring for those with dementia • Communicating with residents/clients • Resident/client care skills such as bathing (need more in ALFs) • How to deal with difficult coworkers

27. CEU Topics Needing More Attention • DCW Teamwork (especially in NHs) • Organizing tasks so everything gets done (especially in HHA) • CPR (especially in NHs) • Problem solving on the job (especially in ALFs) • Managing job stress (especially in NHs) • End-of-life issues/grief (especially in ALFs)

28. Recommendations for Improving Entry-Level Training • Longer/more hours • More clinical time • More one-on-one instruction (peer mentoring) • Cover teamwork, respect, communication, dementia care, lifts/transfers, vital signs

29. Recommendations for Improving Continuing Education • More frequent, shorter sessions • Offer on all shifts/all days of the week • Interactive training (e.g., role plays) • Obtain DCW input on content and design • Ensure coverage to foster attendance • Cover teamwork, respect, communication, mental illness, vital signs, and CPR

30. References Ejaz, F., Noelker, L.S., Menne, H.L. & Bagaka’s, J. G. (in press) The impact of stress and support on direct care workers’ job satisfaction, The Gerontologist. Kanter, R. M. (1993) Men and Women of the Corporation. N.Y.: Basic Books. Noelker, L.S., Ejaz, F.K. & Menne, H.L. (in press) Knowledge as empowerment: Improving nursing assistants’ education and training, in Empowering Work Teams in Long Term Care: Why and How to Create Self-directed Teams, Yeatts, D., Noelker, L.S. & Cready, C.M. (eds.), Health Professions Press.

31. Today, Tomorrow, Together! • Working collaboratively to improve the size and quality of the Direct Care Workforce • Ensuring quality jobs and quality care for older and younger disabled citizens