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Improving long-term care management practices and direct care worker organizational commitment

ProQuest Dissertations and Theses, 2009
Dissertation
Author: Amy L Stott
Abstract:
Research Objective. High turnover of direct care workers is one of the biggest challenges in the long-term care industry today. Several types of management practices, such as staff training, professional development, career advancement opportunities, and work redesign, have been linked to employee organizational commitment. Previous studies show organizational commitment is associated with lower employee turnover. This study provides several contributions to the existing literature by filling gaps in previous research and resolving same-source bias. Testing relationships between direct care worker organizational commitment and management practices will expand on the existing long-term care organizational literature, which is primarily descriptive. Further, investigating the impact of each type of setting on this relationship is a new contribution to this body of literature. Methodologically, the use of separate respondents for organizational and direct care worker-level data reduces same-source bias between the organizational-level predictor variables and the direct care worker-level outcome variables (Fedor, Caldwell, & Herold, 2006). Study design. This analysis contains data from a panel of 76 clinical managers and 911 direct care workers who completed both waves of the Clinical Manager and Direct Care Worker Surveys used in the evaluation of the Better Jobs Better Care (BJBC) demonstration. The Clinical Manager Survey measures the work design, direct care worker training and development, and supervisor training management practice variables. The Direct Care Worker Survey contains items used to measure organizational commitment and demographics. Two types of research designs are used in this study. First, cross-sectional analyses, using baseline responses, investigate the relationship between baseline management practices and organizational commitment. Then, a one-group pretest-posttest design, examines whether changes in management practices change organizational commitment. Several types of linear regression techniques including ordinary least squares (OLS) and logistic regression with robust estimation are used to analyze the data. Results. In the cross-sectional analysis, greater use of feedback is associated with direct care workers recommending the organization for a job and thinking about quitting less often. Supervisor participation in a greater number of training programs and having direct care workers participation in career ladder programs is also related to direct care workers recommending the organization for a job. Staff participation in a greater number of staff training programs is also related to direct care workers being less likely to leave their job in the next year. Being a nursing facility and having staff development and training programs is also linked with direct care worker organizational commitment. However, including interactions only improved the models marginally. The only consistent relationship in the cross-sectional and longitudinal analyses is the association of supervisor training with direct care workers recommending the organization for a job. Conclusion/Implications. Findings suggest aspects of both work design and staff training and development practices are related to direct care worker organizational commitment. For long-term care policy makers and administrators, who are concerned about increasing direct care worker retention, this study offers empirical evidence to formulate policies that improve management practices in these areas.

TABLE OF CONTENTS List of Tables………………………………………………………………………………...…..vii List of Figures…………………………………………………………………………………...viii Acknowledgements………………………………………………………………….…….……..ix

Chapter 1. INTRODUCTION TO THE PROBLEM…………………………………..….…......1

Chapter 2. LITER ATURE REVIEW……………………………………...…………..…...…….4 Background……………………………………………………………………....….….…4 Theoretical Framework…………………………………………………....……..…....…..6 Prior Research…………………………………………………..………………………..10

Chapter 3. STUDY DESCRIPTION……………………………………….……………...……15 Better Jobs Better Care Demonstration……………………………………………....…..15 Research Model and Hypotheses…………………………………………………….......16 Work Design…………...........……………………………………………….…..16 Direct Care Worker Tr aining & Development………………………........……..19 Supervisor Training…...……………...………………………………...….…….20

Chapter 4. METHODS………………………………………………………………………….24 Research Design…………………………………………………………………………24 Data Sources……………………………………………………………………..24 Sample……………………..…………………………………………………….25 Direct Care Workers……………………………………………………..26 Clinical Managers……………………………………………….……….27 Surveys…………………………………………………………………………. 28 Clinical Manager Survey………………………………………………...28 Direct Care Worker Survey…………………………………………….. 29 Measures…………………………………………………………………………………29 Cross-Sectional Measures………………………………………………………..30 Organizational Commitment……………………………...………...…...30 Management Practices…………………………………...……………...31 Work Design………………………………………………….....31 Direct Care Worker Tr aining & Development………………….33 Supervisor Training……………………………………………...34 Type of Long-Term Care Setting…………………………………….....35 Interaction Terms……………………………………………......35 Direct Care Worker Characteristics…………………………………......36 Longitudinal Measures……………………………………………………….....36 Organizational Commitment……………………………....………..…..37 Management Practices…………………………………...………..……37 Work Design……………………………………………..……..37 Direct Care Worker Tr aining & Development…………..……..37 Supervisor Training…………………………………………......38

vi Direct Care Worker Characteristics…………………………….......…...38 Analysis Plan……………………………………………………………………………39 Cross-Sectional Analysis……………………………………………….………..40 Analysis of the Moderating Effects of the Type of Long-Term Care Setting on the Relationship between Management Practices and Organizational Commitment………………………………………...41 Longitudinal Analysis…………………………………………………………...42

Chapter 5. RESULTS……………………………………………………………………….…..44 Cross-sectional Results……………………………………………………...………......45 Descriptives…………………………………………………………………..….45 Organizational Commitment……………………………………….…....46 Control Variables: Direct Care Worker Characteristics…….…………...47 Management Practices……………………………………….………..…47 Regression Analysis………………………………………………….…….….…49 Moderating Effects of the Type of Long-Term Care Setting on the Relationship between Management Practices and Organizational Commitment…………………………………………………………51 Longitudinal Results……………………………………………………………………. 54 Descriptives……………………………………………………….…………..….54 Changes in Organizational Commitment…….……………….…….…....55 Changes in Direct Care Worker Characteristics…………….…………...56 Changes in Management Practices………………………….………..….56 Regression Analysis………………………………………………….…….….…57 Changes in Management Practices on Changes in Organizational Commitment…………………………………...…………………….57

Chapter 6. DISCUSSION……………………………………………………………….………61 Management Practices and Or ganizational Commitment………………………………..61 Limitations……………………………………………………………………………….66 Future Research…………………………...…………………………………………......69 Implications……………………………………………………………………….…......74 Conclusions……………………………………………………………………………...76

References………………………………………………………………………………...……..77

Appendix A: Clinical Manager Survey………………………………………………………....90

Appendix B: Direct Care Worker Survey……………………………………………………...108

Appendix C: Full Models………………………………...……………………………………115

vii LIST OF TABLES

Table 4.1 Direct Care Workers by State and Type of Long-Term Care Setting……………….27 Table 4.2 Type of Long-Term Care Setting by State…………………………………………..28 Table 4.3 Direct Care Worker Or ganizational Commitment Items………………...……….....30 Table 4.4 Work Design Item and Scales…………………………………………………….…32 Table 4.5 Direct Care Worker Training & Development Items and Scales…………….………33 Table 4.6 Supervisor Training…………………………………………………………………..34 Table 5.1 Support for Hypotheses based on Cr oss-sectional and L ongitudinal Results………..45 Table 5.2 Sample Descriptive Cross-sectional Data……………………………………………46 Table 5.3 Effects of Management Practices and the Type of Long-Term Care Setting on Organizational Commitment……………...…………………………………………..49 Table 5.4 Moderating Effects of the Type of Long-Term Care Setting on the Relationship between Management Practices and Orga nizational Commitment controlling for Direct Care Worker Characteristics…………………...…………………………...…52 Table 5.5 Sample Descriptive Longitudinal Data…………...……………………………….....55 Table 5.6 Effects of Changes in Manageme nt Practices on Changes in Organizational Commitment…………..……………………………………………………….……..58

viii LIST OF FIGURES

Figure 1. Steers’s Antecedents and Outcomes of Organizational Commitment Model………7 Figure 2. Research Model…………………………………………………………………….16

ix ACKNOWLEDGEMENTS I could not have completed the requirements for this PhD program without the guidance, assistance, and encouragement of many people who ha ve shared their gifts and talents with me. I thank God for blessing me with the support of th ese brilliant and inspiring individuals. I would like to thank my disse rtation committee members for their expertise, time, and assistance. My deepest gratitude goes to Dr . Diane Brannon. Thank you for your dedication as my advisor and the chair of my committee, even when you were faced with enormous hardships. Not only have you taught me to produce qual ity and meaningful research, but you also encouraged me to strive for academic greatne ss. Without you, I would not have earned a Juran Fellowship nor would I have publis hed my first peer-reviewed j ournal article. Thank you for joyously welcoming my son Maxwell into th e world and sharing all the personal and professional moments. I will miss working with you. I am also deeply grateful to Dr. Joseph Vasey. Thank you for teaching me how to complete many types of analyses in SPSS, SAS, and Mplus. You are th e “Software Master” of the HPA department. I also appreciate your en couragement and upliftin g spirit during this process. Being able to approach you with a variet y of statistical questions was invaluable. I still do not know how you manage your own work with all the interruptions from me and other students, but I want you to know that I am extremely thankful for your enormous time commitment and allegiance to all of the HPA students. I would also like to thank Dr. Melissa Har dy. Your astute, methodological suggestions on this dissertation over the past two and a half years have been invaluable. The Better Jobs Better Care (BJBC) evaluation team and I appreciated your perspec tive. Your ability to conduct

x interdisciplinary research is inspiring. Thank you for your commitment to me and for the parenting advice for Maxwell. Thank you also to Dr. Kathryn Dansky. I appreciated your willingness to serve on my committee after returning from sabbatical and “stepping up to the plate” when I really needed it. Your insightful suggestions and comments, particularly on the management literature, helped significantly. I am also thankful to Dr. Peter Kemper for encouraging me to apply for the National Institute on Aging (NIA) Predoctoral Fellowship (Training Grant: T32 AG00048) and allowing me to experience every aspect of evaluating the BJBC demonstration. You taught me the value of rigorous research and the art of presenting research results at professional conferences. I am sincerely grateful to you and Dr. Diane Brannon for the opportunity to be the first author on a peer-reviewed journal article, which has been a highlight of my time at Penn State. I am also extremely thankful to Dr. Michael Rovine for his methodology consultations every Wednesday for an entire month and for being the best multivariate statistics professor I had at Penn State. I appreciate your eloquent teaching style, and you helped me to understand a myriad of multivariate statistical analyses. Without your expertise, I would have taken a much longer path to get the same answers. I am also grateful for the assistance of Ann Shuey at the Gerontology Center, the Center for Health Care and Policy Research (CHCPR) staff, and the Health Policy and Administration (HPA) staff. First, I would like to thank Ann Shuey. Ann helped me navigate Penn State’s academic system from the very beginning. When I needed help resolving large and small problems over the years, she always gave me her time and wisdom freely. Her smile and encouraging words eased my mind when I was anxious. I know I would not have completed this

xi program without her support. She has been a confidant professionally and personally, and I hope we will remain friends throughout the coming years. Next, I am thankful for the CHCPR staff: Diane Farley, Tracy Johnson, and Edie Rose Allison (a.k.a The CHCPR Chicks). Your assistance with conference travel, software, and payroll was always prompt and extremely professional. I appreciate your dedication and kindness. Finally, I would like to thank the HPA staff members: Bev Fahr, Lucy Taylor, Patricia Corbett, Marc Teenie, Sarah Woodward, and Barbara Fleischer. I am grateful for your help, especially during my final year while I was off- campus, with registering for classes, setting up equipment, and completing paperwork over the years. I would also like to thank Tom Knarr for proofreading my work. You taught me that research is ineffective if the writing is incomprehensible. I appreciate your expertise and time, which helped create several pieces of understandable research, including this dissertation. I am also thankful to the NIA for the generous funding, which allowed me to work on the BJBC evaluation team and complete this dissertation. I would also like to thank the Joseph M. Juran Center for bestowing me with a 2008 Juran Fellowship, which also provided financial support for this dissertation. I would also like to thank the direct care workers and clinical managers at the participating BJBC organizations. I appreciate your time to complete the surveys and efforts during the demonstration. I hope the results of this research reflect some of your positive experiences and contribute to future workforce improvements in the long-term care industry. I am grateful for the support of my family and friends. First, I would like to thank Brigitt Heier for her friendship, proofreading skills, and advice. Thank you for encouraging me to apply to this program, listening to me, and sitting through all of my presentation practice sessions. You have been a true friend over the past five years, and I value our friendship. Next,

xii I would like to thank my classmates Monika Setia and Rajeshwari Punekar. Thank you for your encouraging words, cheerful smiles, and willingness to share your culture with me and my family. Both of you helped to create some very happy memories ranging from our “girls’ night out” to singing Indian songs in the Henderson office. Both of you have made a lasting impression on me. Lastly, I would like to thank Ashley Kaper and Angela Santore for watching my son Maxwell during my third year in the program. I was able to make significant progress that year because I knew both of you were taking very good care of Maxwell while I was working on this dissertation. Finally, I would like to thank my family for supporting me, even during my most stressful moments. First, I would like to thank my parents for instilling a work ethic, stressing the importance of education, and taking an interest in every endeavor I pursued during my life. Dad, thank you for teaching me to be persistent and tough when faced with adversity. Mom, thank you for reminding me that God always provides me with everything I need in life and teaching me that serving is much better than receiving. I also want to thank both of you for taking care of Maxwell. I would not have been in able to finish the Ph.D. program in four years without your help and support. I am forever indebted to both of you for the sacrifices you have made for me over the years. Next, I would like to thank my brothers, David and Dan. Thank you for giving me a love of science and a foundation for understanding math, as well as teaching me the joy of achievement. Lastly, I am grateful for my loving and supportive husband, Derek, and my son, Maxwell. First, I would like to thank Maxwell for his unconditional love and patience over the past two years. You already amaze me with your confidence and intellect, and I am looking forward to watching and helping you grow to your full potential. Most importantly, I would like

xiii to thank Derek for encouraging me to never quit, supporting all of my endeavors, helping me to reach and overcome very difficult decisions, critiquing my writing, teaching me the importance of economics and calculus, and staying up with me late at night when I needed to meet a deadline. Thank you for your unlimited patience and love. I am blessed to have you as my husband, and I look forward to growing old with you.

xiv EPIGRAPH

“But the manifestation of the Spir it is given to each one for the profit of all : for to one is given the word of wisdom through the Spirit, to another the word of knowledge thr ough the same Spirit, to another faith by the same Spirit, to another gifts of healings by the same Spirit, to another the working of miracles, to another prophecy, to another discerni ng of spirits, to another different

kinds of tongues, to another the interpretation of tongues. But one and the same Spirit works all these things, distributing to each one individually as He wills.”

1 Corinthians 12: 7-11

1 CHAPTER 1 INTRODUCTION TO THE PROBLEM The existing and future shortage of direct care workers in the long-term care industry stems from projected increases in the elderly populati on, high turnover, and projected decreases in the traditional pool of this wo rkforce. The elderly population in the United States is projected to grow from 13 million in 2000 to 27 million in 2050, which will significantly increase the demand for health and long-term care services (Assistant Secretary for Planning and Evaluation [ASPE], 2004; Squillace, Remsbur g, Bercovitz, Roseoff, & Brande n, 2006). Progress in medical technology has increased the life expectancy, th ereby increasing the nu mber of people with chronic health conditions and creating a higher demand for long-term care services (Chernichovsky & Markowitz, 2004). By 2010, an additional 1.2 million direct care workers (i.e. certified nursing assistants, home health aides, nursing aides, etc.) will be needed to account for the increasing demand for long-term care services (ASPE, 2004). Findings from the National Nurs ing Assistant Survey indicate that nursing f acilities experience, on average, a 71 % annual turnover rate of nursing assistants (Squillace, Remsburg, Bercovitz, Rose off, & Branden, 2006). The traditional direct care worker population, women be tween 25 and 50 years of age without a post-secondary education, is decreasing, making it difficult to meet the expected demand (ASPE, 2004). This dissertation will test if a significant relationship exis ts between direct care worker organizational commitment and management practices known to be associated with commitment. Direct care workers provide 80-90% of hands-on care and assi st with intimate care needs such as bathing, toileting, and dressing (Banaszak-Holl & Hi nes, 1996). High turnover of direct care workers affects quality of care by decreasing the continuity of care (Castle &

2 Engberg, 2005; Castle, Engberg, & Men, 2007; Schnelle, Simmons, Harrington, Cadogan, Garcia, & Bates-Jensen, 2004). Further, long-term care service recipients associate quality care with the direct care workers who provide these services (Sikorska-Simmons, 2006). Direct care workforce retention continues to be one of the biggest challenges facing long- term care organizations and policy makers. The federal government through the Centers for Medicare and Medicaid Services (CMS) has identified this as a leading policy concern for state- level Quality Improvement Organizations (QIOs). QIOs are directed to assist nursing homes in improving the experience of care by monitoring staff satisfaction and turnover of certified nursing assistants (CNAs) (Centers for Medicare and Medicaid Services [CMS], 2005). This research may provide continuous quality improvement programs with evidence that process redesign, through improving management practices, is linked to direct care worker organizational commitment. Substandard practices, such as poor direct care worker work design, lack of training for supervisors of direct care workers, and inadequate training and professional development opportunities for direct care workers, contribute to retention issues (Harris-Kojetin, Lipson, Fielding, Keifer, & Stone, 2004). Direct care workers ordinarily know when an organization’s procedures are producing poor outcomes (Tang, Robertson, & Lane, 1996) and quality of care (Bowers & Becker, 1992). Bowers and Becker (1992) found some direct care workers quit because they were not able to provide quality care to the residents and clients they served. Management practices typically focus on promoting compliance with rules and regulations rather than developing psychological commitment to the organization (Tang et al., 1996). Long-term care administrators need more than job satisfaction or commitment to the profession from direct care workers; they need organizational commitment to reduce turnover.

3 Therefore, organizational commitment of direct care workers is an important outcome to measure. Providing knowledgeable supervisors to lead and manage direct care workers appropriately, affording opportunities for career advancement, offering discretionary power through work design, and training for direct care workers may increase organizational commitment, leading to decreased turnover and incr eased continuity of care. Work design and training will also allow direct ca re workers to adapt to changes in their residents and clients, thereby improving quality of care.

4 CHAPTER 2 LITERATURE REVIEW Background

The long-term care industry serves people who suffer from chronic conditions or disabilities that impair their phys ical or cognitive function. A majo rity of the clients are over 65 years old and, depending on the severity of their physical or cognitive impairments, will likely use at least one type of long- term care setting during their lif etimes (Kemper, 1992). Nursing facilities, assisted-living facili ties, and home care agencies offe r different types of services. Nursing facilities generally provide 24-hour nursi ng care and offer therapy services to residents who are medically stable but cannot remain in their homes. Assisted-living facilities assist people who cannot remain in their homes but do not need 24-hour nursing care. Housekeeping, meal preparation, and laundry serv ices are usually provided in th is setting. Typically, nursing and assisted-living facilities are in one building or on one campus (Evashwick, 2005; Stone, 2006). In contrast, home care services are provided within a client’s home. Home care agencies provide care to “homebound” clie nts. Homebound eligibility is defined as “able to leave home only with great difficulty” (General Accounting Office [GAO], 2002, p.1). In long-term care settings, direct care work ers provide assistance w ith bathing, dressing, transferring, housekeeping, and feed ing. Typical job titles include nurse aide, home health aide, and personal care attendant; however, direct care workers are not limited to these job titles. Currently, direct care workers are in short supply, and future estim ates for long-term care needs are growing disproportionately to the number of typical work ers who occupy these jobs. Retention of direct care workers in long-te rm care is an ongoing issue. One method of improving retention is to increase wages. Ho wever, federal and state budgets often limit

5 reimbursement to long-term care organizations. This places constraints on increasing wages and benefits for direct care workers in long-term care settings and directly affects the efforts of long- term care organizations to recruit, retain, and maintain direct care workers (Stone, 2006). Another method of improving retention is to improve management practices within long-term care organizations. Several state agencies, organizations, and advocacy groups recognize the urgency of the direct care worker workforce crisis and have attempted to document best practices to retain direct care workers in long-term care (Brannon, Barry, Angelelli, Weech-Maldonado, 2005; GAO, 2002; Harris-Kojetin et al., 2004; ASPE, 2004; Squillace et al., 2006). Few empirical research studies investigate the effects of management practices on direct care workers, and little research compares the types of settings within the long-term care continuum. Stone (2006) reports, “Most evidence has been derived from descriptive, qualitative studies conducted primarily in nursing homes” (p. 413). Harris-Kojetin et al. (2004) identified direct care worker factors associated with poor retention in long-term care as: inadequate training, lack of mentoring, little or no opportunities for continuing education and development within the position, and poor supervision. However, no studies investigate whether greater use of these management practices impacts direct care worker organizational commitment in the long-term care industry using separate respondents for organizational- and direct care worker- level data. Additionally, no studies examine whether the type of long-term care setting influences this relationship. As long-term care settings differ in their physical structure and organizational hierarchy, specific types of management practices may be useful in one setting but not in another. This dissertation addresses two questions:

6 1.

Are management practices previously show n to be associated with organizational commitment related to direct care workers’ reported commitment? 2.

Does the type of long-term care se tting affect this relationship? For long-term care administrators and polic y makers, the results of this study may provide further empirical evidence that management practices are associat ed with direct care worker organizational commitment. This resear ch may also help policymakers to formulate policies appropriate for each type of long-term care setting and help administrators choose management practices that are applicable to their settings, thereby increasi ng retention and continuity of care within their organization. Theoretical Framework

The conceptualization of this study is based on Steers’s (1977) organizational commitment model (Figure 1) and aspects of Hackman and Oldham’s (1980) job characteristics theory and Salancik and Pfeffer’s (1978) social information processing theory. Steers (1977) cited three reasons for studying or ganizational commitment: (1) comm itment is a better predictor of turnover than job satisfaction, (2) highly committed employees perform better than less committed employees, and (3) commitment is a useful indictor of effectiveness of an organization. The definition of organizational commitment used in hi s study was “the relative strength of an individual’s iden tification with and involvement in a particular organization” (p. 46). Since Steers’s publication in 1977, several other definitions of or ganizational commitment have been used in prior research. However, th e general underlying theme and the definition used in this dissertation is the “bond formed between the employee and the organization” (Humphreys, Brunsen, & Davis, 2005, p.121).

7 Findings from recent studies are consistent with Steers’s reasons for investigating organizational commitment. Commitment is lin ked to lower turnover behavior (Eby, Freeman, Rush, & Lance, 1999; Lum, Kervin, Clark, Reid, & Sirola, 1998) and is used as a proxy for retention in several studies on the direct care workforce in long-term care (Adadevoh, 2003; Dobbs, 1997; McKenzie, 2006; Sikor ska-Simmons, 2005). Later work by Mowday, Steers, & Porter (1979) found that commitment was a more stable job outcome than job satisfaction to measure and was less likely to change ba sed on momentary, day-to-day events. One of Steer’s (1977) main objectives wa s to investigate “the process by which commitments are formed … in organizational set tings” (p. 46). His model had three antecedents of organizational commitment: personal charact eristics, job characteristics, and work experiences (Figure 1). Figure 1. Steers’s Antecedents and Outcom es of Organizational Commitment Model

Recent studies investigated the relations hip between direct care worker personal characteristics and organizati onal commitment in long-term care (Parsons, Simmons, Penn, & Furlough, 2003; Sikorska-Simmons, 2005) . These relationships differ based on the type of long- term care settings. In nursing facilities, Parsons et al. (2003) found direct care workers who were older, less educated, and employed at the organi zation for a long period of time were less likely to quit. However, in assisted -living facilities, Sikorska-Simm ons (2005) reported direct care Personal Characteristics Job Characteristics Work Ex p eriences Organizational Commitment Outcomes: •

Desire to remain •

Intent to remain •

Attendance •

Employee retention •

8 workers with more education were more committed to their organization. Because these studies have established the relationship between direct care worker characteristics and commitment in long-term care, the focus of this dissertation is on the relationship between management practices and organizational commitment. However, personal characteristics are used as control variables in the analysis. Job characteristics, such as the amount of feedback provided on the job, and work experiences, or a worker’s feeling that he or she is an important part of the organization, modeled in Steers’s (1977) study had a positive influence on organizational commitment. Steers’s (1977) job characteristic measures included job challenge, opportunities for social interaction, and frequency of feedback provided on the job. Later, Hackman and Oldham (1980) developed the job characteristics theory, which emphasized that improving job outcomes, such as organizational commitment, is a result of improving an employee’s motivation or psychological state. This theory declares that psychological states can be improved by increasing five job characteristics: skill variety, task identity, task significance, autonomy, and job feedback through work redesign (Hackman & Oldham, 1980). Findings from previous research show support for Hackman and Oldham’s (1980) job characteristics model (Wall & Clegg, 1981). In a longitudinal study, including three waves of measurement, of blue collar packing and production workers in a confectionary company, decreased turnover followed changes in feedback, autonomy, and identity (Wall & Clegg, 1981). When testing the validity of the entire job characteristics model, Johns, Xie, and Fang (1992) found first and second level utility company managers did not require all five job characteristics for positive job outcomes, such as decrease turnover cognitions. This dissertation does not have a measure for skill variety, but the remaining four characteristics included in this

9 study can be used to describe the management pract ices that enrich a dire ct care worker’s work design. For example, task identity, through partic ipation in care planni ng; task significance,

through written or verbal communication with ot her direct care workers or their supervisors about their clients’ care; autonomy, through flexible scheduling or flex time; and feedback are all direct care worker job charac teristics that can be improved through management practices. An employee’s work experience in Steers’ s (1977) model was defined as “a major socializing force and…an important influence on the extent to which psychological attachments are formed with the organization” (p. 47). Pr evious work cited by Steers (1977) included group attitudes toward the organiza tion, organizational dependability and trust, rewards or the realization of expectations, and perceptions of personal investme nt and personal importance to an organization as areas of work experi ence known to influence commitment. Salancik and Pfeffer’s (1978) social inform ation processing theory expands on the work experience component of Steers’s (1977) model by emphasizing that “one can learn most about individual behavior by studying th e informational and social environment within which that behavior occurs and to which it adapts” (Sal ancik & Pfeffer, 1978, p. 226). In other words, people gather information about their work envi ronment through interact ions with others and from their own work experiences. Although pr evious direct care worker organizational commitment investigations did not use social info rmation processing theory, direct care workers’ social experiences and the information they receive through their work environments are influenced by management practices. Practices, such as highly visible training and education programs, effective orientation and socializ ation processes, effective leadership, and participation in decisions are all signals that employees are valuable to the organization (Robertson & Tang, 1995). Therefore, improving s upervisor training and direct care worker

Full document contains 175 pages
Abstract: Research Objective. High turnover of direct care workers is one of the biggest challenges in the long-term care industry today. Several types of management practices, such as staff training, professional development, career advancement opportunities, and work redesign, have been linked to employee organizational commitment. Previous studies show organizational commitment is associated with lower employee turnover. This study provides several contributions to the existing literature by filling gaps in previous research and resolving same-source bias. Testing relationships between direct care worker organizational commitment and management practices will expand on the existing long-term care organizational literature, which is primarily descriptive. Further, investigating the impact of each type of setting on this relationship is a new contribution to this body of literature. Methodologically, the use of separate respondents for organizational and direct care worker-level data reduces same-source bias between the organizational-level predictor variables and the direct care worker-level outcome variables (Fedor, Caldwell, & Herold, 2006). Study design. This analysis contains data from a panel of 76 clinical managers and 911 direct care workers who completed both waves of the Clinical Manager and Direct Care Worker Surveys used in the evaluation of the Better Jobs Better Care (BJBC) demonstration. The Clinical Manager Survey measures the work design, direct care worker training and development, and supervisor training management practice variables. The Direct Care Worker Survey contains items used to measure organizational commitment and demographics. Two types of research designs are used in this study. First, cross-sectional analyses, using baseline responses, investigate the relationship between baseline management practices and organizational commitment. Then, a one-group pretest-posttest design, examines whether changes in management practices change organizational commitment. Several types of linear regression techniques including ordinary least squares (OLS) and logistic regression with robust estimation are used to analyze the data. Results. In the cross-sectional analysis, greater use of feedback is associated with direct care workers recommending the organization for a job and thinking about quitting less often. Supervisor participation in a greater number of training programs and having direct care workers participation in career ladder programs is also related to direct care workers recommending the organization for a job. Staff participation in a greater number of staff training programs is also related to direct care workers being less likely to leave their job in the next year. Being a nursing facility and having staff development and training programs is also linked with direct care worker organizational commitment. However, including interactions only improved the models marginally. The only consistent relationship in the cross-sectional and longitudinal analyses is the association of supervisor training with direct care workers recommending the organization for a job. Conclusion/Implications. Findings suggest aspects of both work design and staff training and development practices are related to direct care worker organizational commitment. For long-term care policy makers and administrators, who are concerned about increasing direct care worker retention, this study offers empirical evidence to formulate policies that improve management practices in these areas.