Factors in the psychosocial work environment of staff are associated with satisfaction with care among older persons receiving home care services
2022; Wiley; Volume: 30; Issue: 6 Linguagem: Inglês
10.1111/hsc.14045
ISSN1365-2524
AutoresAnne‐Marie Boström, Dan Lundgren, Zarina Nahar Kabir, Ingemar Kåreholt,
Tópico(s)Employment and Welfare Studies
ResumoHealth & Social Care in the CommunityVolume 30, Issue 6 p. e6080-e6090 ORIGINAL ARTICLEOpen Access Factors in the psychosocial work environment of staff are associated with satisfaction with care among older persons receiving home care services Anne-Marie Boström RN, PhD, Corresponding Author Anne-Marie Boström RN, PhD [email protected] orcid.org/0000-0002-9421-3941 Division of Nursing, Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, Sweden Theme Inflammation and Aging, Karolinska University Hospital, Huddinge, Sweden R&D unit, Stockholms Sjukhem, Stockholm, Sweden Correspondence Anne-Marie Boström, Division of Nursing, Department of NVS, Karolinska Institutet, 23 300, S-141 83 Huddinge, Sweden. Email: [email protected]Search for more papers by this authorDan Lundgren PhD, Dan Lundgren PhD orcid.org/0000-0002-9696-6883 Department of Quality and Development, Division of Social Services, Värnamo Municipality, Värnamo, Sweden Institute of Gerontology, Aging Research Network—Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Jönköping, SwedenSearch for more papers by this authorZarina Nahar Kabir PhD, Zarina Nahar Kabir PhD orcid.org/0000-0003-0465-5701 Division of Nursing, Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, SwedenSearch for more papers by this authorIngemar Kåreholt PhD, Ingemar Kåreholt PhD orcid.org/0000-0002-8617-0355 Institute of Gerontology, Aging Research Network—Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Jönköping, Sweden Aging Research Center, Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, SwedenSearch for more papers by this author Anne-Marie Boström RN, PhD, Corresponding Author Anne-Marie Boström RN, PhD [email protected] orcid.org/0000-0002-9421-3941 Division of Nursing, Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, Sweden Theme Inflammation and Aging, Karolinska University Hospital, Huddinge, Sweden R&D unit, Stockholms Sjukhem, Stockholm, Sweden Correspondence Anne-Marie Boström, Division of Nursing, Department of NVS, Karolinska Institutet, 23 300, S-141 83 Huddinge, Sweden. Email: [email protected]Search for more papers by this authorDan Lundgren PhD, Dan Lundgren PhD orcid.org/0000-0002-9696-6883 Department of Quality and Development, Division of Social Services, Värnamo Municipality, Värnamo, Sweden Institute of Gerontology, Aging Research Network—Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Jönköping, SwedenSearch for more papers by this authorZarina Nahar Kabir PhD, Zarina Nahar Kabir PhD orcid.org/0000-0003-0465-5701 Division of Nursing, Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, SwedenSearch for more papers by this authorIngemar Kåreholt PhD, Ingemar Kåreholt PhD orcid.org/0000-0002-8617-0355 Institute of Gerontology, Aging Research Network—Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Jönköping, Sweden Aging Research Center, Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, SwedenSearch for more papers by this author First published: 26 September 2022 https://doi.org/10.1111/hsc.14045Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Abstract Older persons in Sweden are increasingly encouraged to continue living at home and, if necessary, be supported by home care services (HCS). Studies have examined whether the work environment of staff has an impact on the experiences and well-being of older persons in residential care facilities, but few have examined such associations in HCS. This study examined associations between home care staff's perceptions of their psychosocial work environment and satisfaction with care among older people receiving HCS. The setting was 16 HCS work units. Two surveys were conducted, one on psychosocial working conditions of staff, one on satisfaction of older persons receiving HCS. For each work unit, data on individual satisfaction were matched to average values concerning psychosocial work conditions. Outcomes analysed with linear regressions were overall satisfaction and indices regarding assessment of performance of services, contact with staff and sense of security. The index for treatment by staff was analysed with ordered logistic regressions. Cluster correlated-standard error clustering on work units was used. Results showed that good working conditions were important for satisfaction with care, specifically overall satisfaction, treatment by staff and sense of security. The most important psychosocial work factors were work group climate, sense of mastery, job control, overall job strain, frustrated empathy, balancing competing needs, balancing emotional involvement and lack of recognition. Receiving more HCS hours was associated with stronger relationships between working conditions and satisfaction with care, especially with overall satisfaction and treatment by staff as outcomes. Managers and policymakers for home care need to acknowledge that the working conditions of home care staff are crucial for the satisfaction of older persons receiving HCS, particularly those receiving many HCS hours. Psychosocial work factors together with job strain factors are areas to focus on in order to improve working conditions for staff and outcomes for older persons. What is known about this topic More older persons with increasingly complex needs are living at home with support from home care services. The working conditions of home care staff are reported to be demanding and staff have reported high levels of job strain. What this paper adds Factors in the work environment, such as work group climate, sense of mastery and job control, are associated with satisfaction with care among older persons receiving home care services. A high level of job strain among staff is associated with less satisfaction with care among older persons receiving home care services. Improvement in the work environment will not only be beneficial for staff, but better outcomes for older persons are also expected. 1 INTRODUCTION In accordance with the Swedish 'ageing in place' policy, older persons in Sweden are increasingly encouraged to continue living at home and, if necessary, be supported by home care services (HCS) and family caregivers (The Swedish National Board of Health and Welfare, 2016, 2017). However, the decline in residential care since the turn of the century has not seen a corresponding increase in the availability of home care (Ulmanen & Szebehely, 2015). Provision of HCS is decided on a need basis, which is assessed by social workers in the municipalities (Wolmesjö & Staaf, 2014). The support offered by HCS to persons in need includes personal care and domestic tasks such as cooking and shopping, with a varying range of service hours depending on the needs of the older person (Sandberg et al., 2019). Dignity and respect are the core values in the Swedish national guidelines concerning the care of older persons. A recent longitudinal study indicated that satisfaction with HCS in relation to dignity and respect declined over time (2016–2018) among persons both with and without dementia (Hammar et al., 2021). Recounting their experiences of being cared for at home, older persons described it as becoming a guest in their own home, that their privacy was compromised, and that they had very little influence over their care (Jarling et al., 2018). Thus, there is a need to enhance the satisfaction with HCS among older persons since an increasing number of older people will be dependent on this service. Home care staff meet a heterogenous group of older persons in their work. The older persons can have different medical diagnoses and therefore vary in terms of complexity of care needs, cognitive ability, functional limitations and other factors (Sandberg et al., 2019). Such variations require the staff to adapt their care provision accordingly in order to provide person-centred care. For example, the core process of providing person-centred care for persons with dementia is enacting and re-enacting familiarity (Hedman et al., 2021). Older persons receiving home care also emphasise the importance of continuity and familiarity with home care staff for their own sense of stability in the care delivered (Olsen et al., 2020). For the home care staff, feelings of inadequacy in the provision of care can lead to perceived job strain (Sandberg et al., 2018). Other significant factors contributing to job strain are reported to be a stagnant organisational climate, lack of recognition of their work and not having Swedish as their first language, leading to difficulties in understanding between home care staff and the older persons. A review of the literature reports lower job stability, pay, working hours and fringe benefits among home care aides compared to those working in hospitals and residential care facilities (RCF) (Hewko et al., 2015). Studies have examined whether the work environment of staff has an impact on the experiences and well-being of the older persons they care for. For example, Swedish studies in RCF have shown that a positive work climate, in which staff experience job satisfaction and support in their work, has positive associations with the older persons' ratings of the quality of care and how well they thrive in the RCF (Edvardsson et al., 2008; Lundgren et al., 2019, 2020). A Canadian study has also reported positive associations between a supportive work context and the clinical outcomes of older residents living in RCF (Estabrooks et al., 2015). To our knowledge, few studies have examined whether there are also associations between older persons' perceptions of care and staff's perceptions about their work situation in HCS. A recent study conducted in RCF and home care in one Swedish municipality identified stronger associations between staff work environment and the satisfaction of older people with their care in the RCF settings than in the home care settings (Lundgren et al., 2020). In the study by Lundgren et al. (2020), the researchers did not have information about the number of HCS hours that the older persons had been granted and could not control for this. Since home care for older people will increase and there are calls for enhancing the quality of care and satisfaction with care, there is a need to explore if there are significant associations between older persons' and staff's perceptions in a larger sample including several municipalities. If associations between staff's work environment and older persons' satisfaction with home care are found, interventions could be tailored to modify these aspects in a positive and beneficial direction. Thus, the current study examined the association between home care staff's perceptions of their psychosocial work environment and satisfaction with care among older people receiving HCS. 2 MATERIAL AND METHODS Study design This cross-sectional study combines data from three different data sources to capture the perceptions from older persons receiving HCS and home care staff. Every year, since 2012, the Swedish National Board of Health and Welfare (NBHW) invites all persons aged 65 years and older who have been granted HCS to participate in a national User Satisfaction Survey (USS) concerning their experiences with HCS (The National Board of Health and Welfare, 2012). The USS data from 2018 were combined with data from a national HCS register over support that has been granted; this register is managed by NBHW. The third source of data was a survey conducted among home care staff concerning their psychosocial working conditions at agencies providing HCS to older persons during the same time period as the USS data were collected. Setting and samples The geographical setting for this study was Stockholm County, Sweden. All 26 municipalities in the county were invited to take part in the study and five agreed to participate. Within each municipality, HCS are provided by public or private home care agencies. The selected agencies had to meet the inclusion criteria of (1) having at least 30 employees who had been employed for at least 3 months and had a contract corresponding to ≥50% employment (20 h/week) and (2) providing HCS to at least 30 persons. The criteria were met by five agencies, two private and three public, which included 16 work units in total. 2.2.1 Older person The national USS was sent to all persons aged 65 years and older receiving HCS. The sample consisted of older persons receiving HCS from the 16 work units. Of these, 1239 (60%) participated. Proxy interviews were excluded, resulting in an analytical sample of 723 persons. 2.2.2 Home care staff The inclusion criteria were working in the homes of older persons and having a permanent employment contract or having had a temporary position for at least 3 months. Four hundred and sixty-seven staff members met the criteria in the 16 included work units. Of these, 219 (47%) participated. Data The USS survey of older persons includes 25 questions about overall satisfaction with care, treatment by staff, performance of services, contact with staff and sense of security (The National Board of Health and Welfare, 2012f). The USS survey data were supplemented with individually matched data from the HCS register concerning number of HCS hours granted and type of support provided for each person. The staff survey consisted of two self-reported instruments to assess psychosocial working conditions, the Strain in Dementia Care Scale (SDCS) and the QPSNordic 34+ (QPS). SDCS addresses the perceived level of job strain among care staff (Edberg et al., 2008, 2015). The QPS measures other psychosocial aspects of the work environment and is developed from organisational theories to investigate the relationship between work, health and productivity (Dallner et al., 2000; Lindström et al., 2000; Wännström et al., 2009). Dependent variables The USS includes one question on overall satisfaction with care, 10 additional questions on satisfaction with care and one general question on treatment by staff. The response alternatives were: yes, always/often/sometimes/seldom/never, which were coded as either 4–0 or 0–4 so that positive answers were given a higher value. Item non-response was between 4 and 36 for each of the questions. Multiple imputations based on multivariate normal regressions were conducted on the questions concerning satisfaction with care, but not for the question concerning overall satisfaction. The general question on treatment by staff was followed by nine yes/no questions concerning specific negative aspects of treatment by staff; yes is coded 0, no is coded 1 (no is the positive answer). Five dependent variables were constructed using the USS. These were overall satisfaction, treatment by staff, performance of services, contact with staff and sense of security. Overall satisfaction was a single-item variable. For treatment by staff, a summed index was created from the general question and the nine specific questions, ranging from 5 to 13 (theoretically ranging from 0 to 13), mean 12.5. The 10 additional questions were included in a principal component analysis (PCA) with varimax rotation (Jolliffe, 2002; StataCorp., 2021a). A three-factor solution was suitable. The result is presented in Table S1. Based on the three factors obtained from the PCA, three indices, performance of services, contact with staff, sense of security, were created by adding the answers and dividing by the number of questions. Zero-skewness log transformation and z-transformation were used on the variables, except for treatment by staff where 71% had a score of 13, corresponding to best treatment. All variables were skewed. Zero-skewness log transformation was used to obtain variables without skewness, suitable for linear regression (Box & Cox, 1964; StataCorp., 2021b). Z-transformations involve the original variables being subtracted by the mean and divided by the standard deviation to obtain variables with a mean of zero and a standard deviation of 1.0 (Gujarati, 1988). This makes the results for different variables more comparable. Independent variables The SDCS consists of 27 statements concerning the staff's work situation. For each statement, two aspects were investigated: (1) how frequently the situation occurs and (2) how much stress each situation generates. Both aspects are measured on a four-point Likert scale: 1 = never/no stress to 4 = very often/high stress. The level of perceived job strain is calculated by multiplying the response of frequency and stress for each statement, which creates an output between 1 and 16. A higher number indicates a higher perception of job strain (Edberg et al., 2015). The QPS consists of 37 questions with answers ranging from very seldom or never to very often or always (coded 1–5) (Dallner et al., 2000; Lindström et al., 2000; Wännström et al., 2009). In the sample of 219 staff, item non-response was 15–24 for the variables based on the SDCS questions and 2–6 for the QPS questions. Multiple imputations were performed separately for the SDCS variables and the QPS variables. The 27 SDCS statements were categorised into five factors: frustrated empathy (7 items), difficulty understanding and interpreting (7 items), balancing competing needs (5 items), balancing emotional involvement (4 items) and lack of recognition (4 items) (Edberg et al., 2015). Each factor is based on the average of the included items. In addition, all 27 statements were used as a total job strain variable. The statements are presented in Table S2. This method of coding has been used previously by our research group (Fallahpour et al., 2020; Sandberg et al., 2018). There is no pre-defined solution for creating indices from the QPS questions. We have included them in a PCA with varimax rotation, obtaining six factors. Six summed indices based on the average of the included items were constructed based on the result of the PCA (Table S3). These were support from manager, group work climate, sense of mastery, job control, social work environment and positive challenges. One overall variable was constructed from the summed index of all QPS questions, QPS total. For the QPS index, high means good working conditions. QPS total and total job strain were z-transformed. Background information regarding the staff included age, sex, length of employment, having Swedish as mother tongue/not, being care assistants/other occupation, permanent employment/not, working full time/not, education (lower/upper secondary/university) and care education/not. Furthermore, staff self-reported health was assessed using a summed index based on questions about depressive symptoms, sleep disturbances, feeling worried and fatigue (Engström et al., 2006). Averages and proportions were calculated for all these variables within each work unit. The averages and proportions from each work unit have been merged with the information from the persons receiving care from the staff who were working in that unit. Preliminary analyses showed that the work unit characteristic regarding the proportion of participants having a university education had the strongest association with the dependent variables concerning satisfaction with care. This variable is therefore included as a separate control variable. Due to the high correlations between the other work unit characteristics and average psychosocial working conditions (Table S4), a single factor was created with a one-factor solution from a PCA with varimax rotation based on work unit characteristics (except for working conditions and university education). This factor and the proportion having a university education were used as control variables in the last model of the regression analyses. Control variables for the older persons were sex, age, cohabiting/not and health. None had missing information concerning sex and age, and 24 had missing information concerning cohabitation/not. A new variable was created with three categories: cohabiting/not/missing. Health was measured as global self-rated health (nine missing), symptoms of anxiety (12 missing) and mobility (14 missing). Multiple imputations based on multivariate normal regressions were used. A summed index was created from the resulting health variables. Information about the number of HCS hours granted for each older person was obtained from the HCS register. Data analysis All analyses were transformed with STATA version 16. P-values for the descriptive statistics were based on χ2 tests or binary logistic regressions with overall satisfaction low/high as outcome. The dichotomisation into low/high overall satisfaction was based on median split. Due to the skewed distribution, treatment by staff was analysed with ordered logistic regression. After zero skewness log transformation, the single item question on overall satisfaction and the other three indices were non-skewed and analysed with linear regressions. There might be a clustering of good or bad opinions about the care the older persons receive depending on the unit, which might lead to erroneously low standard errors. Cluster-correlated standard errors, based on the 16 work units, have been used to control for this (White Jr., 1980). The results are presented as β-coefficients and p-values. The β-coefficients for treatment by staff are from ordered logistic regressions and cannot be compared to the β-coefficients for other outcomes. The analyses were made in two models. Model 1: No controls but includes interaction between psychosocial working conditions and HCS hours given linear representation. HCS hours were centred at Q3 (the 75th percentile, 146 h/month). Coefficients for the interactions are also presented. The interactions presented in Model 1 show if the association between independent variables regarding psychosocial work environment had a different association with satisfaction with care depending on the number of HCS hours. Since the number of hours was centred at 146 h, the results for the main effect were the estimated association among people receiving 146 HCS hours. Model 2: Interactions with p < 0.050 in Model 1 are included in Model 2. In addition, this was controlled for older person and work unit characteristics as described earlier. Ethical considerations This study was approved by the Regional Ethical Committee, Stockholm, Sweden (Dnr: 2018/449–31/5). Ethical information was provided to all participants (older persons and staff) before they began filling in the questionnaire. By handing in their responses, the participants gave their informed consent. 3 RESULTS Description of samples The characteristics for the two samples (723 older persons and 219 home care staff) are presented in Table 1 and Table 2. In the group of older persons, two-thirds were women and the mean age was 85 years (range 66–104). Each person received, on average, 28 HCS hours/month (range 1–177 hours). Among home care staff, the majority were women (80%) and the mean age was 48 years. The mean length of HCS employment was 13 years and 57% had Swedish as their first language. TABLE 1. Descriptive statistics for the older persons receiving home care services Variable describeda Overall satisfaction (single item) All Low High p-valueb Number of observations 723 370 353 Dependent variables, the older person's satisfaction with care (log variables are z-transformed) Treatment by staffc 12.5 12.2 12.9 <0.001 Performance of services 3.0 2.7 3.2 <0.001 Log performance of services 0 −0.31 0.32 <0.001 Contact with staff 2.9 2.5 3.3 <0.001 Log contact with staff 0 −0.46 0.48 <0.001 Sense of security 3.2 2.8 3.6 <0.001 Log sense of security 0 −0.63 0.66 <0.001 Overall satisfaction (single item) 3.3 2.7 4.0 <0.001 Log overall satisfaction (single item) 0 −0.93 0.97 <0.001 Other characteristics of the older persons Self-reported questionnaire (vs. mixedd) 90% 89% 92% 0.243 Woman 67% 69% 66% 0.403 Age, mean (range 66–104) 85 85 84 0.215 Service hours/month, (range 1–177) 28 30 25 0.039 Cohabiting, Yes 19% 18% 19% No 78% 79% 77% Missing 3% 3% 4% 0.874 Health problems (range 0–10.7) 4.0 4.4 3.7 <0.001 a Mean values, except when % are indicated after the variable. b p-value for difference between low and high. Based on χ2 tests for discrete variables and binary logistic regressions for ordinal variables. c Theoretical range 0–13, observed range 5–13. d Another person assisted the older person with completion of the survey. Bold value indicates p < 0.05. TABLE 2. Descriptive statistics for the home care staff (n = 219) Psychosocial working conditions, SDCS (high is high level of job strain) (theoretical range 1–16) Min Max Mean Frustrated empathy 3.8 5.7 4.7 Difficulties understanding and interpreting 1.9 3.9 3.1 Balancing competing needs 3.6 6.8 5.2 Balancing emotional involvement 2.5 6.8 4.6 Lack of recognition 4.3 8.0 5.3 Total job strain (z-transformed) −0.58 0.82 0 QPS (high is good) (theoretical range 1–5) Support from manager 2.2 3.9 2.9 Work group climate 2.7 4.2 3.5 Sense of mastery 2.4 4.0 3.4 Job control 1.0 3.1 2.4 Social environment at work 2.8 4.2 3.5 Positive challenges 3.5 4.3 4.0 QPS total (z-transformed) −0.72 0.89 0 Other staff characteristics University education 21% Age (min/max/mean) 18 67 48 Woman 80% Swedish as mother tongue 57% Nursing assistant 36% Permanent position 92% Fulltime position 72% Length of employment (years) 0 40 13 Education < upper secondary 17% Care education 85% Note: Based on total sample of staff included in the study. Associations between psychosocial work environment and satisfaction with care Table 3 shows the results of the regression analysis between psychosocial working conditions and satisfaction with care. The results are presented as β-coefficients and p-values. Significant results (p < 0.05) are marked in bold. The general pattern is that better psychosocial working conditions (lower values for job strain, higher values on QPS) were often significantly associated with the outcomes: overall satisfaction (column 1), treatment by staff (column 2) and sense of security (column 5), but not often associated with performance of services (column 3) and contact with staff (column 4). Among the independent variables, the job strain factors frustrated empathy, balancing competing needs, balancing emotional involvement, lack of recognition and total job strain and the QPS variables (see lower half of Table 3) support from manager, work group climate, sense of mastery, job control and QPS total demonstrated associations with the dependent variables overall satisfaction, treatment by staff and sense of security. TABLE 3. The associations between psychosocial working conditions and the older person's satisfaction with home care services Dependent variables Overall satisfaction (single item) Treatment by staff Performance of services Contact with staff Sense of security Independent variables β (p-value)a β (p-value)b β (p-value)a β (p-value)a β (p-value)a Job strain variables from SDCS (high value indicates high level of job strain) Frustrated empathy Model 1 −0.874 (0.002) −1.503 (<0.001) −0.210 (0.327) −0.281 (0.347) −0.745 (0.001) Interactionc −0.070 (0.001) −0.094 (<0.001) −0.020 (0.265) −0.012 (0.558) −0.051 (0.006) Model 2 −0.936 (0.001) −1.781 (0.001) −0.321 (0.288) −0.085 (0.387) −0.120 (0.239) Difficulties understanding and interpreting Model 1 0.105 (0.809) 0.318 (0.783) −0.093 (0.767) 0.885 (0.079) 0.570 (0.253) Interactionc 0.015 (0.629) 0.042 (0.650) 0.003 (0.906) 0.068 (0.061) 0.053 (0.146) Model 2 −0.110 (0.285) −0.194 (0.491) −0.182 (0.017) −0.019 (0.904) −0.115 (0.228) Balancing competing needs Model 1 −0.531 (0.017) −0.373 (0.012) −0.267 (0.117) −0.019 (0.927) −0.360 (0.030) Interactionc −0.033 (0.040) −0.017 (0.083) −0.016 (0.350) 0.005 (0.656) −0.018 (0.100) Model 2 −0.516 (0.004) −0.440 (<0.001) −0.072 (0.301) −0.033 (0.524) −0.099 (0.101) Balancing emotional involvement Model 1 −0.371 (0.064) −1.338 (0.001) −0.176 (0.240) 0.015 (0.937) −0.443 (0.017) Interactionc −0.033 (0.033) −0.077 (0.008) −0.011 (0.483) 0.002 (0.899) 0.029 (0.036) Model 2 −0.528 (0.007) −1.576 (<0.001) −0.085 (0.228) −0.043 (0.499) −0.515 (0.004) Lack of recognition Model 1 −0.454 (0.006) −0.751 (0.009) −0.033 (0.793) 0.020 (0.898) −0.320 (0.034) Interactionc −0.032 (0.010) −0.040 (0.051) 0.002 (0.892) 0.009 (0.389) −0.017 (0.139) Model 2 −0.461 (0.009) −0.289 (0.010) −0.051 (0.371) −0.056 (0.308) −0.081 (0.132) Total job strain Model 1 −0.412 (0.004) −0.777 (<0.001) −0.116 (0.31
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