Factors Affecting Job Satisfaction Among Agency-Employed Home Health Aides

603195HHCXXX10.1177/1084822315603195Home Health Care Management & PracticeYoon et al research-article2015 Original Article Factors Affecting Job Satisfaction Among Agency-Employed Home Health Aides Home Health Care Management & Practice 2016, Vol. 28(1) 57 69 The Author(s) 2015 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: 10.1177/1084822315603195 hhc.sagepub.com Seokwon Yoon, MSW 1, Janice Probst, PhD 1, and Christine DiStefano, PhD 1 Abstract To examine the predictors of job satisfaction by home health aides, we conducted structural equation modeling to identify how the predicting variables directly and indirectly influence job satisfaction by home health aides. A total of 3,274 female home health aides working in home health care industry were selected for this study from the nationally representative sample. Support from organizations and supervisors, and personal support have positive direct effects on the job satisfaction of home health aides. Organizational support and supervisor support have important roles in weakening the negative relationship between job-related stressors and job satisfaction. We conclude that support from organizations and supervisors might improve job satisfaction by home health aides through reducing stress. Keywords home health care, female home health aides, job satisfaction, organizational support, supervisor support, personal support, stressors Introduction Home health care has played an important role in preventing unnecessary hospitalization of older adults and saving on health care costs. 1 In the home health care industry, home health aides generally provide housekeeping, personal care, and other individual assistance to patients, under the supervision of nurses in patients homes. 2 Increasingly, home health care workers and personal aides have supplemented caregiving roles primarily provided by family and friends. 3,4 They also support the demands experienced by family members and informal caregivers in providing care for older adults. These services are reimbursed by Medicare when provided by Medicare-certified and licensed home health agencies. Two policy developments suggest that the market for home health services will continue to expand, along with an aging population. First, although the Affordable Care Act (ACA) did not directly address home health care, provisions allowing for expansion of state Medicaid programs may provide funding for aging and disabled persons who could not previously access this service. State Medicaid programs offer home health services to persons who would otherwise need institutional care. 5 Second, the court judgment in Jimmo v Sebelius ruled that Medicare recipients did not need to show continued improvement to quality for home care services. This ruling clarifies that services can be provided to disabled individuals, even those whose condition will not change. 6 According to the U.S. Bureau of Labor Statistics, in 2013 about 1.9 million workers worked as direct care workers. 7 In 2012, an estimated 875,100 individuals worked as home health aides in a variety of settings. 7 It is projected that the employment of home health aides will grow by 48% between 2010 and 2022. 7 According to two surveys, the National Nursing Assistant Survey and the National Home Health Aides Survey (NHHAS), certified nursing assistants and home health aides show high overall satisfaction with their current jobs. 8 However, research documents high turnover among direct care workers. In 2007, annual turnover among certified nursing assistants (CNAs) in nursing facilities was 66%. 9 Overall, 45% of CNAs and 35% of home health aides report that they are very likely or somewhat likely to leave their current job in the next year. 9,10 Direct care workers provide the majority of hands-on care for older and disabled adults who have chronic conditions. The home health workforce is characterized by low wages, minimum benefits, and unstable employment with irregular work 1 University of South Carolina, Columbia, USA Corresponding Author: Seokwon Yoon, Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, USA. Email: yoon@mailbox.sc.edu

58 Home Health Care Management & Practice 28(1) hours. 2 The care process exposes this workforce, 95% of whom are women, to physical and emotional occupational stress. 10 One study suggests that direct care staff frequently have impaired mental health, due to effort reward imbalance and over commitment. 11 Another study also showed that personal stressors and job-related stressors were the best predictors of female workers outcomes. 12 These factors contribute to low job satisfaction and high turnover of direct care workers. In the home health care industry, home health aides have become an important human resource that can provide information and feedback through effective communication with patients. However, direct care workers high turnover may negatively influence quality of care, and it can affect the continuity of care because of the difficulty new workers have in getting to know the demands and needs of individual patients. 13 Among the factors affecting turnover intention and actual turnover, job satisfaction is a key factor in helping direct care workers decide whether to leave their current jobs. 2 In this situation, home health agencies face significant challenges to retain highly satisfied workers in providing high-quality services. 14 Although the satisfaction of personnel in nursing home and other institutional settings has been studied broadly, 15,16 very few studies have examined home health aides job satisfaction using nationally representative data. One study showed that the number of years used is highly associated with job satisfaction among home health aides. 17 Studies also provide evidence that various sources of stress are important predictors of job dissatisfaction. 4 Previous research suggests that work environment and an organization s supportive culture have cumulatively played important roles in producing high satisfaction with the current job for direct care workers, and high satisfaction can be connected with a low intention to quit their job. 18 The supportive and appropriate management approach would actively work to reduce workers stress and make workers highly satisfied with their jobs in delivering home health care to patients. The purpose of the present study was to determine factors that directly and indirectly affect job satisfaction among home health aides, using a Long-Term Care Stress and Support Model (LTC-SSM). Although some empirical attention has given to job satisfaction of direct care workers, it generally lacks a comprehensive understanding for home health aides because they have focused more on nursing assistants and used fewer variables in their studies. To address the gaps, we examined a series of direct and indirect pathways in predicting employees job satisfaction. Therefore, the current study is designed to expand the existing model to direct care workers in home health agencies using the attitudinal and supervision variables. 4 Methods Data and Population We conducted a cross-sectional analysis of the 2007 NHHAS dataset. Conducted by the National Center for Health Statistics, the NHHAS was first fielded in 1992 and was designed to provide nationally representative information regarding home health aides who work at home health and hospice care agencies. The 2007 NHHAS was part of the National Home and Hospice Care Survey and used a computer-assisted telephone interviewing. This study was exempted from the institutional review board review because it used a secondary dataset. The 2007 NHHAS included responses from 3,377 aides. Analysis was restricted to female respondents (N = 3,274), for two reasons. First, research suggests that male and female nursing staff may respond to work environments differently. 19-21 Second, with only 103 male respondents, gender-based differences would be difficult to detect. Measures Dependent Variable The dependent variable, job satisfaction, was operationalized using responses to the question, Are you satisfied with the following aspects of your current job? Four aspects of the job were pooled for this variable: Challenging work, salary, benefits, and learning new skills were used to measure the aspects of job satisfaction. All items were rated on 4-point Likert scale (0 = extremely dissatisfied, to 3 = extremely satisfied). The sum of the four items was used as the satisfaction score; values ranged from 0 to 12. This measure was found to have good internal consistency (Cronbach s α =.74). Independent Variables The dimensions explored were as follows: personal characteristics, agency characteristics, personal stressors, jobrelated stressors, personal support, organizational support, and supervisor support. As predictive factors, these factors can be conceptualized as stressors when they are not matched well with personal needs and demands. Personal characteristics are theorized to influence personal stressors, organizational support, and job-related stressors. These include age (less than 30, 31-50, 51+ years), marital status (married or living with significant other; separated, widowed, divorced; never married), education, and health status. Agency characteristics include location (metropolitan county, micropolitan county, and small rural county), type of agency (home health agency, hospice agency, and mixed agency), and ownership (for-profit and others including nonprofit), paralleling previous research. 22 Personal stressors refer to personal sources of stress that can carry over to the work setting. In general, financial and family worries are presented as the sources of the personal stress. However, we used child care and family care requirements while home health aides are working because these requirements can be psychological barriers to performing their tasks. We calculated the child care requirement variable with the following variables: (1) the number of children age

Yoon et al 59 17 or younger in the home, (2) whether the home health aide is responsible for the child care, and (3) the requirement of child care while they are working. 4 Family care responsibility is calculated with the following variables: (1) family and friends with a disability or health problem and (2) family problems that cause the worker to miss time from work to care for family. Job-related stressors refer to the stressors that can be produced by performing the caregiving tasks in delivering home health care. In this study, we include patient assignment, communication problems with agency staff, misinformation about patients health, patient communication problems with the agency, and problems with coworkers. The patient assignment variable is operationalized to answer the question, Are you assigned to care for the same patients on most weeks you work, or do the patients you are assigned to change each week you work? Problems with the agency are operationalized using the statements Types of problems or incidents that make your job with the agency difficult or cause you to dislike job. Each variable was dichotomous (0 = no, 1 = yes). Positive support can decrease the negative effects of stressors or demands on job satisfaction. 4,23 Organizational support can be defined as financial and structural or emotional support from organizations that can lead to positive job satisfaction of their workers. We measured supports using the availability of health insurance, training, and benefits offered from agency. The availability of health insurance was measured asking the question, Is health insurance available to you at agency? The variable was dichotomous (0 = no, 1 = yes). Benefit was created with the number of benefits reported by home health aides in each sampled agency. The following benefits were included in lists of benefits provided by the sample agencies: paid sick leave, paid holidays off, paid vacation and personal days off, pensions, extra pay for working on holidays, paid child care, dental care or vision care, paid disability, and paid bonuses. Scores ranged from 0 to 9. Training was measured with home health aides perceptions of all their home health aide training, using the statement, Think about all the home health aide training you have received, including training to become a home health aide and any training you received since you started working in the field. They were then asked to respond to the following question: How well did the home health aides training you received prepared you to perform in different areas of your job? This variable included 11 items that were measured on a 5-point Likert scale (1 = not received, 2 = poor, 3 = fair, 4 = good, 5 = excellent). Aides responded to each training topic such as patient care skills for activities of daily living, talking with patients, discussing patient care with families, organizing work tasks, dementia care, working with patients that act out or are abusive, preventing personal injuries at work, assisting with duties that do not directly involve patients, end of life issues and coping with grief, abuse and neglect issues, and relating to patients of different cultures or ethnicities. In this study, the internal consistency of the perceptions of the training scale was good (Cronbach s α =.87). As the factor to be related to workers attitude toward their job, personal support factors measured aides perceptions of how they were treated by the agency and by patients, as well as their own self confidence. Respect was measured using the statement, I am respected by my agency for my work. The scale for this item ranged from strongly agree (1) to strongly disagree (4). Challenge was measured using the statement, I am involved in challenging work. The scale for this item ranged from strongly agree (1) to strongly disagree (4). Perceived trust by supervisors was measured using the statement, I am trusted to make patient care decisions. The scale for this item ranged from strongly agree (1) to strongly disagree (4). Confidence is suggested by motivationhygiene theory to be related to positive job satisfaction. 24 Confidence was measured using the statement, I am confident in my ability to do my job. Scoring ranged from strongly agree (1) to strongly disagree (4). Supervisor support was derived from four items addressing the supervisor s behavior and attitudes: clear instructions ( My supervisor provides clear instructions when assigning work ), support for career growth ( My supervisor is supportive of progress in my career, such as further training ), recognition of the worker s input ( My supervisor listens to me when I am worried about a patient s care ), and acknowledging good performance ( My supervisor tells me when I am doing a good job ). Responses for all items ranged from strongly agree (1) to strongly disagree (4). In the present study, the supervisor quality scale had good internal consistency (Cronbach s α =.81). Statistical Analysis Descriptive and bivariate analyses controlled for the complex, structured sample of the NHHAS by using appropriate weights. Bivariate analyses used ANOVA to assess the relationships between population characteristics and job satisfaction and between job characteristics and job satisfaction. For multivariate analysis, structural equation modeling (SEM) is recommended for use in analyzing mediation and providing various model fit indices. 25 SEM was conducted to determine the latent relationship between personal background factors, organizational factors, personal and jobrelated stressors, organizational support, supervisor support, personal support, and job satisfaction. In this study, there are eight latent variables that contained observed indicators of each latent variable in the mediation model. For example, the agency variable contained three observed indicators of agency. In the latent variable of personal characteristics, there were three observed indicators of personal characteristics. The latent variable of personal stressors contained two observed indicators, child care requirement and family care

60 Home Health Care Management & Practice 28(1) responsibility. The latent variable of job-related stressors contained five observed indicators: patient assignments, communication problems with staff, problems with the agency, misinformation about patient health, and problems with coworkers. The latent variable of organizational support contained three observed indicators. There were four observed indicators of personal support in the latent variable of support from organization. There were four observed indicators of perceived supervisor support in the latent variable of supervisor quality. In this study, both a direct effect model and an indirect model were tested. For the analysis conducting SEM, this study used LISREL version 8.8. A full SEM was used in examining the causal links between observed variables and latent constructs. Standardized maximum likelihood estimation was used to estimate the model in this analysis. Model fit was investigated with chi-square statistics and it was evaluated using the approach of comparative fit index (CFI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR). RMSEA is a good fit index model that tells us how well the model would fit the population covariance matrix. As a revised form of normed fit index (NFI), we used CFI because it is least affected by sample size. SRMR is also a good fit index model to interpret much more meaningfully than RMR. A cutoff point of CFI over 0.95 was used to indicate a relatively good fit. An RMSEA value of less than 0.06 and an SRMR value below 0.08 were used to indicate a relatively good fit. Results Characteristics of Home Health Aides The majority of home health aides were between 31 and 50 years old (50.63%; see Table 1). The home health aides were mostly white (53.91%). A majority of workers were married or living with a partner (50.71%). The majority of aides were at least high school graduates (45.13%). Only a small proportion of aides (8.36%) reported fair or poor health status. Most aides (71.78%) did not have children at home. Aides primarily worked at agencies that were located in metropolitan counties (83.56%), focused on home health rather than hospice or mixed services (73.80%), and operated for profit (62.84%). Job Characteristics Perceived by Home Health Aides As presented in Table 2, over three quarters of aides (75.39%) had health insurance available from their workplaces. Home health aides received an average of 4.29 benefits from the agency. Home health aides overall perception of training received averaged 4.24, with responses on the 11 items all above the midpoint on the scale (range = 4.17-4.32). With regard to the attitude toward their jobs, the majority of aides (79.25%) felt trusted in their jobs. Moreover, most aides (73.70%) had confidence in their ability to take care of patients. Most aides felt respect from the agency (85.87%), trust (79.25%), confidence in their abilities (73.70%), and challenge (71.31%). Most aides were satisfied with jobs, showing a higher mean score 8.31. Factors Associated With Job Satisfaction We conducted one-way ANOVA using home health aides job satisfaction to determine if there were significant differences in job satisfaction by each independent variable. Table 3 presents the average job satisfaction score of home health aides, by selected personal and agency characteristics. Strong positive relationships were found between job satisfaction and age, marital status, education, and self-rated health status. Aides who classified themselves as black reported lower job satisfaction than those who identified as white, whereas aides of other race did not differ from white aides. Among agency characteristics, geographic location, agency type, and ownership were associated with job satisfaction. Table 4 presents the association between job characteristics and job satisfaction. Among personal stressors, child care requirements and family stress were significantly associated with job satisfaction. As for job-related stressors, problems with agency staff, with agency, and with coworkers, misinformation about patient, and patient assignment were also significantly associated with job satisfaction. Among organizational support indicating financial and structural characteristics, the availability of health insurance, perception of training received, and the benefits received from the agency were positively associated with job satisfaction. Within attitudinal variables that suggest personal support, a perception of being trusted, respect, challenge, and confidence in one s abilities were positively associated with job satisfaction. With regard to perception of supervisory activities, clear instruction, career support, listening to the workers, and telling them when they do a good job were positively related to job satisfaction. SEM Analysis SEM was used to assess the indirect relationships among personal and agency factors and job satisfaction of home health aides, mediated by personal stressors, job-related stressors, organizational support, attitudes that indicate personal support, and supervisor support indicated by the perception of supervisor behaviors. The job satisfaction model based on the literature review is illustrated in Figure 1 and is evaluated on a sample of 3,274. These constructs were determined by a model that was established from a set of theoretical interrelationships linking the suggested by literature reviews. The model fit was relatively good, as indicated by a value of 0.97 for the CFI, 0.069 for the RMSEA,

Yoon et al 61 Table 1. Characteristics of Hospice and Home Health Aides, 2007 NHHAS (N = 3,274). No. of observations Weighted percent SE Personal characteristics Age (years) Younger than 31 421 13.90 1.63 31-50 1,629 50.63 2.47 51 and older 1,224 35.47 1.85 Race White 2,320 53.91 2.47 Black 702 34.07 2.39 Other 252 12.03 1.85 Marital status Married or living with partner 2,025 50.71 2.46 Separated, divorced, and widowed 843 32.95 2.37 Never married 377 16.34 1.87 Education Less than high school 416 15.62 1.91 High school 1,656 45.13 2.44 More than high school 1,175 39.25 2.41 Self-health Fair and poor 247 8.36 1.35 Good 890 28.12 2.22 Very good 1,212 35.35 2.37 Excellent 901 28.17 2.21 Agency characteristics Metro status Metropolitan county 1,245 83.56 0.93 Micropolitan rural county 1,172 10.62 0.75 Small rural county 857 5.82 0.49 Agency type Home health 927 73.80 1.42 Hospice 1,163 12.51 0.65 Mixed 1,184 13.69 1.21 Ownership For-profit 1,000 62.84 2.18 Others 2,274 37.16 2.18 Note. NHHAS = National Home Health Aide Survey. Table 2. Description of Job Characteristics (Structural and Attitudinal; N = 3,274). Weighted percent SE Personal stressors Child care No children in the household 71.78 2.50 Child or children with child care needs 6.46 1.08 Child or children without child care needs 21.76 2.36 Family stress Among those who are caring for family/friend, missed time from work 18.58 3.81 Among those who are caring for family/friend, did not miss time from work 81.42 3.81 Job-related stressors Problems with agency staff Yes 15.09 1.77 No 84.91 1.77 (continued)

62 Home Health Care Management & Practice 28(1) Table 2. (continued) Weighted percent SE Misinformation about patient health Yes 3.40 0.90 No 96.60 0.90 Problems with agency Yes 1.38 0.56 No 98.62 0.56 Problems with coworkers Yes 6.76 1.19 No 93.24 1.19 Patient assignments Same patients 81.93 1.70 Patients change 9.42 1.23 Combination 8.64 1.26 Organizational support (financial and structural) Availability of health insurance Yes 75.39 2.28 No 24.61 2.28 Benefits (range = 0-9) 4.29 0.13 Training 4.24 0.03 Personal support (attitudinal) Respect Strongly agree 85.87 1.68 Somewhat disagree 10.55 1.40 All others 3.58 1.04 Challenge Strongly agree 71.31 2.28 Somewhat disagree 19.83 2.00 All others 8.86 1.47 Trusted (I am trusted to make patient care decisions) Strongly agree 79.25 2.11 Somewhat disagree 14.87 1.78 All others 5.88 1.38 Confidence (I am confident in my ability to do my job) Strongly agree 73.70 2.08 Somewhat agree 18.52 1.79 All others 7.78 1.29 Supervisor support Provides clear instructions Strongly disagree 7.45 1.39 Somewhat disagree 4.87 1.13 Somewhat agree 20.91 1.94 Strongly agree 66.78 2.33 Is support of progress in my career Strongly disagree 3.82 0.95 Somewhat disagree 3.17 0.97 Somewhat agree 15.26 1.66 Strongly agree 77.76 2.01 Listens to me when I am worried about patient care Strongly disagree 6.19 1.18 Somewhat disagree 3.53 0.83 Somewhat agree 21.12 2.12 Strongly agree 69.16 2.33 Tells me when I am going a good job Strongly disagree 3.61 0.94 Somewhat disagree 1.19 0.52 Somewhat agree 18.40 2.04 Strongly agree 76.81 2.18 Dependent variable Job satisfaction (M, SE) (actual score range = 0-12) 8.31 0.12

Yoon et al 63 Table 3. Mean Home Health Aide Job Satisfaction, by Selected Aide and Agency Characteristics, 2007 NHHAS. No. of observations Estimate SE p value Personal characteristics Age (years) <.0001 Younger than 31 421 8.36 0.31 31-50 1,629 8.26 0.17 51 and older 1,224 8.33 0.21 Race <.0001 White 2,320 2.38 0.04 Black 702 2.29 0.06 Other 252 2.35 0.13 Marital status <.0001 Married or living with partner 2,025 8.28 0.17 Separated, divorced, and widowed 843 8.45 0.22 Never married 377 8.10 0.31 Education <.0001 Less than high school 416 8.45 0.30 High school 1,656 8.30 0.18 More than high school 1,175 8.25 0.20 Self-health <.0001 Fair and poor 247 7.53 0.38 Good 890 8.20 0.20 Very good 1,212 8.38 0.19 Excellent 901 8.54 0.28 Agency characteristics Metro status Metropolitan 1,245 8.27 0.14 <.0001 Micropolitan 1,172 8.49 0.17 Small rural 857 8.43 0.27 Agency type <.0001 Home health 927 8.09 0.16 Hospice 1,163 9.32 0.11 Mixed 1,184 8.52 0.25 Ownership status <.0001 For-profit 1,000 7.96 0.17 Others 2,274 8.89 0.15 Note. Conducted ANOVA. NHHAS = National Home Health Aide Survey. *p <.05. **p <.01. ***p <.001. Table 4. Mean Home Health Aide Job Satisfaction, by Structural and Attitudinal Job Elements, 2007 NHHAS. Estimate SE p value Personal stressors Child care <.0001 No children in the household 8.32 0.16 Child or children with child care needs 8.20 0.36 Child or children without child care needs 7.94 0.36 Family stress <.0001 Missed time from work 7.45 0.56 Did not miss time from work 8.29 0.30 Job-related stressors Problems with agency staff 0.04 Yes 7.77 0.29 No 8.40 0.13 (continued)

64 Home Health Care Management & Practice 28(1) Table 4. (continued) Estimate SE p value Misinformation about patient health 0.004 Yes 6.64 0.59 No 8.36 0.12 Problems with agency 0.0002 Yes 5.62 0.73 No 8.34 0.12 Problems with coworkers <.0001 Yes 8.55 0.51 No 8.29 0.13 Patient assignment <.0001 Same patients 8.23 0.14 Patients change 8.56 0.30 Combination 8.83 0.38 Organizational support (financial and structural) Benefits <.001 Training <.001 Availability of health insurance.0002 Yes 8.56 0.15 No 7.56 0.23 Personal support (attitudinal) Respect.0009 Strongly agree 8.47 0.13 Somewhat agree 7.49 0.25 All others 6.73 1.07 Challenge <.0001 Strongly agree 8.76 0.14 Somewhat agree 7.84 0.20 All others 5.69 0.32 Trusted <.001 Strongly agree 8.64 0.13 Somewhat agree 7.67 0.21 All others 5.42 0.45 Confidence <.001 Strongly agree 8.67 0.15 Somewhat agree 7.65 0.21 All others 6.43 0.33 Supervisor support Provides clear instructions <.001 Strongly agree 9.04 0.13 Somewhat agree 7.53 0.24 Somewhat disagree 6.54 0.46 Strongly disagree 5.21 0.36 Is supportive of progress in my career <.001 Strongly agree 8.75 0.14 Somewhat agree 7.40 0.22 Somewhat disagree 5.98 0.56 Strongly disagree 5.36 0.42 Listens to me when I am worried about patient care <.001 Strongly agree 8.72 0.13 Somewhat agree 7.97 0.29 Somewhat disagree 6.75 0.33 Strongly disagree 5.82 0.54 Tells me when I am going a good job <.001 Strongly agree 8.75 0.13 Somewhat agree 7.17 0.26 Somewhat disagree 5.70 0.38 Strongly disagree 5.68 0.53 Note. Conducted ANOVA. NHHAS = National Home Health Aide Survey. *p <.05. **p <.01. ***p <.001.

Yoon et al 65 Personal stressors Personal Characteris cs Organiza onal support Supervisor support Personal support Job sa sfac on Agency Characteris cs Job-related stressors Figure 1. Theoretical model of job satisfaction among home health aides. and 0.069 for the SRMR. Overall, this model showed acceptable model data fit, χ 2 = 4,656.82 (N = 3,274), df = 282, p =.0000. Because they are not influenced by any subsequent variables, personal characteristics such as age and agency characteristics such as profit status are considered exogenous variables and are represented in Figure 2 by the rectangles at the far left of the diagram. Variables influenced by other variables, such as personal stressors, job-related stressors, organizational support, supervisor support, and personal support, are considered endogenous. Directly measured variables are shown as rectangles at the outside of the figure, while latent variables are represented by the central ovals. In the structural components, some direct and indirect effects were found in the analysis. As shown in Figure 2, personal factors were positively associated with organizational support (β =.18, p <.001) and job-related stressors (β =.14, p <.001). Personal factors were negatively associated with personal stressors (β =.49, p <.001). Agency characteristics were positively associated with organizational support (β =.19, p <.001). Personal stressors were positively associated with organizational support (β =.21, p <.001). However, personal stressors were found to be negatively related to supervisor support (β =.27, p <.001). Also, personal stressors were negatively associated with job satisfaction (β =.19, p <.001). Job-related stressors were positively associated with organizational support (β =.16, p <.001). Job-related stressors were found to be negatively related to supervisor support (β =.53, p <.001). Job-related stressors were also negatively associated with job satisfaction (β =.37, p <.001). Organizational support was positively associated with supervisor support (β =.17, p <.001) and personal support (β =.05, p <.001). Organizational support was also positively associated with job satisfaction (β =.28, p <.001). Supervisor support was positively associated with personal support (β =.71, p <.001) and job satisfaction (β =.21, p <.001). Personal support was significantly associated with job satisfaction (β =.26, p <.001). In addition, a number of indirect effects were found for personal stressors, job-related stressors, personal support, supervisor support, and organizational support. It was found that organizational support was an intermediate variable for the indirect association between personal factors and personal support (β =.05, p =.04). Organizational support was also an intermediate variable for the indirect association between personal stressors and personal support (β =.16, p =.002). However, organizational support was an intermediate variable for the indirect association between job-related stressors and personal support (β =.35, p <.001). Organizational support had an indirect effect on personal support through supervisor support (β =.12, p <.001). Personal stressors had an indirect effect on supervisor support through organizational support (β =.08, p =.004). Furthermore, organizational support mediated the relationship between job-related stressors and

66 Home Health Care Management & Practice 28(1) Figure 2. Final model for home health aides job satisfaction (N = 3,274). *p <.05. **p <.01. ***p <.001. supervisor quality indicated by the perception of supervisor quality (β =.41, p <.001). Organizational support mediated the relationship between job-related stressors and job satisfaction (β =.15, p <.001). Supervisor support also mediated the relationship between job-related stressors and job satisfaction (β =.15, p <.001). Organizational support had an indirect effect on job satisfaction through personal support (β =.08, p <.001). Moreover, supervisor support mediated the relationships between organizational support and job satisfaction (β =.08, p <.001). Supervisor support had an indirect effect on job satisfaction through personal support (β =.18, p <.001). Personal stressors, job-related stressors, personal factors, and agency characteristics accounted for 74% of the variance in organizational support. Personal stressors, job-related stressors, and organizational support accounted for 18% of the variance in supervisor support. In other words, personal stressors, job-related stressors, organizational support, personal support, and supervisor support accounted for 22% of the variance in job satisfaction (R 2 =.22, p <.001). We have presented the results of both direct and indirect models in Figure 2. Discussion and Implications The present study identified potential predictors associated with job satisfaction among female home health aides working in the home health care industry. We found that organizational support and having a positive perception of the tasks performed were important predictors of job satisfaction among direct care workers. This study shows that the perception of supervisor behaviors and organizational support positively affects the perception of home health aides job at an agency, which in turn, leads to greater job satisfaction among female home health aides. Similar results were found in the previous research on the predictors of job satisfaction among direct care workers. 26,27 In general, the respondents in this study were satisfied with their jobs. Consistent with previous studies, the availability of health insurance, training, and benefits provided by their agencies were important predictors of job satisfaction among direct care workers. 4,28,29 The current study also showed the negative influence of personal stressors and jobrelated stressors on job satisfaction. Consistent with the current literature, it is understandable that home health aides who experience worries about family and problems while at work have lower level of job satisfaction. 12 The present study, based on a nationally representative sample of female home health aides, shows that the majority of home health aides were of white race/ethnicity in 2007, expressing high job satisfaction. As an agency-directed model of care, our study focused on workers within Medicare/Medicaid certified

Yoon et al 67 agencies and state licensed agencies. Other studies examining skilled nursing care and home care workers, not using nationally representative data, have explored the perspectives of black and Hispanic aides. 27,28 These studies found that Hispanics and African Americans report less job satisfaction as a result of physical demands and emotional suppression. Minority workers may have more stress from their personal situation and working conditions that can lead to job dissatisfaction. The present study supports that personal support, measured by being respected, being involved in challenging work, being trusted, and being confident in one s ability, was significantly related to both support job satisfaction and supervisor quality job satisfaction. Furthermore, organizational support, operationalized as the availability of health insurance; benefits received from the agency; and the perception of job training were related to job satisfaction both directly and through influence on supervisor behaviors. These findings are in accordance with the current literature that supervisor support plays a mediating role between organizational support and workers job satisfaction. 23,28 Support from organizations and supervisor quality are important factors for workers to have positive feeling for being rewarded and trusted by the agency that can lead to job satisfaction. The findings indicate that workplaces providing more support for their workers lead to positive employee perceptions of supervisor behaviors and can have positive effects on perceptions of their jobs, which in turn increase the job satisfaction of home health aides. For stressors effects, we found that having positive feelings about organizational support may weaken the negative relationship between personal stressors and the perception of supervisor behaviors. Also, organizational support plays a role in weakening the negative relationship between personal stressors and workers job satisfaction. In addition, organizational support and supervisor support also have important roles in weakening the negative relationship between jobrelated stressors and job satisfaction. The study findings indicate that a supportive environment from the agency contributes to higher job satisfaction among home health aides. In particular, support from organizations and supervisor quality were found to be directly or indirectly associated with job satisfaction among home health aides in the home health care industry. The workforce provision of the 2010 ACA emphasizes that training is very important to expand direct care workers scope of practice for taking care of complex health needs of older adults. 30 This study also suggests that training is crucial to help direct care workers to make the right decisions for patients and to advance their careers, to have effective communication skills with other team members in their organization, to develop problemsolving skills, and to evaluate patients conditions. 26 In addition, managers can develop interventions for workers to reduce stressors and build strategies to reduce problems with other workers in agencies through sharing information about patient health and being responsive to the workers needs to improve job satisfaction. 16,31,32 Organizational management that focuses on reducing staff turnover and increasing job satisfaction can be supported by moving toward supportive leadership. In general, the bureaucratic structure of health care organizations may have an influence on reducing workers creativity and disempowering workers decisions. 33 Supervisors who are supportive of employees gain a greater commitment from their workers, which can lead to higher job satisfaction. Supportive leadership can create significant financial benefits for health care organizations by reducing costs spent on the recruitment and the retention of professionals because the direct care workforce shortage can be directly associated with the high burden and high turnover of professionals. In addition, recognition of the ideas of home health aides as a direct care workforce is essential for making organizations healthy through building trust, respect, providing challenging work, and encouraging confidence. With the implementation of ACA, workforce environments should be changed to support direct care workers to encourage them to be involved in the care process. 30 The strategies should help to build supportive leadership by providing training and financial support such as health insurance. The findings of this study suggest that access to well-prepared paraprofessionals is necessary to meet the predicted demands from improving access to care under the ACA provision. The research presented here has several limitations. First, the study sample included only female aides, and thus, results are not generalizable to male staff. Second, only aides employed by home health or hospice agencies were studied; privately hired workers were not included. Finally, study data were collected in 2007; since that time, the demographic composition of the home health care workforce may have changed in ways that may also affect perceptions of supervision. However, the large and nationally representative sample of aides reached by the NHHAS provides advantages over smaller, less generalizable samples when studying managerial issues that may not be detected in smaller settings. Conclusion With the increasing demand for home health care, strategies for effectively managing the direct health care workforce are essential. Despite their importance, home health aides generally receive less organizational support than other professionals. Two major implications are suggested by the present findings. Given the importance of the organization support variable, home and hospice care agencies should demonstrate their support for workers by providing health insurance as an option for workers and by investing in highquality training that relates directly to the challenges of the workplace. Furthermore, the study results emphasize the importance of workers positive perceptions of the job they perform at an agency in moderating the relation between

68 Home Health Care Management & Practice 28(1) organizational support and job satisfaction and between supervisor behaviors and job satisfaction. Developing relevant factors to identify supervisor behaviors within an organization and building supportive leadership in home health care agencies may have considerable significance in direct care workers research and practice. Furthermore, it is important to develop appropriate interventions and supportive programs to reduce workers stress in the process of performing the home health aides tasks. These findings justify further study of effective management for direct care workers in health care organizations, including home health agencies. They also justify systematic examination of which factors most critically affect workers outcomes, such as job satisfaction, turnover, and motivation. 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