Janette S. Dill

The quality of healthcare jobs: can intrinsic rewards compensate for low extrinsic rewards?

Frontline healthcare worker jobs are among the fastest growing occupations in the USA. While many of these are ‘bad jobs’ with low pay and few benefits, the intrinsic nature of frontline work can also be very rewarding. This article examines the influence of extrinsic job characteristics (e.g. wages and benefits) versus intrinsic characteristics (e.g. meaningful tasks) on job satisfaction and intent to stay with one’s current employer. This article uses a mixed-methods approach, drawing on survey data collected from frontline workers and organizations in a variety of healthcare settings, as well as interview and focus group data from frontline workers to contextualize and interpret the findings in the multi-level models. The results indicate that both intrinsic and extrinsic characteristics are significant predictors of job satisfaction, but only extrinsic characteristics help explain intent to stay with the employer.

A Configurational Approach to the Relationship between High‐Performance Work Practices and Frontline Health Care Worker Outcomes

OBJECTIVE To identify high-performance work practices (HPWP) associated with high frontline health care worker (FLW) job satisfaction and perceived quality of care. METHODS Cross-sectional survey data from 661 FLWs in 13 large health care employers were collected between 2007 and 2008 and analyzed using both regression and fuzzy-set qualitative comparative analysis. PRINCIPAL FINDINGS Supervisor support and team-based work practices were identified as necessary for high job satisfaction and high quality of care but not sufficient to achieve these outcomes unless implemented in tandem with other HPWP. Several configurations of HPWP were associated with either high job satisfaction or high quality of care. However, only one configuration of HPWP was sufficient for both: the combination of supervisor support, performance-based incentives, team-based work, and flexible work. These findings were consistent even after controlling for FLW demographics and employer type. Additional research is needed to clarify whether HPWP have differential effects on quality of care in direct care versus administrative workers. CONCLUSIONS High-performance work practices that integrate FLWs in health care teams and provide FLWs with opportunities for participative decision making can positively influence job satisfaction and perceived quality of care, but only when implemented as bundles of complementary policies and practices.

Caregiving in a Patient’s Place of Residence: Turnover of Direct Care Workers in Home Care and Hospice Agencies

Objectives: High turnover and staff shortages among home care and hospice workers may compromise the quality and availability of in-home care. This study explores turnover rates of direct care workers for home care and hospice agencies. Methods: OLS (ordinary least square) regression models are run using organizational data from 93 home care agencies and 29 hospice agencies in North Carolina. Results: Home care agencies have higher total turnover rates than hospice agencies, but profit status may be an important covariate. Higher unemployment rates are associated with lower voluntary turnover. Agencies that do not offer health benefits experience higher involuntary turnover. Conclusion: Differences in turnover between hospice and home health agencies suggest that organizational characteristics of hospice care contribute to lower turnover rates. However, the variation in turnover rates is not fully explained by the proposed multivariate models. Future research should explore individual and structural-level variables that affect voluntary and involuntary turnover in these settings.

Strengthening the Long-Term Care Workforce: The Influence of the WIN A STEP UP Workplace Intervention on the Turnover of Direct Care Workers

Given high rates of turnover among direct care workers in long-term care settings, it is important to identify factors affecting organizational-level turnover rates. In this study, the authors examine the impact of a workforce intervention program (Workforce Improvement for Nursing Assistants: Supporting Training, Education, and Payment for Upgrading Performance [WIN A STEP UP]) on turnover rates of direct care workers in nursing homes. Using data collected yearly between 2002 and 2006 from 405 nursing homes in North Carolina, the authors employ random effects modeling to predict a dichotomous outcome of “above-average” versus “below-average” turnover. Results indicate that nursing homes participating in the WIN A STEP UP program are 15% more likely to have below-average turnover than are nonparticipating nursing homes. Organizational factors such as ownership type and Medicaid participation also influenced turnover, whereas labor market factors had no independent effects. The results suggest that workforce development projects that increase the training of direct care workers and provide associated rewards show some potential to lower turnover rates of the direct care workforce.

Does the “Glass Escalator” Compensate for the Devaluation of Care Work Occupations? The Careers of Men in Low- and Middle-Skill Health Care Jobs

Feminized care work occupations have traditionally paid lower wages compared to non–care work occupations when controlling for human capital. However, when men enter feminized occupations, they often experience a “glass escalator,” leading to higher wages and career mobility as compared to their female counterparts. In this study, we examine whether men experience a “wage penalty” for performing care work in today’s economy, or whether the glass escalator helps to mitigate the devaluation of care work occupations. Using data from the Survey of Income and Program Participation for the years 1996-2011, we examine the career patterns of low- and middle-skill men in health care occupations. We found that men in occupations that provide the most hands-on direct care did experience lower earnings compared to men in other occupations after controlling for demographic characteristics. However, men in more technical allied health occupations did not have significantly lower earnings, suggesting that these occupations may be part of the glass escalator for men in the health care sector. Minority men were significantly more likely than white men to be in direct care occupations, but not in frontline allied health occupations. Male direct care workers were less likely to transition to unemployment compared to men in other occupations.

Mobility for care workers: Job changes and wages for nurse aides

The long-term care industry in the United States faces serious recruitment and retention problems among nurse aides. At the same time, these low-wage workers may feel trapped in poorly-paid jobs from which they would do well to leave. Despite this tension, not enough is known about how workers fare when they leave (or stay in) such care work. Using longitudinal data from the Survey of Income and Program Participation for the years 1996-2003, we examine the relationship between different job and occupational mobility patterns and wage outcomes for nurse aides, focusing on which job transitions offer better opportunities to earn higher wages and on whether job transition patterns differ by race. Our results confirm high turnover among nurse aides, with 73 percent of the sample working in occupations other than nurse aide at some point during the survey time frame. About half of respondents that transition out of nurse aide work move into higher-paying occupations, although the percentage of transitions to higher paying occupations drops to 35 percent when nurse aides that become RNs are excluded. Among black workers especially, wage penalties for moving into other jobs in the low-wage labor market appear to be rather small, likely a factor in high turnover among nurse aides. The findings illustrate the importance of occupation-specific mobility trajectories and their outcomes for different groups of workers, and for understanding the constrained decisions these workers make.

Employability among low-skill workers: Organizational expectations and practices in the US health care sector:

In today’s unstable and uncertain economy, middle-class and professional workers are expected to participate in employability activities, such as ongoing higher education and obtaining additional credentials. These activities are expected by employers, protect workers against layoff, and help to advance workers’ careers. In this article, we argue that the expectations of employability are increasingly being placed on lower-level workers by their employers, in partnership with educational institutions. We draw on 20 case studies of career development programs in a variety of health care settings across the United States. We found that through the development (and requirement) of credentials and partnerships with educational institutions, employers encouraged low-level employees to be continually considering their employability and career pathways. However, while the career development programs in our sample use many of the same employability practices seen among middle-class and professional workers, there were often minimal financial or educational rewards for low-level workers. Career programs that focused on established credentials (e.g. surgical technicians, registered nurses), though, were able to provide substantial upward social mobility for workers.