Table 5. Voices of Frontline Staff page 1 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Identify areas of satisfaction for NAs with high versus low job satisfaction

Utah
6 rural and urban nursing homes
1138 NAs,
33RNs,
41 LPNs
In-house surveys, 21 items with Likert response set

Top areas of satisfaction of NAs
(range of 1 to 5, mean scores reported

Satisfaction Areas	High Sat. NAs	Low Sat. NAs
enjoy helping people	4.72	4.42
job fits w/future plans	4.57	3.12
supervisor helps out sat.	4.35	3.38
plan to be in LTC years	4.17	2.92
good job for education	4.14	3.23
pleasant co-workers	4.00	3.67
job viewed as short-term	3.94	2.96
affirmed by co-workers	3.86	3.14
pay is satisfactory	2.52	2.04

Anderson, Aird, & Haslem, 1991

Determine factors important to NA job satisfaction

Midwestern states
24 nursing homes
283 nursing assistants
Survey: Hackman and Oldham's Job Diagnostic Survey

Factors important to job satisfaction
(significant correlations at p ≤ .05)
Personal growth & development
Job security
Job challenge
Fair treatment & respect (p ≤ 0.1)

Atchison, 1998

Table 5. Voices of Frontline Staff Page 2 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Determine why NA turnover rate is so high and what can be done to make work more appealing. Determine relationships among attitudes.	Madison, Wisconsin 1 home care agency 30 working NAs and 26 former NAs Mail or in person survey -Attitude To Disabled Persons(ATDP) -Gordon Personality Profile -Gordon Personality Inventory -Likes, dislikes & reasons for leaving	Like best=able help others 38% Like least=low salary 27% lack benefits 18% Reasons for quitting: Change in school schedule 23% Client died/need more hours 20% Ways Job could be improved: Fringe benefits, days off, paid vacation, paid sick days Recommendations: Support Groups, 86% Training, 65% Train disabled, 70%	Atkins, Meyer, & Smith, 1982
Identify NA attitudes compared to nurses regarding elderly & care	Cleveland, Ohio 7 nursing homes 239 NAs, 62 LPNs & 62 RNs In-house survey: -Attitudes toward seniors -Preference for custodial vs. therapeutic treatment -Empathy Ability	Compared to nurses, NAs had lowest empathy levels, highest custodial orientation and most negative attitude toward old people. Relationships of attitudes: - more negative attitude=lower empathy - higher custodial orientation=greater negativism & lower empathy	Bagshaw & Adams, 1986

Table 5. Voices of Frontline Staff Page 3 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Examine aspects of work stress, signs of burnout & job satisfaction among home care hospice staff

Sweden
One hospice home care agency
21 NAs,
9 RNs
& 5 MDs
Self-administered questionnaire, 219 closed-ended questions with 4 & 5 point response sets

Daily stress often to very often:
Demands from relatives 17%
Confusing orders 15%
Lack info for job 15%
Job satisfaction often to very often

	Current	Desired
Is meaningful	89%	97%*
Works without supervision	86%	60%*
Opportunity for social contact	77%	43%*

(*significant difference, < 0.01)
RNs and MDs, as compared to NAs, more often felt their work gave them new skills and was varied and stimulating

Beck-Friis, et al., 1991

Explore views of staffing and quality

USA
4 nursing homes
38 NAs
In-depth interviews and participant observations over 2 years

NAs defined quality as a good relationships that leads to trust, respect and affections
Records did not reflect reality of tasks
Staffing impacted greatly ability to provide quality care

Bowers, Esmond, & Jacobson, 2000

Table 5. Voices of Frontline Staff Page 4 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Analyze NAs' job perceptions compared to other LTC nursing staff

Pennsylvania
21 nursing homes
388 nurse's aides
101 LPNs
In-house surveys, using Hackman & Oldham's Job Diagnostic Survey (JDS)

Mean Scores (1-5 range)

Job Characteristics
	All Jobs	Aides	LPNs
Skill variety	4.5	4.3	5.2
Task identity	4.6	5.1	4.8
Task sign.	5.5	6.2	6.6
Autonomy	4.8	4.8	5.4
Job Feedback	4.8	4.9	5.1
Feedback Others	4.1	4.1	4.4
MPS	122	157	128
MPS = is motivational potential score
Job Satisfaction Areas
Pay	4.2	3.8	4.2
Security	4.8	4.6	4.8
Co-workers	5.3	6.0	5.9
Supervisory	4.8	5.0	5.0

Brannon, et al., 1988

Table 5. Voices of Frontline Staff Page 5 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Identify how specific managerial practices support NA job satisfaction

Cincinnati metropolitan area
3 home care agencies
42 home care attendants
In-house surveys
Michigan Organizational Assessment Questionnaire (MOAQ) revised components,
Leadership support,
Mission implementation,
In-service Style
Job satisfaction - intrinsic factors from Feldman's study

52% of intrinsic job satisfaction variance explained by supportive leadership practices, client-centered in-service training style, and mission implementation.

Hierarchical Regression Results
(R² = 0.52)
Personal Characteristics
Education, age, job tenure	.063
Managerial Practices
Client centered in-services	.223**
Supportive leadership	.392***
Mission implementation	.515***

Buelow, Winburn, & Hutcherson, 1999

Gain insight into the experience of quality care for seniors

Central Texas
4 nursing homes
30 NAs in 4 focus groups
Focus groups with structured questions
-NAs definition of quality
-management's facilitation
-visitors' considered quality care

Most were highly committed to quality care for their residents.

Gave managers suggestions to show their commitment to quality

Burke, Summers, & Thompson, 2001

Table 5. Voices of Frontline Staff Page 6 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Identify job satisfiers for excellent NAs
Determine whether reasons for beginning NA work are same as reasons for remaining in jobs

North Carolina
3 nursing homes
30 excellent NAs selected by DON
In-person interviews, open-ended questions

Most Satisfying Aspect of Work
98% feel needed and useful
53% some aspect of job environment (e.g., co- workers, shift working)
Initial attraction to job
40% pleasure helping older people
40% always wanted to be a nurse
23% needed a job
23% positive role models in family
People who started working because of love of older people, nursing ambition or who had positive role models had same reasons for staying in job.

Bye and Iannone, 1987

To identify the values of NAs.

Southeastern Florida,
12 nursing homes
120 NAs
In-house surveys using modified Rokeach Value Survey (ranked 9 values by their importance)

Values ranked in order of most to least important.

Median Values of NAs
Ambitious	2.5
Helpful	3.4
Cheerful	3.9
Capable	4.2
Independent	4.7
Self-controlled	5.3
Broad minded	6.1
Logical	6.8
Imaginative	7.6

Carter, Kooperman & Clare, 1988

Determine relationship between turnover of NAs and Maslow's basic human needs

Washington
74 nursing homes (both rural & urban, profit & nonprofit)
996 NAs
Mail survey
Variables:
Job tenure (LOS) in one state
- 56 items with rankings according to Maslow's needs

Maslow's levels related to job tenure
First: Physiological
Salary, % salary spent on food and shelter, ratio of staff-patient assignment
Second: Safety & Security
Assignments changed less often, health insurance, retirement plan, received CPR in orientation
Third: Love & Belonging
Felt needed by patient, felt part of "group," charge nurse who listened
Fourth: Self esteem
Allowed to criticize, free to make decisions, self rank skills high
NAs stayed twice as long when felt working in a quality facility versus in poor quality facility

Caudill & Patrick, 1989

Table 5. Voices of Frontline Staff Page 7 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Identify factors which may influence plans to leave nursing home employment

Washington
74 nursing homes (both rural & urban, profit & nonprofit)
996 NAs
Mail survey
- 56 item questionnaire

Plan to...	Stay	Leave
n =	817	179
Mean age	35	28
Mean stay, months	37	20
Hourly rate of pay	$4.97	4.63
Plan stay in nursing	89%	11%
First job in nursing	81%	9%
Skill level (10=perfect)	8	7
# of in-services/year	7	6
Attend care conf.	81%	19%
Free to criticize	81%	19%
Did criticize	81%	19%
Attend in-services	82%	18%
Responds to suggestions	83%	16%

Caudill & Patrick, 1991-1992

Assess the attitudes of nursing staff toward the elderly

Mississippi
2 nursing homes
70 NAs, 10 RNs, 21 LPNs
In-house survey
Palmore's FAQ #2
Kogan's Attitudes toward Old People Scale, 17 questions using Likert response scale

Neutral = 3-4
Palmore's FAQ #2 average = -13, which is more significantly more positive than national average of -19
Kogan's OP Scale average= 3.45, which falls within the range for neutral attitude toward old people (3-4)
Of the 3 groups, the NAs were the least positive, but within the neutral range.

Chandler, Rachal, & Kazelskis, 1986

Table 5. Voices of Frontline Staff Page 8 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Examine nursing assistants in the home care industry	New York City 9 home care agencies 306 home attendants 181 home health aides 2 hour interviews in assistants' homes in English, Spanish or Creole Follow-up group interviews	Negative behaviors experienced: 40% expected to do things not part of the job - many to several times 20% difficulty with clients & drug or alcohol abuse Family Relations 14% families ask them to do things not part of job Worker-Client Relationships 88% clients accept and trust them 85% can frequently do a favor for their clients that makes them happy 77% frequently able to spot problems beforehand	Chichin, 1991a
Determine if home assistants who live with their clients around the clock are any different from home care assistants who do not live with their clients	New York City 7 home care agencies 306 home attendants, 44 live-in and 262 daily attendants random sample from home care agencies	Many similarities between two groups of workers, few differences Similarities - very low-income, immigrant women - low measures of job related strain and high measures of job satisfaction Differences with Live-ins - more likely to be widowed, older - more likely to develop close relationships - most important tasks were emotional support versus household tasks	Chichin, 1991

Table 5. Voices of Frontline Staff Page 9 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Identify interactions between home care assistants and clients.	New York City 9 home care agencies 306 home attendants 181 home health aides 2 hour interviews in assistants' homes in English, Spanish or Creole follow-up group interviews 124 questions, single items and standardized scales.	Worker-Client Interactions Occur Frequently Clients accept & trust me 88% Clients make me feel needed 86% Spot problems before serious 77% Family-worker relationships Good quality of relationship 73% Very often knows families 51% Often cares re: workers' feelings 43% Neg. family behaviors Not available when needed 17% Ask to do things not part of job 14% Don't seem to care for elder 9% Worked extra hours without pay 33% Get sense of accomplishment from work 95%	Chichin, E., 1992
Evaluate recruitment, job satisfaction & retention factors	Midwestern state Home care agency from national corporation 57 NAs Focus groups and survey closed and open ended questions regarding sociodemographic characteristics, job satisfaction and recruitment methods	Common Recruitment Methods Word of mouth 53% Newspaper ads 40% Primary reasons for choosing home care: one-on-one patient care & flexibility Mod -Very Imp. Retention Factors Job satisfaction, flexible hours, working conditions, type of nursing and availability of job Slightly Mod - Imp. Retention Factors Salary, job location, job status, company policies, recognition, educational opportunity orientation program, weekend hours, career growth, bonus Lowest dimensions of job satisfaction: - nurse interaction, autonomy & professional status	deSavorgnani Haring & Davis, 1992

Table 5. Voices of Frontline Staff Page 10 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Examine home care NA attitudes and characteristics which influence job satisfaction

Missouri
15 home care agencies
345 home care aides
mail survey
Variables:
- Oberleder attitude scale re: age stereotyping;
- Rosenberg self esteem scale;
- Housekeeping knowledge;
- Job satisfaction;
- Quality of training

	Mean	Range
Job satisfaction	4.78	1-6
Housework	9	2-12
Quality of training	3	1-4
Self-esteem	7	1-8
Age Stereotyping	10	4-16

Regression model revealed self esteem and marital status accounted for 6.2% of explained variance in job satisfaction, no attitude variables
Younger NAs and those with longer work weeks had more stereotypes

Dillard & Feather, 1991

Table 5. Voices of Frontline Staff Page 11 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
To develop a descriptive profile of homemakers and understand work stress of homemakers	New York City 75 home care agencies 404 workers (70% black, 26% Latino, 45% foreign born) In-person 2 hour interviews Variables: - Overall Work Stress Scale - Job vs. home Conflict - Role Conflict - Responsibility - Quality concerns - Psychological distress (Langer) - Job sat. - 1 scale question	Job Satisfaction Levels: 33% very satisfied 52% somewhat satisfied 13% not satisfied at all Worker Autonomy 81% report setting own pace 76% free to decide how to do work Negative working conditions low pay 96% poor fringe benefits 88% no chance for promotion 82% no influence re policies 79% Positive job characteristics Jobs are important to health care 96% see results of their work 95% skill & experience needed 94% value their work 87% Stress Factors rated Sometimes- Often Workload Require work very fast 62% Require work very hard 66% Supervisory Support rely on when things tough 84% will listen to job problems 76% helpful in getting job done 72% Correlation of work stress & job satis = -.21*** Using Langer's psychological distress scale, 53% of NAs had significant symptoms compared with 32% of general population	Donovan, 1989

Table 5. Voices of Frontline Staff Page 12 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Examine nursing home staff stress, psychological well-being, relaxation behavior and coping skills.	Manchester and Redditch, England 11 nursing homes 112 nursing staff, 67% were NAs; mail survey 7 measures in questionnaire: demographics, stressor check-list type A / B behavior, job satisfaction, psychological well-being, relaxation behavior, coping check-list	Greatest Causes of Staff Stress: - Unsatisfactory wages - Shortage of essential resources - Staff shortage per shift - Feeling undervalued by management - Lifting heavy patients - Working with colleagues who are happy to let others do the work Significant multi-item factors contributed to stress variance: - Differing expectations about resident care 29% - Management Factors 7% - Lack support of other staff 5% - Feel inadequately trained 4% - Home-work conflicts 4% Moderately satisfied with jobs, found management factors, lack of support from co-workers and inadequate training significantly correlated Most frequent method of relaxing was drinking coffee, cola or eating. 91% smokers, number drinking daily twice rate of general population	Dunn et al., 1994
Identify qualities needed in outstanding home care assistants.	New York City 1 home care agency 6 homecare assistants with outstanding job performance open ended questions	3 qualities key to working successfully: - patience, compassion and respect Greatest satisfaction from seeing clients improve and their close relationships Difficult situations viewed as challenges & took pride in overcoming	Ebenstein, 1998

Table 5. Voices of Frontline Staff Page 13 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Identify levels and components of job satisfaction among NAs in PACE and Nursing homes

US, nationally dispersed
5 PACE agencies
(136 NAs)
5 traditional nursing homes
(213 NAs)
1 hour survey w/Job description questions
Reality Check indicators
Job satisfaction
- Minnesota Satisfaction Questionnaire
- Myers Briggs Personality type Indicators

Job satisfaction was significantly higher among PACE NAs

	PACE	Nursing Home
Mean sat. score	4.12	3.83
Turnover rate	30%	58%

Regression model (R²=.21)
Positive variables, order of significance:
Frequency respect for suggestions
Importance of ongoing in-services
Frequency of chance to organize work
Age
Work in PACE program
Negative influences=
Frequency to discuss patients w/team
Regular experience w/elderly as child
Note: higher job satisfaction related to work environment, not NA characteristics

Friedman, et al., 1999

Analyze NA turnover with exit interviews

Southern region of U.S.A.
1 nursing home
35 resigned NAs
Exit interviews; 22 closed and open ended questions

Majority of NAs terminated during first 45 days of employment

Reasons for termination
Another position	24%
Personal/staff conflict	24%
Wages	13%
Other	38%

Satisfaction	Poo Good	Fair- Avg.	Excel
Supervisor concerned	34%	17%	50%
Good work recognized	47%	31%	22%
Communication	36%	21%	42%

Gaddy & Bechtel, 1995

Table 5. Voices of Frontline Staff Page 14 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Examine reasons NAs left jobs

Massachusetts
15 home care agencies
66 resigned NAs
Mail survey
Closed & open-ended questions

Reasons for Resignations
Working conditions	45%
Poor Salary	39%
Lack of Benefits	30%
Lack of Recognition	35%
Burnout	21%

Specific Working Conditions
Instability of work hours	39%
Emotional strain of job	31%
Lack input in care plans	25%
No time to complete tasks	23%
Lack of professional advancement	21%

Gilbert, 1991

Determine NA attitudes towards a variety of work aspects

Determine the extent to which attitudes are related to institutional loyalty

New York City
2 nursing homes (unionized staff with turnover rates < 20% & competitive benefits)
219 NAs
In-house survey:
Institutional Loyalty (Porter, commitment scale)
Job Satisfaction,
Organizational Attitude Scales

Hierarchical Regression Analysis:	R²
Sociodemographics	0.16
Morale & social support	0.17
Job satisfaction var.:	0.38

Social atmosphere *
Job tasks
Job benefits *
Job process
Administration *
The largest proportion of loyalty accounted for by these 3 variables

Grau, et al., 1991

Table 5. Voices of Frontline Staff Page 15 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Evaluate the level of satisfaction among NAs in a depressed urban area and affluent suburb Evaluate satisfaction levels with prior study of nursing home aides	St. Louis 2 nursing homes, one in affluent area & one in depressed area Survey with Minnesota satisfaction Questionnaire (MSQ), 20 items with Likert response set	No difference between intrinsic or total satisfaction scores. Extrinsic satisfaction: less dissatisfaction with urban home vs. suburb Lowest satisfaction areas - pay & amount of work, chances for advancement, praise for good job, way policies put into effect, working conditions, way employer handles people Highest satisfaction areas - to do things for other people, to do things that use my abilities, to do things that agree with conscience, able to keep busy, feeling of accomplishment	Grieshaber, Parker, & Deering, 1995
Identify burnout attitudes of nursing assistants Identify differences in NA working in nursing homes versus hospitals	Pacific Northwest 3 hospitals, 10 NAs 7 nursing homes, 96 NAs Mail survey Maslach Burnout Inventory includes scales of emotional exhaustion, deperson- alization & personal accomplishment.	CNAs experienced moderate levels of burnout in emotional exhaustion & depersonalization, not in personal accomplishments No significant differences were found between NAs working in nursing homes versus hospitals	Hare & Pratt, 1988

Table 5. Voices of Frontline Staff Page 16 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Identify NA descriptions of their care	Urban Southern area 3 nursing homes 8 NAs identified by charge nurses as experts 2 question interviews: How do you contribute to resident care? Describe the different types of care you give	Three themes emerged: Functional care activities - "major contribution" to overall health. ADLs and IADLS Psychosocial care - to maintain or promote resident emotional and mental health Delegated care - by the licensed nurse to assess resident status and changes in physical state.	Hartig, 1998
Identify home care assistants' characteristics and conditions	Washington state 16 home care agencies providing publicly funded social services 1900 NAs Mail survey	Home Care Worker Characteristics 92% paid minimum amount stipulated for state vendors 29% worked 31-40 hours/ week; 89% worked more than 41 hours/week, didn't get overtime 43% had no insurance, pension, sick leave, holiday or vacation 73% not paid for travel time to client homes Training topics desired: Personal care skills, Infection control Communication skills, Nutrition info. Lifting & transfer skills, Cleaning, CPR & first aid 26% reported harassment or abuse (primarily verbal)	Hayashi, Gibson, & Weatherley, 1994

Table 5. Voices of Frontline Staff Page 17 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Examine respect and attachment of NA & residents

Cleveland
one nursing home
40 NAs & 37 residents
In-person interviews, closed ended questions & open ended questions regarding personal experiences

NA views
87% said they are sensitive and responsive to residents' feelings
NA experiences re: respect
45% faced accusations from residents & families about inadequate care & theft
30% reported verbal abuse & insults from residents.
Perspectives re: attachment
95% NAs expect to be like family

Heiselman & Noelker, 1991

Identify areas of satisfaction and dissatisfaction of NAs to improve nursing home environment

National
36 nursing homes
245 NAs
Job attitude scales, 17 questions with 5 point Likert response set

Areas of Satisfaction
Job is important	91%
Proud to tell about job	66%
Time for residents	53%
Job activities	53%
Have input on care plans	52%

Areas Not Satisfied
Admin/Super respect NAs	71%
Pay	71%
Co-workers with pay	60%
Benefits/working conditions	38%

Helmer, Olson, Heim, 1993

Table 5. Voices of Frontline Staff Page 18 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Investigate how important motivation-
hygiene factors are to NAs employed 12 months or more in nursing homes

Massachusetts
3 nursing homes
31 NAs
In-person interviews, 20 closed ended questions with Likert response set

Rated as extremely important or very important to job satisfaction:
Interpersonal relationships	100%
Supervision	90%
Achievement	90%
Responsibility	90%
Work itself	84%
Salary	77%
Recognition	77%
Adm. Policies	77%
Work Condition	88%

Holtz, 1982

Investigate nursing assistants' training needs

Wisconsin
18 nursing homes & 21 home care agencies
97 NAs
20 questions re: training needs

67% facilities lack training programs

	No	Some	Great
Psychosocial	55%	50%	5%
Physical	80%	18%	2%
Legal	68%	35%	7%

Janz, 1992

Table 5. Voices of Frontline Staff Page 19 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Determine the relationship between staff burnout and resident-staff interactions. Determine the relationship between decision making and resident-staff interactions.	United Kingdom 2 residential care homes 24 residential workers Survey included: - Maslach Burnout Inventory (MBI) - Perceived Involvement in decision making Observations re: Quality of Interactions	Lower overall burnout scores significantly correlated to more staff resident interactions (r=0.52) Higher decision making involvement correlated with fewer negative staff resident interactions (r=0.58) Staff distress, emotional exhaustion & depersonalization not significantly correlated to quality or quantity of staff-resident interactions	Jenkins & Allen, 1998
Determine NA preferences for outcomes as quality indicators of home care	Minneapolis area 6 home care agencies 6 NAs in focus group discussions	Top outcomes expected for . . . Seniors with minimal needs: Abuse free, Prevent nursing home admission Satisfaction with care Seniors with heavy needs: Abuse free Safety Satisfaction with care Seniors with cognitive impairments: Abuse free Safety Prevent morbidity NAs emphasized importance of human element of care, especially the compatibility between NA and client	Kane, et al., 1994

Table 5. Voices of Frontline Staff Page 20 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Determine preferred educational styles & needs: home care NAs / homemakers

New York City
3 home care agencies
67 NAs / homemakers
In-person interviews, rated various educational styles & open ended questions

Top preferred ed. styles (0-4 scale)
On job experience 1.8
Personal experiences 1.4
Classes at school 1.2
Relative Importance of education v experience:
Experience took precedence over education, although both strategies believed necessary.
Situations didn't feel prepared for
- emotionally needy clients
- client dissatisfied with service
- medical or other emergencies
- client dissatisfied w service plan
- physically disabled client

Kaye, 1985

Understand relationships between home care workers and their clients

New York City
3 home care agencies
67 NAs/ home makers
In-person interviews
Variables:
Client & Staff affectivity used 7 questions with Likert responses
& open-ended questions

Clients were perceived to have higher levels of affection for workers than workers for client

	Perceived Client Affectivity	Self Affectivity
Mean	17.82	19.97
Std. Dev.	3.86	3.93

(Possible score range = 7-35, with higher scores for lower affectivity)
Positive correlations found between worker and client affectivity and length of employment

Kaye, 1986

Table 5. Voices of Frontline Staff Page 21 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Explore factors related to job satisfaction & intent to leave.	North Carolina 7 branches of one home health agency 309 home care assistants In-house interviews. 8 open-ended questions and 91 items on 3 part scale re: affinity for the clients; working relationship with the supervisor; relationship with older people; personnel benefits and specific reasons for considering leaving the job	Top factors related to job satisfaction -Affinity for clients: - 96-98% like their clients & believe making a difference Relationship with supervisor: -95-97% know job responsibilities & hear positive reports about their jobs Relationship with older people: -92-97% feel sense of accomplishment, needed and wanted by older person Personnel benefits: -83-95% want pay increases, health insurance & safe neighborhood Reasons for possible resignation: 49% no pay increase, 43% not feeling appreciated, 39% no health insurance	Kennedy- Malone, 1996

Table 5. Voices of Frontline Staff Page 22 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Determine significant contributors to job turnover

Detroit & Seattle
6 nursing homes
-308 staff (75% NAs)
& 12 community service agencies
-50 staff (75% NAs)
In-house survey:
Personal data,
Attitudes:
Affect toward aged
Affect toward clients
Job characteristics:
Work type, hours, job status, etc.
Job Satisfaction
Intent to leave
1 year later check actual turnover

Regression Outcomes:
Job Satisfaction R² =.24**(p≤.01)
Age	.19 *
Client oriented work	-.14 *
Job tenure	.16 *
Professional job status	.20 **
Community agency	-.13 *
Affect toward aged	.17 *

Intent to leave: R² = .28**(p≤.01)
Age	.36 **
Job tenure	.15 *
Agency type	.13 *
Job satisfaction	.14 *

Actual Turnover R² = .26**(p≤.01)
Intent to leave	.35 **
Job tenure	.18 **

Kiyak, Namazi, & Kahana, 1997

Table 5. Voices of Frontline Staff Page 23 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Describe experiences of empathy and burnout among staff caring for demented seniors Compare experiences, burnout and empathy between staff in a collective living unit (CLU) & nursing home	Small town in Sweden 10 nursing assistants in collective living unit & 10 from nursing home Interviews in 1988 and 1989 3 instruments: semi-structured interview, empathy rating scale and burnout measure 21 items on 7 point scale	Similarities more than differences Both felt valuable & useful Both sometimes felt exhausted Both had deep care & concern for patients, confident in caring abilities CLU staff described seniors with only positive descriptions, nursing home both negative and positive. No significant differences in empathy scores Significantly lower burnout scores in the CLU in 1988 & 1989	Kuremyr et al., 1994
Develop an overall picture of assistants' work experiences related to violence from residents	Ann Arbor, Michigan 7 nursing homes Focus group meeting and approximately 8 hours observation of nursing assistants in each home	All 7 nursing home groups reported physical abuse Assistants reported they "get hurt everyday" patients hit, scratch, pull hair, kick, bite, pinch. Specific injuries reported: Black eye, swollen arm, torn rotator cuff & knee injury (requiring surgeries), injured jaw, dislocation of thumb. Difficult to protect themselves because of necessary proximity to residents and violence is often unpredictable.	Lusk, 1992

Table 5. Voices of Frontline Staff Page 24 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Understand perceptions of compensation, training and abuse in nursing homes	Arkansas, urban areas 3 nursing homes 27 NAs 2 hour interviews with open-ended questions	Compensation Perceptions experience not reflected in wages 50% or more worked extra shifts or second job "to cover basics" Training and In-services 60% said training boring & repetitious, most very critical NAs with in- house training much less cynical 75% wanted in-service on how to communicate with residents with dementia and depression Training areas desired: dealing with aggressive behaviors, CPR and vital signs Racial Discrimination within home 78% reported much discriminatory language & behaviors primarily from residents & families Abuse to Residents 92 % witnessed residents being abused; most episodes were verbal Abuse from Residents 92% reported verbal or physical abuse, mostly from demented residents	Mercer, Heacock, & Beck, 1993
Explore attitudes toward employment in nursing homes	Oregon rural areas 7 nursing homes 76 NAs In-person interviews, open ended questions	Themes, in order of frequency Attachment to others - like helping and working with people; do not like working short of staff / seeing residents given less than optimum care Gratification - work is rewarding, enjoy being needed & appreciated Demands - physically & emotionally demanding; sources of stress include lack of staff & supplies & becoming emotionally attached Monetary Needs - pay is pitiful and benefits are insufficient. Suggestions: pot-luck dinners, aide of the week recognition, respect and caring from administration, smiles and 'thank yous'	Monahan & McCarthy, 1992

Table 5. Voices of Frontline Staff Page 25 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Evaluate the quality of NA education and training

Baltimore, Maryland
6 nursing homes & 5 home care agencies
48 NAs
In-person interviews, open-ended questions

Comprehensiveness of courses -many thought most of what was learned was needed;
criticisms include:
-Courses present unrealistic view of the workload, lead to early burnout
-Courses didn't identify nature of most impairments, dementia, and incontinence
-Courses didn't present proper balance of activities; do much more personal care work
Training needs identified:
interpersonal skills with patients & coworkers; understanding/managing cognitive impairments

Morgan, 1996

Examine the effects of caring for cognitively impaired residents on nursing assistant burnout.

Winnipeg, Manitoba
25 nursing homes
225 nursing assistants
In-person interviews
Variables
Proportion of cognitively impaired in caseload
Minutes/day NA spends on care
Disturbing behaviors (Memory and Behavior Problems Checklist, 35 items on 5 point scale)
Appraisal significance
Maslach's Burnout Components
Personal characteristics of NAs

NAs showed mild burnout on emotional exhaustion & depersonalization & moderate burnout on personal accomplishment
Regression Results - R² & beta values

Emotional Exhaustion R^2M= .23**
Proportion of cog. impaired	.098
Reaction to specific behaviors	.426**
Pleasantness of tasks	.080
Personal Accomplishment R²= .09**
Freq. disturbing behaviors	-.25
Reaction to specific behaviors	.215**
Task pleasantness	.076
Depersonalization R²= .21**
Age	-.147*
Proportion of cog. impaired	.086
Minutes in physical care	-.187*
Reaction to specific behaviors	.272**
Pleasantness of tasks	.220**

Novack & Chappell, 1994

Table 5. Voices of Frontline Staff Page 26 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Determine how much and what type of abuse occurs from staff to residents

New Hampshire
31 nursing homes
352 NAs,
225 LPNs & RNs
Telephone survey
First asked to report on abuse observed from other staff
Second actions they took
- Conflict Tactics Scale
- Frequency response scale
- Burnout scale

Physical Abuse: 2-10 times
	Never	Year
Pushed, grabbed . . .	83%	9%
Slapped or hit	88%	6%

Psychological Abuse:
Yelled w anger	30%	44%
Insulted or swore	50%	30%
Isolated	77%	12%
Threatened to hit	85%	9%
Denied food, etc.	87%	8%

Persons /w high burnout more likely to abuse
Persons /w stressful personal lives more likely to abuse psychologically

Pillemer & Moore, 1989

Table 5. Voices of Frontline Staff Page 27 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Identify the knowledge and perceived imple-
mentation of resident rights by nursing home staff.

Colorado
5 nursing homes,
83 NAs, 62 nurses
Survey during in-service. 11 case scenarios re: specific resident rights issue.
For each scenario, staff answered:
How should the situation be handled?
How is the situation being handled at your facility?

NA responses:
Resident Right	Should Be	Is
*significant difference between what knew should be & is in their facility
Voice concerns	99%	79 *
Choice- bathing	97	84 *
Privacy	96	72 *
Respect	93	57 *
Activities	92	75 *
Roommate selection	73	56
Physical restraints	68	52
Chemical restraints	66	57

Roberto et. al., 1997

Table 5. Voices of Frontline Staff Page 28 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Describe and compare attitudes toward elderly held by nursing assistants of African American, Haitian, and English- speaking Caribbean cultural backgrounds Identify NA personal beliefs & feelings of appreciation.	New York City 5 nursing homes (3 religious & 2 proprietary) 246 NAs; 77 African Americans, 79 Haitian and 90 English- speaking Caribbean. Instrument = PES - Perceptions of the Elderly Scale, 29 questions with Likert response format. 11 Belief & Appreciation questions with Likert response	All three of the cultural groups held favorable attitudes toward older persons with few differences noted Regard sons or daughters placing their parent in a nursing home negatively Majority would not place own parent in a nursing home Majority feels appreciated by residents Majority feels opinion is not asked or only occasionally asked by doctors and nurses.	Robinson, 1993 & 1994

Table 5. Voices of Frontline Staff Page 29 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Determine job satisfaction factors of home care NAs & homemakers.

Ohio
1 home care agency
132 NAs/ homemakers
In-house survey
Locke's Action Tendency Interview Schedule for Job Satisfaction (ATIS), 11 items with 5 point Likert scale

Job Satisfaction Items
	Often Very Often
Look forward to going to work	54%
Suggest this job to a friend	52%
Support & Appreciation
When have concerns turn to Agency personnel	79%
How know clients appreciate their work
Tell me	50%
Trust & depend on me	32%
How do you know when you are doing a good job?
Feedback from supervisor	55%
Heard from clients	32%

Royse, Dhooper, & Howard, 1988

Investigate NA perspectives of job commitment, organizational commitment and other work areas

Cleveland metropolitan area,
5 nursing homes
114 NAs
In person interviews
Variables:
Job commitment -
rate how strongly would like to still be working as a NA in 3 years
Organizational commitment -
rate how strongly want to be working in a nursing home three years from now
Open-ended questions

Job commitment:
- Over ½ did not want to be in job in 3 yrs.; many wanted to be nurses
Organizational commitment:
- Over 1/3 did not want to work in nursing home; most wanted to be in hospitals or other health organizations.
Impact of staffing problems:
- Over 3/4th had been asked to change their scheduled shift time, to stay late or come in early in past 2 months
Involved in decisions:
- 75% never or only minimally involved in residents' pre admission conference
- More than 50% are never or only minimally involved in attending resident care planning conference
Supervision:
- More than ½ dissatisfied with amount of feedback received, lack of attention to suggestions & lack of recognition
Career opportunities:
- More than ½ dissatisfied with opportunities for promotion

Schur, et al., 1998

Table 5. Voices of Frontline Staff Page 30 of 32

Purpose	Location, Sample & Measurements	Findings	Authors
Determine the impact of NA attitudes, supervisors' leadership and management practices to quality ratings	Florida & Texas 25 nursing homes (for profit and nonprofit) (2 failed state inspections for quality care, 23 passed) 530 NAs In-house surveys - Organizational commitment, - job tension, - co-worker cohesion - Attitude toward residents - Leadership behaviors - Organization climate	Organization commitment much higher in nonprofit homes than in for-profit homes (no difference for failed homes) Leadership behaviors varied by for profit versus nonprofit (no difference for failed homes) Maintenance attitudes much higher in failed homes than successful homes Failed homes had lower human relations climate dimensions and higher laissez faire and status orientation climates	Sheridan, White, & Fairchild, 1992

Table 5. Voices of Frontline Staff Page 31 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Identify homemakers perceptions of supervisor support
Identify linkages between supervisor support and staff satisfaction and desire to remain on the job

Southwest state
1 large home care agency
94 homemakers
In-office survey
Job sat - 4 items & 7 point scale (Happock's)
Propensity to remain - 3 items & 5 interval scale
Personal concern - 10 items, 7 point scale

Personal Concern by supervisor
Mean scores, scale 1-7, 7 highest
Input is listened to & valued	4.7
Trust & confidence in staff	4.7
Feel free to talk to supervisor	4.8

Work Group Climate
group is friendly	5.8
group is helpful	5.8
take personal interest in others	5.1
trust in group	5.4
look forward to group	5.0

Recognition
annual picnic is beneficial	5.5
recognition banquet is beneficial	5.6

Correlations to job satisfaction & Intent to Stay (all statistically significant at p≤.05)
	SATISFIED	STAY
Trust staff	. 25	.26
Can talk to supervisor	.31	.27

Work Group Climate
group is friendly	.23	.26
group is helpful	///	.31
interest in individuals	.28	.39
Trust in group	.31	.33
Look forward to group	.51	.51

Recognition
Annual picnic is beneficial	///	.35
Recog. Banquet is valued	.32	.34

Smith, Hood, and Piland, 1994

Table 5. Voices of Frontline Staff Page 32 of 32

Purpose

Location,
Sample &
Measurements

Findings

Authors

Understand contributing factors to NA turnover and NAs' opinions regarding facility management

Central Texas
11 nursing homes
119 Nursing Assistants
30-40 minute interviews, closed and open questions
Variables:
NA turnover
Individual characteristics
Opinions about management

In Homes with NA turnover > 50%

Characteristics of NAs
Only on-the-job training	80%
No experience with elderly	68%
Correct on aging quiz	56%
No nursing home experience	47%

Management Areas
No opportunity for advancement	73%
Nothing done about problems	44%

Wagnild, 1988

Determine if job turnover could be related to:
1) wages and benefits
2) job satisfaction
3) perceptions of ward atmosphere and/or
4) quality of care

Philadelphia
7 nursing homes (proprietary)
234 NAs
Orally administered questionnaire,
115 items Minnesota Satisfaction Scale,
Moos Atmosphere Scale,
Self report employment,
Employment records
HR turnover rates
Nurse quality ranking
Annual state inspection & citations records

No correspondence appeared between the severity of turnover problems and homes' quality or compensation offered.
Homes with higher turnover had
- better compensation
- higher order, organization & program clarity
- greater job satisfaction for aides
- higher quality by state records and nurse rankings

Waxman, Carner, & Berkenstock 1984