The significance of the psychosocial work environment for care workers`perceived health, presenteeism, rationing of care, and job satisfaction: a sub-study of the Swiss Nursing Home Human Resources Project (SHURP)

Healthcare is a high-risk industry, not only for patients, but also for staff, whose health and wellbeing can be affected. While research has extensively examined the health of care workers in hospital settings, nursing homes have been less researched in this regard. Nursing homes are an important sector of the care system that is becoming increasingly complex with the growing elderly population. In Switzerland, with the introduction of Diagnostic Related Group (DRG) with reduced length of hospital stay and accelerated patient discharge, nursing homes are delivering more sub-acute care to residents with complex medical conditions. More than half of residents in Swiss nursing homes are diagnosed with dementia or show signs of dementia, and require assistance to meet basic needs in activities of daily living. Consequently, nursing home care workers often perform nursing activities such as patient handling and positioning, and communicating with challenging residents that put them at risk of physical injuries and compromised mental health. A particular concern is presenteeism, which refers to attending to work while ill, and which showed to be common among care workers.
Workplace environments in health care settings have shown to be with risks for staff health, e.g. for musculoskeletal injuries and needle stick injuries. Researchers also found increased rates of emotional exhaustion and musculoskeletal pain among direct care providers. Job demands at work were found strong factors in contributing to increased injury rates. Mental health outcomes were positively influenced by social support at work. While the magnitude of the problem of care workers working through illness and its ramification on the provision of care in nursing homes has not been fully identified so far, researchers recognize its effect on the quality of care.
This dissertation aims to explore care workers` reported physical and mental health in Swiss nursing homes, analysed relationships with contributing factors (e.g. psychosocial work environment factors) and outcomes (e.g. rationing of residents care and job satisfaction) in four studies. These studies analyse data from the Swiss Nursing Homes Human Resource Project (SHURP), including survey responses from a survey of 5,323 care workers in 162 Swiss nursing homes, across the three language speaking regions (German, French, and Italian).
The dissertation is organized in six chapters:
Chapter 1 is an overall literature-based introduction to the topic. It explores the association of the work environment and care worker’s health. Emphasis is placed on nursing home care workers, and the importance of their perception of work environment factors, including, but not limited to, leadership, staffing adequacy, work stressors, and autonomy at work, and how they influence care workers related behaviour (e.g. presenteeism, absenteeism). The influence of care workers` health on rationing of care, and the relationship between health and work environment with care workers` job satisfaction, are also discussed. An overview of the state of research on care workers` health in nursing homes and the conceptual framework of this dissertation is presented. In the final part of the introduction, gaps in the literature are summarized, along with the contribution of this dissertation to address those gaps. Aims and rationale of the dissertation are described. Findings addressed in four component studies are reported (Chapter 2 to Chapter 5).
Chapter 2 reports on our study describing care workers` perceived health, exploring relationships between selected perceived work environment factors and self-reported physical and mental health outcomes. In this sample of 3,471 care workers from 155 nursing homes across Switzerland, 38% reported at least one compromised physical health outcome, and 27.4% reported at least one mental health outcome. Back pain (19.0 %, n=655), and joint pain (13.5%, n=464) were reported physical health outcomes. Emotional exhaustion (24.2%, n=834), tiredness (14.4%, n=494), sleeplessness (12.6%, n=432) were the most prevalent self-reported mental health outcomes. After controlling for major organizational variables and care workers` characteristics, percentage of residents with dementia, physical violence and participation in decision-making were not predictors of health outcomes in our regression models. However, back pain and joint pain were associated with increased workload, conflict with other professionals and lack of recognition, frequent verbal aggression by residents, and perceived poor staffing adequacy. Sleeplessness, tiredness, headache, and emotional exhaustion from work, were associated with stress related to increased workload and conflict with other professionals and lack of recognition. Perceptions of strong leadership were associated with low-reported emotional exhaustion. Overall, our findings confirmed that poor psychosocial work environmental factors in nursing homes were related to the perceived physical and mental health of care workers. Modifying psychosocial work environment factors in Swiss nursing homes is a promising strategy to improve the health of their staff.
Chapter 3 presents the results of our explorative study of the prevalence of presenteeism and absenteeism in Swiss nursing homes, and their associations with care worker-reported selected psychosocial work environment factors. Of the studied 3,176 care workers in 162 nursing homes, prevalence of presenteeism (32.9%) was higher than absenteeism (14.6%). Although self-reported absenteeism showed no significant association with any of the psychosocial work environment factors investigated in this study, low reported presenteeism was associated with perceptions of supportive leadership (OR 1.22, CI 1.01-1.48), and adequate staffing resources (OR 1.18, CI 1.02-1.38) only. The findings suggest that presenteeism is an area that has been overlooked in nursing homes. Hence, it is reasonable to focus on presenteeism in order to promote care workers` health and to promote productivity and sustain the organization. Future analysis is needed to investigate the influence of presenteeism on the provision of residents care.
Chapter 4 presents study findings on the association between care workers-reported health, presenteeism and perceived implicit rationing of care. Studies showed that the exposure to an unhealthy workplace can compromise care workers physical and mental health. As the WHO Model for Healthy Workplace suggests, ill employees who work through illness have reduced work performance. Work performance can be assessed through omission rates in relation to required tasks. Care providers often reported implicit rationing of care (i.e. omission of care) due to various limitations. Of the 3,239 participating care workers in 162 nursing homes, physical and mental health issues, and presenteeism were of concern, and rationing of care was reported as rare. Our findings give support to the sensitivity of rationing of care to health issues: For rationing of activities of daily living, our regression model showed a positive association with perceived health: joint pain (β 0.04, CI 0.001-0.07), emotional exhaustion (β 0.11, CI 0.07-0.15), and presenteeism (β 0.05, CI 0.004-0.09). For rationing of caring, rehabilitation, and monitoring, results were similar: joint pain (β 0.05, CI 0.01-0.09), and emotional exhaustion (β 0.2, CI 1.16-0.24). Health organizations should be aware of health-related issues at the workplace to promote and maintain care workers` health, in order to ensure resident safety and appropriate provision of care. Further observational studies are needed to gain a deeper understanding of the individual decision of care workers for presenteeism and its’ impact on work performance, which may ultimately impact quality of care.
Chapter 5 presents major findings on care workers` job satisfaction and its association with work environment factors and perceived health. Recruiting and retaining care workers to meet the challenges of a growing elder population are connected to the satisfaction of care workers in the workplace. The conceptual analysis of job satisfaction showed that this affective response behaviour is not only linked to personal characteristics but also to one`s desired and expected outcomes. Hence, this study investigated the influence of work environmental aspects and perceived health on 4,145 care workers in 162 Swiss nursing homes. Results showed that high job satisfaction was associated with perceived supportive leadership (OR 3.76; CI 2.83-5.00), enhanced teamwork and resident safety climate (OR 2.60; CI 2.01-3.33), the availability of nursing home director (OR 2.30; CI 1.67-2.97), and staffing adequacy (OR 1.40; CI 1.15-1.70). However, it was reduced in the presence of workplace conflict (OR 0.61; CI .49-.76), compromised physical health (OR 0.91; CI 0.87-0.97), and emotional strain (OR 0.88; CI 0.83-0.93). To retain care workers and recruit new ones, nursing homes should modify substantial work environment (e.g. leadership and staffing adequacy) aspects in order to promote job satisfaction among their staff. Future longitudinal research is needed to confirm the observations made in this cross-sectional study design.
Finally, in Chapter 6 major findings of the individual studies are synthesized and discussed, substantive theoretical findings are stressed, and methodological strengths and limitations of this dissertation are presented. Moreover, implications for further research and clinical practice are recommended. The findings of this dissertation add to the existing literature the first evidence regarding the impact of health and presenteeism on rationing of care. Our findings confirm the underlying theoretical assumption that safer work environment is a protective aspect of care workers` health and wellbeing. Although these findings suggest the need to improve work environment and care workers` health in Swiss nursing homes to ensure better provision of resident care, it remains unclear whether improving care workers` health will lead to improved quality of care. This dissertation will contribute to the further development of healthy workplaces and their relationship to job performance and quality of care, and raises methodological issues that will require considerations in future studies.