Frontline Staff Perspectives, Leadership Styles and Turnover Intentions
Scholarship & Development Faculty Grant, 2015
Final Report
Project Director: Dr. Debra Hagerty
Co-Director: Dr. Janet R Buelow
Research Goals & Objects:
1. Examine relationships between nursing home frontline staff perceptions of job satisfaction,
leadership relationships, teamwork, affective commitment and turnover intention.
2. Identify the statistical associations between frontline staff perceptions of the work
environment and nurse leaders’ perceptions of the work environment.
3. Support the development of nurse leadership skills and abilities and assess the impact of
specific leader actions.
Attainment:
Objective 1 was met after data was collected and analyzed. Two statistically significant
relationships were identified.
Objective 2 was met after data was collected and analyzed. Two statistically significant
relationships were identified.
Objective 3 was met with development of 4 nursing home reports and individualized meetings
with nursing directors of these nursing facilities.
The Directors of the Nursing homes were interested in the nurse aide perceptions. They
also were impressed by the suggestions that were made based on the research findings.
Improving relationships of staff working in nursing homes is critical to providing quality care.
1
Description of Project:
Certified nursing assistants (CNAs) are the heart and soul of long care facilities. These
workers spend the majority of their shift directly involved with residents; performing intimate
daily living activities, such as bathing, dressing, feeding and toileting. When performing these
tasks CNAs are encouraged to converse and develop a caring relationship with their residents.
Hence CNAs can contribute to expert physical services, as well as emotional and personal care
critical to ensuring a high quality of life and mental health for residents. It falls on the geriatric
nurse to guide, supervise and manage CNAs with this significant work, yet little research has
been conducted in this area.
We used a descriptive survey design to address our research aim. The university ethics
committee granted IRB approval and the Director of Nursing and Administrator of each
participating nursing facility provided participation permission, as required by the institutional
review board.
Nursing home directors from 4 facilities were interested, signed the IRB form and set up
a meeting with the researchers. They agreed to allow the authors to distribute questionnaires to
their CNAs with all completed surveys remaining completely anonymous. Times for the best
response from CNAs were determined, with change of shift times, as well as paycheck days,
being favored. Convenience samples of interested CNAs were recruited from each participating
nursing facility with researchers returning to each facility two to three times to gather the
completed surveys. Candy bars were provided as a thank you for completion of the
questionnaires.
The instrument was developed from questionnaires used with nurses and staff in
Australian hospitals and then modified to be appropriate for CNAs in nursing facilities.
Questions for intrinsic satisfaction, turnover intent, administration and nursing supervisor
originated from surveys in Brunnetto, Farr-Wharton and Shacklock’s work in Australian
2
hospitals. Each item was reviewed and modified as appropriate and then pilot tested with two
current CNAs for content validity.
The data were entered into SPSS for statistical analysis and a p level of .05 was set for
significance. After descriptive analysis for CNA demographics, work history and perceptions
were examined, an analysis of variance (ANOVA) was conducted to assess if there were
differences in any of these variables by nursing facility. No significant differences were found,
so the analysis included CNAs from all nursing homes.
For each variable, the assumption of equality of variance was assessed with a Levene's
test. Results of this test indicated that the assumption was met for each variable, so the
ANOVA was conducted by generations. However, we realize that job tenure may impact the
CNAs’ perspectives, so a multivariate analysis of covariance (MANCOVA) was conducted to
assess if there were differences in the independent variables by generation after controlling for
job tenure. Results of this test showed no significant difference, so the generational scores for
CNA perceptions were examined and are presented below.
Results
For nearly every question, baby boomers provided the poorest perceptions of
administrators. Their two poorest perceptions were that administrators do not call in additional
help when needed and are not concerned for their health and families (mean scores of 2.32 and
2.39, respectively).
Noted is a significant finding that baby boomers felt the supervisor did not understand
their problems as well as the Millennials and Gen X. Although not significant, baby boomers
reported most negatively in regard to their supervisor knowing how good they are at their job.
Gen X CNAs were in the middle with a slight agreement that supervisors understand my work
problems, Millennials were the most positive in their opinions about the supervisor in 4 areas.
All generations reported their most positive mean scores in the same two areas: their
supervisors were satisfied with their work and knew how good they were at their job.
3
Baby Boomers were significantly less likely to hear staff talking about others behind their
back. Millennials on all 3 measures, had the worst perception of workplace climate. Millennials
were more likely to hear staff talk behind their back. Millennials also perceived others not being
helpful to new staff and heard staff use disrespectful language toward others at a higher rate
than both Gen X and Baby Boomers.
A significant finding among generations was in the area of hearing staff talk behind the
backs of other staff. The baby boomers heard staff talk about others the least and the
millennials heard this the most. The Millennials had the strongest opinions all negative about the
climate of the workplace. The baby boomers witnessed staff use disrespectful language towards
others (which could be co-workers or residents) less often than both Gen X and the Millennials.
This behavior may create a work environment which adds to the already stressed atmosphere
of caregiving and meeting human needs. In fact this disrespectful language toward other staff
may lead to an environment at work which breeds incivility. This workplace stressor is not
unique to long-term care and impacts the health care team as well as resident’s nursing home
experience.
Summary
If long-term care organizations are going to retain staff, meeting the needs of employees
and accommodating differences is operationally imperative for success. The lowest mean score
for relationship with supervisor was the Baby boomers although all generations had an average
score of slightly agree with having a positive relationship. Relationships that are empowering
and creating a supervisory workplace environment that allows engagement and active
participation is beneficial to the success of all generations. The care model which is patient
centered engenders a relationship based approach to delivery and requires CNAs to be
collaborative, communicative and coalesced in a teamwork supported environment for quality
4
patient care to be delivered efficiently. This is found in the foundation of Culture Change in
nursing facilities where relationships among residents and staff are fostered, respect is
practiced, empowerment and choice for residents and staff is normalized.
Geriatric nurse supervisors can play a pivotal role in assignments based on acuity and
required support intensity and should ensure that staff do not feel overwhelmed. Care
procedures for residents may consume more time per activity by virtue of the multiple
comorbidities including mental health impairments ranging from mild cognitive impairment to
dementia and other psychiatric disorders. The time and finesse of patient-centered approaches
requires an astute, clinically competent geriatric nurse. The nurse needs to be able to assess,
as well as assign, based on staff expertise and the clinical behavioral presentations of the
patients. Nurse managers play a critical role in the work milieu and stress. Supervisor support
and decision authority can buffer the adverse effects of job demands on feelings of emotional
exhaustion.
Supportive managers also play an instrumental role in CNA education, skill building and
the provision of resources which facilitate completion of work. According to research,
organizations who wish to retain committed baby boomers need to focus on supportive
management, organizational culture and career development or lateral moves. Supportive
managers help their subordinates instrumentally and emotionally by giving recognition when
deserved, listening to concerns, standing up for the staff and providing challenging
opportunities. When health care teams function as a collaborative unit with regular two-way
communication, they can achieve great things—positive patient outcomes, safer care, and
increased patient and family satisfaction.
Baby Boomers also were in highest disagreement with staff not using disrespectful
language towards others. All generations were found to be ambivalent toward the nursing home.
The lower job ambivalence experienced, the stronger job satisfaction and organizational
5
citizenship both critical to a civil work atmosphere. The mean score for thinking about leaving
the job was highest for the Baby Boomers. Work expectations that are unreasonable, i.e., high
workload has been shown to impact turnover intention. Manager support and behavior has
been shown to differentiate baby boomers turnover intention and this emphasizes the
importance of supportive behaviors such as providing recognition when deserved, listening to
concerns about workload and other issues and standing up for the staff as well as providing
challenging opportunities to ensure organization commitment and prevent turnover.
Supervision is positively related to job satisfaction and negatively related to intent to leave
across generations. Talking behind ones back breeds mistrust and conflict and is dysfunctional
for the team. Work climates which have negative disruptive conversations occurring do not
support collegiality and collaboration so important in long term care.
Timeline Implementation Plan
December
Develop survey instrument and obtain IRB approval
January
Pilot test and recruit nursing homes
February
Survey staff in 2 nursing homes
Data entry &analysis
March
Survey staff in 2 nursing homes
Data entry &analysis
April
Develop individualized Reports for each nursing home
Meetings with nursing home administrators and nurse leaders
– share findings in reports
May-August
Data analysis, targeting writing of findings for journal submission
6
Outcomes – Community Benefit, Student Benefit and Scholarly Output:
1. Community nursing homes benefited from this research. Providing staff with improved
understanding of the functioning of their team and relationships is important. Students
who assisted in data collections benefited immensely in developing relationships and
improving their understanding of the operations of the nursing home.
2. Collaborative relationships have developed between faculty within the College of Health
Professions in 2 different disciplines in the college. These relationships produced
opportunities for students to engage in the community specifically related to their
educational endeavors and produced outcomes which benefit the university, the student,
faculty and community.
3.
Progress is being made toward completion of an article for publication. The targeted
date for submission to the Journal of Geriatric Nursing is September 29, 2015.
4. Because of this project the researchers were able to secure one of the students a
position in a nursing home as an administrator in training. This is a fantastic transitional
position from Master’s degree to career employment.
5. The Armstrong State University and community relationships have been solidified further
and doors are open for new research and educational endeavors in our community
partner settings.
7