Work stress/strain, low job
satisfaction, and intent to leave
home health care nursing among
Home Health Care Registered
Nurses (HHC RNs)
Paxson Barker, PhD, MS, RN
Purpose
The purpose of this study was to explore the work
stress/strain reported by HHC RNs that may influence
job satisfaction and “intent to leave” their positions
and/or profession.
Background

Home Health Care (HHC) services enable people to remain at home
rather than use residential, long-term, or institutional-based nursing
care.

By 2020, the greatest demand increase will be 109% for HHC
nurses (HRSA, 2004) with a resultant 36% shortfall of HHC nurses
(U.S. Department of Labor, 2007).

The most recent national average of turnover rates among HHC
RNs is estimated to be 22% and an estimated 25-33% of HHC RNs
report an “intent to leave” their current position.

Strategies to improve or remove the work environment factors that
negatively influence the nurses may improve retention.
Statement of the Problem

Effort-Reward Imbalance (ERI) due to work stress/strain measured
in other occupations results in low job satisfaction, which is
recognized as an antecedent to Home Health Care (HHC) RNs
“intent to leave” their current position and/or profession in the
published literature.

HHC RNs, as caregivers, can experience disequilibrium between
the amount of effort they invest in their care-giving in relation to the
rewards and benefits they receive for those efforts.

If a lack of reciprocity occurs between the nurses’ efforts expended
and the rewards received, then this imbalance can result in work
strain/stress leading to low job satisfaction for the HHC RN.
Significance

This secondary analysis of HHC RNs responses is the first to apply
the ERI model to calculate their ERI ratio/score from reported work
stress/strain.

Acknowledging the specific issues reported by HHC RNs will help
frame and develop the needed interventions required to improve the
work environment of HHC nurses.

Research has demonstrated that latent conditions, such as
inadequate staffing and the nurses’ work environment, are the
primary sources of threats to patient safety and health care errors.
Study Aims
1. To identify categories of work stress/strain reported by the HHC RNs
via the narratives contained within their 2006 questionnaire
response.
2. To examine the association between the two Organization Of Work
(OOW) components (effort, and reward) and “intent to leave” as well
as examine the association between the two OOW components and
job satisfaction, while controlling for personal characteristics.
3. To explore differences in the ERI scores between two sets of groups:
(1) RITL respondents as compared to the NRITL respondents as
well as (2) the respondents without a narrative as compared to the
respondents with a narrative.
Literature Review



Recurring themes regarding sources of work strain in the published
research studies include unreasonable administrative
demands/expectations, excessive paperwork, low wages and
benefits, lack of professional advancement, lack of autonomy,
difficult work characteristics, lack of cohesive co-worker
relationships, and emotional strain of the job (Ellenbecker, 2004;
Navaie-Waliser et al., 2004; Flynn, 2005, Ellenbecker & Byleckie,
2005).
The literature review noted 17 published research studies exploring
the HHC nurses’ job satisfaction and intent to leave but none of the
studies included the ERI theory measuring work strain/stress among
HHC nurses.
The ERI model was used to study burnout among 204 hospital
nurses in Germany that noted nurses with reported effort reward
imbalances had significantly higher emotional exhaustion and
depersonalization scores measuring burnout. (Bakker et al., 2000).
ERI theory

The Effort Reward Imbalance (ERI) theory is a psychosocial model
that incorporates external and internal components of work
characteristics to assess levels of job strain/stress associated with
job satisfaction.

The model assumes that work contracts are not always balanced in
reciprocity of rewards for the efforts requested.

This imbalanced reciprocity of “high costs” and “low gains” results in
work strain/stress that may impair successful self-regulation and this
sustained strain/stress may result in an “intent to leave” among
nurses
Conceptual Framework
Study Narratives
Study Narratives
ANTECEDENTS
Negative
organizational traits
Inadequate financial
compensation
Burnout
ATTRIBUTES
Co-worker
support
Work stress
Fatigue
Supervisor
support
Personal
Characteristics
age
race
gender
education
yrs in HHC
yrs with HHC
employer
Parent Questionnaire
one OOW item
Overwhelming
paperwork
COPSOC Items
HIGH/LOW ERI SCORE
Job stress/strain
1,5,6,8*,9*,11*,12*,13*,14,15,17*,1
8*,19*,20,21*,23*,25*,26*,28*,29*,
31*,32,33*,35,38*,39*,
40,43*,44*
ERI Items
2,3,4*,9*,11*,12*,13*,
17*,18*,19*,22*,23*,24,25*,27,28*,
31*,34*,36*,37,38*,39*,45*
JOB SATISFACTION
JCQ Items
8,*9*,11*,13*,22*,28*,
29*,33*,36*
FOCUS GROUP Items
Study
Narratives
INTENT TO LEAVE
REPORTED
* Overlap of item sources
Exhaustion
NOT REPORTED
4*,7,10,16,21*,26*,30,
31*,42,43*,44*,45*,46,
47,48,49
Aim 1 Results
Top 6 issues reported in narratives:
1. negative organizational traits
2. work stress
3. love homecare
4. overwhelming paperwork
5. inadequate financial compensation
6. nurse attrition
69.4%
63.6%
50.0%
43.7%
42.7%
40.3%
(n=143)
(n=131)
(n=103)
(n= 90)
(n= 88)
(n= 83)
27.2% of eligible 206 sample specifically stated that they had left or were
leaving homecare work
Aim 2 Results
Logistic Regression final model for respondents with (206)and
without narratives (572) for job satisfaction (n=772)
Scales
B
S.E.
Wald
df
Exp(B)
95% CI
p
value
Lower Uppe
r
6.781
-.089 .034
Reward
.104 .026 15.695
1
1.110 1.054
Overcommittment
-.026 .018 1.981
1
.974 .940
* Significant p<.05
1
.914
.855
Effort
.978
.009*
1.169 <.001*
1.010
.159
Aim 3 Results
Proportion of high and low ERI scores by narrative group,
respondents with narratives (206) and respondents without
narratives (572).
Variable
N= 206
n (%)
N= 572
n (%)
Low ERI scorea
117 (56.8)
402 (70.3)
High ERI scoreb
89 (43.2)
170 (29.7)
Low OCERIc score
122 (59.2)
405 (70.8)
High OCERIc score
84 (40.8)
167 (29.2)
a Low ERI score (.01 – 1.00)
b High ERI score (1.01 – 4.
c Overcommittment scale included in the ERI scores
Aim 3 Results cont.’
Mean scores of ERI and OCERI scores with t test results for
respondents with and without narratives.
SCALE
n= 206
N
min
max
n=572
m
sd
n
min
max
m
sd
t(df), p
ERI
score
206 1.12 3.88
1.45
.35 572 .17
1.12
.80
.19
54.31(565), <.001*
OCERI
score
206
1.40
.40 571
1.36
.80
.20
32.29(511), <.001*
.72 3.92
* statistically significant p <.05
.10
Conclusions










The qualitative results were consistent and supported by published literature
on HHC nurses and their work environment.
27.2% (56) of respondents with narratives reported intent to leave.
30.4% (17) of those 56 respondents with narratives specifically stated that
they loved homecare.
Negative organizational traits (69.4%)was the most frequently reported
issue among the respondents with narratives.
Work stress (63.6%) was the next most frequently reported and is also
supported by the literature.
Respondents with and without narratives (n=778)
The effort scale (subscales of exhaustion and cognitive stress) and reward
scale (subscales of autonomy and rewards) were statistically significant for
job satisfaction
43.2% of the 206 HHC RNs with narratives reported elevated ERI scores
35.0% of the 572 HHC RNs without narratives reported elevated ERI scores
The surprising result was that the group without narratives reporting
elevated ERI scores, only 18.5% (n= 37) of this group (n=200) reported low
job satisfaction despite the evidence of elevated work stress/strain
65% (n=372) respondents without narratives reported no/low effort-reward
imbalance and 97.8% reported experiencing good job satisfaction.
Implications for Policy





A place to begin is to establish federal standards for HHC nurses’ work
environment including but not limited to work hours, physical hazards,
overtime (paid and unpaid), workload, and safety so that all nurses are
protected regardless of geographic location or employer.
The OASIS paperwork, (federal documentation requirements), and being
grossly underpaid (federal reimbursement issue) are issues resulting in
unpaid overtime for HHC RNs. The need for HHC RNs to use their
uncompensated private family time to conduct business for their HHC
agencies is an unreasonable expectation of employers and the federal
government.
CMS reimbursement for patient services should be based on total hours
worked including travel time to provide care versus only face time with
patients.
The reported level of elevated effort-reward imbalance increases the
responsibility and burden of management to identify the sources of job
stress/strain in the work environment for their employees and intervene
appropriately.
Policy makers need better data to improve the reimbursement of homecare
nursing.
Implications for Practice





HHC agencies must balance their number of admissions to the
amount of resources available to provide safe, quality care to the
clients they serve.
The voices of these HHC RNs provides key information for the
development of interventions that reduce and/or eliminate these
work environment hazards.
Employers must address and resolve work hazards including
unsupportive employer behavior, work stress, and
unreasonable/excessive hours worked by HHC RNs to improve the
retention of these highly qualified nurses.
Almost 50% of the 794 HHC RNs responding to this study reported
elevated effort reward imbalances with 27% having left or planning
to leave homecare. These results should capture the attention and
response of decision-makers.
The employer can resolve many of the issues through improved
“organization of work” policies.
Implications for Research






Quantitative analysis alone does not provide comprehensive results
and interpretation of the HHC RNs lived experience and requires the
inclusion of qualitative analysis to capture relevant data.
Additional research using the ERI model is indicated to assess
levels of work strain/stress among HHC RNs.
Hazards in the HHC RNs workplace persist despite published
literature identifying these hazards due to a disconnect between
research and practice. This disconnect indicates that improved
dissemination of research results to federal policy and decision
makers is needed.
The nurse’s voice must be respected, heard, and responded to
appropriately for resolution of practice errors and problems in the
health care delivery system of homecare.
Qualitative research is required with quantitative methods to achieve
an in-depth understanding of the phenomena of workplace issues
among HHC RNs.
Homecare employers need research findings to identify and
implement needed changes in homecare documentation and
compensation to retain nurses.
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