Job Satisfaction and Career Commitment Among Alzheimer’s Care Providers: Addressing Turnover and Improving Staff Empowerment

Abstract

This study investigated the relation between job satisfaction and career commitment among 262 Alzheimer’s care staff working in long-term and community-based care settings. It was anticipated that the results would suggest whether career commitment could be enhanced to positively influence job satisfaction, and conversely, if improvements in job satisfaction might contribute to a deepened sense of vocational empowerment. Participants attended dementia-specific training and completed 2 short work-related questionnaires that measured job satisfaction and career commitment. The results of stepwise regression revealed interrelations between the 2 constructs. Congruence appeared to be reciprocal with respect to the overall scale scores and the intrinsic job satisfaction measure. Unexpected relations appeared in analyses of the extrinsic job satisfaction measure and the career planning subscale. Results are indicative of the fundamental distinction between job satisfaction and career commitment. Implications for efforts to reduce turnover and improve staff empowerment are also considered.

Introduction

The Direct Care Workforce Crisis

The recruitment and retention of direct care workers in the US long-term care industry have been the subject of numerous studies over several decades. ^1,2 The State of Aging and Health in America report from the Merck Institute of Aging and Health and the Gerontological Society of America ³ indicates that half of all adults worry about whether an adequate number of trained health care personnel will be available when they need care. Other national organizations have also been gathering data about the pending crisis in direct care and state of the art initiatives to address it. The Assisted Living Workgroup, ⁴ in its report to the US Senate Special Committee on Aging, estimated that the cost to replace a staff person lost as a consequence of turnover is between $1750 and $5000. The report provided recommendations and cited productive management and human resources practices to address recruitment and retention issues.

The Institute of Medicine Report, Retooling for an Aging America, recognizes the importance of investigating solutions to this problem and identifies the direct care workforce crisis as a primary challenge if adequate care is to be provided for the growing number of aging baby boomers in the United States. ⁵ Various models and policy-oriented approaches have been offered, ^{6 –11} and a conceptual framework for interpreting the research has been established. ¹² Furthermore, policy makers have been urged to encourage and assist the development of incentives, including career and worker empowerment training, to attract and retain qualified people for these jobs. ^{13 –17}

Recommendations Related to Continuing Education and Career Ladders/Lattices

The National Commission on Nursing Workforce for Long-Term Care ¹⁸ recommends that individual facilities and other providers offer opportunities for the direct care nursing workforce to grow professionally in the long-term care workplace. National surveys and studies have documented the career ladder and other initiatives implemented by different states to address aide recruitment and retention in long-term care settings. One of the most comprehensive was released from the National Center for Health Workforce Information and Analysis in the Health Resources and Services Administration’s Bureau of Health Professions. ¹⁹ The report advocates for data-driven modifications in workforce training programs and concludes that effective planning will depend on better data about state-level training programs and career ladders. The authors cite fieldwork (interview and focus group) results in 4 states demonstrating that many facilities and organizations are interested in further opportunities for training. There is evidence that long-term care providers and state officials unanimously agree that career ladders are important for retention. The report further contends that education will ultimately be a part of any long-term care workforce solution, since the changes that are necessary in workforce training will require modifications to the existing educational programs. In specifying the factors that can influence the supply and demand for long-term care paraprofessionals, the report cites current discussions around the theme of developing better career tracks to help recruitment efforts and care models that emphasize humanistic, patient-centered care.

At the state level, there are illustrative examples of how staff development efforts can help address the present difficulties. For example, a survey of providers in the California Association of Homes and Services for the Aging found that the workplace environment is at least as important as money in determining the job satisfaction of more experienced workers. ²⁰ The Good Samaritan Society based in South Dakota exemplifies the benefits of providing career lattices for those who do not want to move into more professional nursing careers but are interested in other options within the caregiving field such as geriatric nursing assistants, dementia specialists, or medication aides. ¹⁸ With support from the US Department of Labor, this program allows nursing assistants to become apprentices, choosing to specialize in a particular clinical area such as dementia or wound care. By strengthening the training and support available, this model is intended to address the factors that often result in worker frustration and turnover.

Dementia-Specific Training Interventions

Clearly, the provision of career-related opportunities is part of the solution. There is also anecdotal evidence that dementia-specific training can influence career commitment in nursing assistants. ²¹ Interventions that are grounded in the intention to encourage a more career-focused orientation are more likely to be successful in addressing the difficulties related to turnover, job stress, and quality of care. The other side of the coin is related to job satisfaction. Alzheimer’s disease caregiver training to manage problem behaviors can increase job satisfaction and reduce burnout. ²² Direct care staff trained specifically in caring for residents with dementia are better able to deal with job-related stress ²³ and more satisfied with their jobs. ^24,25 When organizational adjustments that enhance empowerment (eg, structural incentives, recognition, and mentoring) accompany dementia care education for nursing assistants, improvements in the quality of care provided and decreased turnover have also been documented. ^26,27 There is also data documenting decreased absenteeism among registered nurses in a special care unit following the implementation of dementia-specific training. ²⁸

The Interrelation of Job Satisfaction and Career Commitment

Although the relation between job satisfaction and turnover among nursing assistants has been explored, ²⁹ and there is an apparent connection between job satisfaction and career development programs, ²⁵ only one previous study has explored the relation between career commitment and job satisfaction in these workers. Specifically, certain aspects of intrinsic job satisfaction (personal growth, professional identity, and attachment aspects) were shown to be more important than extrinsic motivators in determining levels of job and career commitment among professional caregivers for patients with dementia. ³⁰ But no one has investigated exactly how a deepening career commitment might be related to job satisfaction among these workers. If methods to enhance levels of both of these can help address the turnover problem in long-term or community-based care, it is important to understand how the two are related to each other. This study was intended to explore the relation between job satisfaction and career commitment among paraprofessional Alzheimer’s care providers who participated in dementia-specific training. It was anticipated that the study would suggest whether career commitment could be enhanced to positively influence job satisfaction, and conversely, if job satisfaction might contribute to a deepened sense of career commitment.

Worker Empowerment and Career Commitment

Kanter’s ³¹ theory of organizational empowerment predicts that staff will be more engaged in meeting organizational goals if the work environment is structured in a manner that promotes opportunities for professional development. Nursing studies that have applied Kanter’s structural theory of power in organizations (eg, see Ref 32) have found that the perception of empowerment is related to job satisfaction and results in reduced turnover and absenteeism in long-term care settings. ^{33 –35} More specifically, intrinsic factors (personal growth, professional identity, and attachment aspects) have been shown to be more important than extrinsic motivators in determining levels of job and career commitment among professional caregivers for patients with dementia. ³⁰ Mounting evidence indicates that dementia-specific training to empower workers by promoting vocational advancement and improving skills can impact turnover and reduce staff burnout. ^36,37 There is also evidence that management practices used to empower nurse aides can improve resident outcomes by stabilizing staff turnover and increasing retention. ³⁸

If job satisfaction can be increased through employee empowerment, by extension, it seems reasonable to expect that career planning would also be nurtured by an empowering organizational environment that promoted vocational development. For this study, then, it was hypothesized that among paraprofessional staff providing dementia care in long-term or community-based care settings, the relation between job satisfaction and career planning would involve factors that contribute to worker empowerment (eg, opportunities for achievement and recognition). Specifically, it was expected that a relation would be uncovered between the career planning subscale of the Career Commitment Measure (CCM) and the intrinsic job satisfaction subscale of the Minnesota Satisfaction Questionnaire (MSQ).

Materials and Methods

Data were collected as part of a statewide dementia-specific training collaborative that included 12 hours of person-centered care training for all long-term care workers and an 8-hour train-the-trainer program for direct care workers only. The implications of this person-centered care training as a valuable approach to addressing the workforce crisis have been discussed.39

To focus on paid providers of direct care to persons with dementia, a subsample of the initial group of training participants (N = 930) was selected. The participants for this study (n = 262) included certified nurse aides (84.7%), medication aides (1.9%), or other direct care nursing assistants (13.0%). More than a third (37.1%) of participants were also primary caregivers for a relative or friend with Alzheimer’s disease, and an additional 15.1% had been primary informal caregivers for someone with Alzheimer’s disease in the past. They worked primarily in assisted living facilities (57.4%) or nursing homes (23.0%), although a few were affiliated with adult day care centers (5.1%), home care agencies (5.0%), or hospitals (2.7%). About three quarters (74.7%) were employed full time (40 or more hours/week) in their current positions. On average, they had been employed in their current positions for several years (M = 3.71, SD = 4.52) and had devoted a considerable number of years to working in their current career fields (M = 9.95, SD = 7.72). They ranged in age from 19 to 74 years (M = 40.66, SD = 11.62) and were predominantly Caucasian (46.4%) or African American (46.0%) females (98.0%).

Training participants completed a paper-and-pencil survey that asked for demographic data and included 2 short career-related questionnaires to measure job satisfaction (ie, the MSQ) and career commitment (ie, the CCM). To accommodate for missing data, participants were excluded from analyses if more than 5 answers were missing on the job satisfaction measure or more than 3 answers were missing on the CCM (25% of total items missing for each scale, respectively). Overall and subscale scores were then computed by summing across the valid items and dividing by the number of responses.

A short form of the MSQ was included as a measure of job satisfaction with specific aspects of work and work environment. ⁴⁰ The scale contains 20 statements related to pay, work environment, and management style. It employs a 5-point Likert-type scale (1 = very dissatisfied; 2 = dissatisfied; 3 = neutral; 4 = satisfied; and 5 = very satisfied), so that higher scores indicate a higher level of job satisfaction. The MSQ is composed of 2 subscales. The intrinsic or job content subscale is related to achievement, recognition, responsibility, and nature of the work. It measures feelings of satisfaction associated with such items as “The chance to do things for other people,” “The freedom to use my own judgment,” and “The feeling of accomplishment I get from the job.” The extrinsic or job context subscale probes aspects related to the type of supervision, company policy, administrative style, interpersonal relations, working conditions, and salary. Sample items include, “The praise I get for doing a good job,” “The chances for advancement on this job,” and “My pay and the amount of work I do.” The MSQ has been shown to be a reliable instrument ⁴⁰ that also meets validity criteria. ⁴¹ Internal consistency measures calculated for these scales, on the basis of a wide variety of occupational groups, produced a median reliability coefficient of .86 for the intrinsic satisfaction scale, .80 for the extrinsic scale, and .90 for the general satisfaction scale. The MSQ has been used successfully in 2 prominent studies to measure job satisfaction among nursing assistants. ^42,29

In order to measure the extent to which trainees had developed a commitment to their careers, the 12-item CCM was included on the questionnaire. ⁴³ It employs a 5-point Likert-type scale (1 = strongly disagree and 5 = strongly agree), so that higher scores indicate a higher level of career commitment or a greater sense of professionalism. The scale measures motivation to work in a chosen vocation and is comprised of 3 underlying dimensions of career commitment: career identity (establishing a close emotional association with one’s career), career planning (determining one’s developmental needs and setting career goals), and career resilience (resisting career disruption in the face of adversity). It has been shown to have coefficient α (Cronbach) reliabilities ranging from .79 to .85. The CCM has detected differences in career commitment levels associated with varying degrees of vocational empowerment across occupational groups. Factor analytic results support the CCM’s discriminant validity, and an analysis of correlate relations generally supports the CCM’s construct validity. ⁴³

Results

Total scores for the MSQ ranged from 27 to 100. The average score was 79.53 (SD = 11.03). For the intrinsic subscale, scores ranged from 13 to 60, with a mean of 50.38 (SD = 6.41). Scores for the extrinsic scale ranged from 6 to 30, and the average score was 21.34 (SD = 4.71). The subscale results are slightly higher than the overall occupational group averages originally reported. ⁴⁰ The total score, however, is comparable to the reported norms for nursing assistants (M = 80.62, SD = 9.52), though the scores of trainees are more variable since the sample does not constitute a completely homogenous occupational group.

Total scores for the CCM ranged from 2.08 to 5.00, and the mean was 3.70 (SD = 0.71). For the career identity subscale, scores ranged from 2 to 5, with a mean of 4.28 (SD = 0.62). The range of scores for the career resilience subscale spanned the full range (1-5), with a mean of 3.26 (SD = 1.14). The career planning subscale scores also spanned the full range and the average was 3.59 (SD = 1.00). The overall average for the CCM in the present study is comparable to that of the original field studies. ⁴³ Their sample included practical nurses and nursing aides in a nursing home but resulted in slightly less variability of scores (M = 3.79, SD = 0.55). The career identity score may be slightly elevated in comparison with the reported norms (M = 4.10, SD = 0.74), while the career planning score appears to be lower than has been previously reported (M = 3.85, SD = 0.68), and the career resilience score also seems slightly depressed in comparison (M = 3.41, SD = 0.87).

Table 1 shows the results of the 7 stepwise regression analyses conducted to detect relations between the job satisfaction and career commitment variables. Two of the career commitment subscales (career identity and career resilience) were predictive of the 3 job satisfaction constructs, collectively accounting for almost 10% of the variance in overall and intrinsic job satisfaction scores and about 6% of the variance in extrinsic job satisfaction scores. Two of the career commitment subscales (career identity and career resilience) were predictive of the 3 job satisfaction constructs, collectively accounting for almost 10% of the variance in overall and intrinsic job satisfaction scores, and about 6% of the variance in extrinsic job satisfaction scores. Both of the job satisfaction subscales were predictive of the overall CCM, collectively accounting for 7% of the variance in scores. But only the intrinsic job satisfaction measure was predictive of career identity and career resilience (respectively, accounting for 7% and 4% of the variance in subscale scores), and the extrinsic job satisfaction measure alone was predictive of the career planning subscale, accounting for 3% of the variance in subscale scores.

Table 1.

Results From Stepwise Regression Analyses Relating Job Satisfaction and Career Commitment Variables

Variables	β	F	df	R	R 2	Change in R 2	Change in F	df
Overall job satisfaction		13.12 a	2, 259
Step 1: Career identity	.216			.264	.070	.070	19.50 a	1, 260
Step 2: Career resilience	.157			.303	.092	.022	6.35 b	1, 259
Intrinsic job satisfaction		12.38 a	2, 259
Step 1: Career identity	.223			.265	.070	.070	19.62 a	1, 260
Step 2: Career resilience	.137			.295	.087	.017	4.86 b	1, 259
Extrinsic job satisfaction		8.13 a	2, 259
Step 1: Career identity	.167			.208	.043	.043	11.72 c	1, 260
Step 2: Career resilience	.133			.243	.059	.016	4.39 b	1, 259
Overall Career commitment		11.08 a	2, 259
Step 1: Intrinsic satisfaction	.171			.255	.065	.065	18.09 a	1, 260
Step 2: Extrinsic satisfaction	.145			.281	.079	.014	3.88 b	1, 259
Career identity		19.62 a	1, 260
Step 1: Intrinsic satisfaction	.265			.265	.070	−	19.62 a	1, 260
Career resilience		11.44 c	1, 260
Step 1: Intrinsic satisfaction	.205			.205	.042	−	11.44 c	1, 260
Career planning		9.18 a	1, 260
Step 1: Extrinsic satisfaction	.185			.185	.034	−	9.18 a	1, 260

^a P < .005.

^b P < .05.

^c P < .01.

Discussion

Our results indicated the extent of interrelations between the job satisfaction and career commitment constructs, respectively. The analyses suggest that although congruence among the 2 constructs appeared to be reciprocal with respect to the overall scale scores and the intrinsic job satisfaction measure, unexpected relations appeared in the analyses that included the extrinsic job satisfaction measure and the career planning subscale.

The stepwise regression analyses (Table 1) provide a basis for regarding the interrelations as moderately low. Statistically significant relations were uncovered, but the proportion of shared variance was not substantial. Career identity and career resilience are both predictive of overall, intrinsic, and extrinsic job satisfaction. In contrast, the career planning construct has no predictive value with respect to job satisfaction. Although both intrinsic and extrinsic job satisfactions are related to overall career commitment, only intrinsic job satisfaction is predictive of career identity and career resilience, and extrinsic job satisfaction is exclusively predictive of career planning.

Essentially, then, the interrelations uncovered vary depending on whether the question concerns the relation of job satisfaction to career commitment or the converse relation of career commitment to job satisfaction. With respect to the first question, the extent to which participants had well-developed career plans and goals was a function of their satisfaction levels with the quality of the interpersonal relations at work and working conditions they encountered (extrinsic job satisfaction). But this career-planning aspect of their motivation to provide care was unrelated to their satisfaction with the opportunities for achievement and recognition offered by the nature of their positions (intrinsic job satisfaction). Instead, the degree to which they had established a close emotional association with their careers (career identity) or resisted career disruption in the face of diversity (career resilience) were more important determinants of their intrinsic job satisfaction. On the other hand, if we are asking about whether career commitment is related to job satisfaction, the extent to which participants have well-developed career plans and goals is likely to be irrelevant as it is unrelated to job satisfaction. The other aspects of career commitment however (having a close emotional association with the chosen vocation and resisting career disruption in the face of diversity), are related to both aspects of job satisfaction (the quality of the interpersonal relations or working conditions encountered and the availability of opportunities for achievement and recognition).

This lack of congruence is indicative of the fundamental distinction between the job satisfaction and career commitment and suggests that they are theoretically dissimilar constructs. Their association, on the other hand, is established through the statistically significant relations uncovered. On the basis of these analyses 2 conclusions with implications for future studies can be drawn. In general, when there is interest in establishing the commonality shared by the 2 constructs, it is advantageous to investigate how career commitment relates to job satisfaction. Conversely, if the intention is to draw distinctions between the 2, it will be more germane to ask how job satisfaction is related to career commitment.

It is also important to consider these results within the larger context of the literature. Although some studies have suggested that enhanced paraprofessional training can increase job satisfaction, and other studies have explored the relation between job satisfaction and turnover, there has been no data relating career commitment to these constructs. Perhaps this is not surprising, given the conceptual distinctions drawn between paraprofessionals and professionally trained nurses. Because our training was intended to enhance the level of professionalism among those who participated, it was natural to consider the extent to which we could engender a greater involvement in their jobs and the work being done. In order to investigate this, we used a scale constructed for professionals who may have more choices in their career selection. A legitimate question arises as to the appropriateness of using a measure originally intended for persons who have intentionally made career choices. But given the lack of any corollary measure that might be better suited, the real questions pertain to how findings among persons who may not have had those opportunities should be interpreted.

As some of the participants in this study may have been limited in their ability to choose this particular vocation, we interpret the results on our measure to be more reflective of the extent to which participants considered themselves to be invested in their vocational positions, as a consequence of being empowered in the workplace. In this context, empowerment refers to a sense that one has “the ability to get things done, to mobilize resources, to get and use whatever it is that a person needs for the goals he or she is attempting to meet.” ^31(p166) When applied to paraprofessionals, it seems as though empowerment would naturally lead to greater engagement in vocational pursuits. In this way, it is akin to what is normally regarded as career commitment in professionally trained individuals. Given these considerations, we have concluded that there is really no a priori impediment to employing the CCM in paraprofessional populations. We saw no need to modify the wording of items included on the questionnaire, but this does not preclude the possibility that a more concerted psychometric effort could result in a better-tailored instrument that would be more ideally suited for paraprofessionals who may have limited options in the job market.

This study is limited as a consequence of the sample composition. Although the participants in this study were drawn from a variety of environments (assisted living, nursing homes, home care agencies, etc), it would be instructive to limit the sample to one segment of the continuum of care. In addition, although the overall scale scores are comparable to those reported in previous field studies, expanding the study to include nursing assistants who do not provide direct Alzheimer’s care or those who are not seeking dementia-specific training would strengthen the conclusions presented here.

It seems, however, that interventions designed to enhance levels of career planning could improve intrinsic job satisfaction. Applying this result to the direct care workforce crisis, it is logical to expect training programs that have the potential for facilitating the adoption of a career ladder or career lattice orientation may improve satisfaction with the job context of work as well. We have previously reported on data establishing an increase in extrinsic job satisfaction as a consequence of training to instill a person-centered orientation to Alzheimer's care. ⁴⁴ Although our training program was intended to increase the quality of care and quality of life for care recipients, a more pointed focus on concomitantly (or subsequently) enhancing career planning among the staff might have had a more positive influence on extrinsic job satisfaction. Our Enhanced Care Assistant Training (ECAT) program, implemented subsequent to the present training initiative, was intended to do exactly that. The curriculum was designed to increase career commitment and self-efficacy ⁴⁵ by instilling the values of recognition, responsibility, and respect among personal care attendants providing services for recipients of Medicaid-waiver home care. Beyond the delivery of content to improve problem-solving, communication, and stress management skills, the program also encouraged peer mentoring and the application of learning by including work-based homework assignments between training sessions. ⁴⁶

However, caution should be exercised in these kinds of interventions so that an expectation of pursuing career ladders or lattices is not superimposed upon participants who may be fully satisfied in their current positions. Professional educators, who intervene to improve the care provided by paraprofessionals as a way of enhancing the quality of life for care recipients, must be ever mindful that they may be wearing lenses tinted by inculcation of the protestant work ethic.

Further application of this study’s results to the direct care workforce crisis suggests that mentoring programs to assist with exploring developmental needs and establishing a career path could engender greater satisfaction with job context. The implementation of mentoring programs will be challenging, however, because high turnover and vacancies leave new workers with fewer experienced mentors on the job. ¹⁹ Although programs will most likely need to be imposed from outside of the organization, they should maintain the facility or agency as a third member of the mentoring relationship. ⁴⁷

It is recommended that future efforts to implement training interventions include an additional focus on vocational development. Indeed, levels of career commitment as a consequence of staff training has been most recently shown to be better among personal care attendants with relatively higher levels of extrinsic job satisfaction. ⁴⁸ In addition to the primary goal of promoting an optimal balance between the desired long-term (or community-based) care services and the provision of those services, interventions should seek to modify the work environment in a way that will promote the empowerment of direct care staff. Although the retraining of staff provides specific opportunities for vocational development, this should occur within an enhanced work environment that encourages and promotes individuals within the organization. The achievement of increased knowledge and ability must be recognized, and trainees need to be able to apply and practice new skills in the workplace.

Conclusion

Our results suggest that efforts to improve job retention and reduce turnover should consider changes in career commitment, as well as job satisfaction, since both of these latter constructs are logical contributors to worker empowerment. Indeed, our data point to a relation between career planning and satisfaction with work-based opportunities for achievement and recognition (ie, intrinsic job satisfaction), in addition to a relation between career planning and extrinsic job satisfaction. It seems that job satisfaction may encourage the pursuit of work-related goals, and environments that promote vocational development can result in improved job satisfaction.

The exact causal relation of the 2 constructs under consideration awaits a more rigorous study and directional hypothesis testing. A longitudinal study using structural equation modeling and/or cross-lagged analyses would be informative. In the meantime, however, it appears that both factors are important in addressing the direct care workforce crisis, and efforts to seek solutions should consider career commitment as well as job satisfaction.