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. 2024 May 2;64(6):gnae033. doi: 10.1093/geront/gnae033

The Association of Nursing Homes’ Organizational Context With Care Aide Empowerment: A Cross-Sectional Study

Alba Iaconi 1,✉, Matthias Hoben 2, Whitney Berta, PhD 3, Yinfei Duan 4, Peter G Norton 5, Yuting Song 6, Stephanie A Chamberlain 7, Anna Beeber 8, Ruth A Anderson 9, Holly J Lanham 10, Janelle Perez 11, Jing Wang 12, Katharina Choroschun 13, Shovana Shrestha 14, Greta Cummings 15, Carole A Estabrooks 16
Editor: Nicholas Castle
PMCID: PMC11129593  PMID: 38695153

Abstract

Background and Objectives

Organizational context is thought to influence whether care aides feel empowered, but we lack empirical evidence in the nursing home sector. Our objective was to examine the association of features of nursing homes’ unit organizational context with care aides’ psychological empowerment.

Research Design and Methods

This cross-sectional study analyzed survey data from 3765 care aides in 91 Western Canadian nursing homes. Random-intercept mixed-effects regressions were used to examine the associations between nursing home unit organizational context and care aides’ psychological empowerment, controlling for care aide, care unit, and nursing home covariates.

Results

Organizational (IVs) culture, social capital, and care aides’ perceptions of sufficient time to do their work were positively associated with all four components of psychological empowerment (DVs): competence (0.17 [0.13, 0.21] for culture, 0.18 [0.14, 0.21] for social capital, 0.03 [0.01, 0.05] for time), meaning (0.21 [0.18, 0.25] for culture, 0.19 [0.16, 0.23] for social capital, 0.03 [0.01, 0.05 for time), self-determination (0.38 [0.33, 0.44] for culture, 0.17 [0.12, 0.21] for social capital, 0.08 [0.05, 0.11] for time), and impact (0.26 [0.21, 0.31] for culture, 0.23 [0.19, 0.28] for social capital, 0.04 [0.01, 0.07] for time).

Discussion and Implications

In this study, modifiable elements of organizational context (i.e., culture, social capital, and time) were positively associated with care aides’ psychological empowerment. Future interventions might usefully target these modifiable elements of unit level context in the interest of assessing their effects on staff work attitudes and outcomes, including the quality of resident care.

Keywords: Long-term care, Organizational context, Psychological empowerment, Work environment

Background and Objectives

With the aging global population (Statistics Canada, 2022; WHO, 2021), staff in nursing homes (long-term care homes or care homes) are facing enormous challenges in delivering quality of care to an increasing number of residents with complex care needs (Castle & Ferguson, 2010; Corazzini et al., 2015; Estabrooks et al., 2020). The COVID-19 pandemic has highlighted the challenges that have plagued nursing homes for decades, including a voiceless care aide workforce, silenced residents, profound inequities and inequalities, lack of support for leaders, and insufficient funding (Estabrooks, 2021; Estabrooks et al., 2020; Grabowski, 2022). Thus, empowerment of care aides now is needed more than ever.

Residents in nursing homes are a vulnerable population; often diagnosed with dementia, Alzheimer’s disease, and multiple comorbidities; dependent; and without a strong advocacy (Estabrooks et al., 2013, 2020; Office of the Chief Science Advisor of Canada, 2020). Up to 90% of the complex direct care needs of residents in nursing homes are provided for by care aides (also referred to as health care aides, nursing assistants, direct care workers) (Berta et al., 2013; Chamberlain et al., 2019; Estabrooks, Squires, Carleton, et al., 2015; Hewko et al., 2015). Most care aides are immigrant middle aged or older women speaking English as an additional language, and are often marginalized within their employer organizations and the healthcare system (Chamberlain et al., 2019; Estabrooks, Squires, Carleton, et al., 2015; Song, Iaconi, et al., 2020). Working short-staffed, receiving low wages and limited benefits, consequently 38% of care aides hold more than 1 job, either working in multiple homes or outside of the nursing home (Baughman et al., 2022; Duan et al., 2020). Additionally, care aides who are Black experience more job strain and earn less compared with White care aides (Hurtado et al., 2012). Current research reports that care aides experience negative outcomes and report high rates of missed and rushed essential care (Song, Hoben, et al., 2020); responsive behaviors from residents (Song et al., 2022) which are reactive behaviors of persons living with dementia as a way of responding to something negative, frustrating, or confusing in their environment including but not limited to aggressions, wandering, paranoia (Alzheimer Society of Canada Responsive Behaviours, 2017); high risk of burnout (Chamberlain et al., 2017); and heightened health and financial risk (Almeida et al., 2020). Consequently, the quality of care aides’ work-life is negatively affected.

One way to facilitate improvements in the quality of work and work-life is through staff empowerment. Greater staff empowerment is associated with greater retention (Berridge et al., 2018), which is important as the turnover rate of care aides is as high as 119% per year (Castle et al., 2006), and a high turnover is linked to low quality of care for residents (Lerner et al., 2014). To date, most studies have focused on structural empowerment (Caspar & O’Rourke, 2008; Caspar et al., 2013; Laschinger & Finegan, 2005; Spence Laschinger et al., 2014). Although structural empowerment refers to the social structures (opportunities, information, support, and resources) that facilitate one’s work (Kanter, 1977, 1979), psychological empowerment refers to one’s experiences derived from engaging in work tasks (Spreitzer, 1995). Although the relationship between structural and psychological empowerment has been established (Lethbridge et al., 2011; Stewart et al., 2010; Wagner et al., 2010), less is known about the organizational context factors that lead to care aides’ feelings of empowerment in nursing homes.

Theoretical Frameworks

Organizational Context

These organizational unit factors have been studied extensively in the nursing research using the Alberta Context Tool (ACT) (Estabrooks, Squires, Cummings, Birdsell, & Norton, 2009) (Table 1). Based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, context is defined as the environment in which a proposed change is to be implemented and consists of 3 core elements: culture, leadership, and measurement (Kitson et al., 1998). The instrument has been translated in several languages and studied in various populations (Eldh et al., 2013; Estabrooks et al., 2011; Hoben et al., 2013, 2014; Schadewaldt et al., 2019; Squires et al., 2015), including care aides (Estabrooks et al., 2011). It measures 10 modifiable elements at the unit level of a nursing home: culture, leadership, evaluation, formal interactions, informal interactions, structural and electronic resources, social capital active connections among people on the unit team in the form of bonding, bridging, and linking (Aldrich, 2012; Szreter & Woolcock, 2004), organizational slack (unit staffing), organizational slack (space), and organizational slack (time resource) (Table 1). For example, evidence of the modifiability of ACT elements is demonstrated in the INFORM randomized controlled trial, where a goal-setting feedback intervention was proven effective at improving formal communication and active connections (social capital) among people in interdisciplinary healthcare teams in nursing homes (Hoben et al., 2020). Specifically, compared with the control group the higher intensity feedback intervention groups, care aide involvement in formal communications at 1-year follow up was 0.17 points higher, and a similar increase was observed for the active connections among team members on the unit. To continue to better understand strategies to empower care aides within their work environment (context), in this study we seek to identify the organizational unit factors within nursing homes that are associated with care aides’ psychological empowerment (competence, meaning, self-determination, impact).

Table 1.

The Alberta Context Tool (ACT) and Psychological Empowerment Variables

Variable Description No. of items Scoring Cronbach Alpha
Organizational context (iv) Care aides’ perception of their work environment in the LTC unit measured with the Alberta Context Tool
Leadership Actions of individuals with leadership roles in an unit to influence changes and excellence in practice; items generally reflect emotionally intelligent leadership 6 Continuous: mean of items on a 5-point Likert scale where 1 = strongly disagree and 5 = strongly agree 0.73
Culture The way “we (care aides) do things” in organization and work units; reflective of a supportive work culture 6 Continuous: mean of items on a 5-point Likert scale where 1 = strongly disagree and 5 = strongly agree 0.72
Evaluation The process of using data to assess group or team performance and to achieve outcomes in organizations or units 6 Continuous: mean of items on a 5-point Likert scale where 1 = strongly disagree and 5 = strongly agree 0.72
Formal interaction Formal exchanges that occur between individuals working within an organization or unit through scheduled activities that can promote the transfer of knowledge 4 Continuous: mean of items on a 5-point frequency Likert scale where 1 = never and 5 = almost always; recoded to 0 = no interaction, 1 = interaction, and a count of recoded items was taken 0.73
Informal interaction Informal exchanges among individuals working within an organization or unit that can promote the transfer of knowledge 9 Continuous: 5-point frequency Likert scale where 1 = never and 5 = almost always; recoded to 0 = no interaction, 1 = interaction and a count of recoded items was taken 0.74
Social capital Stock of active connections among people, including 3 types of connections: bonding, bridging, and linking 6 Continuous: mean of items on a 5-point Likert scale where 1 = strongly disagree and 5 = strongly agree 0.73
Structural and electronic resources Structural elements of an organization or unit that facilitate the ability to assess and use knowledge 7 Continuous: 5-point frequency Likert scale where 1 = never and 5 = almost always; recoded to 0 = no interaction, 1 = interaction and a count of recoded items was taken 0.70
Organizational slack in use of staff
 Human resources
 Staff
 Time
 Space		 Cushion of actual or potential staff resources that allows an organization or unit to adapt successfully to internal pressures for adjustments or to external pressures for changes 3
2
4		 Continuous: mean of items on a 5-point Likert scale in which 1 = strongly disagree and 5 = strongly agree 0.72
0.75
0.71
Psychological empowerment (dv) Increased task motivation manifested in a set of four cognitions reflecting one’s orientation to their work role
 Competence A belief in one’s capability to perform work activities with skill and is analogous to agency beliefs, personal mastery, or effort-performance expectancy 3 The overall score is derived by taking the average of the 3 items with a possible range from 1 to 5 0.84
 Meaning Involves a fit between the needs of one’s work role and one’s beliefs, values, and behaviors 3 The overall score is derived by taking the average of the 3 items with a possible range from 1 to 5 0.92
 Self-determination A sense of choice in initiating and regulating one’s actions 3 The overall score is derived by taking the average of the 3 items with a possible range from 1 to 5 0.84
 Impact The converse of helplessness; the degree to which one can influence strategic, administration, or operating outcomes in one’s department or work unit 3 The overall score is derived by taking the average of the 3 items with a possible range from 1 to 5 0.75
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Notes: LTC = long-term care; iv = independent variable; dv = dependent variable.

Psychological Empowerment

In the organizational psychology literature, empowerment is defined as an active participatory process by which individuals, organizations, and communities gain mastery over issues of concern to them (Rappaport, 1987). The psychological empowerment lens integrates perceptions of personal control, a proactive approach to life, and a critical understanding of the sociopolitical environment (Zimmerman, 1995). In the workplace, psychological empowerment is defined as 4 motivational cognitions that reflect one’s proactive orientation to their work role (Thomas & Velthouse, 1990). These are meaning—the value of a work goal or purpose; competence—one’s belief in their ability to perform work activities with skill; self-determination—one’s perception of having choice and control over work actions; and impact—the influence one has of work outcomes (Spreitzer, 1995; Thomas & Velthouse, 1990). Each component adds a unique facet to an individual’s experience of empowerment.

Important to note is that competence and self-efficacy are synonymous and analogous to agency beliefs, personal mastery, or effort-performance expectancy (Bandura, 1977, 1989; Spreitzer, 1995). Meaning involves a fit between the work role requirements and an individual’s beliefs, values, and behaviors (Brief & Nord, 1990; Spreitzer, 1995). Self-determination is based on the self-determination theory which offers an approach to human motivation, with 3 psychological needs all of which when met lead to enhanced intrinsic motivation and general well-being for an individual (Deci et al., 1989; Ryan & Deci, 2000; Spreitzer, 1995). Impact is different from locus of control—a personality trait that explains the degree of an individual’s perception of the root causes of events in their life (Rotter, 1966; Spreitzer, 1995).

Psychological empowerment has positive implications for organizations undergoing organizational change by creating mechanisms for people to have ownership over change process (Spreitzer, 2008). Psychological empowerment has been shown to result in greater effectiveness at work, higher job satisfaction, less job-related strain, greater organizational commitment, less turnover, more innovative behaviors, and better performance (Spreitzer, 2008; Spreitzer et al., 1997). Within nursing home care settings, psychological empowerment has been shown to similarly and positively be associated with job satisfaction (Aloisio et al., 2018; Cicolini et al., 2014; Li et al., 2018), organizational citizenship behavior and quality of work-life (Berta et al., 2018), innovation (Knol & van Linge, 2009), work engagement (Ginsburg et al., 2016), and retention (Zurmehly et al., 2009) and reduces job strain (Laschinger et al., 2001).

The relationship between modifiable features of the work environment—including leadership, culture, and communication on the care home unit—and the psychological empowerment of care aides is unknown. Thus, in this study, we examined a series of hypotheses regarding the relationships between features of nursing homes’ organizational unit context, measured by the ACT, and the psychological empowerment of care aides. Hypotheses 1–10: Modifiable elements of organizational unit context—culture (1), leadership (2), evaluation (3), formal interactions (4), informal interactions (5), structural and electronic resources (6), social capital (7), staffing (8), space (9), time (10)—were each hypothesized to be positively associated with care aides’ psychological empowerment—competence, meaning, self-determination, and impact.

Research Design and Methods

Study Design

This study is a retrospective secondary data analysis and part of a large mixed-method project called “The influence of context on implementation and improvement” (ICII) (Estabrooks et al., 2022). ICII, in turn is part of the larger Translating Research in Elder Care (TREC) program (Estabrooks, Squires, Cummings, Teare, & Norton, 2009). The ICII project aims to address how modifiable organizational context elements are associated with staff and resident outcomes.

Data Sources

TREC’s longitudinal database includes 17 years of regularly administered surveys to regulated, unregulated, and allied nursing home staff and resident administrative data (Estabrooks, Squires, Cummings, Teare, & Norton, 2009). Unregulated staff (care aides) completed computer-assisted in-person interviews (Estabrooks, Squires, Cummings, Teare, & Norton, 2009; Squires et al., 2012). We examined care aide survey data collected between September 2019 and March 2020. We also included some covariate measures from unit and facility surveys that are completed by managers, administrators, or directors of care. Sampling and recruitment methods are described elsewhere (Estabrooks, Squires, Cummings, Teare, & Norton, 2009).

Setting

The study setting was 91 nursing homes with 324 resident care units in 3 Western Canadian Provinces: Alberta, Manitoba, and British Columbia (Estabrooks, Squires, Cummings, Teare, & Norton, 2009). Nursing homes were stratified by health regions or zones, size (small <80 beds, medium 80–120 beds, large >120 beds), and owner-operator model (public nonprofit, voluntary nonprofit, private for-profit).

Participants

Care aides were eligible to complete the TREC survey if they met the following eligibility criteria: worked in a nursing home for 3 months or longer and worked 50% or more (6 or more shifts) on a unit during the month prior to data collection.

Ethics

We obtained ethics approval from the research ethics boards of the respective Universities leading the TREC study. Regional health authorities and participating nursing homes provided operational approvals for data collection processes. We obtained written informed consent from all care aides.

Measures

Our model included 1 dependent variable (psychological empowerment) with 4 constructs, and 1 main independent variable (organizational context) with 10 constructs. Control variables included 6 outer (macro) and inner (meso and micro) context factors and 5 individual care aides’ characteristics.

Dependent variables

We measured care aides’ psychological empowerment using an adapted version of Spreitzer’s Psychological Empowerment Scale (Spreitzer, 1995), including 4 dimensions (competence, meaning, self-determination, and impact) each measured using 3 items. The Cronbach alpha reliability coefficients for all 4 scales in the original study were between 0.62 and 0.72, tested in 2 different samples (Spreitzer, 1995). The adapted psychological empowerment scales were tested in a sample of care aides and a 4-factor model was confirmed via confirmatory factor analysis (Ginsburg et al., 2016). We derived the overall score for each dimension by taking the 3-item average with a possible score range of 1–5, with 1 indicating strongly disagree and 5 indicating strongly agree (Table 1). Higher scores indicate higher psychological empowerment. The 4 variables were continuous.

Independent variables

Organizational context was measured using the ACT (Estabrooks, Squires, Cummings, Birdsell, & Norton, 2009). Descriptions, scoring, and Cronbach alphas for the 10 ACT scales are presented in Table 1. For each ACT scale a composite score was generated by taking the mean or sum of the items. All items were scored on a 5-point Likert scale.

Control variables

The included covariates represent nursing home and unit level characteristics associated with empowerment or related outcomes in the care aide population (Chamberlain et al., 2016, 2017; Estabrooks, Squires, Hayduk, et al., 2015; Song, Hoben, et al., 2020) and are based structurally on the iPARIHS framework (Harvey & Kitson, 2016).

The outer context covariate was the region where the nursing home was located. The inner context variables were the unit structure including the nursing homes’ owner-operator model and size, unit type, total staffing (managers, registered nurses and registered psychiatric nurses, licensed practical nurses, and health care aides’ total care hours per resident day), and the unit case mix index derived from the individual resident (average of individual residents’ case mix index for the unit).

Individual covariates were included that may confound the analysis are: age, gender, language, work tenure, and work shift (Chamberlain et al., 2016; Koberg et al., 1999; Olds & Clarke, 2010; Zimmerman & Rappaport, 1988).

Statistical Analyses

We conducted analyses using the Statistical Package for Social Science software v28 (IBM SPSS, Armonk, NY). Descriptive statistics (mean, median, standard deviation) were used to characterize the distribution of outcome variables, perceptions of organizational context, and covariates. We ran 4 mixed-effects linear regression models, 1 for each dependent variable (the 4 psychological empowerment scores) with unit- and facility-level random intercepts accounting for clustering and controlling for covariates. All organizational context variables and covariates were entered to the model simultaneously. A multicollinearity check identified no problems when entering these variables simultaneously (Myers, 1990; Neter et al., 1985). R2 values for each model were estimated to determine the variance explained.

Results

Sample Characteristics

Table 2 presents care aide characteristics. The majority of care aides identified as middle-aged females (89.2%) with English as an additional language (68.3%) and an average of 6.14 years of experience on a unit. Care aides’ psychological empowerment average scores were high or moderately high (4.51, 4.56, 4.06, and 3.75 for competence, meaning, self-determination, and impact, respectively). The internal reliability scores for the psychological empowerment dimensions were very good (Table 1).

Table 2.

Characteristics of Care Aide Participants (n = 3765)

Variables N (%)/mean (SD)
Age n (%)
 <30 318 (8.4)
 30–39 815 (21.7)
 40–49 1186 (31.5)
 50–59 1019 (27.1)
  ≥ 60 427 (11.3)
Gender n (%)
 Male 403 (10.7)
 Female 3359 (89.2)
English as first language n (%)
 Yes 1194 (31.7)
 No 2571 (68.3)
Number of years of experience as a care aide on a unit, mean (SD) 6.14 (6.26)
Shift worked most often n (%)
 Day 1909 (50.7)
 Evening 1381 (36.7)
 Night 475 (12.6)
Psychological Empowerment (possible range 1–5), mean (SD)
 Meaning 4.56 (0.49)
 Competence 4.51 (0.47)
 Self-determination 4.06 (0.72)
 Impact 3.75 (0.69)
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Notes: N = number; SD = standard deviation.

Table 3 presents the results of the context characteristics with care aide responses. Majority of care aides worked in general long-term care units (69.9%) or dementia care units (18.7%). Approximately half (56.6%) of the care aides worked in large nursing homes (more than 120 beds), and less than a quarter (19.9%) worked in public not-for-profit nursing homes.

Table 3.

Outer and Inner Organizational Context Characteristics with Care Aide Responses (n = 3765)

Variables N (%)/mean (SD)
Region n (%)
 Edmonton zone 894 (23.7)
 Calgary zone 696 (18.5)
 BC interior health 380 (10.1)
 BC Fraser health 1037 (27.5)
 Winnipeg regional health 758 (20.1)
Care home owner/operator n (%)
 Public not for profit 748 (19.9)
 Private for profit 1574 (41.8)
 Voluntary not-for-profit 1443 (38.3)
Care home bed size n (%)
 Small (35–79) 470 (12.5)
 Medium (80–120) 1164 (30.9)
 Large (>120) 2131 (56.6)
Unit type n (%)
 General LTC 2630 (69.9)
 Dementia care 703 (18.7)
 Other/mental health 432 (11.5)
Total staffing, mean (SD) 2.70 (0.80)
Unit case mix, mean ± SD 0.67 (0.09)
Organizational context (possible range), mean ± SD
 Leadership (1–5) 3.97 (0.57)
 Culture (1–5) 4.07 (0.51)
 Evaluation (1–5) 3.78 (0.61)
 Formal interactions (0–4) 1.48 (0.82)
 Informal interactions (0–9) 4.14 (1.74)
 Social capital (1–5) 4.05 (0.51)
 Structural resources (0–7) 2.65 (1.56)
 Organizational slack; staffing (1–5) 2.86 (1.11)
 Organizational slack; space (1–5) 3.56 (1.23)
 Organizational slack; time (1–5) 3.47 (0.87)
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Notes: N = number; SD = standard deviation; BC = British Columbia; LTC = long-term care.

Unit-Level Organizational Context

The regression results show that elements of organizational unit context were associated with all 4 psychological empowerment dimensions. The statistical results of the 4 mixed-effects models are presented in Table 4. The organizational unit’s culture, social capital, and time were positively associated with all 4 dimensions of psychological empowerment: competence (0.17 [0.13, 0.21] for culture, 0.18 [0.14, 0.21] for social capital, 0.03 [0.01, 0.05] for time), meaning (0.21 [0.18, 0.25] for culture, 0.19 [0.16, 0.23] for social capital, 0.03 [0.01, 0.05] for time), self-determination (0.38 [0.33, 0.44] for culture, 0.17 [0.12, 0.21] for social capital, 0.08 [0.05, 0.11] for time), and impact (0.26 [0.21, 0.31] for culture, 0.23 [0.19, 0.28] for social capital, 0.04 [0.01, 0.07] for time).

Table 4.

Association Between Organizational Context in Care Home Units and Care Aides’ Psychological Empowerment Components: Two-Level Random Intercept Regression Models

Outcome variables -> Competence Meaning Self-determination Impact
Independent variables Coeff. [95% CI] p-Value Coeff. [95% CI] p-Value Coeff. [95% CI] p-Value Coeff. [95% CI] p-Value
Organizational context (inner context micro)
 Leadership 0.01 [−0.02, 0.04] .61 0.01 [-0.02, 0.04] .54 0.05 [0.001, 0.09] .04 0.01 [−0.04, 0.05] .72
 Culture 0.17 [0.13, 0.21] <.001 0.21 [0.18, 0.25] <.001 0.38 [0.33, 0.44] <.001 0.26 [0.21, 0.31] <.001
 Evaluation 0.02 [−0.01, 0.05] .16 0.03 [−0.001, 0.06] .053 0.09 [0.04, 0.13] .001 0.12 [0.08, 0.17] <.001
 Formal iInteractions −0.02 [−0.04, 0.004] .11 −0.03 [−0.05, −0.01] .01 0.02 [−0.01, 0.05] .24 0.02 [−0.01, 0.04] .28
 Informal interactions 0.01 [−0.001, 0.02] .08 0.002 [−0.01, 0.01] .72 0.02 [0.002, 0.03] .03 0.04 [0.03, 0.05] <.001
 Social capital 0.18 [0.14, 0.21] <.001 0.19 [0.16, 0.23] <.001 0.17 [0.12, 0.21] <.001 0.23 [0.19, 0.28] <.001
 Structural resources −0.003 [−0.01, 0.01] .66 0.01 [−0.002, 0.02] .12 −0.02 [−0.04, −0.01] .01 −0.005 [−0.02, 0.01] 0.55
 OS staffing −0.03 [−0.05, −0.01] <.001 −0.04 [−0.05, −0.02] <.001 0.02 [−0.001, 0.04] .06 0.02 [−0.001, 0.04] .06
 OS space 0.02 [0.003, 0.03] .02 0.01 [0.0001, 0.03] .05 0.003 [−0.02, 0.02] .77 0.01 [−0.01, 0.02] .56
 OS time 0.03 [0.01, 0.05] .001 0.03 [0.01, 0.05] .01 0.08 [0.05, 0.11] <.001 0.04 [0.01, 0.07] .01
Covariates
Outer context (macro)
region (Ref. Manitoba)
 Edmonton zone −0.02 [−0.09, 0.05] .52 −0.02 [−0.09, 0.06] .67 0.03 [−0.08, 0.15] .58 −0.03 [−0.14, 0.08] .65
 Calgary zone 0.06 [−0.02, 0.13] .13 0.08 [−0.0004, 0.16] .051 −0.02 [−0.15, 0.10] .71 −0.01 [−0.13, 0.10] .82
 BC interior health −0.03 [−0.11, 0.05] .47 −0.03 [−0.11, 0.06] .58 0.16 [0.02, 0.30] .02 −0.04 [−0.18, 0.09] .504
 BC Frazer health 0.04 [−0.01, 0.09] .09 0.02 [−0.03, 0.08] .40 −0.04 [−0.12, 0.05] .39 −0.05 [−0.13, 0.03] .26
Inner context (meso)
care home level
Owner-operator model (Ref. private for profit)
 Public not for profit −0.05 [−0.09, −0.01] .02 −0.04 [−0.09, 0.01] .11 −0.09 [−0.17, −0.01] .02 −0.14 [−0.21, −0.07] <.001
 Voluntary not-for-profit 0.001 [−0.04, 0.04] .95 0.01 [−0.03, 0.05] .76 −0.06 [−0.13, 0.0003] .051 −0.09 [−0.15, −0.03] .01
Care home size (Ref. Small < 80 beds)
 Medium (80–120) 0.01 [−0.04, 0.06] .70 −0.05 [−0.10, 0.01] .10 0.04 [−0.05, 0.12] .36 −0.02 [−0.10, 0.07] .71
 Large (>120) 0.02 [−0.03, 0.07] .48 −0.04 [−0.09, 0.02] .18 0.05 [−0.03, 0.13] .21 −0.03 [−0.11, 0.05] .47
Inner context (micro) unit level
Unit type (Ref. General)
 Dementia −0.02 [−0.06, 0.02] .42 −0.04 [−0.09, 0.001] .06 −0.05 [−0.11, 0.02] .15 −0.01 [−0.07, 0.05] .74
 Other 0.01 [−0.02, 0.04] .56 0.01 [−0.02, 0.05] .54 −0.03 [−0.08, 0.02] .21 −0.002 [−0.05, 0.05] .94
Total staffing −0.01 [−0.03, 0.01] .48 −0.02 [−0.04, 0.01] .16 0.02 [−0.01, 0.05] 0.25 −0.003 [−0.03, 0.03] .83
Unit case mix 0.06 [−0.24, -.36] .69 −0.14 [−0.45, 0.18] .38 −0.27 [−0.73, 0.20] .26 −0.16 [−0.60, 0.28] .47
Care aide individual factors
Age (Ref. ≥50)
  <30 years −0.06 [−0.12, −0.01] .03 −0.05 [−0.10, 0.01] .11 −0.20 [−0.28, −0.12] <.001 −0.16 [−0.24, −0.08] <.001
 30–39 years −0.004 [−0.04, 0.03] .85 0.004 [−0.04, 0.04] .85 −0.11 [−0.16, −0.05] <.001 −0.10 [−0.15, −0.05] <.001
 40–49 years −0.01 [−0.05, 0.02] .45 −0.01 [−0.04, 0.03] .77 −0.05 [−0.10, −0.01] .03 −0.07 [−0.12, −0.03] <.01
Sex (female ref.) 0.05 [0.0005, 0.09] .047 −0.02 [−0.07, 0.02] .35 −0.002 [−0.07, 0.06] .94 0.06 [−0.002, 0.12] .06
Language ESL (Ref. English speaking) −0.07 [−0.10, −0.03] <.001 −0.05 [−0.08, −0.01] .01 0.10 [0.05, 0.15] <.001 0.03 [−0.02, 0.08] .21
Year of experience in unit 0.001 [−0.002, 0.003] .59 −0.001 [−0.003, 0.002] .52 −0.0003 [−0.003, 0.003] .87 0.001 [−0.003, 0.004] .75
Shift worked most often (Ref. night shift)
 Day shift −0.01 [−0.06, 0.04] .65 0.004 [−0.04, 0.05] .87 −0.11 [−0.18, −0.04] <.01 −0.09 [−0.16, −0.03] <.01
 Evening shift −0.02 [−0.07, 0.03] .44 0.02 [−0.03, 0.06] .53 −0.08 [−0.15, −0.01] .02 −0.12 [−0.18, −0.05] <.001
Model parameter
Intercept 2.99 [2.74, 3.24] <.001 2.97 [2.70, 3.23] <.001 1.05 [0.66, 1.43] <.001 1.17 [0.81, 1.54] <.001
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Notes: Coeff., = Coefficient; SE = standard error; SD = standard deviation; Ref., = Reference; BC = British Columbia; ESL = English as a second language.

Coefficients of variables are the results of the 3 random intercept model. The random intercepts for unit and care home clustering (ICC values) are close to zero for the components of psychological empowerment: competence (unit = 0.0002 [0.002], care home = 0.001 [0.001]), meaning (unit = 0.001 [0.002], care home = 0.001 [0.001]), self-determination (unit = 0.004 [0.004]), care home = 0.005 [0.003], and impact (unit = 0, care home = 0.01 [0.003]). Due to the small ICC values, the R-squared and R-squared adjusted values were calculated from the linear regression models on each component of psychological empowerment. The R-squared adjusted values for psychological empowerment were: competence = 0.130, meaning = 0.159, self-determination = 0.248, and impact = 0.233.

Evaluation (feedback on performance data) and informal interactions (a measure of informal exchanges between individuals working on a unit) were positively associated with care aides’ self-determination (0.09 [0.04, 0.13] and 0.02 [0.002, 0.03]) and impact (0.26 [0.21, 0.31] and 0.04 [0.03, 0.05]). The perceived leadership on the unit (the person that care aides report to most often) and space availability were each positively associated with 1 component of psychological empowerment, although formal interactions (care aide engagement in events such as family conferences) and structural resources and space availability were each negatively associated with one component of psychological empowerment. Staffing was negatively associated with competence and meaning. Clustering at the facility and unit level contributed little or almost no variance in all 4 models. Thus, the variance explained by each model, based on the R2 adjusted values, ranged between 13% for competence to 24.8% for self-determination (Table 4).

Discussion

To meet the need for an empowered care aide workforce caring for the needs of residents in nursing homes, we must identify malleable environmental factors that hold potential for transformational change and improved quality of care. This study offers initial evidence that specific nursing home organizational context features are either positively or negatively associated with care aides’ psychological empowerment. We found that elements of organizational context—culture, leadership, evaluation (the 3 elements from the PARIHS framework), social capital, time, evaluation, leadership, informal interactions, and space—were positively associated with one or more of care aides’ cognitions of psychological empowerment. Conversely to our hypothesis, formal interactions, structural resources, and staffing were negatively associated with care aides with psychological empowerment cognitions of meaning, self-determination, and competence.

Our findings suggest that by focusing on specific modifiable environmental factors holds the potential of empowering care aides with subsequent positive outcomes. For example, focusing on improving the organizational culture on the unit may not only enhance care aides’ empowerment at work, but also increase employee morale, productivity, well-being, health, and performance (Cameron & Quinn, 2011). Our positive finding on social capital’s positive association with care aides’ psychological empowerment adds to the positive relationships found in the literature that teamwork can augment care aides’ flexibility, persistence, and ability to maintain composure (Janes et al., 2008). However, management support is essential to the success of the teams, and the highest performing teams are those that make the most of the daily decisions and have a manager willing to help with tasks as needed (Yeatts & Seward, 2000).

Our findings are similar to Caspar et al., who identified that when care aides experience supportive supervisory relationships, their self-determination increases, in turn affecting their perceived ability to provide person-centered care to residents (Caspar et al., 2019). Responsive leaders cultivate organizational trust that is reciprocated by care teams, thus enhancing care aides’ quality of work-life and positively influencing the quality of care they provide (Caspar et al., 2020). Thus, attention to leadership, teamwork, and a positive culture within the unit will empower care aides and improve resident care.

We found that care aides’ engagement in formal interactions was negatively associated with the meaning derived from their work. An earlier clinical trial, Improving Nursing Home Care Through Feedback on Performance Data (INFORM), within the TREC program demonstrated that including care aides in resident care decisions (formal interactions) was only successful when a supportive work culture was present (Hoben et al., 2021). Involving care aides in formal communication and decision making about residents must be initiated by the managerial team and encouraged with appropriate information and feedback mechanisms (Hoben et al., 2020), as it can lead to low turnover, higher retention rates, higher aggregate social engagement scores, and lower incidence of pressure ulcers for residents in nursing homes (Barry et al., 2005). Formal interactions measured by the ACT reflect formal exchanges between team members, such as participating in team meetings about residents, in family conferences, and continuing education external to unit/nursing home (Estabrooks, Squires, Cummings, Birdsell, & Norton, 2009). Meaning reflects the value of a work goal judged in relation to a care aide’s own ideas, beliefs, values, or standards (Spreitzer, 1995). Although engaging in these types of formal interactions was negatively associated with care aides’ meaning derived from their work, other types of formal exchanges, such as formation of ‘team huddles’ at certain points in the team’s work-schedule may exhibit a positive association. This may indicate that the present structure of formal exchanges does not match care aides’ personal ideas, beliefs, values, or standards in relation to their judgment of the value of a specific work goal such as participating in team meetings about residents. More research is needed to identify the effects of the quality and structures of formal interactions among staff members.

Conversely, we found that care aides engaging in informal discussions in the hallway or nursing stations or through informal bedside teaching were associated with increased self-determination in their work and their perceptions of impact. A recent study demonstrated that care aides can effectively lead internal initiatives, resulting in better team cohesion, communication, and improvements in resident outcomes (Doupe et al., 2022). Therefore, finding ways for care aides to engage in quality formal and informal interactions is essential.

And lastly, work resources such as care aides time to care for residents were positively associated with their psychological empowerment. Previous research indicated that lack of time and frequent interruptions resulted in care aides missing at least 1 care task during a shift (Knopp-Sihota et al., 2015; Song, Hoben, et al., 2020). Interestingly, social capital was associated with missing 49% fewer care tasks. Thus, an interplay between teamwork and time on the unit may influence the care delivered to residents. A reorganization of care aides time to avoid interruptions could lead to care aides being able to use their time with residents more effectively (Mallidou et al., 2013).

Strengths and Limitations

This study has several strengths, including a large sample size of care aides from 91 stratified random samples of urban nursing homes, data collected using a rigorous in-person structured interview process, and accounting for the clustering effect of care aides within care units and facilities. An important limitation is that the cross-sectional sample precludes claims to causation. The sample is located in western Canada, thus generalizations beyond this population must be made with caution. Self-reported data are subject to concerns about recall bias and social desirability bias.

Implications and Future Research

Practical Implications

The findings of this study add to the organizational context literature and lend to further credence of the need for improved organizational culture, relationships among members of a team, and providing adequate resources for frontline workers to meet the needs of every resident in nursing homes. Improving organizational culture could take form of expressing appreciation for care aides, providing training opportunities, and reward incentives that will enhance their competence and motivation to meet residents’ needs. The hierarchical structures within nursing homes may prevent the fostering of quality relationships between care aides and other staff members of a unit team. Additionally, a fundamental challenge in nursing homes as part of the health care setting, is that it offers limited agency to all actors, including residents and staff working in various roles. Increasingly, directors of nursing, administrators, and other managers have reduced autonomy when practicing in an environment controlled by complex financial entities while the health care aides, although considered being the closest to the residents, lack visibility and inclusivity in decision-making processes of care. Even with these challenges, our hope is to help the directors of nursing homes and managers to identify the specific organizational components that may be modifiable to achieve behavioral and organizational change. For example, there is a unique opportunity for managers to create a culture where quality relationships among team members are built, and the barriers to effective communication are replaced with bridges of respect of appreciation. By empowering the care aide workforce, job satisfaction and retention as well as improvement in the quality of care for residents is a promising residual outcome.

Policy Implications

The successful INFORM trial mentioned earlier, designed for managers in nursing homes, was proven effective at improving formal communication and active connections (social capital) among workers. To continue to better understand strategies to empower nursing home workers within their work environment (context) tailored studies to health care aides are needed. Specifically, designing and testing pilot interventions tailored to modify targeted organizational context elements with psychological empowerment as a staff outcome in relation to a resident outcome are needed to provide nursing homes and policy makers with the necessary data needed for transformative change. And lastly, we envision offering ACT as a tool to nursing homes and health care settings to measure their organizational context for improved work performance and quality of care.

Theoretical Implications

To our knowledge, no previous empirical studies have simultaneously considered the organizational context concepts measured by ACT in association with the psychological empowerment of health care aides in the nursing home setting; hence, our findings advance general understanding of the complex concept dynamics between the work environment and of workers’ work psychology.

Future Research

Our study is essential in identifying specific organizational features of the nursing home environment that are associated with care aides’ psychological empowerment. Future research is needed to further examine the mechanisms between specific organizational context factors, worker’s work attitudes, and quality of work-life, on nursing home resident outcomes. Additionally, future research must focus on better understanding the perspectives of male care aides and those who work the night shift, as both were underrepresented in this study.

Conclusion

In summary, to meet the needs for an empowered care aide workforce caring for the needs of residents in nursing homes, our findings suggest that improving the organizational unit culture, creating active connections between staff members on a team, and understanding and addressing care aides’ perceived time shortages have the greatest potential to increase empowerment. Specific attention is needed to malleable organizational factors that are negatively associated with components of psychological empowerment, such as access to staffing, resources, and engaging health care aides in family conferences and decision-making processes. Investment in tailored actions to improve specific organizational context factors for specific workers may result in improved work-related attitudes, holding the potential for transformational change and improved quality of care.

Acknowledgments

The authors acknowledge the Translating Research in Elder Care team for their support in data collection processes. Furthermore, Tara Penner at TJPenner Consulting provided professional editing services for the manuscript.

Contributor Information

Alba Iaconi, Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.

Matthias Hoben, Faculty of Health, School of Health Policy and Management, York University, Toronto, Ontario, Canada.

Whitney Berta, PhD, Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.

Yinfei Duan, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.

Peter G Norton, Family Medicine, University of Calgary, Calgary, Alberta, Canada.

Yuting Song, Faculty of Nursing, Qingdao University, Qingdao, Shandong, China.

Stephanie A Chamberlain, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.

Anna Beeber, School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA.

Ruth A Anderson, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Holly J Lanham, Joe R. & Teresa Lozano Long School of Medicine, The University of Texas Health San Antonio, San Antonio, Texas, USA.

Janelle Perez, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Jing Wang, Nursing Department, College of Health and Human Services, University of New Hampshire, Durham, New Hampshire, USA.

Katharina Choroschun, School of Public Health, Bielefeld University, Bielefeld, Germany.

Shovana Shrestha, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.

Greta Cummings, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.

Carole A Estabrooks, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.

Funding

This work was supported by the Canadian Institutes of Health Research [#165838].

Conflict of Interest

None.

Data Availability

Due to the confidential nature of our data, it is not available to the public at this time. The Translating Research in Elder Care (TREC) data used for this article are housed in the secure and confidential Health Research Data Repository (HRDR) in the Faculty of Nursing at the University of Alberta, in accordance with the health privacy legislation of participating TREC jurisdictions. The data were provided under specific data sharing agreements only for approved use by TREC within the HRDR. Where necessary, access to the HRDR to review the original source data may be granted to those who meet prespecified criteria for confidential access, available at request from the TREC data unit.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Due to the confidential nature of our data, it is not available to the public at this time. The Translating Research in Elder Care (TREC) data used for this article are housed in the secure and confidential Health Research Data Repository (HRDR) in the Faculty of Nursing at the University of Alberta, in accordance with the health privacy legislation of participating TREC jurisdictions. The data were provided under specific data sharing agreements only for approved use by TREC within the HRDR. Where necessary, access to the HRDR to review the original source data may be granted to those who meet prespecified criteria for confidential access, available at request from the TREC data unit.

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