Abstract
Objectives.
This study examines the influence of race on perceived similarity and conflict between nursing home staff and family members of residents. Despite evidence that the caregiving experience varies by race for both family and professional caregivers, little is known about how race plays a role in staff conflict with residents’ family members.
Methods.
We used a representative sample of Certified Nursing Assistants (CNAs) to test relationships between race, treatment from family members, similarity to family members in expectations for care by CNAs, and conflicts with family members concerning aspects of resident care.
Results.
Results of structural equation modeling indicated that race was not a predictor of staff perception of conflict with family members or of poor treatment from residents’ families. However, Black nursing assistants were more likely to perceive that their own expectations of nursing care are dissimilar from those of residents’ family members. Dissimilarity predicted reports of poor treatment from family members, and poor treatment was a positive predictor of perception of conflict.
Discussion.
The personal long-term nature of nursing home care necessitates a high level of connectedness between family caregivers and nursing home staff. Results highlight the importance of establishing organizational pathways for communication of expectations between nursing staff and residents’ families.
Keywords: conflict, long-term care, race
IN the United States, approximately 13% of nursing home residents are Black (Jones, Dwyer, Bercovitz, & Stahan, 2009), whereas 38.8% of Certified Nursing Assistants (CNAs) working in nursing homes are Black (Centers for Disease Control, 2009). Although the population of Black residents differs between metropolitan and nonmetropolitan areas, even in cities, White residents are in the majority in most nursing homes due to the lower utilization of long-term care by Blacks (Jones et al., 2009; Smith, Feng, Fennell, Zinn, & Mor, 2007). Thus, a structural characteristic of many nursing homes is that they are multicultural environments where Black CNAs often care for White residents. The influence of race, however, on the relationship between nursing staff and family members of residents is largely unexamined. Using a representative sample of nursing assistants, we address two research questions: (a) Do Black nursing assistants perceive a higher level of conflict with residents’ family members than White nursing assistants? and (b) Is the relationship between race and conflict mediated by a staff perception that family expectations of care are similar or dissimilar from their own?
BACKGROUND
Conflict Between CNAs and Family Members
CNAs are often assigned tasks that are deeply personal and carry emotional salience for family members, such as bathing, feeding, dressing, and toileting. Frequent and emotionally intense contact between family and staff provides opportunities for conflict when family members feel that nursing assistants are not meeting their expectations of care (Vinton, Mazza, & Kim, 1998) or family members are not interacting with the resident in a manner consistent with nursing assistant expectations (Berdes & Eckert, 2007).
There is some evidence that interactions between Black nursing assistants and residents are affected by race. Past research has shown that Black nursing assistants face racial insults from residents, which, due to their role as personal caregivers with low organizational status, they are frequently required to ignore (Dodson & Zincavage, 2007; Grau & Wellin, 1992). Berdes and Eckert (2001) found that three quarters of the minority nursing assistants in their study had experienced race-related insults from residents, confirming the earlier work of Mercer, Heacock, and Beck (1993), who found that the majority of Black nursing assistants included in the study reported experiencing racism and frequently recounted incidents where they had been called names or insulted due to their race.
The studies just mentioned focused only on relationships with residents, but it is widely assumed that racial tension exists in relationships with family members as well. It is important to note, however, that to date, no study has specifically addressed the issue of whether race contributes to negative interactions between CNAs and family members using a large and representative sample. Despite the absence of research on the issue, based upon previous findings regarding race and the overall work environment of Black nursing assistants, we predict that Black nursing assistants will perceive higher levels of conflict with family members than White nursing assistants.
Hypothesis 1: In comparison with White nursing assistants, Black nursing assistants will perceive higher levels of conflict with family members of residents.
The second research question addresses the effect of similarity of expectations on the relationship between race and conflict. Conflict and dissatisfaction have been found to increase when staff members perceive that family members have expectations for long-term care that are different from their own (Abrahamson, Suitor, & Pillemer, 2009). It is possible that differences in caregiving expectations by race exist, given that the experience of caring for an aged family member differs between Black and White caregivers. Black families are less likely to utilize formal care services than White caregivers and therefore may more highly value maintaining older relatives at home. Blacks caring for a family member are also less likely than White caregivers to express burden and depression related to caregiving (Connell & Gibson, 1997; Janevic & Connell, 2001; Navaie-Waliser et al., 2001). Hypotheses 2 and 3 are based upon evidence from this literature that the family caregiving experience varies by race as well as the previous finding that similarity of expectations is negatively related to conflict.
Hypothesis 2: Black nursing assistants will perceive less similarity in care expectations between themselves and residents’ family members than White nursing assistants.
Hypothesis 3: Greater perception of similarity will decrease the amount of perceived conflict between nursing staff and family of residents.
In addition to interpersonal conflict, it is also possible that Black staff members will more often be the targets of poor treatment from family members. Such treatment may occur because some White families hold racist attitudes or are uncomfortable interacting with Black staff. As discussed earlier, research has documented that Black nursing staff can experience negative interactions with residents related to race. Therefore, we predict that Black CNAs will more often experience poor treatment from family members in comparison to White CNAs and that poor treatment will increase the level of conflict between staff and family.
Hypothesis 4: Black nursing assistants will experience poor treatment from family members more frequently than White nursing assistants.
Hypothesis 5: Nursing assistants who perceive less similarity with family members will experience poor treatment from them more frequently than those who perceive greater similarity.
Hypothesis 6: Nursing assistants who more frequently experience poor treatment from family members will have greater levels of conflict with them than those who less frequently experience poor treatment.
In summary, we hypothesize that nursing assistant race will directly predict conflict with the family members of residents and that nursing assistant race will indirectly predict conflict through poor treatment from family members. Additionally, nursing assistant race will indirectly predict conflict through perceived dissimilarity and it's implications for treatment by family members.
See Figure 1 for detailed representation of hypotheses.
Figure 1.
Model of hypothesized relationships.
METHOD
Data
Data used for the analyses were collected as part of the Partners in Caregiving (PIC) study (for a full description of methods, see Pillemer et al., 2003). The PIC study sought to evaluate the effectiveness of a cooperative communication intervention for nursing home families and staff. Participating nursing homes were randomly selected from the total of 60 nursing homes belonging to the New York Association of Homes and Services for the Aging, the state association for not-for-profit nursing homes. Units in each nursing home were randomly selected for the study within the 20 facilities, and data collection was attempted with all staff and family members on the units. Interviews used for this analysis were collected from nursing staff and family members prior to the commencement of the cooperative communication intervention. Of importance for this study, 94.7% of the family members sampled reported their race as White, reflecting the demographic makeup of the Central New York Region.
Participants
Because this project addressed the relationship between race and conflict with family members from a staff member perspective, only staff member interviews were used. From the total of 817 staff members, completed interviews were obtained from 655 respondents, a completion rate of 80% (Chen, Sabir, Zimmerman, Suitor, & Pilllemer, 2007; Pillemer et al., 2003). Of the 655 staff respondents, 76.8% reported their race as White, 16.9% reported their race as Black, 2.1% Hispanic, 1.2% Asian, 1.1% Native American, and 1.8% other. Nursing assistants accounted for 66.7% of respondents (n = 435). Thirty-one of the 435 nursing assistants reported a racial category other than Black or White. Only staff members who reported their race as Black or White and listed their job title as nursing assistant were included in the analysis, resulting in a sample size of 404.
The majority of CNAs were White (76.2%) and female (94.8%). Ninety-two percent of the sample had a total family income under $50,000, and 76% had no formal postsecondary education. Because postsecondary education may influence the level of conflict between staff and family, education was added to the structural model as an exogenous variable. Gender and income were excluded from the structural model because of the small number of cases who were male or had an income above $50,000, especially among Black respondents. Only six nursing assistant respondents were Black males, and only two Black nursing assistants reported an income of greater than $50,000 annually. See Table 1 for characteristics of the study sample.
Table 1.
Characteristics of Study Sample
| Total Sample (n = 404) | White Subsample (n = 308) | Black Subsample (n = 96) | |
| Race | |||
| White | 308 (76%) | — | — |
| Black | 96 (24%) | — | — |
| Gender | |||
| Female | 383(95%) | 293 (95%) | 90 (94%) |
| Male | 21 (5%) | 15 (5%) | 6 (6%) |
| Education | |||
| No postsecondary education | 304 (76%) | 236 (77%) | 68 (71%) |
| Postsecondary education | 97 (24%) | 70 (23%) | 27 (28%) |
| Missing | 3 (1%) | 2 (<1%) | 1 (1%) |
| Income | |||
| Household Income less than $50,000 annually | 360 (89%) | 270 (88%) | 90 (94%) |
| Household Income more than $50,000 annually | 32 (8%) | 30 (10%) | 2 (2%) |
| Missing | 12 (3%) | 8 (2%) | 4 (4%) |
Statistical Method
We tested the hypotheses using structural equation modeling (SEM). The Analysis of Moment Structures, or AMOS, computer program was used to test the hypothesized model (Arbuckle, 2005). SEM does not assume perfect measurement; instead, models are created for both the measurement of latent variables and the hypothesized structural relationships between variables (Garson, 2007; Kline, 2005).
The current project is a priori, or confirmatory, meaning a model is specified based upon theory and previous literature prior to analysis (Kline, 2005). A limitation of confirmatory model testing with cross-sectional data is the inability to address possible endogeneity between variables. Parameter estimates address the relationships between variables as specified by the research model and do not reflect the reciprocal influence variables may have upon each other. For example, poor treatment is predicted by the specified model to influence conflict, though it is quite possible that conflict increases the perception of poor treatment. The confirmatory model is designed to test how well the theoretically formed hypotheses fit the empirical data and should not be interpreted as the only possible configuration of structural relationships.
SEM was selected as the analytic method because it provides the advantage of assessing indirect as well as direct effects, a significant advantage given the complex nature of the topic addressed. Because the sample of nursing assistants is clustered within nursing homes and our use of SEM does not control for such clustering, we felt it was important to examine the degree to which the nursing assistants from each facility tended to report similar levels of conflict. To do so, we ran an analysis of variance (using SPSS 18) for conflict by nursing home and calculated the intraclass correlation coefficient (ICC; Grawitch & Munz, 2004; Kenney & La Voie, 1985; Kenny, Mannetti, Pierro, Livi, & Kashy, 2002). The ICC was .035, indicating that there was a very small tendency for the nursing assistants within facilities to report similar ratings of conflict with family. In other words, despite the clustered nature of the data, only about 3.5% of the variance in conflict is due to clustering of responses by nursing home. Therefore, given our current research questions, we believe that the strength of an SEM analysis outweighs the inability to adjust for clustering. However, it should be noted that the inability of the current analysis to account for nursing assistants being clustered within similar work environments is a limitation to our findings.
The amount of missing data for indicators used by this project was minimal, ranging from 8% to less than 1% of responses. Missing data were addressed by maximum likelihood estimation through the estimation of means and intercepts in the AMOS program.
Measurement
Latent variables utilize multiple indicators to represent an underlying construct and are confirmed through the development of a measurement model. The outcome variable “Staff/Family Conflict” was measured using the Frequency of Interpersonal Conflict Scale as developed by (Pillemer & Moore, 1989). Nursing assistants were asked about the frequency of conflict with family members in regards to personal care, meals, laundry, toileting, resident appearance, staff attentiveness, and administrative rules. The scale demonstrated an alpha of .840 with this sample. The latent variable “Similarity of Role Expectations” assessed nursing assistants’ perceptions regarding how similar they felt their expectations of nursing assistant care were in comparison with the care expectations of family members. Similarity was measured using four survey items from the Similarity of Values Scale, developed for use in the PIC pilot study (Pillemer, Hegeman, Albright & Henderson, 1998). The four survey items asked staff members to assess how similar they felt their values were to those of residents’ family members in general (“How similar are your values to those of family members: in general?”) and in terms of how hard staff should work in the job, how clean the resident should be kept, and how much family members should assist with care. The scale demonstrated an alpha of .608 with this sample. “Poor Treatment by Family” captured nursing assistant perception of being treated in a kind and respectful manner by family members and was measured using the Treatment by Family Members Scale as developed by (Pillemer et al., 1998). Staff members were asked how frequently family members are rude with requests, ignore them, treat them with respect, and smile/greet them. Items were recoded for analysis such that all survey items addressed the concept of being treated poorly. This four-item scale produced an alpha of .679 with this sample.
The observed variable “Education” was measured in two categories: no postsecondary education (76%) and some postsecondary education (24%). Race was measured as a dichotomous variable; only staff members who identified themselves as White (coded as 1) or Black (coded as 2) were included in the sample.
A measurement model was constructed for the three latent variables (Similarity, Poor Treatment, and Conflict) using 15 observed indicators (4 indicators for similarity, 4 indicators for poor treatment, and 7 indicators for conflict). The error terms associated with the three latent variables in the measurement model were allowed to be correlated, and each correlation was below .6. Evaluation of the measurement model produced an excellent model fit: relative chi-square 1.949, Tucker Lewis Index (TLI) .922, comparative fit index (CFI) .944, and root mean square error of approximation (RMSEA) .049 (.037-.059). Standardized regression weights for the measurement model are displayed in Table 2. A structural model was then created from the measurement model to test the hypothesized relationships between observed and latent variables.
Table 2.
Standardized Regression Weights for Measurement Model
| Similarity of values | Poor treatment from family | Staff/family conflict | |
| How hard I work | .500 | ||
| How clean is resident | .463 | ||
| How much family helps | .615 | ||
| Values in general | .541 | ||
| Rudeness | .441 | ||
| Ignore me | .507 | ||
| Respectful | .610 | ||
| Smile | .607 | ||
| Conflict over care | .707 | ||
| Conflict over rules | .557 | ||
| Conflict over meals | .690 | ||
| Conflict over laundry | .655 | ||
| Conflict over appearance | .655 | ||
| Conflict over attentiveness | .714 | ||
| Conflict over toileting | .667 |
Note: Model fit statistics: relative chi-square 1.949, Tucker Lewis Index .922, comparative fit index .944, root mean square error of approximation .049 (.037-.059).
RESULTS
We predicted that Black nursing assistants would report more conflict with family members of residents than would White nursing assistants. Unexpectedly, race was not a significant predictor of staff/family conflict. We also predicted that Black nursing assistants would be less likely than White nursing assistants to perceive similarity between themselves and the family members of residents in regards to expectations of care. Consistent with our hypothesized prediction, similarity of care expectations was negatively influenced by race (p < .01; see Table 3 for standardized parameter estimates). Black nursing assistants were more likely to perceive that their care expectations were different or dissimilar from the care expectations of the family members of residents. Additionally, we predicted that this perception of dissimilarity would result in increased conflict. The relationship between similarity of care expectations and conflict between staff and family did not reach statistical significance.
Table 3.
Standardized Parameter Estimates for Structural Model
| Similarity of values | Poor treatment from family | Staff/family conflict | |
| Black | −.215** | −.018 | −.090 |
| Some college | −.007 | −.036 | .117* |
| Poor treatment from family | .579*** | ||
| Similarity of values | −.488*** | .085 |
Notes: Model fit statistics: relative chi-square 1.882, Tucker Lewis Index .909, comparative fit index .935, and root mean square error of approximation .047 (.037-.057).
*p < .05; **p < .01; ***p < .000.
The relationship between race and perception of poor treatment was also not significant; Black staff members were not more likely to perceive poor treatment from resident's families. However, perceived dissimilarity resulted in a higher level of reported poor treatment from family members (p < .000), and staff perception of poor treatment from family members did result in increased staff/family conflict. Therefore, race was not a direct predictor of either conflict or poor treatment from family members but did negatively influence similarity of care expectations, which in turn influenced a perception of poor treatment, a strong predictor of staff/family conflict. Although Black nursing assistants were not more likely to report conflict or poor treatment from family members of residents, they did perceive less similarity with family members, and this perception of dissimilarity was a predictor of poor treatment, which in turn increased conflict. Interestingly, nursing assistant education was not a significant predictor of similarity or poor treatment but had a significant direct effect on staff/family conflict. As nursing assistant education increased, staff/family conflict increased as well.
Overall fit statistics demonstrate how well the empirical data reflects the research model proposed, both in terms of measurement and proposed structural relationships. The proposed structural model fits the empirical data acceptably. Fit statistics are as follows: relative chi-square 1.882, TLI .909, CFI .935, and root mean square error of approximation .047 (.037-.057). Table 3 displays standardized parameter estimates for the structural model.
DISCUSSION
We found that race was not a direct predictor of either conflict with family members or poor treatment from family members for nursing assistants caring for a predominately White resident population. This finding was unexpected, given that previous research has shown that Black nursing assistants face numerous forms of racial discrimination from residents. However, no prior research has specifically addressed the influence of race on the relationship between staff and residents’ families. Furthermore, recent studies have failed to find racial differences among CNAs in overall job satisfaction (Decker, Harris-Kojetin, & Bercovitz, 2009).
This finding contrasts with previous studies that suggest that racial prejudice and tension characterizes the work life of Black CNAs (Berdes & Eckert, 2001; Dodson & Zincavage, 2007; Mercer et al., 1993). The implications of our findings therefore are positive, suggesting that race does not play a major role in staff-family conflict or the perception of poor treatment of family members. It is important to note, however, that our study did not include direct measures of racially motivated aggression or discrimination from family members. Future research should address the issue of the role of the experience of racism by CNAs and its effect on attitudes toward families rather than focusing only on the race of CNAs as we have done.
Although our findings revealed no race differences in staff/family conflict, we believe that this may be due to the type of conflict captured in this study. For instance, one study of race in organizational groups showed that race was not a determinant of conflicts over specific tasks but was related to emotional conflict or relationship strain (Pelled, Eisenhardt, & Xin, 1999). The measure of conflict we used in this study focused specifically on conflict over the tasks involved in caring for the older family member. However, our finding that there are race differences in similarity of values, which is strongly related to strain in relationships (Jehn, Northcraft, & Neale, 1999; Rossi & Rossi 1990), leads us to suspect that race may play a greater role in relationship strain between staff and family.
Prior research has shown that conflict increases when staff feel that family members have expectations of care that are dissimilar to their own expectations (Abrahamson et al., 2009). Dissimilar role expectations are likely to result in unmet behavioral expectations and interpersonal conflict (Katz & Kahn, 1978). Although perceived dissimilarity did not directly influence conflict, it did increase perceived poor treatment from family members, which in turn increased conflict. Conflict is not increased by racial differences but through the perception of dissimilarity and poor treatment that results when those with differing care expectations come together with in the organizational setting of a nursing home.
This finding suggests that one promising approach to intervention may be programs that increase perceived similarity between family members and CNAs. Several intervention studies have been conducted that provide preliminary evidence in this direction. These interventions specifically encourage family members and staff to see themselves as having similar goals and shared interests (Pillemer et al., 2003; Robison et al., 2007). The results of these studies indicate that increasing perceived similarity reduces staff-family conflict and perceived poor treatment. Thus, although race differences were not found, the results of this study support an intervention approach that focuses on enhancing similarity between CNAs and families as well as additional research on such options. Large-scale studies using randomized controlled designs are recommended to further establish the effects of promoting perceived similarity in long-term care and its effects on family-staff relationships.
FUNDING
This research was supported by an Edward R. Roybal Center grant from the National Institute on Aging (1P30AG022845), K. Pillemer, Principal Investigator, and by grants from the National Institute on Aging (RO1 AG18869-01; 2RO1 AG18869-04), J. Suitor and K. Pillemer, Co-Principal Investigators. Jill Suitor also wishes to acknowledge support from Center on Aging and the Life Course at Purdue University. We are grateful to Yasamin Miller, Director, and the staff at the Cornell Survey Research Institute who performed data collection activities, as well as Leslie Schultz, Rhoda Meador, and Carol Hegeman for invaluable assistance with the study.
Acknowledgments
K. Abrahamson contributed to study design, data analysis, and preparation of the manuscript; K. Pillemer contributed to data collection and preparation of the manuscript; J.Sechrist contributed to data analysis and preparation of the manuscript; J. Suitor contributed to data collection and preparation of the manuscript.
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