Does connectedness matter? The association between mutuality and job satisfaction among home health aides caring for adults with heart failure

Abstract

Home health aides (HHAs) provide care to many adults with heart failure (HF) in the home. As the demand for HHAs increases, there is a need to promote HHAs’ job satisfaction and retention. In this cross-sectional community-partnered study, we examined whether mutuality (e.g., quality of the HHA-patient relationship), is associated with job satisfaction among HHAs caring for adults with HF. Mutuality was assessed with the Mutuality Scale, which measures overall mutuality and its four domains (reciprocity, love and affection, shared pleasurable activities, and shared values). Our final sample of 200 HHAs was primarily female. The mean overall mutuality score was 2.92 out of 4 (SD 0.79). In our final model, overall mutuality and each of the four domains were associated with increased job satisfaction; however, only the shared pleasurable activities domain was significant (aPR: 1.15 [1.03–1.32]). Overall, mutuality may play a role in promoting job satisfaction among HHAs.

Background and Objectives

Home health aides (HHAs) represent one of the fastest growing jobs in the healthcare industry (U.S. Home Care Workers: Key Facts, 2019). Largely employed by licensed home care agencies, there are currently 3.4 million HHAs in the United States (US) and estimates project that the home care sector will need to fill an additional 1.1 million jobs over the next decade (Home Health and Personal Care Aides: Occupational Outlook Handbook, 2021). The increased demand for home care and utilization of HHAs is fueled in part by a rapidly aging population that wants to age in place, but also by health systems that are trying to reduce the length of hospitalizations and avoid readmissions (Rosenfeld & Russell, 2012). This is especially true for adults with heart failure (HF) (Jones et al., 2017). HF patients, who tend to be older and have functional impairments and multiple chronic conditions, frequently receive assistance from HHAs (Gorodeski et al., 2018). For many patients with HF, a disease which often requires close symptom monitoring, diet changes, and frequent medical appointments, the assistance of a HHA allows them to safely remain at home. HHAs help with personal care (assist with activities of daily living, encourage healthy habits), medically oriented care (taking vital signs, monitoring symptoms), and provide emotional support (Reckrey et al., 2019). Because HHAs are with patients for hours at a time on a near-daily basis, they have an opportunity to form close relationships, observe, and advise patients in a way that differs from many other healthcare professionals (e.g., doctors, nurses) (Reckrey et al., 2019).

The training and education needed to work as a HHA varies by state and place of employment, as does the training oversight and content (Kelly et al., 2013). In New York, HHAs must complete 75 hours of training which includes both classroom learning and clinical skills supervision (Home Care - Information for Health Care Professionals 2022). Most HHAs receive training at an educational institution or through their home care agency, however the curriculum usually consists of how to help clients complete activities of daily living rather than disease specific education (Kelly et al., 2013).

Despite being trained healthcare professionals who are integral to patient care, HHAs themselves are a vulnerable group of people who experience many challenges in their day-to-day work. Mostly women and racial and ethnic minorities, HHAs earn low wages (median wages have remained relatively stagnant at less than $12/hour over the last decade), receive few benefits (sick leave; health insurance), and have few opportunities for career advancement (Khatutsky, 2011; U.S. Home Care Workers: Key Facts, 2019). Prior studies have shown that HHAs often feel unsupported by supervisors, experience verbal abuse, and do not feel like part of the healthcare team (Muramatsu et al., 2019; Sterling et al., 2018). Additionally, providing care in the home environment poses threats to their physical and mental health, contributing to isolation and injuries due to the use of non-standard equipment (Quinn et al., 2021). Taken together, it is unsurprising that HHAs have high turnover rates and that the home healthcare industry is facing a HHA shortage to meet demand (Shaw et al., 2022; U.S. Home Care Workers: Key Facts, 2019).

Identifying factors that can improve HHAs’ retention in the workforce and satisfaction on the job is critical. Mutuality is one such factor that warrants investigation. Mutuality can be thought of as the positive quality of the relationship, or connectedness, between the caregiver and the care recipient; a more comprehensive explanation is provided by Brown: “beneficial mutuality involves reciprocal transactions and exchanges, mutual influence and responsiveness and a sense of common purpose” (Brown, 2016). Mutuality, and the four domains by which it is measured (shared values, love and affection, shared pleasurable activities, and reciprocity), have been shown to be important and modifiable contributors to professional satisfaction and successful caregiver-care recipient relationships among nurses (Brown, 2016; Cilluffo, Bassola, Pucciarelli, et al., 2021; Ramos, 1992). Additionally, studies among family caregivers have found that higher levels of mutuality are associated with less caregiver burden, increased caregiver resilience and decreased anxiety (Gibbons et al., 2019; Godwin et al., 2013; Lum et al., 2014; Park & Schumacher, 2014). Yet, to date, mutuality and its impact on HHAs’, a workforce that has a different relationship to care recipients as compared to nurses and family caregivers, job satisfaction has not been examined.

Herein, we aimed to examine the association between mutuality (between HHA and patient) and job satisfaction among HHAs, as well as the association between individual mutuality domains and HHA job satisfaction. Our study aims to fill a knowledge gap regarding the significance of mutuality between HHAs and their patients and explore how HHA-patient mutuality may impact job satisfaction and help address the HHA shortage. We did this in the context of HF, a chronic condition for which HHAs often provide care. We hypothesized that increased mutuality would be associated with increased job satisfaction.

Research Design and Methods

Guiding Conceptual Model

The conceptual framework by Zarska et al (Figure 1) guided this study (Zarska et al., 2021). The framework elucidates the relationships between HHAs providing care to patients and demonstrates how policies, organizational factors (i.e. agency size and staffing), and working conditions influence the care provided by HHAs to patients and patient outcomes. The framework also demonstrates how these factors, worker characteristics (i.e. demographics, training, prior experience with caregiving), and patient factors influence worker outcomes (i.e. job satisfaction). For this study, mutuality (main variable of interest) is a concept related to worker characteristics and their perceptions of the caregiving relationship. Job satisfaction (main outcome) is considered a worker outcome.

Figure 1.

Conceptual framework adapted from work by by Zarska, Avgar, Sterling (2021)

Conceptual model representing the relationship between Working Conditions, Worker Outcomes, Characteristics of Care, and Patient Outcomes for frontline health care workers. For this study, mutuality is a concept related to Worker Characteristics and job satisfaction can be considered a Worker Outcome. One-way arrows represent unidirectional relationships between domains. Bidirectional arrows represent reciprocal relationships between domains.

Adapted with permission from the authors.

Study design, setting, and population

Our study is part of a larger cross-sectional survey that examined HHAs’ experience caring for community-dwelling adults with HF. We collected data from August 2018 through May 2019 in partnership with the 1199SEIU-Training and Employment Fund (1199SEIU TEF), a non-profit labor management organization that trains and provides education and job placement benefits to 55,000 HHAs employed by over 50 licensed and certified agencies across New York City (NYC). The 1199SEIU TEF is affiliated with the 1199 Service Employees International Union (SEIU) United Healthcare Workers East. This is the largest healthcare union in the United States and represents more than 400,000 workers in hospitals, nursing homes, clinics, pharmacies, and home care agencies (1199SEIU Training and Employment Funds (TEF)). To obtain an even more diverse sample, we also directly approached private home care agencies across NYC independent of 1199SEIU TEF to distribute our survey to their HHAs. To be eligible to take the survey, HHAs had to be English speaking, currently employed by a licensed or certified home care agency in NYC, affiliated with the 1199SEIU TEF, have at least one year of job experience as a HHA, and have cared for a HF patient in the last year. The Institutional Review Board of Weill Cornell Medicine approved this study (protocol number 1706018271).

Data collection and the survey instrument

The entire pen-and-paper survey, which was comprised of novel and validated items, took roughly 30 minutes to complete. Questions assessed participants’ demographics, employment history, caregiving experience, and their experiences caring for patients with HF, including their contributions to patient care. The survey also assessed their connectedness to patients (mutuality) and their attitudes towards their job (including job satisfaction). The survey was pilot tested and refined with a group of five HHAs, whose data were not included in the final study.

Home care agency and 1199SEIU TEF staff screened HHAs at regularly scheduled in-person meetings (for training and other purposes) for eligibility and interest in participating. Paper surveys were then distributed by staff to participants to be completed in private rooms. The first page of the survey included a written informed consent form. Study staff from the research team were available to answer any questions before participants provided consent. Community-partners were not involved in the consent process. Participants who completed the survey were entered in a raffle to win a $50 gift card. Data from the surveys were de-identified and uploaded into REDCap for storage.

Main variable of interest: Mutuality

The Mutuality scale is a 15-item scale originally designed to measure mutuality between caregivers and patients (Archbold et al., 1990). The Mutuality scale has previously been utilized among family caregivers and was recently validated among HHAs (M. R. Sterling et al., 2022). Questions from the Mutuality scale measure four domains of mutuality: 1) reciprocity (e.g. How much do you confide in him or her?), 2) love and affection (e.g. How attached are you to him or her?), 3) shared pleasurable activities (e.g. How much do the two of you laugh together?), and 4) shared values (e.g. To what extent do the two of you share the same values?) (Supplemental Table 1, Supplemental Figure 1). Each item on the scale uses a five-point Likert scale ranging from “not at all” = 0 to “a great deal” = 4. Overall mutuality is measured by calculating a mean score of 0–4 by averaging all 15 items, with a higher score representing greater mutuality. The four domains of mutuality can also be assessed separately, each with scores ranging from 0–4 (Dellafiore et al., 2018). HHAs were asked to complete the Mutuality scale with their most recent HF patient in mind.

Main Outcome: Job Satisfaction

Job satisfaction was assessed with a one-item question, “In general, how satisfied are you with your current job as a HHA?” Using a four-point Likert scale, responses were categorized as extremely dissatisfied, somewhat dissatisfied, somewhat satisfied, and extremely satisfied. This and similar scales have been previously used among HHAs, notably in the Centers for Disease Control and Prevention’s 2007 National Home Health Aide Survey among other studies (Bercovitz et al., 2011). For modeling our outcome, participants were defined as having job satisfaction if they responded they were “extremely satisfied” or “somewhat satisfied.”

Covariates:

Sociodemographic data collected from all participants included age (years), race/ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, other), sex (male/female), education level (no degree, completed high school or received GED, some college or higher), and whether the participant was US born (yes/no). Employment history, current agency size (small [1500 HHAs], medium [1,500–6,000] and large [more than 6,000]), and caregiving experience data were also collected and included years spent as a paid HHA, duration of time spent with HF patients per week (hours), and training history (receipt of HF training, none/a little/some/a lot). We also collected data on HHAs’ preparedness for caregiving and their contributions to their HF patients’ self-care using the Caregiving Preparedness Scale (CPS) and the Caregiver Contribution to Self-Care of Heart Failure Index (CC-SCHFI), respectively. Both scales have been previously validated among HHAs (M. R. Sterling et al., 2022).

The CPS is an 8-item unidimensional scale that measures how prepared caregivers feel to meet a patient’s physical and emotional needs (Archbold et al., 1990). An example item is, “Overall, how well prepared do you think you are to care for people?” Each item on the scale uses a 5-point Likert scale ranging from not at all prepared = 0 to very well prepared =4. The total score is a mean of all item scores and higher overall scores represent greater caregiver perception of preparedness.

The CC-SCHFI is a 22-item instrument that includes three scales: caregiver contribution to self-care maintenance scale (e.g. how often the caregiver recommends that the patient checks their weight); caregiver contribution to self-care management scale (e.g. how quickly the caregiver recognizes trouble breathing or ankle swelling in their patient); caregiver confidence scale which evaluates caregiver confidence in contributing to self-care (e.g. how confident a caregiver is that they can keep a patient stable and symptom free) (Vellone et al., 2013). Items use a mix of 4 and 5-point Likert scales and each dimension is measured on a scale of 0–100 with scores above 70 considered adequate caregiving contribution or confidence. Higher scores represent greater contribution to self-care and greater self-care confidence.

Statistical analysis:

We first performed descriptive statistics on the overall study population and calculated frequencies and means as well as medians and interquartile ranges (IQRs) for non-normally distributed data. Next, we conducted a univariate analysis to examine differences in participant and caregiving characteristics by mutuality using tests of association. An ANOVA test or Kruskal-Wallis test was used for continuous characteristics and chi-square test for categorical variables. For the univariate analysis, mutuality was treated as a categorical variable and participants were divided into low mutuality (one or more standard deviations below the average mutuality score among participants), average mutuality, and high mutuality groups (one or more standard deviations above average mutuality). To examine the association between mutuality (total score and by subscale) and job satisfaction, we used robust Poisson multivariable regression to calculate prevalence ratios (PR) and 95% confidence intervals (CI). Poisson multivariable regression was chosen due to the high prevalence of our outcome of interest (job satisfaction); prevalence ratios are deemed more appropriate as they don’t overestimate the strength of an association when the prevalence of an outcome is high. We started with a crude model and adjusted for covariates found to have a significant association with mutuality (at the p<.10 level), which included agency size, education, median hours spent with a HF patient per week, degree of HF training received, CPS score, and CC-SCHFI scores. Our final model adjusted for covariates found to have a significant association with mutuality (at the p<.10 level). All analyses were performed using Stata version 14.2.

Results

A total of 338 HHAs took the survey. Among them, 5 did not include information on job satisfaction (main outcome), 126 did not complete the Mutuality scale (main variable of interest), and 7 did not include agency information; these were all excluded. The participants who did not complete the Mutuality scale, were demographically similar to those who did. However, they spent less hours per week with a HF patient and had higher CPS scores (see Supplemental Table 2). Thus, the final analytic sample included 200 HHAs employed by 22 unique home care agencies.

As shown in Table 1, participants were primarily female (94.0%) and foreign born (72.9%). They had a median age of 47.95 years (SD 13.86) and 42.9% identified as non-Hispanic Black while 25.1% identified as Hispanic. For most participants the highest level of education achieved was a high school degree or below (61.4%). Participants primarily worked for small (33.5%) and medium sized (47.5%) home care agencies and had worked as a HHA for a median of 9 years (IQR 5–15). Participants reported moderate levels of preparedness for caregiving (median CPS score of 2.88 out of 4). With respect to contributions to their patients’ HF self-care, 61% had adequate (scores above 70) contribution to patient self-care maintenance and 39% reported adequate confidence in their self-care contributions as measured by the CC-SCHFI.

Table 1:

Characteristics of study population.

Characteristics (N = 200)	n (%)
Age (years), mean (SD)	47.95 (13.86)
Gender
Male	12 (6.0%)
Female	187 (94.0%)
Race/Ethnicity
Non-Hispanic White	18 (9.4%)
Non-Hispanic Black	82 (42.9%)
Hispanic	48 (25.1%)
Other	43 (22.5%)
Foreign born
Yes	145 (72.9%)
No	54 (27.1%)
Education
No degree	42 (21.3%)
Completed high school or GED	79 (40.1%)
Some college or higher	76 (38.5%)
Hours per week spent with a HF patient, median (IQR)	24.00 (8.00, 36.00)
Years worked as a HHA, median (IQR)	9.00 (5.00, 15.00)
Agency size
Small (<1500 HHAs)	67 (33.5%)
Medium (1500–6000 HHAs)	95 (47.5%)
Large (>= 6000 HHAs)	38 (19.0%)
Heart failure training
No to little training	141 (70.5%)
Some to a lot of training	59 (29.5%)
Caregiving Preparedness Scale scorea, mean (SD)	2.72 (0.95)
Caregiving Preparedness Scale scorea, median (IQR)	2.88 (2.13, 3.50)
CC-SCHFI Maintenance subscale score ≥ 70b	122 (61.0%)
CC-SCHFI Confidence subscale score ≥ 70b	78 (39.0%)
CC-SCHFI Management subscale score ≥ 70b	49 (24.5%)
Mutuality Scale score overall and by domainc, mean (SD)
Overall	2.92 (0.79)
Shared values	2.86 (0.86)
Love and affection	3.08 (0.82)
Shared pleasurable activities	3.16 (0.80)
Reciprocity	2.62 (0.99)
Job satisfaction
Extremely satisfied	82 (41.0%)
Somewhat satisfied	78 (39.0%)
Somewhat dissatisfied	25 (12.5%)
Extremely dissatisfied	15 (7.5%)

HHA = home health aide, HF = heart failure, CC-SCHFI = Caregiver Contribution to Self-Care of Heart Failure Index.

^aThe Caregiving Preparedness Scale is a an 8-item scale that measures caregiver preparedness to meet a patient’s physical and emotional needs. Each item uses a 5-point Likert scale ranging from not at all prepared = 0 to very well prepared =4. The total score is a mean of all item scores and higher overall scores indicate greater caregiver preparedness.

^bThe CC-SCHFI is a 22-item instrument that aims to measure three dimensions of caregiver contribution to HF self-care: contribution to self-care maintenance, contribution to self-care management, and caregiver confidence in self-care contribution. Each dimension is measured on a scale of 0–100 with scores above 70 considered adequate caregiving contribution or confidence. Higher scores represent greater contribution to self-care and greater self-care confidence.

^cThe Mutuality Scale is a 15-item scale designed to measure four domains of mutuality between caregivers and patients: shared values, love and affection, shared pleasurable activities, and reciprocity. Each item on the scale uses a 5-point Likert scale ranging from “not at all” = 0 to “a great deal” = 4. Overall mutuality is measured by calculating a mean score of 0–4 by averaging all 15 items, with a higher score representing greater mutuality. The four domains of mutuality can also be assessed separately, each with scores ranging from 0–4.

Participants had a mean Mutuality scale score of 2.92 (SD 0.79) out of 4. Within the four mutuality domains, scores were highest for the shared pleasurable activities domain, with a mean score of 3.16 (SD 0.80), and lowest for the reciprocity domain, with a mean score of 2.62 (SD 0.99). As shown in Table 2, 13.5% of participants had low levels of mutuality (overall mutuality scale scores under 2), 70% had average levels (scores from 2–3.7), and 16.5% had high levels (scores above 3.7). With respect to sociodemographic variables, there were no statistically significant differences by level of mutuality. However, we did see differences in mutuality levels by employment and HF caregiving characteristics. That is, those with high levels of mutuality had a lower number of median hours per week spent with a HF patient (11 hours, IQR 5–33), as compared to participants with average (25 hours, IQR 10–36) and low (25 hours, IQR 12–40) levels of mutuality. Compared to participants with low or average mutuality levels, high levels of mutuality were associated with higher levels of preparedness for caregiving (mean CPS 3.43, SD 0.70) and greater contributions to HF self-care (see Table 2). Lastly, high levels of mutuality were associated with employment by a small home care agency (51.5%), as compared to average (32.1%) and low mutuality (18.5%).

Table 2.

Study population characteristics by mutuality.

Characteristics	Low Mutualitya	Average Mutualitya	High Mutualitya	P valueb
n (%)	27 (13.5%)	140 (70%)	33 (16.5%)
Age, mean years (SD)	46.4 (13.8)	47.9 (13.7)	49.6 (14.8)	0.68
Gender				0.74
Female	25 (92.6%)	131 (93.6%)	31 (96.9%)
Male	2 (7.4%)	9 (6.4%)	1 (3.1%)
Race/Ethnicity				0.33
Non-Hispanic White	3 (11.5%)	11 (8.3%)	4 (12.5%)
Non-Hispanic Black	9 (34.6%)	59 (44.4%)	14 (43.8%)
Hispanic	11 (42.3%)	29 (21.8%)	8 (25.0%)
Other	3 (11.5%)	34 (25.6%)	6 (18.8%)
Foreign born				0.14
Yes	16 (59.3%)	102 (73.4%)	27 (81.8%)
No	11 (40.7%)	37 (26.6%)	6 (18.2%)
Education				0.067
No degree	5 (18.5%)	33 (23.9%)	4 (12.5%)
High school or GED	9 (33.3%)	50 (36.2%)	20 (62.5%)
Some college or higher	13 (48.1%)	55 (39.9%)	8 (25.0%)
Hours per week spent with a HF patient, median (IQR)	25 (12, 40)	25 (10, 36)	11 (5, 33)	0.081
Number of years spent working as a HHA, median (IQR)	6 (5, 12)	9 (5, 15)	10 (5, 16)	0.44
Heart failure training				0.076
No to little training	24 (88.9%)	94 (67.1%)	23 (69.7%)
Some to a lot of training	3 (11.1%)	46 (32.9%)	10 (30.3%)
Caregiving Preparedness Scale scorec, mean (SD)	1.96 (0.93)	2.70 (0.88)	3.43 (0.70)	<0.001
Caregiving Preparedness Scale scorec, median (IQR)	2.00 (1.25, 2.63)	2.75 (2.13, 3.38)	3.88 (3.00, 4.00)	<0.001
CC-SCHFI Maintenance scale score ≥ 70d	13 (48.1%)	84 (60.0%)	25 (75.8%)	0.084
CC-SCHFI Confidence scale score ≥ 70d	4 (14.8%)	50 (35.7%)	24 (72.7%)	<0.001
CC-SCHFI Management scale score ≥ 70d	2 (7.4%)	34 (24.3%)	13 (39.4%)	0.016
Agency size				0.01
Small (<1500 HHAs)	5 (18.5%)	45 (32.1%)	17 (51.5%)
Medium (1500–6000 HHAs)	12 (44.4%)	73 (52.1%)	10 (30.3%)
Large (>= 6000 HHAs)	10 (37.0%)	22 (15.7%)	6 (18.2%)

HHA = home health aide, HF = heart failure, CC-SCHFI = Caregiver Contribution to Self-Care of Heart Failure Index.

^aParticipants were stratified into those with low (one SD or more below the mean), average, and high (one SD or more above the mean) overall scores on the Mutuality Scale. The Mutuality Scale is a 15-item scale designed to measure mutuality between caregivers and patients. Each item on the scale uses a 5-point Likert scale ranging from “not at all” = 0 to “a great deal” = 4. Overall mutuality is measured by calculating a mean score of 0–4 by averaging all 15 items, with a higher score representing greater mutuality.

^bP value represents the significance of difference between the categories but does not signify the presence of a trend.

^cThe Caregiving Preparedness Scale is a an 8-item scale that measures caregiver preparedness to meet a patient’s physical and emotional needs. Each item uses a 5-point Likert scale ranging from not at all prepared = 0 to very well prepared =4. The total score is a mean of all item scores and higher overall scores indicate greater caregiver preparedness.

^dThe CC-SCHFI is a 22-item instrument that aims to measure three dimensions of caregiver contribution to HF self-care: contribution to self-care maintenance, contribution to self-care management, and caregiver confidence in self-care contribution. Each dimension is measured on a scale of 0–100 with scores above 70 considered adequate caregiving contribution or confidence. Higher scores represent greater contribution to self-care and greater self-care confidence.

Overall, 80% of participants reported being satisfied with their job as a HHA (39% somewhat satisfied and 41% extremely satisfied) and 20% were not satisfied (12.5% somewhat dissatisfied and 7.5% extremely dissatisfied), (see supplemental Table 3 for associations between participant characteristics and job satisfaction). Models that examine the association between mutuality (overall score and by the four domains) and job satisfaction are shown in Table 3. In our crude (unadjusted) model, overall mutuality (PR 1.13, CI: 1.02–1.126) was significantly associated with greater job satisfaction; a similar relationship was seen for three of the four domains of mutuality (shared values PR 1.11, CI: 1.10–1.23; love and affection PR 1.14, CI: 1.02–1.27; shared pleasurable activities PR 1.17, CI: 1.04–1.31) whereas the association between the reciprocity domain and job satisfaction did not reach statistical significance (PR 1.06, CI: .98–1.14). After adjustment for covariates, only the shared pleasurable activities domain of mutuality remained significantly associated with job satisfaction (aPR: 1.15 [1.01–1.32]). In our fully adjusted model, each one-point increase in the mean shared pleasurable activities domain score was associated with a 15% increase in job satisfaction.

Table 3.

Association between an increase in the Mutuality Scale^a total score or subscale score and job satisfaction^b among HHAs caring for patients with HF.

	Crude model PR (95% CI)	Adjusted model PR (95% CI)c
Overall mutuality scorea	1.13 (1.02–1.26)	1.11 (0.97–1.27)
Shared values domain scorea	1.11 (1.01–1.23)	1.11 (0.98–1.25)
Love and affection domain scorea	1.14 (1.02–1.27)	1.09 (0.96–1.23)
Shared pleasurable activities domain scorea	1.17 (1.04–1.31)	1.15 (1.01–1.32)
Reciprocity domain scorea	1.06 (0.98–1.14)	1.04 (0.95–1.13)

HHA = home health aide, HF = heart failure

^aThe Mutuality Scale is a 15-item scale designed to measure four domains of mutuality between caregivers and patients: shared values, love and affection, shared pleasurable activities, and reciprocity. Each item on the scale uses a 5-point Likert scale ranging from “not at all” = 0 to “a great deal” = 4. Overall mutuality is measured by calculating a mean score of 0–4 by averaging all 15 items, with a higher score representing greater mutuality. The four domains of mutuality can also be assessed separately, each with scores ranging from 0–4.

^bJob satisfaction was assessed on a four-point Likert scale, responses were categorized as extremely dissatisfied, somewhat dissatisfied, somewhat satisfied, and extremely satisfied. For our models, job satisfaction was defined as reporting “extremely/somewhat satisfied” (n=160).

^cOur final model adjusted for covariates found to have a significant association with mutuality (at the p<.10 level): agency size, education, median hours spent with a heart failure patient per week, level of heart failure training received, Caregiving Preparedness Scale score, Caregiver Contribution to Self-Care of Heart Failure Index scores.

Discussion and Implications

To our knowledge, this cross-sectional survey of agency employed HHAs caring for adults with HF is the first to characterize mutuality among HHAs. We found that 16.5% of participants had high levels of mutuality and high levels of mutuality were associated with higher levels of preparedness for caregiving and greater perceived contributions to patients’ HF self-care. Higher levels of mutuality (between HHAs and their patients), both the overall score and several of the domain scores, were associated with greater HHA job satisfaction. Notably, the strength of these associations differed by the domain, with only the shared pleasurable activities domain remaining significantly associated with greater job satisfaction after adjustment for other factors. Our findings highlight mutuality as a possible way to improve the HHA work experience.

Our study expands on the prior literature in a few important ways. To date, research on mutuality among paid caregivers has been limited to qualitative or descriptive studies and lacked formal measurement of the degree of connection between the paid caregiver and patient. One prior study examined the structural relationship between HHA characteristics and contributions to patients’ HF self-care, with mutuality being one characteristic, however, the influence of mutuality on workers themselves was not explored (M. R. Sterling et al., 2022). Prior qualitative studies have shown that among paid caregivers, quality relationships with patients can give meaning to caregiving and contribute to job satisfaction, but also have the potential to complicate the caregiving relationship (Brown, 2016; Franzosa et al., 2019; Ramos, 1992). For example, one qualitative study of 41 HHAs, patients, and family members, found that close HHA-patient relationships have benefits for both patients and HHAs, but can also make it difficult to maintain boundaries (Piercy, 2000). Additionally, other studies have found that although higher levels of connectedness provide meaning, HHAs can struggle to cope with patient death, especially in the context of long-standing relationships (Tsui et al., 2019). Our findings add to the existing research and emphasize the potential of utilizing mutuality to increase job satisfaction as well as the importance of understanding which specific mutuality domains make most sense to promote in the context of paid caregiving.

Among family caregivers, a population where the Mutuality scale has been more widely used, the mutuality level (between family caregivers and care recipients) ranged from 2.51 to 3.45 (Dellafiore et al., 2019; Gibbons et al., 2019; Godwin et al., 2013; Lum et al., 2014; Shim et al., 2011). However, studies have found that the highest scoring domain of mutuality among family caregivers is love and affection (Cilluffo, Bassola, & Lusignani, 2021). For example, a study of 366 HF patient-family caregiver dyads in Italy found the love and affection domain to be the most highly scored (3.33), compared to the shared pleasurable activities domain (2.67) (Dellafiore et al., 2019). These findings highlight the differences between family caregivers and paid caregivers, who are often caring for multiple patients simultaneously for varying lengths of time, and emphasize the need to approach interventions to increase caregiver-care recipient mutuality differently among these two groups. Overall, literature on family caregivers supports the idea that mutuality can give meaning to caregiving and protect caregivers from the negative impacts of caregiving, such as depression and caregiver burden (Gibbons et al., 2019; Karlstedt et al., 2020; Pucciarelli et al., 2021).

Understanding the role of mutuality in HF may be especially important since it is a condition that requires a high degree of self-care which often necessitates caregiver support. We found that HHAs who reported higher levels of mutuality with their patients also reported greater perceived contributions to their patients’ HF self-care. Existing research supports this link between mutuality and caregiver self-care contributions, as well as caregiver outcomes (Hooker et al., 2018). One study of over 300 HF patient-family caregiver dyads found that higher scores on the shared pleasurable activities domain of mutuality was associated with greater contributions to HF self-care maintenance activities (Vellone et al., 2018). Our study adds to the existing literature by exploring the association between HF self-care and mutuality among paid caregivers and highlights the potential of mutuality, and specifically the shared pleasurable activities domain, to benefit not only HHAs’ satisfaction on the job, but impact the care provided to HF patients and potentially patient outcomes.

Implications

Given the challenges and long-standing inequities that HHAs face, it is not surprising that home care agencies are struggling to recruit and retain workers even as demand for HHAs continues to rise. Although levels of job satisfaction among HHAs are high nationally, job satisfaction and intention to leave are key metrics for workforce retention efforts (Bercovitz et al., 2011; Stone et al., 2017).

Our findings suggest that organizational initiatives aimed at increasing mutuality between HHAs and their patients could be beneficial, not just in HF but among older adults with multiple chronic conditions. Although certain domains of mutuality, such as love and affection, may be difficult and inappropriate to modify, the shared values and shared pleasurable activities domains are promising targets for future interventions. Efforts aimed at promoting activities between HHAs and patients, such as meaningful conversations or learning circles, could improve worker satisfaction, and potentially benefit patients. Additionally, efforts to pair HHAs with patients who may share similar interests, backgrounds, or native languages could also serve to increase mutuality and allow for more meaningful caregiver-patient relationships. Lastly, existing research on brief interventions that can increase mutuality through empathic conversational responses could potentially be adapted for HHAs (Chambliss et al., 2014). However, such initiatives would need to account for the barriers that currently exist to such relationships such as breaks in continuity of care, professional boundaries, and concerns about becoming too enmeshed in patients’ lives, as well as the attitudes of home care agencies, which may not always promote the formation of close relationships (Berta et al., 2013; Piercy, 2000).

Investing in programs and initiatives to increase mutuality may have additional benefits for home care agencies beyond worker satisfaction and retention. As Medicare and Medicaid move to implement home care reimbursement models that consider quality of care, improved mutuality may represent a way to improve quality ratings and ultimately reduce costs. For example, patients receiving home care from a Medicare-certified agency are often asked to complete the Consumer Assessment of Healthcare Providers and Systems Home Health Care Survey (HHCACHPS) to assess their home care experience (Home Health Care CAHPS Survey, 2020). The survey contains questions on whether patients felt respected and heard, two metrics that would likely improve with increased mutuality. Additionally, a recent survey of community dwelling adults receiving home care for themselves or someone in their household found that the emotional labor contributions of paid caregivers were associated with participants’ perceived value of care (Madeline R Sterling et al., 2022). Further research is needed to better understand how we can work to retain and strengthen the HHA workforce, but mutuality remains a promising factor that may help improve not only worker outcomes but patient care and home care quality as well.

Limitations

Our study has several limitations. First, our sample was limited to English speaking agency-employed HHAs in the New York City area which may impact the generalizability of our findings. Additionally, our sample was highly diverse with a larger percentage of ethnic minorities and immigrants as compared to national samples; and cultural influences on perceptions of mutuality were not explored (Khatutsky, 2011). Second, we lacked data on the HHA-patient dyadic relationship (length of relationship, its intensity) and on the patients’ perspective of the relationship, as well as their characteristics or severity of disease, all of which may have influenced our findings. HHAs also often care for multiple patients at once which can complicate measurements of mutuality. Third, surveys were distributed in collaboration with community partners; although our sample was diverse in agencies represented, we were unable to ascertain the total number of HHAs contacted to participate or calculate a response rate, which raises concerns about a potential selection bias. Additionally, a sizable number of HHAs did not complete the mutuality scale; although demographics were similar to those who did, other agency and employment-related characteristics were not and therefore reasons for not completing the scale warrant further investigation. We also note that due to the large number of agencies with one or very few participants, a multilevel modeling approach was not used which may have allowed us to account for the random effects on the practice level. Lastly, our study used a cross-sectional design and thus we cannot infer casualty or temporality from the data.

Of note our data were collected prior to the start of the COVID-19 pandemic, which drastically altered working conditions for HHAs and has exacerbated many existing occupational challenges (Quinn et al., 2021). It is possible that the pandemic has changed HHA perceptions of job satisfaction and additional research in the setting of this ongoing pandemic would be valuable.

Conclusion

As the demand for HHAs increases in the US, there is a need to identify factors which can promote HHAs’ job satisfaction to keep them in the workforce and improve their experience caring for patients. Mutuality, or the connectedness they experience with patients, is one such factor. Our study found that increased mutuality, specifically the shared pleasurable activities domain, between HHAs and HF patients is associated with higher job satisfaction among HHAs. These findings have implications for the home care industry and suggest that interventions promoting mutuality may help improve HHAs experience on the job and potentially patient care.

What this paper adds

• HHA-patient mutuality was found to be associated with HHA job satisfaction

• Of the mutuality domains, shared pleasurable activities was the only domain that remained significantly associated with HHA job satisfaction in our final model.

Applications of study findings

• Home care agency initiatives aimed at promoting mutuality, specifically shared pleasurable activities, between HHAs and patients may improve HHA job satisfaction.

• Efforts to increase HHA-patient mutuality may have benefits for home care agencies beyond worker satisfaction and retention, such as quality of care and patient outcomes.