Journal of Gerontological Nursing

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Innovations in Long-Term Care 

Organizational Culture and Work-Related Attitudes Among Staff in Assisted Living

Elzbieta Sikorska-Simmons, PhD

Abstract

Nursing administrators wishing to improve job satisfaction and reduce staff turnover should examine the organizational culture at their facilities.

Abstract

Nursing administrators wishing to improve job satisfaction and reduce staff turnover should examine the organizational culture at their facilities.

Organizational culture is being recognized as an important determinant of quality of care. The "culture change" movement in nursing homes aims to improve quality through changes in organizational culture and focuses on the link between the quality of care and the quality of work environment for staff (Eaton, 2000). Those who advocate "the culture change" in nursing homes stress the importance of staff empowerment and staff relationships with residents in the provision of quality care (Barba, Tesh, & Courts, 2002). Similarly, in assisted living, staff relationships with residents are considered central to the quality of care (Ball et al., 2000; Greene, Hawes, Wood, & Woodsong, 1998). Assisted living, as a combination of housing and services, is designed to support resident choice and independence in a homelike environment (Kane, Wilson, & Clemmer, 1993). Both assisted living residents and their families value staff and tend to equate quality of care with staff members' caring attitudes toward residents (Ball et al., 2000; Greene et al., 1998). Little, however, is known about staff perceptions of organizational culture and their attitudes toward working in assisted living (Hawes & Phillips, 2000).

Organizational culture is a complex and difficult to measure phenomenon. According to Schein (1985), culture consists of shared values, beliefs, and assumptions that guide the behavior of individuals and groups in organizations. At the core of organizational culture are assumptions about human nature (e.g., as dishonest or trustworthy), which frequently operate unconsciously and ultimately determine how organization members perceive their work, treat their customers, and relate to each other. As a system of values, beliefs, and assumptions, culture has a powerful influence on employee work-related attitudes, such as job satisfaction and organizational commitment, which in turn, have been linked to organizational effectiveness (O'Reilly, 1989; Schein, 1985).

A growing number of studies point to the relationship between organizational culture and workrelated attitudes among staff in health care settings (Aiken & Sloane, 1997; Cox, 2001; Gilford, 2002). In hospitals, stafforiented organizational cultures have been linked to positive staff outcomes (Aiken & Sloane, 1997; Cox, 2001; Gifford, 2002). Aiken and Sloane (1997) found that organizational cultures valuing teamwork, job discretion, and good working relationships among staff were associated with higher staff commitment and lower turnover. Similarly, Cox (2001) indicated that organizational cultures characterized by high morale and good working relationships had positive effects on staff job satisfaction and commitment. Gifford (2002) reported that organizational cultures promoting social cohesion, openness, honesty, and high morale foster greater job satisfaction and commitment among staff.

Research in nursing homes also suggests that the quality of work environment for staff, which tends to reflect the underlying organizational culture, has a strong influence on staff work-related attitudes (CohenMansfield, 1989; Francis-Felsen et al., 1996; Grau, Chandler, Burton, & Kolditz, 1991; Schaefer & Moos, 1996; Sheridan, White, & Fairchild, 1992). In particular, nursing homes that foster supportive relationships among staff and participation in decisionmaking, tend to have positive effects on staff job satisfaction and commitment (Banaszak-Holl & Hines, 1996; Schaefer & Moos, 1996). Banaszak-Holl and Hines (1996) found that nursing homes that involved nursing staff in care planning and valued their input had turnover rates 30% to 50% lower than the nursing homes that did not involve staff in decision-making.

Additionally, policies fostering effective communication, supportive supervision, and respect for staff have been shown to increase staff job satisfaction and commitment (Francis-Felsen et al., 1996), whereas poor relationships with supervisors and lack of respect for lower-level staff have been linked to lower job satisfaction and a lack of commitment (Cohen-Mansfield, 1989; Schaefer & Moos, 1996). Little is known about the quality of work environment for staff in assisted living.

Evidence also suggests staff sociodemographic characteristics, such as age, marital status, education, and organizational tenure can influence work-related attitudes. Research indicates that older workers and those with longer organizational tenure tend to be more satisfied with their jobs and more committed than younger workers (Kiyak, Namazi, & Kahana, 1997; Price & Mueller, 1981). According to Meyer and Allen (1984), this occurs because those with longer tenure accumulate more "side-bets," such as pension plans and other benefits. Also, married individuals tend to report higher levels of job satisfaction and commitment, presumably because they have greater financial burdens and family responsibilities than those who are unmarried (Price & Mueller, 1981). Additionally, education has been linked to work-related attitudes. While some studies point to an inverse relationship between education and commitment (Grau et al., 1991), other studies suggest that more educated staff tend to be more satisfied (Cohen-Mansfield, 1989). There are no studies examining the influence of staff characteristics on their work-related attitudes in assisted living.

This study was performed with the purpose of examining the relationship between staff perceptions of organizational culture and their work-related attitudes in assisted living. Based on the literature, it is hypothesized that more favorable perceptions of organizational culture will be associated with greater job satisfaction, satisfaction with coworkers, and organizational commitment. Furthermore, it is expected that organizational culture will contribute more significantly to the prediction of work-related attitudes than staff sociodemographic characteristics. A knowledge of how staff perceptions of organizational culture are related to their work-related attitudes will be helpful in designing interventions to improve the quality of the work environment for the staff.

METHODS

Sampling Procedure

Data for this analysis come from a larger study that examined organizational determinants of resident autonomy in assisted living. A total of 317 staff members in 61 facilities participated in the study. Assisted living was defined as a residential care program providing housing, supervision, and health-related services to elderly individuals who need assistance in the activities of daily living (Hawes & Phillips, 2000; Kane et al., 1993). The study sampling was conducted in two stages. First, a sample of assisted living facilities was drawn, and subsequently, a sample of staff was selected from each facility.

Sample of Facilities. The sampling frame consisted of all licensed assisted living programs in Maryland (Maryland Department of Health and Mental Hygiene, 2001). To select an organizationally diverse sample, facilities were stratified into three groups based on the assisted living typology developed by Zimmerman et al. (2003). Of the 61 facilities, 22 (36%) were small facilities (with fewer than 16 beds), 22 (36%) were "new model" (purpose-built after 1986 with 16 or more beds), and 17 (28%) were traditional facilities (with 16 or more beds that could not be classified as "new model"). The participating facilities varied in size from 7 to 164 beds, with a mean of 42 and a median of 30 beds. Of the 61 facilities, 7 (11%) were owned by individuals, 19 (31%) were owned by small corporations, 12 (20%) were owned by large corporations, and 23 (38%) were operated as non-profit corporations.

Sample of Staff . All staff hired and paid by the facility and who had daily contact with residents were invited to participate in the study. The variability in staff position types was needed to establish the effect of organizational culture on all staff in assisted living. Private pay nursing staff and relatives who were not hired on a contract, and administrative or other staff who had very limited contact with residents were excluded. A researcher distributed staff questionnaires during 1-day visits to each facility. Each staff member received a survey packet consisting of a cover letter, a consent form, and a questionnaire with an addressed, stamped envelope. The completion of a questionnaire took 10 to 15 minutes. Staff members were asked to return the completed questionnaire in the attached envelope. Identifying numbers were used on questionnaires instead of names to maintain anonymity.

A total of 574 questionnaires was distributed to staff in 61 facilities with a response rate of 317 (55%), which compares favorably with response rates achieved in health care settings (Scott, Mannion, Davies, & Marshall, 2003). The number of questionnaires distributed in each facility varied from 1 to 25 with a mean of 9. The staff response rates by facility ranged from 0% to 100%, with a median of 50% and a standard deviation of 31%.

Table

TABLE 1CHARACTERISTICS OF STAFF (N= 317)

TABLE 1

CHARACTERISTICS OF STAFF (N= 317)

The characteristics of staff who participated in the study are shown in Table 1. The mean age of respondents was 43 years, and more than half of the participating staff (61%) had been working in their facility for 2 or more years. These staff characteristics were comparable to the characteristics of assisted living staff reported by Hawes and Phillips (2000) in their national study.

Measures

The dependent variables for this study were work-related attitudes, represented by job satisfaction, satisfaction with coworkers, and organizational commitment.

Job Satisfaction. Job satisfaction was measured by the three-item scale from the Michigan Organizational Assessment Questionnaire (Seashore, Lawler, Mirvis, & Cammann, 1982). The scale is used to assess the extent to which staff are satisfied with their jobs (e.g., All in all, I am satisfied with my job). Each item was scored on a 7-point Likert-type scale with responses ranging from 1 = Strongly Disagree to 7 = Strongly Agree. Higher summative scores reflected greater satisfaction. In the current study, the Cronbach's a for the scale (.79) was similarly high to the alpha of .77 reported in the literature (Seashore et al., 1982).

Coworker Satisfaction. Coworker satisfaction was measured by the Social Rewards Satisfaction scale from the Michigan Organizational Assessment Questionnaire (Seashore et al., 1982). This three-item scale measures the extent to which staff are satisfied with treatment, respect, and friendliness of individuals with whom they work. Each item was scored on a 7-point Likert-type scale, with responses ranging from 1= Very Dissatisfied to 7 = Very Satisfied. In this study, the scale had a Cronbach's a of .92, which compares favorably to the scale alpha (.87) reported in the literature (Seashore et al., 1982).

Organizational Commitment. Organizational commitment was assessed with a 9-item scale developed by Cook and Wall (1980) for use with blue-collar workers. The scale measures organizational commitment according to such components as identification (pride in the organization), involvement (willingness to invest personal effort for the sake of the organization), and loyalty (a wish to remain a member of the organization). Each item was scored on a 7point Likert-type scale with responses ranging from 1 = No, I Strongly Disagree, to 7 = Yes, I Strongly Agree. Scale scores were obtained by summing responses across items, with higher scores reflecting greater organizational commitment (Cronbach's a = .81).

Organizational Culture. Organizational culture, the main independent variable in this study, was assessed with the Organizational Culture Survey (OCS) developed by Glaser, Zamanou, and Hacker (1987). The instrument consists of 36 items grouped into six subscales measuring staff perceptions of teamwork, morale, information flow, involvement, supervision, and meetings. The authors established the OCS validity using observations and 45-minute critical incident interviews.

The Teamwork scale measures staff perceptions of coordination, honesty, support, and concern for each other (e.g., the individuals I work with function as a team). The Morale scale assesses staff perceptions of the quality of their working relationships and organizational character (e.g., this organization respects its workers). The Information Flow scale refers to the quality of communication between staff and their supervisors (e.g., I get the information I need to do my job well). The Involvement scale measures the extent to which staff are involved in the decision-making (e.g., I have a say in decisions that affect my work). The Supervision scale refers to staff perceptions of their supervisors (e.g., When I do a good job my supervisor tells me). The Meetings scale assesses staff's perceptions of meetings (e.g., Decisions made at meetings get put into action).

Table

TABLE 2DESCRIPTION OF THE MEASURES USED IN THIS STUDY

TABLE 2

DESCRIPTION OF THE MEASURES USED IN THIS STUDY

Each OCS item was scored on a five-point scale (1 = To a Very Little Extent to 5 = To a Very Great Extent) and summed across items. In the current study, the Cronbach's a for the entire OCS was .98, and the reliability estimates for the separate subscales (.92 to .95) were higher than the estimates (.63 to .91) reported in the original research (Glaser et al., 1987).

The predictive ability of organizational culture on work-related attitudes was examined while controlling for staff age, gender, marital status, education, and organizational tenure. Education was measured according to five levels (i.e., 1 = Grade School, 2 = High School, 3 = Post-secondary/Some College, 4 = Bachelor's Degree, 5 = Graduate Degree). Marital status was assessed using one item reporting respondent's marital status (1= Single, 2= Married, 3 = Divorced, 4 = Separated, and 5 = Widowed). The literature suggests that married individuals tend to report more positive attitudes toward work than those who are unmarried (Price & Mueller, 1981). Therefore, in the multiple regression analysis, marital status was recoded as a dichotomous variable with two categories: Married (1) and Unmarried (0).

Organizational tenure was measured by the number of months since the beginning of employment in the facility. All individual-level data were obtained from staff using self-administered questionnaires. The description of measures used in the study is shown in Table 2.

Data Analysis

Simple correlations (Pearson's r) were used to examine the strength and direction of relationships among variables representing organizational culture and work-related attitudes. Hierarchical regression analyses were conducted to assess the extent to which work attitudes were explained by sociodemographic characteristics and organizational culture. The sample of 317 staff was adequate for the proposed analysis. In the multiple regression analysis with six independent variables, a sample of 317 staff allowed to detect an R2 of .05 or greater at the .05 alpha level with a probability (power) of 80% (Cohen, 1987). Examination of the assumptions underlying multiple regression analysis revealed that one of the variables in the study, organizational tenure, had positively skewed distribution. Therefore, a natural log of organizational tenure was taken to bring the distribution closer to normal. Statistical analysis of the data was conducted using the Statistical Package for the Social Sciences (SPSS Inc. Version 10.0, Chicago, IL).

Table

TABLE 3BIVARIATE CORRELATIONS BETWEEN WORK-RELATED ATTITUDES, ORGANIZATIONAL CULTURE, AND STAFF CHARACTERISTICS

TABLE 3

BIVARIATE CORRELATIONS BETWEEN WORK-RELATED ATTITUDES, ORGANIZATIONAL CULTURE, AND STAFF CHARACTERISTICS

RESULTS

Organizational Culture Correlates of Work-Related Attitudes

Zero-order correlations were used to examine the strength and direction of relationships between variables in the study. The bivariate correlations between the measures of work-related attitudes (i.e., job satisfaction, satisfaction with coworkers, organizational commitment), organizational culture, and staff sociodemographic characteristics are shown in Table 3.

The zero-order correlations indicated strong positive relationships between organizational culture and work-related attitudes. Consistent with the hypothesis, staff who had more favorable perceptions of organizational culture reported higher levels of job satisfaction (r = .60, p < .001), satisfaction with coworkers (r = .72, p < .001), and organizational commitment (r = .69, p < .001). In particular, staff members who reported higher levels of satisfaction and commitment had more favorable views of teamwork, morale, information flow, involvement, supervision, and meetings. From the dimensions of organizational culture, perceptions of organizational morale had the strongest influence on job satisfaction (r = .57, p < .001) and commitment (r = .71, p < .001), whereas perceptions of teamwork had the strongest influence on satisfaction with coworkers (r = .69, p < .001).

Additionally, the bivariate correlations show that staff age, organizational tenure, and education were associated with work-related attitudes. The magnitudes of these correlations, however, remained well below those for organizational culture. Older staff members were more committed (r= ?2, p < .05) and satisfied with their jobs (r = .12, p < .05) and coworkers (r= 16, p < .01) than their younger counterparts. Similarly, those who worked in the facility for a longer time were more satisfied with their jobs (r = .13, p < .05) and coworkers (r= .13, p < .05). Additionally, higher levels of organizational commitment were reported by staff who had more education (r= .14, p < .05).

Organizational Culture as a Predictor of Work-Related Attitudes

Hierarchical regression analysis was used to assess the predictive ability of organizational culture on staff work-related attitudes, controlling for staff characteristics (i.e., age, gender, marital status, education, organizational tenure). The data were analyzed separately for the three outcome measures, which included job satisfaction, satisfaction with coworkers, and organizational commitment. In the first step of each regression equation, the outcome variable was regressed on age, gender, marital status, education, and organizational tenure to estimate how much variance in the attitude was explained by sociodemographic characteristics. In the next step, organizational culture (total OCS score) was entered into the regression equation, and the increment in the explained variance was tested for statistical significance using the .F ratio. The results of the multiple regression analyses are shown in Table 4.

Table

TABLE 4HIERARCHICAL REGRESSION RESULTS OF JOB SATISFACTION, SATISFACTION WITH COWORKERS, AND ORGANIZATIONAL COMMITMENT ON SOCIODEMOGRAPHIC CHARACTERISTICS AND ORGANIZATIONAL CULTURE

TABLE 4

HIERARCHICAL REGRESSION RESULTS OF JOB SATISFACTION, SATISFACTION WITH COWORKERS, AND ORGANIZATIONAL COMMITMENT ON SOCIODEMOGRAPHIC CHARACTERISTICS AND ORGANIZATIONAL CULTURE

As expected, based on the correlations, organizational culture was a strong predictor of job satisfaction, satisfaction with coworkers, and organizational commitment. While controlling for respondents' age, gender, marital status, education, and tenure, organizational culture explained 36% of the variation in job satisfaction, 50% of the variation in satisfaction with coworkers, and 48% of the variation in organizational commitment. Staff characteristics failed to account for a significant amount of variance in work-related attitudes. These results provided support for the hypothesis that organizational culture is a stronger predictor of work-related attitudes than sociodemographic characteristics.

DISCUSSION

The study findings indicated that staff who had more favorable perceptions of organizational culture reported higher levels of job satisfaction, satisfaction with coworkers, and greater organizational commitment. Overall, organizational culture emerged as a strong predictor of work-related attitudes, explaining 36% of the variance in job satisfaction, 50% of the variance in satisfaction with coworkers, and 48% of the variance in organizational commitment. These findings are consistent with previous studies which showed that staff-oriented organizational culture is a strong predictor of work-related attitudes. In particular, cultures that promote teamwork, participation in decision-making, and supportive relationships among staff tend to have positive effect on staff outcomes (Aiken & Sloane, 1997; Cox, 2001; Gifford, 2002).

Among the dimensions of organizational culture, perceptions of teamwork had the strongest influence on satisfaction with coworkers and perceptions of organizational morale had the strongest influence on job satisfaction and organizational commitment. In particular, staff members who viewed their employing organizations as fair and respectful of its workers were more satisfied with their jobs and reported higher levels of organizational commitment. These findings point to the central importance of organizational morale and the value assigned to staff in shaping staff attitudes.

It has been long recognized that staff devaluation is a major problem in long-term care (Eaton, 2000; Tellis-Nayak & TellisNayak, 1989). Common examples of such devaluation include lack of trust, lack of feedback, lack of recognition, and few or no opportunities for participation in the decision-making process. Staff who feel devalued as workers and as human beings are more likely to leave their jobs (Bowers, Esmond, & Jacobson, 2003). Therefore, administrators who want to improve staff attitudes should focus on their human resource policies and examine how these policies communicate to staff their role and value to the organization. More research is also needed to determine if long-term care organizations that create supportive work environments for staff also provide a better quality of care.

Overall, staff characteristics failed to account for a significant amount of variance in work-related attitudes. Although age, education, and organizational tenure were correlated with work attitudes, none of these characteristics became an independent predictor when considered together with other variables. Despite considerable literature suggesting links between sociodemographic characteristics and work-related attitudes, few studies found these characteristics to be independent predictors. Researchers tend to use sociodemographic characteristics as descriptive statistics rather than explanatory variables (Price & Mueller, 1981). There is also a lack of consistent theoretical explanation of why and how sociodemographic characteristics influence work-related attitudes. Price and Mueller (1981) indicate that the frequently reported positive relationship between age and job satisfaction might be because older employees have more rewarding jobs, participate in more decision-making, and are better integrated into the workplace. Therefore, it is not age per se that "increases" satisfaction, but rather the better quality of jobs and the work experience which are positively correlated with age (Price & Mueller, 1981).

LIMITATIONS

The main methodological limitations of this research are related to its cross-sectional design, the measurement of organizational culture, and the biased sample of staff who participated in the study. Because the study was based on a cross-sectional design, the relationship between organizational culture and work-related attitudes can be interpreted only as associations rather than causal relationships. Future longitudinal studies should examine the effects of organizational culture on staff attitudes over time to establish causal links between variables.

There are also limitations related to the measurement of organizational culture in the present study. Because this study was designed to examine the relationship between organizational culture and work-related attitudes, a quantitative measure of organizational culture, the OCS, was used (Glaser et al., 1987). Although, the OCS has high validity, it does not measure the underlying values and assumptions that constitute the essence of organizational culture and ultimately determine staff behavior (Schein, 1985). Future studies should include qualitative measures to capture these deeper layers of organizational culture.

Furthermore, it is important to note that the views of staff who participated in the study may not be representative of all staff in assisted living. Individuals completing the survey had a relatively long length of employment in the facilities, and their perceptions may be different from views of staff with shorter organizational tenure. Future studies should include a more diversified sample of staff in terms of organizational tenure.

IMPLICATIONS AND CONCLUSION

The study findings have practical implications for nursing administrators who want to improve work attitudes among staff in assisted living. Because organizational culture is a strong predictor of job satisfaction, satisfaction with coworkers, and organizational commitment, interventions aimed at changing staff attitudes should focus on creating organizational cultures that promote teamwork, high organizational morale, participation in decision making, and supportive relationships among staff. In particular, efforts to improve staff attitudes should address the underlying cultural assumptions concerning the value and the role of staff in the provision of care. As stressed by advocates of culture change in long-term care, only staff members who feel valued and respected will be able to provide the quality of care that residents need (Eaton, 2000).

The findings of this study point to the central importance of organizational culture in understanding work-related attitudes among staff in assisted living. Future studies should provide more insight into the role of organizational culture and its influence on staff attitudes and quality of care. The success of assisted living as a person-centered model of care will greatly depend on its ability to create a person-centered organizational culture that values both residents and staff and recognizes the key role of staff in the provision of quality care.

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TABLE 1

CHARACTERISTICS OF STAFF (N= 317)

TABLE 2

DESCRIPTION OF THE MEASURES USED IN THIS STUDY

TABLE 3

BIVARIATE CORRELATIONS BETWEEN WORK-RELATED ATTITUDES, ORGANIZATIONAL CULTURE, AND STAFF CHARACTERISTICS

TABLE 4

HIERARCHICAL REGRESSION RESULTS OF JOB SATISFACTION, SATISFACTION WITH COWORKERS, AND ORGANIZATIONAL COMMITMENT ON SOCIODEMOGRAPHIC CHARACTERISTICS AND ORGANIZATIONAL CULTURE

10.3928/0098-9134-20060201-07

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