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Keywords:

  • cognitive impairment;
  • job satisfaction;
  • long-term care;
  • nursing;
  • person-centred

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Aim:  To determine care staff attitudes to dementia, assess levels of job satisfaction and explore how these attitudes and experience may relate to each other.

Methods:  Forty-nine staff from four long-term care facilities were surveyed using the Approaches to Dementia Questionnaire and the Staff Experience of Working with Demented Residents Questionnaire.

Results:  Attitudes were positive, focusing most on ‘person-centred’ care (4.35) as opposed to ‘hopefulness’ (3.66). Job satisfaction was also good, being highest in terms of ‘resident contact’ (2.92) but lowest for work ‘environment’ (2.12). Care staff attitudes to dementia were positively correlated with job satisfaction (r= 0.366, n= 48, P= 0.011), particularly for attitudes focused on ‘person-centred’ care (r= 0.393, n= 48, P= 0.006).

Conclusions:  Findings suggest an important relationship between care staff attitudes and levels of job satisfaction. More work is needed to specify this relationship.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Dementia is a clinical syndrome, comprised of a group of conditions that are characterised by impairments in brain functioning. It is typically degenerative in nature, usually occurring in older age but not necessarily so, and is associated with symptoms including loss of memory and language skills, and personality changes [1]. A number of behavioural changes are also common in dementia, such as increases in aggression, agitation and wandering [2], and these can often pose considerable challenges to staff in long-term care (LTC) facilities that are tasked with maintaining the quality of life (QOL) of the older person with dementia. For instance, aggressive behaviour is commonly cited as a significant problem that can alienate formal and informal caregivers [3] and is often a precursor to the decision to institutionalise family members [4,5]. In addition, these challenging behaviours can also cause some managers of LTC facilities to be apprehensive about admitting people with dementia [6], as it can be more time-consuming to provide care [7] and lead to increased caregivers' stress [8]. This may then have implications for the recruitment and retention of staff and, more importantly, potentially put the person with dementia at greater risk of abuse and neglect [9].

In trying to improve the quality of care provided to people with dementia, researchers have primarily looked at establishing a better understanding of care staff attitudes and workplace experiences in the hope that, by developing ways in which these can be changed, practice can be improved [10]. In doing so some studies have shown that more ‘hopeful’ attitudes predict more positive care staff behaviours with the person with dementia, such as positive engagement and stimulation [11]. Furthermore, care staff who have attitudes that are more ‘person-centred’[12] have been shown to have a greater recognition of dementia in residents [13]. There is also evidence to suggest that positive care staff attitudes, particularly ones focused on ‘person-centredness’, are related to better job satisfaction [14] and that staff who report higher levels of satisfaction provide better care [15]. Negative attitudes towards the person with dementia are regarded as an obstacle to care and can result in staff focusing on the resident's physical deficits [16]. In addition, continued high levels of staff stress can lead to burnout, which causes more negative attitudes towards the person with dementia and a reduction in the levels of emphathy shown [17].

To create positive care staff attitudes and better workplace experiences, the obvious policy response is to provide better education and training [18]. Indeed, within the literature there is evidence that care staff who have a good knowledge of dementia care also have positive attitudes [19] and those who are better trained are more likely to adopt a ‘person-centred’ approach and report more satisfaction [14]. Training programs that seek to move care staff away from focusing on the physical deficits associated with dementia (i.e., the biomedical model), and more towards a greater appreciation of the person's abilities and their maintained sense of personhood, can positively influence attitudes and knowledge levels [10,20] and possibly improve job satisfaction and staff morale.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Aim

The study sought to measure care staff attitudes to, and experiences of, working with older people with dementia in LTC facilities, and explores how these attitudes and experiences may relate to each other.

Design

This study was part of a larger funded research project, which aimed to provide an understanding of the QOL and moral worth of older people with dementia to inform a new model of care. Data for this paper were collected from August to December 2007. Ethical approval was granted by the Griffith University human research ethics committee and the partner aged care organisation provided a support statement.

Sample and setting

Convenience sampling was used and was purposeful at two levels: choice of setting and participants. Four mixed-sex LTC facilities, providing low (assisted living), high (nursing home), special (dementia specific) and respite care were chosen. All were located across New South Wales and Queensland, Australia, and were managed by a not-for-profit aged care organisation. Bed numbers at the facilities ranged from 40 to 125. All nursing and unregulated care staff from each facility (total pool of 182 day-shift staff) who provided care to the 61 residents taking part in the larger research program were eligible to take part in this study.

Data collection

Two measures were used to collect data regarding attitudes and experiences of working with older people with dementia.

  • 1
    Approaches to Dementia Questionnaire (ADQ) [21]: a 19-item scale related to staff attitudes towards dementia. Care staff rated on a 5-point scale from ‘strongly disagree’ to ‘strongly agree’, the extent to which they concurred with statements about dementia. A total score and two subscores were calculated to indicate ‘hopefulness’ and the extent to which a ‘person-centred’ approach was adopted. Higher scores were indicative of more positive attitudes to dementia. When used in this study, the internal consistency of the scale was shown to be good both overall (α= 0.80) and for the subscales of ‘hopefulness’ (α= 0.71) and ‘person-centred’ (α= 0.83). Previous research has also shown adequate internal reliability (total score α= 0.83; ‘hopefulness’α= 0.76; ‘person-centred’α= 0.85) [10].
  • 2
    Staff Experience of Working with Residents with Dementia Questionnaire (SEWDRQ) [17]: a 21-item assessment of staff experiences, satisfaction, and relationships with both other staff and relatives of residents with dementia. In the original version, statements are scored on a scale from ‘0 – not at all’ to ‘4 – extremely’, with a total score and six subscores calculated to provide measures of satisfaction with: ‘feedback’; ‘care organisation’; ‘one's own expectations’; ‘patient contact’; ‘expectation of others’; and ‘the environment’. Higher scores indicate greater staff satisfaction. In the current study, the instrument was modified for ease of application to the context and only included the word options on the response scale (i.e. ‘not at all’ to ‘extremely’). Other modifications included: culturally appropriate wording (i.e. ‘patient’ was changed to ‘resident’); the inclusion of the stem question ‘to what extent’ before each statement; and the computation of a mean total score and six mean subscores. When used in this study, which is believed to be one of the first in an Australian context, the internal consistency of the total scale was adequate (α= 0.80) and similar to previously reported values for the instrument (α= 0.87) [14].

A range of demographic information about all care staff was also collected at baseline (see Table 1).

Table 1. Sample characteristics of care staff
CharacteristicSubcategoryn%
Sex (n= 49)Female4591.8
Male48.2
Age (n= 44)<2536.8
26–35511.4
36–45818.2
46–552147.7
56–65715.9
Facility worked in (n= 49)Facility A (available staff 46)1530.6
Facility B (available staff 75)1326.5
Facility C (available staff 11)714.3
Facility D (available staff 50)1428.6
Employment position (n= 49)Personal Care Worker/Assistant in Nursing2755.1
Enrolled Nurse/Endorsed Enrolled Nurse36.1
Registered Nurse612.2
Diversional Therapist/Activity Officer816.3
Care Coordinator/Learning Mentor510.2
Level of employment (n= 48)Full-time1327.1
Part-time3368.8
Casual24.2
Highest level of education (n= 45)Nil48.9
Certificate III1942.2
Certificate IV920.0
Diploma511.1
Bachelor24.4
Masters24.4
Hospital trained/Nursing Certificate48.9
Time in current position (n= 45)<1 year817.8
1–5 years2964.4
6–10 years36.7
11+ years511.1
Number of other long-term care facilities worked in (n= 48)1–22756.3
3–41122.9
5–6612.5
7–824.2
9–1012.1
11+12.1

Data analysis

All data were entered and analysed using the Statistical Package for the Social Sciences Version 17.0 (SPSS Inc., Chicago, IL, USA). Before analysis, basic frequencies were run to screen for missing values and outliers and establish data entry accuracy. Total scores and subscores were computed for the ADQ and SEWDRQ, with reverse scoring being undertaken where applicable. Internal consistency of the two instruments and their subscales was verified through the computation of Cronbach's coefficient alpha (α). Basic frequencies were run for participant demographics and the instruments, and a series of Kolmogorov–Smirnov tests were undertaken to assess distributions of normality in relation to all care staff demographics.

To explore any differences in responses to subscales of the ADQ and SEWDRQ, the following was undertaken: a paired samples t-test to examine significant differences between the ‘hopefulness’ and ‘person-centred’ subscales of the ADQ; and a repeated measures anova, with Bonferroni pairwise comparisons, to explore any significant differences between the six subscales of the SEWDRQ. To determine if there was a relationship between attitudes and experiences, a series of Pearson correlational tests was undertaken for scores on the ADQ (total and subscales) and scores on the SEWDRQ (total and subscale).

All reported significant differences are at the P-value of 0.05, and where sphericity was not assumed, the Greenhouse Geisser P-value is given.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Sample characteristics of care staff

Of the 182 staff eligible to take part in this study, 49 completed surveys, resulting in a 27% overall response rate (see Table 1). These care staff were broadly representative of the aged care workforce [22], bring predominantly female (91.8%) and older than 46 years (63.6%), although aged from 19 to 60 years. In terms of employment, over half were Personal Care Workers/Assistants In Nursing (55.1%) and were employed on a part-time basis (68.8%). The highest level of education typically recorded by respondents was completion of Certificate III (42.2%) or IV (20.0%) (Vocational skills and knowledge). Care staff had worked in their current position from 8 months to 15 years, but most commonly from 1 to 5 years (64.4%). Over half had worked at one or two other LTC facilities (56.3%), and 35.4% had worked in three to six facilities (see Table 1).

Care staff attitudes and experiences of working with people with dementia

Overall, care staff attitudes towards the person with dementia were positive, with the ADQ total and two subscale scores clustering around the middle to higher end of the rating scale (see Table 2). Staff satisfaction, as measured by the SEWDRQ, was also generally good, with the total score and the six subscale scores again clustering around the middle to higher end of the scale (Table 2).

Table 2. Care staff ADQ (total and subscale) and SEWDRQ (total and subscale) scores: means and standard deviations (SD)
InstrumentnMeanSD
  1. ADQ, Approaches to Dementia Questionnaire; SEWDRQ, Staff Experience of Working with Demented Residents' Questionnaire.

AQD: Total494.060.39
ADQ: Hopefulness493.660.56
ADQ: Person-centred494.350.44
SEWDRQ: Total482.530.37
SEWDRQ: Resident contact492.920.43
SEWDRQ: Expectation of others482.670.53
SEWDRQ: Feedback at work492.520.55
SEWDRQ: One's own expectations492.510.52
SEWDRQ: Care organisation492.460.69
SEWDRQ: The environment492.120.50

Care staff recorded significantly higher scores for the ADQ subscale ‘person-centred’ care than for ‘hopefulness’ (t=−7.96, d.f. = 48, P= 0.000). There were also significant differences in the mean scores of the subscales of the SEWDRQ (F(3.756, 176.514) = 18.309, P= 0.000), with staff most satisfied with ‘resident contact’ (2.92) and least satisfied in their work ‘environment’ (2.12).

A series of Pearson correlational tests showed that there were a number of significant positive correlations between ratings on the SEWDRQ and the ADQ (Table 3). Overall, attitudes to people with dementia (ADQ total score) were correlated with experiences of working with people with dementia (SEWDRQ total score). There was also a correlation between overall scores on the SEWDRQ and the ADQ ‘person-centred’ subscale. Staff satisfaction with ‘feedback’ at work was correlated with all aspects of the ADQ including total score and both the ‘hopefulness’ and ‘person-centred’ subscales. Staff ratings of ‘resident contact’ were correlated with overall attitude to people with dementia and the ‘person-centred’ subscale. Finally, staff satisfaction with ‘expectations of others’ was correlated with scores on the ‘person-centred’ subscale.

Table 3. Pearson correlation coefficients for care staff AQD (total and subscales) and SEWDRQ (total and subscales): n, r and P-values
SEWDRQADQ: TotalADQ: HopefulnessADQ: Person-centred
nrPnrPnrP
  • *

    P < 0.05.

  • **

    P < 0.01. ADQ, Approaches to Dementia Questionnaire; SEWDRQ, Staff Experience of Working with Demented Residents' Questionnaire.

SEWDRQ: Total480.370.011*480.180.218480.390.006**
SEWDRQ: Resident contact490.440.002**490.270.063490.430.002**
SEWDRQ: Expectation of others480.260.075480.0020.989480.400.005**
SEWDRQ: Feedback at work490.540.000**490.420.002**490.440.002**
SEWDRQ: One's own expectations490.180.211490.080.594490.210.156
SEWDRQ: Care organisation490.050.71749-0.080.570490.160.280
SEWDRQ: The environment490.100.476490.130.388490.040.774

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Caring for a person with dementia can be challenging as it often demands a lot of time [7] and can lead to high levels of stress among staff [8]. Within the LTC setting these challenges have implications not only for the recruitment and retention of staff, but also for the quality of care provided to the person with dementia [9]. Given the imperative to safeguard the well-being of those in care, the study presented here sought to determine care staff attitudes to dementia, to assess levels of job satisfaction, and to explore how attitudes and experience may relate to each other.

Care staff attitudes towards people with dementia were positive and there was a particular focus on person-centred care, which is consistent with previous studies [13,14,23,24]. Such positive assessments are not unexpected as it makes sense that a person with a positive attitude towards older people with dementia will gravitate to work in a health-related care profession. However, it may be that staff person-centredness reflects the current emphasis on this approach in LTC and in staff training and skill development.

Care staff reported good levels of job satisfaction, and this was highest for ‘resident contact’ but lowest for the work ‘environment’. Such a finding is broadly consistent with previous work in this area [14] and so may be an accurate reflection of satisfaction levels. However, it may also be important to consider how care staff may have been influenced, in some part, by social desirability bias and that their responses may represent their desire to present themselves and their facility in a positive light [25]. The finding that satisfaction was highest for resident contact is supported by previous research, which has found that contact with residents can promote enjoyment, encourage job satisfaction [26] and act as an incentive for staff to remain working in their positions [27]. The finding that staff members were least satisfied with their environment highlights the importance of the working environment in influencing satisfaction and morale. Indeed, previous studies have shown that care staff feel greatest satisfaction when the care facility is clean and has adequate equipment [27]. Other studies have shown that staff satisfaction can be influenced by aspects of the built environment, such as the provision of personalised space for the person with dementia [28,29]. Unfortunately, the instrument used to measure staff satisfaction in our study (the SEWDRQ) did not allow a greater exploration of what it was about the ‘environment’ that staff were least satisfied with (i.e. the building layout, the facilities for staff, etc.). This, however, may be something to pursue in future studies exploring influences on satisfaction, possibly through a more qualitative approach.

Finally, but most importantly, this study found that care staff attitudes to people with dementia were significantly and positively correlated with job satisfaction, with more positive attitudes, particularly those focused on ‘person-centred’ care, relating to greater satisfaction. These results support the conclusions of a study from the USA of care staff attitudes, stress and work satisfaction [14]. While the cross-sectional nature of the current study precludes any conclusions on causality, the results are consistent with the hypothesis that the adoption of positive attitudes, particularly ones that take a person-centred perspective, is positively related to the well-being of care staff. In understanding this finding, it has been suggested that adopting a person-centred approach not only benefits the person with dementia by maintaining their sense of personhood but also helps sustain the satisfaction of care staff by preparing them for the challenges of providing care [14]. This suggests that training programs that seek to move care staff away from focus on the physical deficits associated with dementia and towards a greater appreciation of the person's abilities can positively influence attitudes and care practices [10,20].

In interpreting these findings it is important to consider a number of issues that limited the study. First, because of non-normally distributed data, no subgroup or multiple regression analyses were undertaken to explore how characteristics of care staff may have influenced attitudes. Previous studies have shown the importance of demographic factors (i.e. age, education, training levels and extent of work experience [23]) in accounting for attitudinal differences of care staff and it would be beneficial for future studies to explore these influences further. Second, the overall response rate achieved in this study was relatively low (27%; 49 out of 182). However, this may be a conservative estimate of response, given that some staff from the total pool available worked casually for very few hours and therefore may not have been accessible. Other issues with the sample include evidence of a particularly transient workforce, with some staff reportedly having worked in more than nine LTC facilities and some only having worked in the facilities for a short time. Such issues make it difficult to determine whether the results are representative of other care staff or if they are particular to those surveyed. However, our results are supported by previous literature [13,14,23,24], suggesting the wider application of findings beyond this study's sample. Finally, the study may be limited by its use of the relatively unknown SEWDRQ. A more thorough investigation of the scale's reliability and validity, particularly within an Australian context, would be beneficial. However, the good levels of internal consistency evidenced in our study are reassuring, as is its use in a number of large-scale US studies [14,30].

In conclusion, this study showed that there is a positive relationship between the attitudes of care staff and their levels of job satisfaction. Given the potential importance of this relationship there is a need for more work to further understand and delineate the influences on attitudes and also experiences in the workplace. This may then help improve both the well-being of care staff and, ultimately, the quality of life of people with dementia living in LTC facilities.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

This paper reports on an outcome of a larger collaborative research project funded by the Australian Research Council (LP0775127) under the Linkage Project Scheme for 2007–2009 and RSL Care, the industry partner. The authors acknowledge support and contributions by RSL Care management (particularly Deborah Oxlade and Jenni Marshall), facility staff, family and residents and members of the International Advisory Panel.

Key Points

  • • 
    Care staff had positive attitudes towards people with dementia, particularly in terms of being person-centred in their approach to care.
  • • 
    Staff job satisfaction was reported to be generally good, with care staff being most satisfied with ‘resident contact’ but least satisfied with their work ‘environment’.
  • • 
    There was a positive correlation between staff attitudes to dementia and job satisfaction, with more positive attitudes, particularly those focused on person-centred care, related to higher levels of satisfaction.

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  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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