474707

2013
WES27510.1177/0950017012474707Work, employment and societyMorgan et al.

On the front line with service workers: article

Work, employment and society

The quality of healthcare 27(5) 802­–822

© The Author(s) 2013
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DOI: 10.1177/0950017012474707
compensate for low extrinsic wes.sagepub.com

rewards?

Jennifer Craft Morgan

Georgia State University, USA

Janette Dill
University of Akron, USA

Arne L Kalleberg
University of North Carolina at Chapel Hill, USA

Abstract
Frontline healthcare worker jobs are among the fastest growing occupations in the USA. While
many of these are ‘bad jobs’ with low pay and few benefits, the intrinsic nature of frontline work
can also be very rewarding. This article examines the influence of extrinsic job characteristics (e.g.
wages and benefits) versus intrinsic characteristics (e.g. meaningful tasks) on job satisfaction and
intent to stay with one’s current employer. This article uses a mixed-methods approach, drawing
on survey data collected from frontline workers and organizations in a variety of healthcare
settings, as well as interview and focus group data from frontline workers to contextualize and
interpret the findings in the multi-level models. The results indicate that both intrinsic and extrinsic
characteristics are significant predictors of job satisfaction, but only extrinsic characteristics help
explain intent to stay with the employer.

Keywords
frontline workers, healthcare, job satisfaction, low-wage work, mixed methods, organizational
commitment

Corresponding author:
Jennifer Craft Morgan, Gerontology Institute, Georgia State University, P.O. Box 3984, Atlanta GA 30302,
USA.
Email: jmorgan39@gsu.edu

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Morgan et al. 803

Introduction
Healthcare jobs are among the fastest growing occupations in the USA (Bureau of Labor
Statistics, 2012/13). Their expansion is due in large part to population aging and the atten-
dant increase in demand for health services, which have swelled healthcare expenditures
in the USA, as in most industrial countries. Despite the importance of healthcare jobs,
many are relatively low skilled (e.g. home care aide) and have elements that are often
associated with ‘bad jobs’, or jobs with low wages, poor benefits, a lack of job security
and little opportunity for advancement (Cooper, 2008; Kalleberg, 2011; McGovern et al.,
2004). Pressures to reduce costs have encouraged US healthcare organizations, like many
other employers, to expand their use of such ‘bad jobs’, a strategy that is likely to have
increased after the 2009 Affordable Care Act health reform, which limited government
insurance reimbursements to healthcare organizations for many procedures.
While frontline healthcare jobs in the USA might be ‘bad’ in an economic sense, they have
features that may compensate workers for the low pay, poor fringe benefits and other negative
job qualities (Macdonald and Merrill, 2002; Mittal et al., 2009). In particular, the intrinsic
nature of frontline worker jobs (i.e. the inherent relational nature of care work) can be very
rewarding and may meet the expectations and values held by workers in these jobs (Berg and
Frost, 2005; Decker et al., 2009; Rakovski and Price-Glynn, 2010; Stacey, 2005). In this
article, the authors ask whether these intrinsic rewards of frontline healthcare work may com-
pensate for these ‘bad job’ qualities in terms of workers’ overall job satisfaction and organi-
zational commitment. The theoretical work of this article draws attention to the duality of
intrinsic versus extrinsic factors to conceptualize the factors that influence low wage workers’
perceptions of job satisfaction and intent to stay (see e.g. Herzberg et al., 1959).
The study draws on survey data collected from frontline healthcare workers nested
within a range of healthcare organizations (e.g. acute care settings, long-term care facili-
ties, community health centres, behavioural health settings), as well as qualitative data
from focus groups with frontline healthcare workers. This mixed-method approach allows
the authors to build a predictive model and also to contextualize how these jobs are meet-
ing the needs and preferences of low-wage, low-skill workers relative to their job satisfac-
tion and their intent to remain with their current employer or seek other work. The article
assesses the relative impact of characteristics of frontline healthcare jobs and healthcare
organizations (such as wages, benefits, opportunities for promotion, supervisor support of
job tasks and relationships with clients) on overall job satisfaction and on intent to stay
with one’s employer. The interview and focus group data from frontline workers help to
contextualize and interpret the findings from the multi-level multivariate models. Rather
than testing specific hypotheses, the data analysis is richly descriptive, using multivariate
methods to determine the patterns of job quality and the implications for job satisfaction
and employment intentions among frontline healthcare workers.

Background and significance

Who are frontline healthcare workers in the USA?
The frontline healthcare workforce constitutes approximately half of the total healthcare
workforce (about 12 million workers) and consists of diverse occupations within various

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804 Work, employment and society 27(5)

health services and healthcare delivery roles, including nursing assistants, respiratory
therapy technicians, social and human service assistants, home health aides, mental
health counsellors and medical transcriptionists. For the purposes of this study, frontline
healthcare workers are those who:

1) provide a high level of patient care or support services;

2) have a low threshold to entry (generally a high school or a small amount of addi-
tional training); and
3) generally earn $40,000 or less (Schindel et al., 2006).

Frontline workers comprise a particularly vulnerable segment of the population.

These jobs are heavily dominated by women and minorities: 79 per cent of the frontline
workforce is female; and 32 per cent are African American, Hispanic or Asian (Price-
Glynn and Rakovski, 2012; Schindel et al., 2006). Moreover, 28 per cent of nursing
assistants working in nursing homes are single mothers, as compared to 14 per cent of all
female workers (Smith and Baughman, 2007).

Are frontline healthcare jobs ‘bad jobs’?

Frontline healthcare workers in general have very high levels of job satisfaction compared
to workers in other occupations (Rose, 2003) and yet turnover in many of these occupa-
tions is also very high (Castle et al., 2007; Donoghue, 2010; Rosen et al., 2011). What
explains this paradox? The article draws on Herzberg and colleagues’ (1959) distinction
between extrinsic (e.g. pay, benefits) and intrinsic job qualities (e.g. social relations, chal-
lenging work) as a theoretical framing for understanding why these trends differ from
much previous research, which has shown that job satisfaction is a strong and direct pre-
dictor of employment intentions and turnover (Bannister and Griffeth, 1986; Griffeth
et al., 2000; Mobley et al., 1978). In their dual-factor theory of job satisfaction, Herzberg
et al. (1959) argue that different characteristics are responsible for job satisfaction and job
dissatisfaction. They posit that job satisfaction is driven primarily by the nature of the
work (i.e. intrinsic rewards), while job dissatisfaction is shaped by the external work envi-
ronment (i.e. extrinsic rewards). While this framing has not necessarily held firm for pre-
dicting job satisfaction (both extrinsic and intrinsic factors are important in determining
job satisfaction), in this article it is argued that the duality of intrinsic and extrinsic factors
helps to make sense of the tension felt in workers and in the healthcare managers between
the meaning-making aspects of work and the compensation aspects of the work, a tension
which is reflected in high job satisfaction among workers accompanied by high turnover.
Extrinsic job characteristics are factors that provide the external context in which job
tasks are performed, such as wages, benefits and supervision (Herzberg et al., 1959;
Olsen et al., 2010). Arguably, wages are the single most important extrinsic job reward
to workers. Health benefits are also especially important in the USA because individuals
are primarily dependent on employers for health insurance coverage (Appelbaum, 2011).
Another important extrinsic job quality is opportunity for advancement (McGovern
et al., 2004). Jobs with access to internal labour markets and those in the primary seg-
ments of the labour markets provide not only promotion opportunities, but chances to

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Morgan et al. 805

attain higher wages, prestige and security (see e.g. Doeringer and Piore, 1971; Gordon
et al., 1982). Thus, a low-wage job is not necessarily a ‘bad job’ if it is a stepping stone
to a job with higher wages and better benefits. However, most low-wage jobs in the USA
provide few opportunities for meaningful promotions and wage growth (Andersson
et al., 2005; Gottschalk, 1997; Gottschalk and Danziger, 2005).
Many frontline healthcare jobs have ‘bad’ characteristics (Kalleberg et al., 2000). For
example, while most nursing assistants in nursing homes work nearly full-time, approxi-
mately 18 per cent live in households with earnings below the Federal poverty line and
52 per cent live in households with incomes below 200 per cent of the Federal poverty
line (Smith and Baughman, 2007). Approximately 40 per cent of nursing assistants in
nursing homes receive health insurance through their employers and, in most cases, the
employer pays for only part of the monthly premium. Also, a substantial percentage
(11.3%) of nursing assistants receive health insurance through Medicaid (Yamada,
2002). Finally, most frontline healthcare workers remain low earners throughout their
careers (Andersson et al., 2005; Baughman and Smith, 2011).
Most research on low-wage workers in US healthcare settings has focused on nursing
assistants in nursing homes rather than other settings (e.g. hospitals, behavioural health,
community health). For example, studies have found that nursing assistant job dissatis-
faction is associated with low levels of compensation, few benefits and lack of promo-
tional opportunities (Castle et al., 2007; Ejaz et al., 2008).
Likewise, researchers have found that higher wages and opportunities for advance-
ment are associated with intent to stay with an employer (Bishop et al., 2008; Stearns
and D’Arcy, 2008). Not surprisingly, pervasive problems in recruitment and retention of
frontline workers are reported nationally. National estimates of turnover among nursing
assistants in nursing homes, for example, are often near or above 100 per cent (Donoghue,
2010). Hospitals generally pay higher wages than other healthcare sectors and tend to
have less difficulty with recruitment and retention. However, Appelbaum et al. (2003)
reported that in the late 1990s and early 2000s, when unemployment rates were
extremely low, even hospitals experienced turnover of frontline workers that approached
100 per cent as they began losing employees to other sectors, such as fast food restau-
rants and retail.

The intrinsic rewards of frontline healthcare work

In contrast to extrinsic job qualities, intrinsic job qualities are rooted in the nature of
work required by the job, such as the meaningfulness of the work to an individual or
autonomy at work. This intrinsic aspect of work continues to be important in workers’
evaluation of their work and in employment outcomes despite a rhetorical emphasis on
the extrinsic aspects of job quality (Gallie et al., 2012). Frontline healthcare work,
whether it includes entry level tasks (e.g. transporting patients to surgery, cleaning the
rooms of new mothers), administrative work (e.g. admitting patients to the hospital), or
direct care work (e.g. helping patients to bathe) in these settings often requires a deeper
level of intimacy with clients than typical service work. This work is gendered, as it often
mimics the emotional and instrumental caring work that is largely done as unpaid work
by women. For example, Diamond (1995) argues that ‘mother’s wit’ – tacit knowledge

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806 Work, employment and society 27(5)

that comes mainly from the experience of caregiving – lies at the heart of direct care
work. Mother’s wit allows workers to satisfy the needs of their clients and enables work-
ers to gain altruistic and social rewards as well as a sense of expertise and mastery that
results from developing strong relationships with clients (Anderson et al., 2005;
Diamond, 1995).
The positive discourse surrounding frontline workers’ evaluations of their jobs cent-
ers on a gendered orientation to their paid work and is characterized by a heavy emphasis
on both interpersonal care rewards and social rewards (Daykin and Clarke, 2000; Fine
and Glendinning, 2005; Kittay, 1999; Stacey, 2005). As Spenner and Rosenfeld (1990)
point out, ‘it is not that “good” jobs keep women in the labor force but that the nature of
what is considered “good” differs by a woman’s work identity’ (1990: 281). In other
words, the sense of altruism and concern for caring for others required by care work is
highly valued by women and may provide intrinsic fulfilment that compensates in part
for low wages (England and Folbre, 2003; England et al., 2002; Himmelweit, 2002) and
poor working conditions (Dodson and Zincavage, 2007). On the other hand, many front-
line workers may feel ambivalent about the ‘body work’ required in many of these jobs;
they may find it to be uncomfortable or demeaning while also enjoying the emotional
intimacy that comes from working closely with other people (Twigg, 2000).
Given that gendered notions of care work and its associated rewards are pervasive in
how frontline workers in healthcare settings talk about their work, intrinsic rewards are
likely to play an important part in workers’ evaluations of their jobs (e.g. overall job
satisfaction). At the same time, the high turnover rates among frontline healthcare work-
ers suggest that an intrinsically rewarding nature of the work is not necessarily enough to
keep workers in their jobs. It is expected that the extrinsic ‘bad job’ characteristics of
these jobs (e.g. wages, benefits, advancement opportunity) have a stronger impact on the
employment intentions of workers than do intrinsic rewards.

Research design and method

The article draws from three data sources to evaluate job quality among frontline health-
care workers. First, survey data collected from 1006 frontline workers in 25 healthcare
organizations across the USA are analysed.1 Multiple imputation is used to impute miss-
ing values for individual level variables in the model to retain the whole sample (see
Table 1 for the n for each variable). Using Stata 11 MI commands, 20 imputed datasets
were generated for the analysis (Rubin, 1987). Survey data are supplemented by using
answers obtained from key informants (e.g. HR personnel, evaluation liaisons) who
responded to organizational profile surveys (n=25, 100% response rate). Finally, 31
focus groups conducted with a subset of the survey respondents are also analysed to
contextualize the survey findings. Focus group participants were recruited based on
availability of workers relative to site visit schedules.2 Survey data and focus groups
were conducted as part of a national evaluation of the Jobs to Careers programme. At the
time of writing, 63 per cent of survey respondents were participants in a grant-sponsored
workforce development programme, though the data examined in this study are baseline
data that were collected before the programmes were implemented.3 Both qualitative and
quantitative data collection protocols were reviewed and approved by the University of

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 Table 1.  Summary of dependent and independent variables included in models of job satisfaction and intent to stay.

N Mean SD Min Max

Dependent Variables
Morgan et al.

Job Satisfaction (alpha=0.88) 992 7.70 1.37 2.67 10.00

  Overall, I am satisfied with what I do in my job.  
  I am generally happy with my current work environment.  
  My job measures up to the sort of job I wanted when I took it.  
  If a good friend of mine told me that he/she was interested in working in a job like  
mine for my current employer, I would recommend he/she take the job.
  Knowing what I know now, if I had to decide all over again, I would still decide to  
take the job I now have.
  On a scale 1 to 10, with 1 being very dissatisfied and 10 being very satisfied, how  
satisfied are you with your current position?
Intent to stay Indicates that the individual answered ‘yes’ to one of the following statements: 996 0.77 0.42 0.00 1.00
either ‘Chances are very slight that I will leave within the year’, or ‘Definitely will
not leave within a year’.
Independent Variables: Extrinsic Job Characteristics
Financial Rewards (alpha=0.65) 990 2.63 0.72 1.00 4.00
  The pay is good.  
  The job security is good.  

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  Your fringe benefits are good.  
Employer Respondent has health insurance that is either partially or fully paid by employer 971 0.68 0.46 0.00 1.00
insurance (1).
Promotion Opportunity (alpha=0.75) 972 2.83 0.65 1.00 4.00
  There are opportunities for promotion with my employer.  
  This job is a stepping stone to other better-paying jobs with my employer.  
  If I complete education programs or degrees, I will be promoted within this  
employer.
Organizational Support for Education and Training (alpha=0.80) 973 2.87 0.61 1.00 4.00
807

  I am encouraged to take formal training or classes relevant to my job.  

(Continued)
 Table 1. (Continued)
808

N Mean SD Min Max

  My employer helps me to acquire or improve my skills while at work.  
  My employer provides opportunities for workers to improve their math, reading  
or English as a second language skills.
Supervisor Support of Career Development (alpha=0.91) 972 1.14 0.69 0.00 2.00
  My supervisor helps me identify career opportunities.  
  My supervisor advocates for me for wage increases or promotions.  
  My supervisor helps me identify educational opportunities.  
  My supervisor teaches me new skills through examples at work.  
  My supervisor creates a learning environment at work.  
Workload (alpha=0.79) 1006 2.41 0.49 1.00 3.89
  There is not enough time to get required work done.  
  I never seem to have enough time to get everything done on my job.  
  It is difficult to take off of work for personal or family matters.  
  This job just wears me out.  
  You have to be physically strong to do this job.  
  You do your best and sometimes your best isn’t good enough.  
  The client load is too high.  
Independent Variables: Intrinsic Job Characteristics
Supervisor Support of Job Tasks (alpha=0.90) 994 1.58 0.50 0.00 2.00

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  My supervisor treats me as an equal member of the health care team.  
  My supervisor listens carefully to my observations and opinions.  
  My supervisor gives me credit for my contributions.  
  My supervisor respects my ability to observe and report.  
  My supervisor lets me know how helpful my observations are.  
  My supervisor trusts me to do a good job.  
  My supervisor helps me with job tasks when help is needed.  
Input into Job Tasks (alpha=0.69) 1006 2.97 0.52 1.25 4.00
Work, employment and society 27(5)

  You are given the chance to do the things you do best.  

(Continued)
 Table 1. (Continued)

N Mean SD Min Max

  You can see the results of your work.  
Morgan et al.

  It is basically my own responsibility to decide how my job gets done.  

  I have a lot of say about what happens on my job.  
  I generally have opportunities for creative input and innovation in my work.  
Meaning of Job Tasks (alpha=0.73) 997 3.33 0.39 2.13 4.00
  We treat clients like family.  
  My clients give me a reason to return to work each day.  
  We care about the job we do.  
  I spend time just listening to the clients I care for.  
  I treat clients like I would like to be treated.  
  I know what my clients want and need.  
  It upsets to me to return after being off to find my clients not well cared for.  
  I try to keep the clients’ routines in place when caring for them.  
Co-Worker Support (alpha=0.87) 986 2.49 0.60 1.00 4.00
  Some frontline healthcare workers act hostile towards clients.  
  Sometimes our frontline healthcare workers take out their bad days on the clients.  
  Some frontline healthcare workers here do not show up for work.  
  Frontline healthcare workers from the previous shift often leave some of their  

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work for me to do.
  Some frontline healthcare workers here don’t want to be around clients.  
  Some of the frontline healthcare workers are clock-watchers.  
  Some of the frontline healthcare workers I work with are troublemakers.  
  Some frontline healthcare workers do the least work they can do.  
  Some frontline healthcare workers act like they are here only for the paycheck.  
Independent Variables: Individual Level Characteristics
Age Age in years. 929 36.76 12.25 17.00 74.00
809

(Continued)
 Table 1. (Continued)
810

N Mean SD Min Max

Female Respondent is female (1) or male (0). 954 0.88 0.32 0.00 1.00
Black Respondent identified themselves as Black (1). 921 0.24 0.42 0.00 1.00
Hispanic Respondent identified themselves as Hispanic (1). 895 0.27 0.44 0.00 1.00
Other minority Respondent identified themselves as another minority (1). 924 0.26 0.44 0.00 1.00
Married Respondent is married (1) or not married (0). 987 0.52 0.50 0.00 1.00
Children under Respondent cares for children under the age of 18. 982 0.53 0.50 0.00 1.00
18
Single mother Respondent is a single mother (1) or not a single mother (0). 977 0.20 0.40 0.00 1.00
Need for wages Indicates that the respondent answered ‘yes’ to this statement: ‘I (or my family) 969 0.59 0.49 0.00 1.00
depend completely on my paycheck.’
Education Indicates whether the respondent has a high school degree or less (1) or more 977 0.65 0.48 0.00 1.00
than a high school degree (0).
Full-time status Indicates if the respondent is a full-time or a part-time employee. 994 0.89 0.31 0.00 1.00
Tenure The number of years the individual has worked for her current employer. 980 5.30 6.39 0.17 43.42
Independent Variables: Organizational Level
Acute care Hospitals or health systems. 1006 0.46 0.50 0.00 1.00
Behavioural Organizations that provide substance abuse or psychiatric services. 1006 0.20 0.40 0.00 1.00
health

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Community Organizations that provide primary health care services to medically underserved 1006 0.13 0.33 0.00 1.00
health communities and vulnerable populations.
Long-term care Nursing homes or assisted living facilities. 1006 0.22 0.41 0.00 1.00
Entry level Employees surveyed at the organization provided ancillary support services (e.g. 1006 0.17 0.38 0.00 1.00
FLWs dietary, housekeeping, or laundry services).
Direct care Employees surveyed at the organization worked directly with patients (e.g. nursing 1006 0.68 0.47 0.00 1.00
FLWs assistants or medical technicians).
Administrative Employees surveyed at the organization performed administrative duties (e.g. unit 1006 0.15 0.36 0.00 1.00
FLWs clerks).
Work, employment and society 27(5)

(Continued)
 Morgan et al.

Table 1. (Continued)

N Mean SD Min Max

Size Number of employees at the organization (divided by 100). 1006 22.13 27.68 0.28 94.00
Independent Variables: County Level
Population County population size (divided by 100,000). 1006 6.30 4.11 0.39 18.27
Median income Median income in county (divided by 10,000). 1006 5.24 1.06 3.07 6.85
Poverty Percentage of residents below the poverty level in county. 1006 13.68 5.00 6.60 24.50
Unemployment County unemployment rate. 1006 4.76 1.24 3.60 10.30
rate
Northeast 1006 0.29 0.45 0.00 1.00
South 1006 0.35 0.48 0.00 1.00
Midwest / West 1006 0.36 0.48 0.00 1.00

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811
812 Work, employment and society 27(5)

North Carolina Institutional Review Board. Summary statistics of the characteristics of

the individuals and organizations in the sample are included in Table 1.

Measurement
The variables included in the quantitative analyses were measured at three levels: the
individual level, the employer level and the county (labour market) level. Table 1
summarizes all variables. The article examines two individual level outcomes. First,
job satisfaction is widely regarded as an indicator of the overall quality of work
experience. The scale of job satisfaction consists of responses to six survey items,
and has an alpha of 0.88 (see Table 1 for sample survey items included in the scale).
Second, intent to stay with one’s current employer is an indicator of a worker’s
attachment to the organization, an aspect of her or his organizational commitment.
Intention to stay has been shown to be negatively related to quits and so is an impor-
tant feature of the ability of organizations to retain workers (Rosen et al., 2011). The
measure used in this study is a dichotomous variable coded 1 if the individual
responded ‘Chances are very slight that I will leave within the year’ or ‘Definitely
will not leave within a year’ to the question ‘Do you expect to leave your current
employer in the coming year?’

Extrinsic job qualities. Characteristics that describe the external work environment

include scales of individuals’ perceptions of financial rewards and whether an indi-
vidual had health insurance that is either partially or fully paid for by their employer.
Three multi-indicator scales measure an individual’s perception of: opportunity for
promotion (e.g. ‘There are opportunities for promotion with my employer’); organiza-
tional support for training and education (e.g. ‘I am encouraged to take formal train-
ing or classes relevant to my job’); and supervisor support of career development (e.g.
‘My supervisor advocates for me for wage increases or promotions’). A measure of
workload is also included. Workload measures the physical and emotional require-
ments of performing one’s job.

Intrinsic rewards.  Measures of intrinsic rewards include scales of: input into job tasks
(e.g. ‘It is basically my own responsibility to decide how my job gets done’); meaning of
job tasks (e.g. ‘My clients give me a reason to return to work each day’); supervisor sup-
port of job tasks (e.g. ‘My supervisor treats me as an equal member of the healthcare
team’). A multi-item quality of co-workers measure which captures an individual’s per-
ceptions of the quality of the work performed by their co-workers as an intrinsic measure
was also used. Supervisor support and quality of co-workers are classified as intrinsic job
characteristics because the survey items measure how an individual’s supervisor or co-
workers influence their experience of job tasks and thus this influence relates directly to
job autonomy and relationships. Table 1 details all survey items included in the per-
ceived job characteristic scales as well as reliability statistics. The scales used in this
study have been used and validated elsewhere (Dill, 2012).
Finally, in the models a number of individual, organizational and economic/geo-
graphic control variables are included. These models are described in detail in Table 1.4

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Morgan et al. 813

Analysis
Random effects models are used since they allow the authors to control for the hierarchi-
cal structure of the data and take into account the clustering of error caused by the nesting
of individuals within organizations. Because job satisfaction is a continuous variable a
random effects regression model with a continuous outcome is used. For intent to stay, a
binary variable, a random effects logistic regression model is used. All analyses were
conducted using Stata 11 software. To supplement the quantitative analysis, qualitative
data on the context of these workers’ experiences are presented. This information illus-
trates the significant relationships identified through the multivariate analysis.5

Findings
Job satisfaction
Table 2 indicates that significant predictors of job satisfaction are primarily intrinsic job
qualities.

Table 2.  Multi–level models of frontline worker job satisfaction and intent to stay in current job.

Job satisfaction Intent to stay

  Coef. Std. Err. Coef. Std. Err.
Job satisfaction 0.39 0.17*
Extrinsic Job Characteristics  
Financial rewards 0.19 0.03*** 0.50 0.16***
Employer insurance –0.04 0.04 –0.32 0.22
Promotion opportunities 0.03 0.04 0.54 0.22*
Organizational support of education 0.04 0.05 0.13 0.25
Supervisor career support 0.01 0.04 0.15 0.19
Workload –0.24 0.04*** –0.58 0.23**
Intrinsic Job Characteristics  
Supervisor support of job tasks 0.19 0.05*** 0.01 0.24
Input into job tasks 0.47 0.04*** 0.03 0.23
Meaning of job tasks 0.25 0.05*** –0.09 0.26
Co-worker support –0.07 0.04* 0.12 0.19
Individual Level Characteristics  
Age (logged) 0.09 0.06 1.07 0.33***
Female 0.13 0.06* –0.06 0.28
Black –0.03 0.06 0.12 0.29
Hispanic 0.08 0.04 0.23 0.23
Other minority 0.04 0.05 0.13 0.28
High school or less 0.06 0.04 0.04 0.19
Full-time 0.10 0.06 –0.03 0.30
(Continued)

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814 Work, employment and society 27(5)

Table 2. (Continued)

Job satisfaction Intent to stay

  Coef. Std. Err. Coef. Std. Err.
Tenure (logged) 0.00 0.02 0.13 0.10
Married –0.10 0.05* 0.27 0.25
Kids 0.07 0.05 0.42 0.25
Single mother –0.14 0.07* 0.01 0.35
Dependence on wages –0.04 0.04 0.50 0.19**
Organizational Level Characteristics  
Entry level frontline worker –0.06 0.09 –1.14 0.50*
Direct care frontline worker –0.09 0.12 –0.11 0.63
Community health centre 0.01 0.15 –0.64 0.89
Behavioural health centre 0.12 0.15 –1.37 0.82
Long-term care –0.01 0.15 –0.75 0.88
Size (divided by 100) 0.00 0.00 0.00 0.01
County Level Characteristics  
Population (divided by 1000) 0.00 0.01 0.02 0.04
Unemployment rate –0.04 0.03 0.09 0.15
Percentage below poverty line –0.01 0.01 –0.10 0.08
Median income –0.08 0.07 –0.47 0.40
South 0.04 0.09 –0.95 0.52
West/Midwest 0.06 0.09 –0.77 0.49
Constant 1.53 0.65* –1.92 3.61

Notes: n=992, 29 organizations.

Reference categories are ‘direct care frontline worker’ for type of worker, ‘acute care’ for type of healthcare
organization and ‘Northeast’ for region.
*≤ .05, **≤ .01, ***≤ .001.

For example, individuals who reported that they found a high level of meaning in their
job tasks, such as developing strong relationships with clients, also reported higher over-
all job satisfaction, as did workers who perceived a high degree of input into job tasks.
That workers who had the ability to perform their work tasks in the way they thought best
suited patients were more satisfied overall was reflected in the words of one focus group
participant:

And for me working as a clinical assistant you know it’s, it’s really not glamorous, some parts
of it, it’s not very glamorous. Again, dealing with different types of cancers, different types of
smells and you know that come along with the different types of cancers. Ah, but I really enjoy
working with patients. A lot of patients you know are very old so these are their final hours,
their last hours. So I get a great sense of ah, feel-goodness ah, you know when I go in and, and
take care of somebody that, that’s dying or you know take a wet rag and wipe somebody’s face.
You know I go home and I really feel good about myself.

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Morgan et al. 815

Moreover, respondents who perceived higher levels of supervisor support of job tasks
reported significantly higher levels of job satisfaction. One focus group participant talked
about how her relationship with her supervisor improved her experience at work:

It’s like a family here with [administrators] and, and I know my boss, there’s support everywhere.
So you can go absolutely and make more money somewhere else but then you leave the support
and so it’s a catch 22 ….

As the above quote illustrates, supervisor support might improve one’s intrinsic
rewards on the job. In this worker’s evaluation of her job, the experience of intrinsic
rewards derived from supervisor support was weighed against other options for jobs
where there might be more money to be made. Here was a clear example of how intrin-
sic rewards might compensate for low extrinsic rewards in how the job quality is
evaluated.
Not surprisingly, workers who reported heavier workloads were less satisfied in
their jobs. Heavy workloads are physically and emotionally exhausting and workers
perceived that heavy workloads kept them from doing their job well. One worker
stated, ‘The only thing that kind of worries me is the patient load because you want to
give every patient their care, but quite frankly, when you got nine to 12 patients, it’s
not going to happen.’ Despite the importance of intrinsic rewards, financial considera-
tions were not irrelevant, however, and those who were more satisfied with financial
compensation were also more satisfied with their jobs. For those who were not satis-
fied with their pay, their wages were often viewed as a matter of respect and value.
They felt that their work was not highly valued in the organization, and that this was
reflected in their low wages.

I’m still angry … about how the cost of living has gone up and our pay hasn’t gone up … and
then after that they take out health insurance and taxes. And it kind of and it still sticks with me
and makes me angry and um, because it, [these decisions] come from people who … make,
make a lot more money than us. The people I work with everything we do we invest our times,
our lives, we work on days we’re not supposed to, we stay when other people can’t come in …
we all work together.

Intent to stay
In contrast to the results for job satisfaction, intrinsic characteristics were not signifi-
cantly related to individuals’ intent to stay with their current employer. Rather, intention
to remain was primarily related to extrinsic rewards such as higher financial rewards.
Mean wages for the sample of frontline healthcare workers included in this study were
quite low at US$12.18 per hour, with the median wage at US$11.54 per hour. This was
well below the average mean and median hourly wage in the USA, which stood at $20.90
and $15.95 per hour, respectively, in May 2009 (Bureau of Labour Statistics, 2010).
Clearly, low wages inflicted considerable hardship on these workers. Indeed, many focus
group participants talked about holding a second job to make ends meet. Others talked
about having to make difficult choices between supporting their families or pursuing

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816 Work, employment and society 27(5)

additional education, which they knew they needed to advance within their organiza-
tions. For example, one worker talked about safe housing versus going back to school:

At the mean time right now I live in the housing which they go based on my income … I have
to move by summer time. I have a 14-year-old daughter I don’t want her to grow up in that
environment no more. My pay, we depend on my pay … my two children depend on my pay.
With what I make I’m not gonna be afford to go back to school. I’m not gonna be afford to
move. I mean I have to move … but do I have to put my schooling in the back burner because
my job doesn’t provide me enough pay to go to school?

This worker’s need for higher wages is expressed in this quote. The worker’s words
reflect the myriad of factors related to extrinsic rewards that influenced decisions whether
to remain employed even if workers were likely to be highly satisfied with the work.
Individuals who reported greater promotion opportunities were also more likely to
intend to stay with their current employer. Frontline workers in the sample were gener-
ally optimistic about promotion opportunities with their current employer which is
somewhat surprising given findings of previous studies indicating low mobility out of
frontline jobs. Over 70 per cent replied that they ‘Agree’ or ‘Strongly agree’ with the
following statements: ‘There are opportunities for promotion with my employer’ or
‘This job is a stepping stone to other better-paying jobs with my employer’. In focus
groups, workers often gave examples of moving from one type of position (e.g. house-
keeping) to a better position (e.g. certified nursing assistant) with their current employer.
Workers in hospital settings generally had a higher sense of opportunity. One focus
group participant said, ‘I like the growth opportunities here … at the hospital because
they do push education and support you in that … I mean just seeing other people and
we know how they started out and we know where they’re at now … it’s amazing.’
Many respondents had plans to return to education in order to gain the credentials (the
most common goal was a nursing degree) needed to be promoted within the organiza-
tion. At the same time, many were realistic about their promotion opportunities. They
recognized that in order to make a substantial jump within the organization, they would
need to have additional training or certification and many expressed doubts about their
ability to obtain additional education.

I’m a single mom with two kids and really have thought of going to school but it would you
know financially there’s no way … I just can’t. And I know for me to advance in my job and to
earn salaries that [our] other co-workers earn I have to have a degree. There’s, just, I will never
make the same amount of money ever, that’s just [my employer’s] policy.

Evidently many frontline workers were looking for ways to advance their careers and
promotion opportunities within an organization (or lack thereof) influenced workers’
employment intentions.
Finally, those who reported that they had higher workloads and entry level workers
were less likely to say that they intended to stay with their current employer. We also
found that older workers and those that reported that they depended on their wages were
more likely to report they intended to stay with their current employer, most likely

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Morgan et al. 817

because primary breadwinners have a greater need to maintain a steady income and may
be dependent on the benefits offered by their employer.

Conclusions
Theoretically, the findings of this article help to explain why frontline workers report
relatively high job satisfaction yet are also likely to leave their jobs. Indeed, the correla-
tion between job satisfaction and intent to stay in one’s current job is quite low in this
study’s sample at 0.28. Low wages and other bad characteristics associated with the jobs
of frontline workers might be offset somewhat by the intrinsic nature of many of these
jobs. Workers may be relatively satisfied with these jobs when they are structured in a
way that supports care work, including having reasonable workloads and supportive
supervision. However, employment intentions are primarily driven by extrinsic rewards.
Thus, while the nature of care work may be satisfying for frontline healthcare workers,
these ‘bad job’ characteristics play a stronger role in whether workers will stay with their
employers.
Second, this article contributes to knowledge about the job quality of a large and
growing group of workers – frontline healthcare workers. For a number of years,
researchers and policy makers have been looking to the healthcare sector – and hospitals
in particular – as a promising industry for career advancement and upward mobility
among low-wage workers (Bartik, 1997; Fitzgerald, 2006; Foster-Bey and Rawlings,
2002; Pindus et al., 1995; Wolf-Powers and Nelson, 2010), although little comprehen-
sive quantitative work has been done on the job quality of frontline healthcare jobs.
These analyses are not without limitations. While there was substantial variation in
organizational supports for frontline worker educational and career advancement among
the organizations in the sample, future research could expand on this study by examining
extrinsic and intrinsic job qualities among a larger sample of frontline healthcare work-
ers. Another extension of this work could map extrinsic and intrinsic rewards by the
category of worker (in this study we used three categories: entry level, administrative
and direct care). Extrinsic and intrinsic job quality is likely to vary across the roughly six
million frontline healthcare workers. Future research should focus on the impact of job
content on these relative rewards and the implication of those findings for understanding
job satisfaction, intent to leave and turnover.
Despite these limitations, this article has a number of practical implications. The find-
ings suggest that efforts to reduce turnover should include strategies aimed at increasing
extrinsic rewards (e.g. pay, benefits, career opportunities) (Bishop et al., 2008). In the
USA, healthcare organizations typically try to fill positions with the lowest possible skill
and wage levels. This fact is compounded by the lack of employment protection regula-
tion in the USA, which increases the insecurity of workers who can be easily sloughed
off when employers need to show cost savings (Appelbaum, 2011). The low wages and
few benefits associated with these jobs are not due to the intrinsically low skill levels of
these jobs, however. In some countries, frontline healthcare sector jobs are well paid and
employ highly skilled workers (Appelbaum and Schmitt, 2009). The fact that these jobs
are ‘bad’ in the USA thus reflects both the labour market institutions that influence the
way that these jobs have been designed (e.g. to minimize the skills involved, thereby

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818 Work, employment and society 27(5)

keeping wages low) and the availability of vulnerable populations who are forced to take
these kinds of jobs (such as women, minorities and immigrants) (Tilly, 2011).
Unfortunately, the use of ‘bad jobs’ to control costs may ultimately make US healthcare
organizations less competitive and raise labour costs over time as they are faced with
high levels of frontline worker turnover and a contingent workforce that is under-
prepared to meet critical skills gaps ( Appelbaum, 2011; West et al., 2006).
By contrast, other wealthy countries facing similar pressures to meet patient care
needs and reduce costs have employed different work organization and compensation
strategies (Méhaut et al., 2010). Appelbaum and Schmitt (2009) report that European
hospitals are more limited in their ability to replace more highly skilled workers with
workers with lower skills (due to greater institutional protections), where a highly skilled
workforce is a significant political and social issue. When healthcare organizations in
European countries do employ nursing assistants, they generally have higher levels of
training as compared to the USA. For example, a nursing assistant in Denmark is required
to complete a 34-month training programme. Consequently, nursing assistants in
European countries are also less likely than in the USA to be low-wage workers (between
0% and 5% in the Netherlands, France and Denmark as compared to 38% in the USA).
While wage and benefit levels are more difficult to adjust in this current economic
climate, increasing career opportunities may be feasible for organizations given their
need to meet worker shortages in mid-level positions. These high-road strategies are not
widespread (Méhaut et al., 2010), but there are more efforts to build career ladders and
design better jobs for low-wage workers in healthcare today than in any other industry
(Fitzgerald, 2006). These results suggest that these efforts would be best employed both
to protect workers’ ability to derive intrinsic rewards from these jobs (e.g. through input
into care planning and supportive supervision) and to improve extrinsic rewards (e.g.
through compensation and increased career opportunity).

Funding
The ‘National Evaluation of the Jobs to Careers: Transforming the Front Lines of Healthcare’
conducted by the University of North Carolina (UNC) at Chapel Hill was funded by the Robert
Wood Johnson Foundation with supplementary funds from the Hitachi Foundation. The primary
research team from the Institute on Aging and the Cecil G. Sheps Center for Health Services
Research at UNC Chapel Hill consisted of Jennifer Craft Morgan, Lead Principal Investigator;
Thomas R. Konrad, Co-Principal Investigator; Melissa Mann, Study Coordinator; Ashley Rice,
Data Manager; and Emmeline Chuang, Janette Dill, Brandy Farrar, Kendra Jason, Graduate
Research Assistants.

Notes
1. Healthcare organizations included in the sample have received funding from the Robert Wood
Johnson Foundation in collaboration with the Hitachi Foundation and the US Department of
Labor as part of the Jobs to Careers initiative to build partnerships with educational institu-
tions to help them create the systems changes needed to implement educational and training
programmes aimed at frontline worker career advancement. We did not include data from
organizations with fewer than five survey respondents.
2. Study liaisons within employers were asked to recruit six to eight participants for each super-
visor and frontline worker focus group. Employers recruited workers – based largely on their

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Morgan et al. 819

availability – from the positions and departments that were going to be involved in a training
programme.
3. The organizations included in the sample are not likely to be ‘typical’ healthcare organiza-
tions. The sample included organizations that had received grant funding and although the
data used were collected at baseline, in order to apply for the grant the employer organi-
zations had to demonstrate that the organization had a commitment to utilizing policies
and practices to promote frontline worker advancement. Thus, frontline healthcare workers
included in the sample work in healthcare settings that have shown an interest in ‘high-
road’ job redesign.
4. We consider entry level and administrative healthcare workers to be frontline healthcare
workers because firstly they typically have wages under US$40,000 per year, secondly they
have a low threshold to entry and thirdly they provide patient support and usually have a high
degree of patient interaction.
5. Interview and focus group transcripts were coded for themes using NVivo 8.0. Coders were
trained to apply codes consistently. Each transcript was coded twice and discrepancies between
codes were discussed until consensus was achieved. Primary level thematic coding was com-
pleted to understand the themes related to job characteristics and evaluation of job quality.

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Jennifer Craft Morgan is an assistant professor in the Gerontology Institute at Georgia State
University. Dr. Morgan’s interests include workforce aging, medical sociology, gender stratifica-
tion, evaluation research, healthcare workforce and the sociological study of work and careers over
the life course. She is currently working on projects studying the work and careers of three femin-
ized occupational groups: frontline workers, library and information professionals and nurse
faculty.

Janette Dill is an assistant professor in the sociology department at the University of Akron. Her
current research focuses on the career mobility of low-wage workers in healthcare settings and job
quality among low-wage workers in service work. Her interests include occupational stratification,
gender and work and medical sociology.

Arne L Kalleberg is a Kenan Distinguished Professor of Sociology at the University of North

Carolina at Chapel Hill. He is also a Global Scholar at Chung-Ang University in the Republic of
Korea for 2012–14. He has published more than 120 articles and chapters and 11 books on topics
related to the sociology of work, organizations, occupations and industries, labour markets and
social stratification. His most recent book is Good Jobs, Bad Jobs: The Rise of Polarized and
Precarious Employment Systems in the United States, 1970s–2000s (Russell Sage Foundation,
2011). He served as President of the American Sociological Association in 2007–8 and is currently
the editor of Social Forces.

Date submitted February 2011

Date accepted November 2012

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