Home Health Care Management & Practice

http://hhc.sagepub.com/

Promoting Sustainability in Frontline Home Care Aides: Understanding Factors Affecting Job Retention in
the Home Care Workforce
Anna C. Faul, Tara J. Schapmire, Joseph D'Ambrosio, Dennis Feaster, C. Shawn Oak and Amanda Farley
Home Health Care Management Practice 2010 22: 408 originally published online 30 December 2009
DOI: 10.1177/1084822309348896

The online version of this article can be found at:

http://hhc.sagepub.com/content/22/6/408

Published by:

http://www.sagepublications.com

Additional services and information for Home Health Care Management & Practice can be found at:

Email Alerts: http://hhc.sagepub.com/cgi/alerts

Subscriptions: http://hhc.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

Citations: http://hhc.sagepub.com/content/22/6/408.refs.html

Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010

 Home Health Care Management & Practice

Promoting Sustainability in Frontline 22(6) 408–416

© 2010 SAGE Publications
Reprints and permission:
Home Care Aides: Understanding sagepub.com/journalsPermissions.nav
DOI: 10.1177/1084822309348896

Factors Affecting Job Retention in the http://hhcmp.sagepub.com

Home Care Workforce

Anna C. Faul, PhD,1 Tara J. Schapmire, MSSW,1 Joseph D’Ambrosio,

JD, MSSW,1 Dennis Feaster, MSW,1 C. Shawn Oak, MSSW,1
and Amanda Farley, MSSW1

Abstract
With the growth of the older adult population increasing at an exponential rate, caring for this population has become increasingly
difficult. As many choose to age in place (i.e., in the home environment), both the public and private sectors are being forced
to respond.The emergence of home health care and the employment of home care aides is one of the ways that the industry
has evolved to meet this crisis. However, retention of home care aides has proven problematic. This study explores factors
affecting home care aide retention in agencies that employ home care aides. A sample of 116 home care aides employed by
three agencies was surveyed to identify retention issues relative to the home care aide. A hypothetical model of home care
aid job retention was tested with a hierarchical regression analysis, where 11 variables were entered in five steps, using a
time-sequenced order. The results indicated that the hypothetical model was able to explain 41% of the variance in months
employed as home care aides, with age, education, wages earned, and intrinsic satisfaction as the most significant contributors
to the model. Being able to predict retention of home care aides allows employing agencies to realign themselves to retain
workers and improve quality of care. However, it is important to realize that the same traits that predict retention among
home care aides may also leave these workers vulnerable to exploitation.

Keywords
home care aides, job retention, turnover, older adults

Introduction
In recent years, the expanding population of those 65 and
older in the United States has been a source of interest and
concern. By 2008, the U.S. population of those 65 and older
increased to 12.6% of the population (approximately 37.3
million people) and is expected to rise to 21% of the total
population (or 86.6 million people) by 2050 (U.S. Census
Bureau, 2009). This growth in the older adult population can
be attributed to several factors, including the collective aging
of the massive baby boomer generation and the prevalence
of medical and pharmaceutical technologies that allow aging
persons to live longer.
This aging population finds itself with numerous residen-
tial options, although many prefer to remain at home in their
older years (Hooyman & Kiyak, 2002). Baby boomers weaned
on independence, thoughts of agelessness, and a desire to
mai­ntain their quality of life will continue to nurture the trend
to remain at home and avoid aging the way their parents aged
(Boris & Klein, 2006; Novak, 2006). Economics also plays a
big part in the decision to remain at home as the cost of alter-
native living arrangements continues to increase and place
burdens on personal finances. Also, the need for chronic home
care increases as hospitals decrease the amount of time per-
mitted during hospital stays (Kendra, 2002). Although older
adults are healthy, remaining at home is not an issue, but
once health-related illnesses occur, the choice to remain at
home becomes difficult. Many studies conducted on aging
populations have focused on the nature of the care that older
persons receive, for instance, aging in place, as opposed to
1
University of Louisville, Louisville, KY, USA
Corresponding Author:
Anna C. Faul, Kent School of Social Work, University of Louisville,
Louisville, KY 40292, USA
Email: anna.faul@louisville.edu

Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010

Faul et al. 409
leaving familiar environments and moving into some version of
institutionalized care (e.g. assisted living, supported living, and
long-term/intermediate care; Meagher, 2006; Montgomery,
Holley, Deichert, & Kosloski, 2005; Osterhout & Zawadski,
2006). Because of the challenges that this presents to the tradi-
tional health care system, this necessitated a number of changes
to better meet the demands of consumers aging in place, one of
the most significant of which is the rise of home health care
services (Crown, 1994; Crown, Ahlburg, & MacAdam, 1995;
Osterhout & Zawadski, 2006).
Home health care represents a large and growing industry
and is funded through a variety of sources, one of the most
important being Medicare. The 2000 U.S. Census revealed
that the health care sector employed nearly 14 million people
in a variety of positions, including home health professionals,
such as nurses and allied health professions (physical thera-
pists, occupational therapists, etc.), and nearly 800,000 of
whom were home health and home care aides (Montgomery
et al., 2005). The growing demand for these services has pla­
ced a premium on the available supply (Crown et al., 1995).
The increased demand for home health care is leading growth
in the health care industry (Dansky & Brannon, 1996).
The position of the home care aide has received increas-
ing scrutiny in recent years in the home health care industry.
Home care aides represent a work force of approximately
767,000, with a projected growth to 1.2 million by 2016,
which represents a 51% growth over 10 years (U.S. Bureau
of Labor Statistics, 2008). The services that are provided by
home care aides include “housekeeping, assistance with err­
ands, accompanying individuals outside their homes, and
assisting in . . . personal care” (Health Workforce Solutions,
2005). Without home care aides, the demand on families and
informal caregivers to support older adults in their homes
would be impossible in many cases (Boris & Klein, 2006).
The irony for those who work in these vital positions is
that for all of the importance that society places on these
services, the positions are considered to be low skilled and
low status, and consequently, they receive low pay and work
under a variety of difficult circumstances (Crown et al., 1995;
Jacoby, 2006). Home care aide employment is characterized
by low wages, minimal benefits, irregular hours of work, and
unstable employment. Consequently, recruitment and reten-
tion of this workforce is problematic (Feldman, 1993). Those
who choose to enter this long-term care workforce are fre-
quently marginalized populations themselves, mainly women
who often come from disadvantaged economic and educa-
tional backgrounds (Montgomery et al., 2005; Yamada, 2002).
Given this set of factors, it is perhaps not surprising that the
turnover among home care aides is significant, and retention
of home care aides is proving difficult for the home care
industry (Montgomery et al., 2005).
There have been several efforts in recent years to under-
stand this institutionalized turnover. The cost of turnover in
these positions to employers is significant in terms of training,
Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010
experience, and quality of care (Konrad, 2003). The cost to
consumers is even higher, considering issues such as safety
and the quality of the relationship with caregivers (Meagher,
2006). A number of studies have pointed out the part-time
and temporary nature of the home care workforce, inferring
that many home care workers also have other employment,
perhaps for medical or other benefits (Crown et al., 1995;
Yamada, 2002).
As a result of this increased investigation into this area, a
number of tools have been developed to assist in identifying
factors related to turnover in these key caregiving positions.
Specifically, the U.S. Departments of Health and Human
Services and Department of Labor collaborated in funding
research that compiled a number of different tools to aid in
assessing issues related to the experience of being a long-
term care worker, including home care aides (Kiefer et al.,
2005), some of which were used in this study.
Purpose of Study
The purpose of the study was to understand the factors that
affect job retention rates for home care aides. The hypotheti-
cal model shown in Figure 1 drove this study. In the model,
the different hypothesized explanatory factors affecting job
retention that were investigated in this study are shown.
As can be seen from Figure 1, five blocks of variables
were hypothesized as important predictors of job retention.
These variables were selected after a literature review of
possible factors influencing job retention of home care aides.
The first block in the hypothetical model is demograph-
ics. With this block the model is trying to determine how
much the individual characteristics of home care aides,
namely, race, age, and education, affect job retention. With
more than 88% of the workforce being women, it was not
seen as important to investigate gender as part of this block
(Montgomery et al., 2005). These characteristics are normally
predisposing characteristics of people starting careers as home
care aides.
Crown et al. (1995) and Yamada (2002) found that more
than a third of home care aides (38%) never complete high
school. Only 4% of home care aides have completed at least
4 years of college. The Defining the Frontline Workforce
Study (Health Workforce Solutions, 2005) found that home
care aides leave the profession because of many obstacles, of
which few educational advancement opportunities are one.
Given the fact that these frontline workers are normally from
a low educational background, employed in a profession with
very little opportunities for improvement of educational back-
ground, educational level of the workers can be an important
factor to consider in job retention. When workers realize that
their profession is a dead end in terms of career prospects and
better education, they may well decide to leave.
Crown et al. (1995) compared the demographics of home
care aides, nursing home aides, and hospital aides. They found
410 Home Health Care Management & Practice 22(6)
Figure 1. Hypothetical model of job retention for home care aides
that home care aides tend to be older than these other work-
ers. It is possible that this age difference forms part of the
problems associated with keeping home care aides in the
profession. Because of low advancement opportunities,
you­nger workers tend to leave the profession seeking to find
better opportunities elsewhere, whereas older workers tend to
remain in their positions, perhaps because of their stage in life
and the knowledge that the home care environment is less
stressful then personal care delivery in other settings.
The home care profession tends to be characterized as a
“minority” industry, meaning that the share of minority work-
ers in this profession is substantially higher than that in the
national workforce as a whole (Montgomery et al., 2005).
For some reason this profession does not attract White work-
ers, and therefore, race could be a predictor of retention.
The second block of variables in Figure 1 highlights salary
(hourly wage) and benefits (health insurance) as hypothesized
predictors of job retention. Montgomery et al. (2005), Yamada
(2002), and Crown (1994) also discussed their findings with
regard to the hourly wage paid to home care aides; all rep­
orted home care aides as among the lowest paid workforce.
Boris and Klein (2006) described the evolution of the direct
care workforce in the United States and identified wages as
being relevant to the retention of direct care workers (includ-
ing home care aides), stating, “the labor remained so poorly
Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010
remunerated that most of those certified eventually left for
restaurants, retail sales, and manufacturing” (p. 88). Presum-
ably, if home care aides’ wages were competitive with these
other industries, home care workers would not leave home
care work because of wages alone.
The other variable in the second block in Figure 1 is that
of benefits, which this study has limited to health insurance.
Nearly half of the home care aides lack health insurance,
according to a report by the Institute for Future of Aging Ser-
vices (Lipson & Regan, 2004). Of those who are eligible for
health insurance through their employer many find it cost pro-
hibitive (Stowell-Ritter et al., 2003). Many are however not
eligible because of their part-time status as home care aides
(Crown, 1994). Osterhout and Zawadski (2006) addressed
the benefit of health insurance as a potential predictor for
home care aide retention. They reported that three annual
studies of workers in Los Angeles County “show that homecare
workers receiving medical benefits have a lower rate of turn-
over and a higher rate of workforce stability” (p. 30).
Given the importance of job skills and the training that
helps develop these skills, this study proposes quality of tra­
ining (third block in Figure 1) as a potential predictive
variable with regard to home care aide job retention. In a
qualitative study of how home care aides assign meaning to
their work, Stacey (2005) found a variety of motivations
Faul et al. 411
among those employed as home care aides. Interestingly, she
noted that although many in the health care industry and in the
general population view home care work as being essentially
a “dead-end job,” some home care aides themselves view their
work as a means to receive the training that will enable them
to either excel in their present positions or that would enable
them to eventually move to a more desirable position. Regard-
less, Stacey draws the important conclusion that,
irrespective of whether skills building provides home
care aides with horizontal or vertical mobility within the
job market, the perception of skill is central to the way
that aides craft dignity on the job, countering mispercep-
tions that caregiving is work “anyone can do.” (p. 847)
Despite the importance of training, not many resources are
put into training entry-level workers, because of high initial
turnover (Health Workforce Solutions, 2005).
The fourth block in Figure 1 hypothesizes work condi-
tions as additional predictors of job retention. Stacey (2005)
writes at length about the unique employer/employee rela-
tionship that occurs in the home care context:
Home care workers interviewed describe a sense of
practical autonomy that comes from having the freedom
to informally negotiate certain terms of employment
with clients, depending on client needs and level of
functioning (i.e. what time to arrive and depart; when to
perform certain caregiving tasks). In both the context of
CHS and for-profit home care, all aides—in some way
or another—seek out and hold on to jobs where they
have some flexibility to determine hours worked and
control over care. Some workers describe this as a sense
of “being your own boss,” while others simply like the
fact that they can work with the client to determine when
and how to provide care. (pp. 845-846)
Given that Stacey (2005) identified areas that promote home
care workers to seek out jobs that offer them a working envi­
ronment that provides them with some level of autonomy and
independent decision making, this study uses the relationship
with the employer, employer encouragement, and problems
with supervisor as being potential predictors with regard to
home care aide retention.
The category of “other problems” in the work conditions
block (Figure 1) relates to many of the stresses and strains
that home care aides may experience in the course of their
daily work activities, especially in the course of direct client
care. Dale, Brown, Phillips, and Carlson (2005) and Muntaner
et al. (2006) identified and addressed both emotional and
physical demands related to direct care worker well-being.
Consequently, the present study hypothesizes potential pre-
dictive value in terms of home care aide retention with regard
to additional perceived problems related to emotional and
Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010
physical demands, for example, physical strains (catching an
illness or getting hurt) and emotional strains (facing difficul-
ties because of race or gender issues).
Workers’ experience of respect by their client systems is
another important variable that forms part of work conditions.
According to Dale et al. (2005), 12.4% of workers employed
by agencies desire more respect from their clients, and 22.4%
desire more respect from the families and friends of their cli-
ents. Not having respect from the people you work with closely
can result in additional emotional strains; therefore, client sys­
tem respect was included in the predictive model.
Intrinsic rewards are the last hypothesized predictor of
job retention in the model for this study (Figure 1, fifth block).
Given that home care aides receive relatively low wages for
doing work that many others may well find distasteful (per-
sonal care, toileting, and hygiene assistance, for example),
the researchers wrestled with the question of why people
chose to work as a home care aides when they could get a
job with an organization that paid more, offered more and
better fringe benefits, and did not require the aforemen-
tioned “dirty work” for entry-level workers. Stacey (2005)
addresses this, writing:
For home care aides, however, there is also a third
reward—doing dirty work—that is unique to the car­
egiving relationship, and is relational (rather than
individual) in nature. Workers draw meaning from
their willingness and ability to perform dirty and
mundane tasks that others avoid, knowing that their
efforts improve the lives of clients. Taking on dirty
work, therefore, is an important source of dignity for
workers whose labour is invisible and undervalued
by the general public. (p. 845)
This, combined with the intrinsic satisfaction many derive
from helping others, may well account for the decision to
become and remain a home care aide and therefore was
included in the model.
The research questions driving the study were the following:
Research Question 1: What factors (demographics, sal-
ary and benefits, training effectiveness, work condi-
tions, and intrinsic rewards) predict length of time
working as a home care aid?
Research Question 2: Are there any factors that do not
contribute significantly to the prediction model?
Methods
Design
A quantitative, nonexperimental, contextual cross-sectional
survey design was used to answer the research questions.
The institutional review board of the University of Louisville
412 Home Health Care Management & Practice 22(6)
approved this study. In an effort to isolate the identified pre-
dictors of job retention, data were gathered—at essentially
one point in time—from three Area Agencies on Aging (AAAs)
who contracted home care service providers.
Participants
A convenience sampling method was used to include as many
home care aides as possible in the study. The sample con-
sisted of 116 home care aides employed by home care service
providers contracted by the following AAAs within the Ken-
tucky Office of Aging Services representing five regions in
Kentucky: KIPDA (N = 90), Lincoln Trail AAA (N = 19),
and Northern Kentucky AAA (N = 7).
Data Collection
Data were collected using two different methods. In the
KIPDA and Lincoln Trail regions, data were collected at the
mandatory annual trainings completed by home care aides.
The study was advertised at the offices of the different home
care aide service providers. During the training sessions, the
research team administered the survey to the participating
home care aides, after informed consent was obtained. In the
Northern Kentucky region, the surveys were delivered to the
offices of two of the contracted home care aide service pro-
viders. The surveys were given to the home care aides and
returned in sealed envelopes by the employees who chose to
participate. Data was collected over a time period of 6 months.
Measures
The survey consisted of 25 items and was modeled after the
Better Jobs Better Care Survey of Direct Care Workers
(BJBC). The BJBC Survey was developed as part of a 4-year,
$15.5 million program funded by The Robert Wood Johnson
Foundation and The Atlantic Philanthropies (Kiefer et al.,
2005). The different parts of the conceptual model (Figure 1)
were measured as follows.
Demographics. Age and education were measured in years.
Ethnicity was recorded as either White or Other Race. Gender
was not included in the analysis, because of the homogeneity
of the sample (97% female).
Salary and benefits. Salary was measured in hourly wages.
Health insurance was measured by asking if it was offered or
not offered by the agency.
Training effectiveness. Training effectiveness was mea-
sured by listing 12 specific training topics relevant to the job
performed by home care aides. Aides had to rate the useful-
ness of the training on each of the topics with scores that
could range between 1 = not at all useful and 4 = extremely
useful.
Work conditions. The relationship with their employers
was measured by asking them if they would recommend the
Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010
services provided by the employers to friends or family
members. They were also asked if they would recommend
their employers as a place to work. These two items were
measured on a scale that ranged from 1 = definitely recom-
mend it to 4 = definitely not recommend it. Employer
encouragement was measured with one item, asking the
employee if his/her employer is doing anything out of the
ordinary to improve their job or to encourage them to keep
working there. The item was measured on a scale that ranged
from 1 = never to 4 = all the time. Five items were used to
measure problems with supervisor, namely, not having sup-
port from supervisor, unrealistic expectations from supervisor,
not using skills, not being valued by supervisor, and supervi-
sor not being good at the job. These items were measured on
a scale that ranged from 1 = not at all a problem to 4 = an
extremely big problem. These five items had an internal con-
sistency coefficient of .87. Four items were used to measure
other potential work problems, namely, catching an illness,
getting hurt, facing difficulties because of race or ethnicity,
and facing difficulty because of gender issues. These items
were measured on the same scale as indicated above. These
four items had an internal consistency coefficient of .79.
Client system respect was measured with two items, namely,
if their clients and their families respect them as part of the
health care team. These items were measured on a scale that
ranged from 1 = strongly disagree to 4 = strongly agree.
Intrinsic satisfaction. Intrinsic satisfaction was measured
with a 19-item scale asking questions about the rewarding
part of their job, for example, helping others, feeling a sense
of accomplishment, feeling needed by others, being valued,
and having a job that fit interests. The items were measured
on a scale that ranged from 1 = not at all rewarding to 4 =
extremely rewarding. The scale had an internal consistency
coefficient of .86.
Time worked as home care aide. This item was measured in
months and asked the respondents how long they have been
employed as home care aides.
Analysis
A hierarchical regression analysis was done to test the hypo-
thetical model. The predictor variables were entered in five
blocks, using a time-sequenced order. All the tests used in
the analysis are based on the assumption of normality. To
ensure that this assumption was not violated, a total of five
variables had to be transformed. Client respect was negatively
skewed and transformed with a reflected log transformation.
Relationship with employer, other problems, and problems
with supervisor were all positively skewed and transformed
with a log transformation. Time worked as a home care aide
was positively skewed and transformed with a square root
transformation. Three percent of the values on different items
related to the predictor variables were randomly missing and
replaced with the agency mean for that variable. A total of
Faul et al. 413
101 cases were included in the final analysis; 13 were rem­
oved because of missingness on the dependent variable, and
two multivariate outliers were removed from the analysis.
Because of the use of 11 variables in the analysis, and the
relatively small sample size, a priori power analysis sug-
gested that the detection of only a large effect size would be
possible for the ideal power of .80. To adjust for this prob-
lem, the alpha level was set at .10 to enable at least a power
of .80 for a medium effect size.
Results
In this section, the participants are first described in terms of
the predictor and criterion variables, after which the results
of the model testing are shown.
Description of Participants: Predictor Variables
Demographics. Participants were predominantly Cauca-
sian (N = 70; 61%), female (N = 111; 97%), ranging in age
from 20 to 80 years (M = 50; SD = 14.4). Participants’ years
of formal education (starting at first grade) ranged from 1 to
18 (M = 12; SD = 2.1). Twenty percent did not complete high
school, nearly half (47%) completed high school, 14% com-
pleted an associate degree, and 19% had education higher
than an associate degree.
Wages and benefits. Hourly wages ranged from $6.75 to
$11.75 (M = 8.74; SD = 1.02). Close to two thirds of the
sample (N = 66; 61%) were not offered health insurance by
their agency.
Training effectiveness. Mean scores for all the topics cov-
ered ranged between 1.6 and 4, with a mean of 3.13 (SD =
0.61), a median of 3.17, and a mode of 3.0 indicating train-
ings offered were considered very useful.
Work conditions. The sample rated their work conditi­ons
as satisfactory. Specifically, the scores on the relationship
with employer variable for the two items ranged from 2 to
8, with a mean of 3.13 (SD = 1.39) and a median of 3, indi-
cating they would recommend their agencies for care and
employment. Employer encouragement scores ranged
from 1 to 4, with a mean of 2.77 (SD = 1.01), a median of
3, and a mode of 3, indicating that participants felt employ-
ers did things to improve their job or encourage retention
at least some of the time. Problems with supervisor scores
for the five items ranged from 5 to 20, with a mean of 8.41
(SD = 4.07), indicating minimal problems. Other potential
work problems scores ranged from 4 to 16, with a mean of
6.12 (SD = 2.70), indicating minimal problems. Client
system respect scores ranged from 2 to 8, with a mean of
7.22 (SD = 1.41). Participants felt respected by clients and
families.
Intrinsic satisfaction. The last predictor variable, intrinsic
satisfaction, had scores ranging from 38 to 75, with a mean
of 62.64 (SD = 8.34), indicating that participants rated their
work to be very rewarding.
Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010
Description of Participants: Criterion Variable
Time worked as a home care aide ranged from 1 month to
480 months (40 years), with a mean of 102.27 months (8.5
years; SD = 99.76 months); median months worked was 60
(5 years), and mode was 12 months.
Model Testing
The results of the model testing are provided in Table 1.
Hierarchical regression analysis was used to explore which
of the 11 predictor variables were the best predictors of job
retention. Predictor variables were entered in five blocks. In
the first step, only demographic variables (age, ethnicity, and
education) were entered as predictors. As can be seen in
Table 1, all three variables showed strong predictive ability,
with the overall model predicting 15% of the variance in
months employed as a home care aides (R2 = .15; F(3, 97) =
5.87; p = .001). Adding the salary and benefits variables in
the second step improved the model significantly, with the
overall model predicting 32% of the variance in months
employed as a home care aides (R2 = .32; F(5, 95) = 9.09;
p = .001). After training effectiveness was added in the third
step, the model improved significantly, with the overall model
predicting 34% of the variance in months employed as a home
care worker (R2 = .34; F(6, 94) = 8.17; p = .001). The addi-
tion of the five work condition variables in the forth step did
not significantly improve the model. The overall model pre-
dicted 39% of the variance in months employed as home
care aides (R2 = .39; F(11, 89) = 5.13; p = .001). The addition
of the fifth and final step—intrinsic satisfaction—signifi-
cantly improved the model, with the overall model predicting
41% of the variance in months employed as a home care
worker (R2 = .41; F(12, 88) = 5.07; p = .001). In this final
model, the significant predictors from block one were age
(b = .19; p = .03) and education (b = .20; p = .02), from block
two wages (b = .38; p = .001) and from block five intrinsic
satisfaction (b = .17; p = .08). No variables from the training
effectiveness block or the work conditions block contributed
to the model.
Discussion
Retaining workers in a low-pay, limited benefits, physically
challenging job is difficult in any industry and home care aides
are no exception. Given the dramatic increase of elders that
has been predicted in the population over the coming decades,
the importance of a stable home care workforce in providing
services to this population is of vital importance. Being able to
isolate the variables that predict retention among this work-
force will allow employing agencies to adjust to the needs of
these workers, thereby promoting fair work practices and,
indirectly, better care for the client population.
The results of this quantitative study support prior findings
and assertions and suggest that home care aides could remain
414 Home Health Care Management & Practice 22(6)

Table 1. Hierarchical Regression Analysis (N = 101)

Variables B SE B b

Step 1
Demographic variables
Age 0.09 0.03 0.26**
White ethnicity -1.76 0.90 -0.18*
Education 0.45 0.21 0.20**
Step 2
Demographic variables
Age 0.07 0.03 0.21**
White ethnicity -1.02 0.84 -0.11
Education 0.41 0.19 0.18**
Salary and benefits
Wages 1.57 0.42 0.34***
Health insurance -1.79 0.85 -0.19**
Step 3
Demographic variables
Age 0.06 0.03 0.19**
White ethnicity -1.03 0.83 -0.11
Education 0.43 0.19 0.19**
Salary and benefits
Wages 1.61 0.42 0.35***
Health insurance -1.76 0.85 -0.18**
Training
Training effectiveness 1.07 0.64 0.14*
Step 4
Demographic variables
Age 0.06 0.03 0.18**
White ethnicity -1.52 0.88 -0.16*
Education 0.41 0.19 0.19**
Salary and benefits
Wages 1.73 0.43 0.38***
Health insurance -1.40 0.87 -0.15
Training
Training effectiveness 1.10 0.67 0.15
Work conditions
Relationship with employer 2.93 2.68 0.11
Employer encouragement -0.36 0.47 -0.08
Problems with supervisor -1.13 0.81 -0.16
Other problems -0.80 3.47 -0.03
Client respect -2.07 1.72 -0.11
Step 5
Demographic variables
Age 0.06 0.03 0.19**
White ethnicity -1.28 0.88 -0.13
Education 0.45 0.19 0.20**
Salary and benefits
Wages 1.76 0.43 0.38***
Health insurance -1.16 0.87 -0.12
Training
Training effectiveness 0.69 0.70 0.09
Work conditions
Relationship with employer 4.22 2.74 0.16
Employer encouragement -0.33 0.46 -0.07
Problems with supervisor -1.25 0.81 -0.18
Other problems 1.36 3.44 -0.05
Client respect -2.01 1.70 -0.11
Intrinsic satisfaction
Intrinsic satisfaction 0.10 0.06 0.17*
Note: R2 = .15 for Step 1; DR2 = .17 for Step 2 (p = .001); DR2 = .02 for Step 3 (p = .10); DR2 = .05 for Step 4 (p = .27); DR2 = .02 for Step 5 (p = .08).
*p < .10. **p < .05. ***p < .01.

Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010

Faul et al. 415
on the job longer when certain variables are taken into consid-
eration, namely, age, education, salary, and intrinsic satisfaction.
The literature confirms that younger workers are more likely
to leave a low paying profession with fewer prospects for
advancement. Older workers, however, appear to be less likely
to leave because of their stage of life (Crown et al., 1995). Also,
older workers potentially may prefer to work in an environ-
ment where they enjoy autonomy and without the constraints
of a direct supervisor. Home care aides mostly work inde-
pendently, therefore the environment fits within the life stage
of older workers.
The study indicates that more years of education will result
in higher retention. The less educated workers seek profes-
sions where there are opportunities for advancement. Without
this opportunity they are sometimes forced to leave the pro-
fession to find a career where they can improve their educational
levels (Health Workforce Solutions, 2005).
The study confirms that if home care aides’ wages were
competitive with other industries, home care workers would
not leave home care work because of wages alone. Wages
was one of the strongest predictors in the model, indicating
that it is important to pay attention to the low wages received
by home care aides. Health Workforce Solutions (2005) clearly
indicates the problems associated with low wages and advo-
cate for policies to remedy the situation.
In the analysis of this helping profession, it was no sur-
prise that intrinsic satisfaction was a significant predictor in
this model. These workers gain significant rewards from
providing care, and sometimes these rewards may over-
shadow the problems associated with low wages, lack of
advancement opportunities, and difficult working conditi­
ons. However, the interplay between the importance of
intrinsic rewards and low wages discussed previously leave
these workers vulnerable to exploitation. Care should be
taken by employing agencies to ensure appropriate remu-
neration for these vital frontline workers.
Although the training effectiveness and the work condi-
tions blocks in the hypothetical model did not show any
significant predictors in the final model, it is important to
realize that the sample for this study had unique circum-
stances that may have prevented these variables from being
significant. A large portion of the sample worked in a region
that recently instituted mandatory training for all home care
workers. This training has been seen as effective in dealing
with the training needs of the workers, with almost all par-
ticipants feeling very satisfied with the training. Therefore,
there was not enough variance in the training effectiveness
variables to make this a significant predictor for this sample.
Furthermore, the employers of the home care aides all indi-
cated relatively good relationships with their workers,
resulting in the variables related to the work conditions not
showing any predictive power that could explain the differ-
ence between respondents with varying times employed as
home care aides.
Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010
As the demand for these workers increases, so will the col-
lective power of this workforce. Being able to identify ways to
align with their needs and interest now will allow for a smooth
transition to the changing needs of the overall population.
Limitations
The study has a few specific limitations, of which sample size,
generalizability of results, and socially desirable responses are
the most important. Because a convenience sample was used,
results from this study cannot be generalized to a target popu-
lation and should be interpreted with caution, although they do
indicate a need for increased research in this area beyond the
home care aides surveyed. The sample size is relatively small,
but the decentralized nature of home care work and the diffi-
culty in getting large numbers of study participants together at
the same time proved to be problematic. Although participants
were assured that individual survey results would not be rep­
orted, some expressed concern that their participation would
negatively affect their job status or their relationships with their
employers. This fear may have affected their responses, specifi-
cally in relation to the work conditions block in the hypothetical
model.
Conclusion
Although salary and benefits appear to be the solution that
employers think about to increase job retention in our declin-
ing economy, alternative factors need to be considered. This
study, although showing that age, education, and salary sig-
nificantly influence job retention, indicates intrinsic satisfaction
must also be taken into account when trying to improve job
retention of home care aides. Home care aides, like many in
the “helping professions,” do what they do because they get
intrinsic satisfaction, and this appears to override the effects
of low pay. Ethically, employers should also be aware of the
importance placed on intrinsic satisfaction by home care aides
and the possibility of taking advantage of employees who do
a job because it makes them feel good. The danger of this is
that it could lead to the oppression and abuse of this vital seg-
ment of the workforce that provides a significant addition to
the health care industry.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interests with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research and/or
authorship of this article.
References
Boris, E., & Klein, J. (2006). Organizing home care: Low-waged
workers in the welfare state. Politics & Society, 34(1), 81-108.
416 Home Health Care Management & Practice 22(6)
Crown, W. H. (1994). A national profile of homecare, nursing
home, and hospital aides. Generations, 18(3), 29-33.
Crown, W. H., Ahlburg, D. A., & MacAdam, M. (1995). The demo-
graphic and employment characteristics of home care aides: A
comparison with nursing home aides, hospital aides, and other
workers. The Gerontologist, 35(2), 162-170.
Dale, S., Brown, R., Phillips, B., & Carlson, B. L. (2005). How do
hired workers fare under consumer-directed personal care? The
Gerontologist, 45(5), 583-592.
Dansky, K. H., & Brannon, D. (1996). Using TQM to improve man-
agement of home health aides. Journal of Nursing Administra-
tion, 26(12), 43-49.
Feldman, P. H. (1993). Work life improvements for home care work-
ers: Impact and feasibility. The Gerontologist, 33(1), 47.
Health Workforce Solutions. (2005). Defining the frontline work-
force. Princeton, NJ: Robert Wood Johnson Foundation.
Hooyman, N. R., & Kiyak, H. A. (2002). Social gerontology: A
multidisciplinary perspective (6th ed.). Needham Heights, MA:
Allyn & Bacon.
Jacoby, D. (2006). Caring about caring labor: An introduction. Poli-
tics & Society, 34(1), 5-9.
Kendra, M. A. (2002). Perception of risk by administrators and
home health aides. Public Health Nursing, 19(2), 86-93.
Kiefer, K. M., Harris-Kojetin, L., Brannon, D., Barry, T., Vasey, J.,
& Lepore, M. (2005). Measuring long-term care work: A guide
to selected instruments to examine direct care worker experi-
ences and outcomes. Washington, DC: U.S. Department of
Health and Human Services and Department of Labor.
Konrad, T. R. (2003). Descriptive results from the annual short
turnover surveys conducted for the office of long-term care of
the NC Department of Health and Human Services. Chapel Hill:
North Carolina Institute on Aging.
Lipson, D. & Regan, C. (2004). Health insurance coverage for
direct care workers: Riding out the storm Better Jobs Better
Care (Vol. 3). Washington DC: Institute for the Future of Aging
Services.
Meagher, G. (2006). What can we expect from paid carers? Politics
& Society, 34(1), 33-53.
Montgomery, R. J. V., Holley, L., Deichert, J., & Kosloski, K. (2005).
A profile of home care workers from the 2000 Census: How it
changes what we know. The Gerontologist, 45(5), 593-600.
Downloaded from hhc.sagepub.com by Teguh Santosa on September 21, 2010
Muntaner, C., Li, Y., Xue, X. N., Thompson, T., Chung, H. J., &
O’Campo, P. (2006). County and organizational predictors of
depression symptoms among low-income nursing assistants in
the USA. Social Science & Medicine, 63(6), 1454-1465.
Novak, M. (2006). Issues in aging (2nd ed.). Boston: Allyn & Bacon.
Osterhout, R., & Zawadski, R. (2006). On homecare workforce. Pol-
icy & Practice of Public Human Services, 64(1), 30.
Stacey, C. L. (2005). Finding dignity in dirty work: The constraints
and rewards of low-wage home care labour. Sociology of Health
& Illness, 27(6), 831-854.
Stowell-Ritter, A (2003). Iowa long-term care: A synthesis of con-
sumer and provider research. Des Moines, IA: Iowa Department
of Elder Affairs. AARP.
U.S. Bureau of Labor Statistics. (2008). Occupational outlook hand-
book. Retrieved February 4, 2009, from http://www.bls.gov/oco/
U.S. Census Bureau. (2009). American Community Survey.
Retrieved February 2, 2009, from http://factfinder.census.gov
Yamada, Y. (2002). Profile of home care aides, nursing home aides,
and hospital aides: Historical changes and data recommenda-
tions. The Gerontologist, 42(2), 199-206.
Bios
Anna C. Faul, PhD, is a Hartford Faculty Scholar and Associate
Dean of Academic Affairs at the Kent School of Social Work. She
teaches advanced research and statistics in the PhD program at Kent
School.
Tara J. Schapmire is a PhD student in social work at the Kent
School of Social Work.
Joseph D’Ambrosio is a PhD student in social work at the Kent
School of Social Work.
Dennis Feaster is a PhD student in social work at the Kent School
of Social Work.
C. Shawn Oak is a PhD student in social work at the Kent School
of Social Work.
Amanda Farley is a PhD student in social work at the Kent School
of Social Work.