Working in Long-Term Residential Care : A Qualitative Metasummary Encompassing Roles , Working Environments , Work Satisfaction , and Factors Affecting Recruitment and Retention of Nurse Aides

By means of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE and Ageline (AARP) database searches, the author presents a review of the literature addressing residential care aidestheir roles, working environments, work satisfaction, and factors affecting recruitment and retention. Using the method of qualitative metasummary, eight broad themes emerged: job dissatisfaction, low wages, attrition and retention difficulties, threats to personal safety, the experience of hierarchy (devaluation and domination), the importance of relationships and collegial support, excessive workloads and inadequate training. Heavy reliance on American research is a limitation, but there appears to be general agreement across eight countries that residential care aide work can be arduous, demanding and demoralizing. At the same time, given the constraints that most aides work under, many aides care greatly about their clients and are very concerned about the quality of care that they are able to provide. Their voices, however, remain relatively overlooked or ignored.


Background
Over the past three decades, Canada has experienced a dramatic increase in the number of persons living beyond age 65.In 2000, life expectancy at age 65 reached 16.8 years for males and 20.5 years for females, an increase of 0.3 years and 0.2 years respectively compared with 1999 (Statistics Canada, 2002, p.52).By the year 2030, Canada's aging population is predicted to form nearly one-quarter of Canada's entire population (Statistics Canada, 2002).The change in life expectancy is anticipated to bring many economic, social, political and health care challenges but the greatest of these will be the challenge to provide quality long term nursing care to the increasing population of persons who will require it.Over the past decade, there have been dramatic shifts in staffing patterns in long term care facilities in Canada and in other countries.Nurse aides are being employed in escalating numbers.In Canada, this increase is said to be related to three important factors: the need to control health care costs, a current and projected shortage of regulated health care professionals and an ageing population which requires new approaches to health-care delivery (Canadian Nurses Association -CNA, 2008, p. 2).In the United States, aides now provide 90% of the care to residents who live in long term care facilities (Castle, 2007;Friedman, Daub, Cresci, & Keyser, 1999;Riggs, & Rantz, 2001).
In long term care institutions, aides provide basic resident care.This includes but is not limited to answering calls for assistance, assisting in all activities of daily living (bathing, dressing and grooming, serving meals and feeding residents), taking measurements such as resident's weight, blood pressure, temperature and pulse, collecting urine and stool specimens, administering suppositories and enemas, administering non prescription medications, emptying ostomies and catheters, applying prosthetics or orthotics, assisting with oxygen equipment, assisting with bi-level positive airway pressure (BIPAP) or continuous positive airway pressure (CPAP), and care of a body after death (BC Ministry of Health, 2007;Work Futures BC, 2005).

Purpose
The purpose of this qualitative metasummary is to expose tensions, map diversity and communicate the complexity of how different research traditions and investigators from different countries have contributed to our understanding of nurse aides as a whole (Greenhalgh et al., 2005, p. 427).

Qualitative Metasummary
Qualitative metasummary (also known as mixed research synthesis) is a technique developed by Sandelowski, Barroso and Voils (2007).Initially, the method was used exclusively to review and summarize qualitative findings presented in the form of surveys.In contrast to solely descriptive literature reviews, these qualitative metasummaries were analytical as well as descriptive.They reflected "a quantitative logic" (p.101) because the authors would assess the relative magnitude of each abstracted finding and then arrange and present all abstracted findings in a mathematical manner.
Throughout the process of completing several qualitative metasummaries, Sandelowski et al. observed that lists contained in qualitative reports were very similar "in form (and)…the degree of interpretation" (p.102) to lists offered in quantitative studies.In addition, the authors observed fewer "methodological differences (between qualitative and quantitative) than might be expected" (p.103).Although qualitative and quantitative studies are widely viewed as dissimilar with regards to sampling, the same authors became aware that the samples in qualitative and quantitative reports often converged in the homogeneity of composition (p.103).Therefore, they expanded their technique to include synthesis of both qualitative and quantitative reports.
The method of qualitative metasummary appears to be particularly appropriate for a review of the literature concerning nurse aides: First, the literature is mixed but predominantly quantitative.Second, the qualitative studies rely heavily on surveys or questionnaires.Third, both qualitative and quantitative studies converge in the homogeneity of the sample composition: more than 90% of all nurse aides world wide are women the majority of the studies about nurse aides report that the aides belong to minority groups the majority of all nurse aides world wide belong to low or lower middle income categories.

Extraction
Each metasummary begins with a comprehensive search using multiple strategies.For this metasummary, the electronic databases CINAHL (1982 to present), MEDLINE (1966 to present), EMBASE (1988 to present) and AARP (1978 to present) were searched using a combination of the different titles used to represent nurse aides namely: residential care attendant, certified nursing assistant, personal care aide/worker, geriatric aide, residential care aide, nurse aide, and personal support aide/worker.Searches were restricted to English language articles.Unpublished dissertations were excluded.Forty-six journal articles were identified at first.A separate search of key journals followed, and a 'snowball' search of references contained within all previously obtained empirical papers completed the process.A total of 138 articles and eight trade or organizational reports published between 1983 and 2007 were sampled in this way.
Of these, 16 were published in the 1980s, 60 were published in the 1990s and 68 were published from 2000 onwards.One hundred and four articles were written by American authors, 15 articles were British, thirteen were Canadian, two were Australian, five were Swedish, one was Dutch, four articles were from Taiwan and two were from the Netherlands.Twenty-six were qualitative studies, 72 were quantitative studies, six were mixed methods, ten were literature reviews and 23 were descriptive or opinion papers (including articles theorizing about the practice or modeling the practice of nurse aides).For the full contribution (origin, authors, date, methods and findings) of the different sources to the final metasummary, please refer to Table One.
In a qualitative metasummary, the bias is towards inclusion and not exclusion of reports (Sandelowski et al. 2007) therefore no report was excluded because my own "paradigmatic lens" directed me to an 'obvious' body of literature with a preferred methodology (Greenhalgh et al., 2005, p.427).

Abstraction and Grouping
After an initial reading each primary source was annotated (reduced to a single page or less of single spaced type).This approach facilitated systematic comparison of specific issues, variables or sample characteristics (Whittemore & Knafl, 2005).The next step was "data display" (Whittemore & Knafl, 2005, p. 551).The annotations were grouped by gathering comparable studies together which allowed for "visualization of patterns and relationships within and across primary data sources (and) a starting point for interpretation" (p.551).The data display (abstraction and grouping) follows (See Table 2.).Sandelowski et al. (2007) caution that every metasummary is subjective and negotiable because at every stage of a review, judgements have to be made regarding "what constitutes a finding, which findings are unique enough to be listed separately, which findings are similar enough to be grouped together, and what categories (they) represent" (p.109).

Calculating Frequency Effect Sizes
To assess the relative magnitude of the abstracted findings, the frequency effect size was calculated by "taking the number of reports containing a finding (minus any reports derived from a common parent study and representing a duplication of the same finding) and dividing this number by the total number of reports (minus any reports derived from a common parent study and representing a duplication of the same finding)" (Sandelowski et al,p.107).Frequency effect size "moves the interpretive effort from the description of patterns and relationships to higher levels of abstraction" (Whittemore & Knafl, 2005, p.551).(See Table 3.).

Interpretation of Synthesis Results
Eight broad themes emerged from the metasummary: job dissatisfaction, low wages, attrition and retention difficulties, threats to personal safety, the experience of hierarchy (devaluation and domination), the importance of relationships and collegial support, excessive workloads and inadequate training.

Job Dissatisfaction
Researchers in 25 studies investigated various aspects of job satisfaction.Of these studies 18 were American.In general, investigators observed that organizational factors, the working environment, facility characteristics, the supervisory style, and the aide's feelings or beliefs all influence the degree to which care aides are satisfied with their jobs.
Aides collectively feel dissatisfied with rigid care routines and time constraints that inhibit them from providing personalized care (Brannon, Streit, & Smyer, 1992;Krovach & Krejci, 1998).They complain that they are not listened to (Moyle, Skinner, Rowe, & Gork, 2003); they complain that they are not involved in the care planning process (Beck et al. 1999); they complain that they are unable to make changes or improvements that they feel would benefit the residents because they lack any decision-making authority (Parson, Simmons, Penn, & Furlough, 2003;Monahan & McCarthy, 1992).
Burdened by minimal supervision coupled with inadequate information (Eaton, 2000) and a heavy workload (Chappell & Novak, 1992), some aides break rules out of desperation (Bowers & Becker, 1992).Others bundle tasks to accomplish several tasks at once but feel guilty about it (Bowers, Esmond, & Jacobson, 2000).

Low Wages
Lack of financial compensation also shapes general job dissatisfaction in the United States, where wages are less than a living wage and not competitive with the fast food industry (Harrington et al. 2003).Many American aides work extra shifts or have a second job just to cover basic expenses (Mercer, Heacock, & Beck, 1993).Some nurse aides set firm boundaries on their work: "I will do no more and no less.I'm not going up and above my way because y'all ain't gonna pay me for it" (quote from aide, Jervis, 2002a, p.19).Low wages are associated with high turnover rates (Banaszak-Holl & Hines, 1996;Bowers et al. 2000;Caudill & Patrick, 1989;Harrington & Swan, 2003) and reduced quality of care (Jervis, 2002a).In some studies, approximately 17-20% of nurse aides report an intention to quit (Broughton & Golden, 1995;Caudill & Patrick, 1989).Harrington et al. (2003) reported that the average annual turnover rate for aides in the US in 2001 was 78%.Concern about low wages is not limited to American aides.In Taiwan, the monthly wage is also less than service industries (Hsieh & Su, 2007).In Mexico, the average salary per day is just adequate for necessities (Douglas, Meleis, Eribes, & Kim, 1996).In Canada wages vary between provinces.In British Columbia, aides currently earn $19.73 per hour (as per the Hospital Employees Union Facilities Subsector Wage Schedule, 2008).
Care aides who stay employed cite being around elderly people -helping and caring for them, being part of a team, feeling valued and needed by the residents and feeling virtuous as motivational factors (Berdes & Eckert, 2001;Douglas et al. 1996;Hsieh & Su, 2007;Kristiansen et al. 2006).Research also indicates that caring relationships between aides and residents or aides and families, and collegial connections are very important motivational factors that reduce turnover rates and increase quality of care (Bowers et al. 2000;Brannon et al. 1990;Grau, Chandler, Burton, & Kolditz, 1991;Parsons et al. 2003).Several investigators found that a uniform culture (religious, ethnic, social and/or economic) between residents/families and staff contributes to harmony and/or decreased staff turnover (Berdes & Eckert, 2001;Foner, 1994;Grau & Wellin, 1992;Jervis, 2002a).Satisfied aides feel respected and supported (Grau et al. 1991;Friedman et al. 1999).They believe that they are competent and that they are able to affect residents (Parsons et al. 2003).
In summary, care aides who stay are more likely to be older (Cotton & Tuttle, 1986) and of the same social, cultural, religious or ethnic background as the residents and their families (Grau & Wellin, 1992).They become involved in care planning and decision-making (Banaszak-Holl & Hines, 1996;Broughton & Golden, 1995;Friedman et al. 1999) and they are more likely to feel that their contributions are valued and acknowledged by the residents, families and supervisors (Broughton & Golden, 1995).As a consequence, they feel that they are able to provide care in a way that is like family (Bowers et al. 2000).Feelings more strongly determine whether aides are dissatisfied than the more objective features of the job (Grieshaber, Parker, & Deering, 1995).
Although low turnover rates may appear desirable, the metasummary also revealed that very low turnover rates are undesirable.Some aides stay precisely because middle management is lacking or the supervisors are untrained (Brannon, Zinn, Mor, & Davis, 2002).Other aides stay because they have become demoralized and have developed a cynical and callous detachment to the job (Tellis-Nayak & Tellis-Nayak, 1989).

Threats to Personal Safety
There are major concerns in the literature about violence and aggression in the workplace posing a threat to the personal safety of the care aide.Nineteen articles focused specifically on nurse aides' experiences of assault by residents in long term care.Many other articles mentioned assault as a source of stress.The subject of assault is delicate one.Multiple authors describe residents who are bitter and hostile towards the aides (Brodaty, Draper, & Low, 2003;Foner, 1994;Gates, Fitzwater, & Succop, 2003;Kristiansen et al. 2006;Ramirez, Teresi, & Holmes, 2006).Psychological aggression such as shouting, name calling, threats and inappropriate sexual remarks have been found to be significantly related to nurse aides' feelings of reduced personal accomplishment and feelings of emotional exhaustion (Evers, Tomic, & Brouwers, 2002;Ramirez et al. 2006).These authors suggest that caregivers who experience aggressive behaviour feel isolated and demoralized.Several authors describe how residents or family members make demeaning racist remarks to aides (Berdes & Eckert, 2001;Foner, 1994;Mercer et al. 1993) or treat aides as servants (Grau & Wellin, 1992).
On top of this, aides endure physical violence (Burgio, Jones, Butler, & Engel, 1988;Foner, 1994;Freyne & Wrigley, 1996;Gates et al. 2003;Kristiansen et al. 2006).More than half of all aides report receiving an injury from a resident at some point during their employment (Fitzwater & Gates, 2002).The experiences of physical assault include being squeezed against a wall, pinched, scratched, spat at, hunted, hit or having objects thrown towards a person (Burgio et al. 1988;Kristiansen et al. 2006)."It is not little…not small smacks we get.They are in fact quite heavy punches and pinches and bruises….There are times when you want to scream for help" (quotes from support workers, Kristiansen et al. 2006, p. 248-249).These authors found that physical assault "was regarded as a very trying and unpleasant part of the job" (p.248) and resulted in feelings of humiliation.
Whether physical or verbal assault is intentional or not, many nurse aides regard it as violence (Gates et al. 2003) and sometimes view the residents' aberrant behaviour as deliberate (Brodaty et al. 2003).These same authors concluded that nursing home staff generally perceive residents in more negative ways than positive ways.

The Experience of Hierarchy: Devaluation and Domination
Most care aides are employed in highly structured, complex, hierarchical systems that resist change.A number of studies report very distressing findings of nurse aides' perceptions of hierarchies, leading to devaluation and domination (Helmer, Olsen, & Heim, 1993;Jervis, 2002a;Kristiansen et al. 2006).Nurse aides have been found to have feelings of humiliation, vulnerability, insignificance, invisibility, uncertainty and insecurity (Dewar & McCleod-Clark, 1992;Kristiansen et al. 2006).Kristiansen et al. (2006) refer to the "employer's meta message" (p.252) which is interpreted by nurse aides as "not feeling valued" or "confirmed" by their employer (p.252).The same authors refer to a gap "between the current economic and moral reality and the ideal moral desire, resulting in nurse aides' awareness of their own feelings of inadequacy and failure" (p.252).Jervis (2002a) explored the relationships among nurses and nurse aides in an urban nursing home in the United States and found a militaristic paradigm for staff organization in which nurse aides served as subordinates.Nurse aides were assigned rank-specific duties and were held accountable to individuals higher in the staff hierarchy.In describing this hierarchy, one staff member utilized a feudal system metaphor: "Nursing homes are like little principalities.You've got your royalty, your minor nobility, and your peasants.Everybody is trying to get in with the royalty and the peasants are getting screwed" (quote from staff member, Jervis, 2002a, p.14).The administration's embrace of hierarchy was reflected in their choice of words such as "delegate down" and "down at the unit level" (p.14).

The Importance of Collegial Support
Generally, nurse aides express strong feelings of mutuality with their co-workers."My work-mates are the most positive thing about working here…you are never alone" (quote from support worker, Kristiansen et al. 2006, p.251).Job tasks and job process are less important to institutional loyalty than the warmth, friendliness, support and caring of co-workers and superiors (Brannon et al. 1990;Grau et al. 1991)."If it wasn't for these nurses aides socializing with one another, somebody would crack" (Quote from nurse aide, Jervis, 2002a, p. 18).

Excessive Workload
There is not enough time in the day for nurse aides to get everything done (Bowers et al. 2000;Krovach & Krejci, 1998).Workload is affected by a high ratio of residents to aides or a high acuity level of the residents (Garland, Oyabu, & Gipson, 1988;Mercer et al. 1993).Time saving measures include not allowing the resident to choose clothing, hurrying their dressing, cutting back on grooming, eliminating oral care and abbreviating the bath (tops and tails only) (Bowers et al. 2000)."They'll get washed up, they're kept dry and turned over, but they don't get lotion, they don't get the one on ones, they don't get walks" (quote from aide, Bowers et al. 2000, p.60).Inadequate equipment or lack of supplies also prevents aides from doing their job effectively (Garland, Oyabu, & Gipson, 1989;Mercer, Heacock, & Beck, 1994).Experienced aides find ways to get the job done by integrating demands, maximizing efficiency through organization and knowing when to safely cut corners (Bowers & Becker, 1992).

Inadequate Training
Three quarters of all aides feel inadequately trained for the job (Mercer et al. 1993).Due to heavy workloads and time constraints, aides receive varied and limited orientations and limited in-service education (Banaszak-Holl & Hines, 1996;Eaton, 2000;Lin et al. 2002).
In the United States, a 75 hour training course and certification testing is federally mandated (Castle, Engberg, Anderson, & Men, 2007), although some states (for example, California) require up to 160 hours of training (Harrington, O'Meara, Collier, & Schnelle, 2003).Aides in Taiwan are supposed to receive 100 hours of training and a certification exam, but not all aides receive minimum training and certificates (Sung, Chang, & Tsai, 2005).In Mexico, aides receive "some on the job training" (Douglas, Meleis, Eribes, & Kim, 1996).In Canada, the length of the care aide program varies from seven weeks in Ontario (personal support worker) to 32 weeks in the Northwest Territories (long term care attendant) (Health Employers Association of British Columbia, 2000).Canadian care aides are not regulated by provincial legislation and regulations seen for other members of the nursing team (LPNs, RPNs and RNs).

Discussion
Of the total articles (138), the frequency effect size was greatest for caring relationships and/or connectedness between aides and residents or aides and families, and collegial connections which appear to be very important motivational factors that may reduce turnover rates and increase quality of care (44.8%).A number of nurse aides remain committed and motivated to remain on the job even though the working conditions appear to be deplorable.These aides are not motivated by solely by wages or the working environment but by a combination of intrinsic factors such as a belief that their job is important (Parsons et al. 2003) or a belief that they are needed (Monahan & McCarthy, 1992).
This finding was followed closely by the concern regarding lack of financial compensation and rewards which shape general job dissatisfaction (frequency effect size 38.0%),supervisory styles that are generally hierarchical, demeaning and dismissive (frequency effect size 37.3%) and violence and aggression in the workplace which pose serious threats to the personal safety of the aide (frequency effect size 36.6%).As a group, nurse aides have complained that they very little voice.They are rarely directly consulted about their opinions and experiences.They are marginalized by frequent episodes of assault and by feelings of degradation and humiliation resulting from bureaucracy.Poor working conditions lead to feelings of guilt because most genuinely care about the residents.
There is a cost to society for overlooking the work of nurse aides, portraying nurse aide work as unskilled or ignoring aides as valuable sources of information.As the population ages, the care aide role will become a pivotal issue.Aides serve a very vulnerable segment of our society therefore "some interest must be taken in (aides)…if the care provided to the elderly is truly a concern" (Atchison, 1998, p.137).
Although care aides are most commonly utilized in residential continuing care they are also now being introduced to acute care settings.Job/role descriptions are continuously being updated and rewritten as part of the process of introducing the care aide to medical and surgical nursing units (nursing service aide).These are the same aides who report not feeling valued or nourished by their organizations."I know I am dispensable" (quote from aide, Jervis, 2002a, p. 18)."It's like you're low class as a nursing assistant, you're on the bottom -which I don't like" (quote from aide, Jervis, 2002a, p.17).
Research about nurse aides is important because there are so many qualities of care issues and so many unsolved problems in their working environments.If organizations are concerned about positive outcomes for patients in acute and long term care and if they are concerned about improving the performance of individual workers and the organizations themselves, then they should address the needs voiced by the aides (Liu, 2006, p.56).Finally, heavy reliance on American research regarding the work as arduous, demanding and often demoralizing is a limitation.Further work is required to determine if American findings are truly generalizable to other countries.There is not enough time to have a personal relationship with residents (Krovach & Krejci, 1998) 3

2004) 1
Administration that is sensitive to the social needs of the nurse aide (Tellis-Nayak & Tellis-Nayak, 1989) 1 Administration that nurtures idealism (Tellis-Nayak & Tellis-Nayak, 1989) 1 Administration that fosters a family spirit (Tellis-Nayak & Tellis-Nayak, 1989) 1 Administration that boosts the self esteem of the aide (Tellis-Nayak & Tellis-Nayak, 1989) 1 Focusing less on health status in conversation with residents, and more on resident as person (Wadensten, 2005) 1 Higher levels of RN staffing reduce the likelihood of receiving a mental health deficiency citation (Castle & Myers, 2006) 1

Aspects of Experience of Assault
Most assaults occur during basic care activities (Gates, Fitzwater, & Succop, 2003) 3 More than half of aides report receiving an injury from a resident at some point in employment (Fitzwater & Gates, 2002) 1 Mean number of assaults per 80 hours work is 4.69 (Gates, Fitzwater, & Succop, 2003) 1 5% of assaults result in an injury (nature not specified) (Gates, Fitzwater, & Succop, 2003) 1 55% of assaults result in bruises, abrasions or scratch marks (Freyne & Wrigley, 1996) 1 In 61% of assaults on aides, no specific action is taken after the incident (Freyne & Wrigley, 1996) 1 Younger aides experience more assaults (Gates, Fitzwater, & Succop, 2003) 1 Aides with negative attitudes experience more assaults (Gates, Fitzwater, & Succop, 2003) 1 Aides with complaints of physical illnesses or poor self care habits experience more assaults (Gates, Fitzwater, & Succop, 2003) 1 Aides with more state anger (angry feelings, perceiving unfair treatment) experience more assaults (Gates, Fitzwater, & Succop, 2003) 1 Residents with mental illnesses (but without dementia) exhibit more verbal disruption than residents with dementia (and without mental illness) (McCarthy, Blow, & Kales, 2004) 1 Training helps aides feel more confident in ability to prevent assaults (Fitzwater & Gates, 2002) 2 Education can decrease the number of assaults against caregivers (Fitzwater & Gates, 2002) 1 Factors Specifically Pertaining to Increased Job Satisfaction Teamwork (being a member of a team) (Krovach & Krejci, 1998) 3 A network of interpersonal (collegial) relationships (Brannon, Cohn, & Smyer, 1990) 5 Working in a community based program rather than in a facility (Friedman, Daub, Cresci, & Keyser, 1999) 1 Administrative support (Krovach & Krejci, 1998) 1 Relationships with residents (Bowers, Esmond, & Jacobson, 2000) 6 Being able to provide care in a way that is like family (Bowers, Esmond, & Jacobson, 2000) 2 Feeling that one is performing a service (Douglas, Meleis, Eribes, & Kim, 1996) Aides collectively prefer to be involved in care planning and decision-making 14.9% Caring relationships and/or connectedness between aides and residents or aides and families, and collegial 44.8% connections are very important motivational factors that reduce turnover rates and increase quality of care Violence and aggression in the workplace poses serious threats to the personal safety of the aide 36.6% " guides aides who treat residents as their own children = infantilization and misinterpretations of depression and pain.The Golden rule: respond to residents as you would want someone to respond to you.Aides act without the benefit of professional interpretations.Aides possess raw data that can be interpreted by RNs.Aides should be involved in care planning.poor quality of care?RNs who have minimal interaction with aides, LPNs who have minimal interaction with aides, aides in small cliques, no rewards for team work, heavy reliance on rules and rule enforcement, managers who have inadequate information and managers who fail to survey Lower turnover is dependent on interaction climate and communication.Reward based climates, communication openness and accuracy = lower turnover rates.empathy rated close contact with patients as most important.Staff with lowest empathy rated improvement in patients' health and contact with colleagues as most important.Those who have less positive outcomes in work risk more burnoutclarification of roles: support workers saw their work as similar to RNs.RNs saw support workers' roles as basic at the in-service training was marginal due to lack of time and requirement to forgo patient care in order to attend. of aides in care planning can significantly reduce turnover.Intensity of work demands does not result in increased turnover.Training for aides does not reduce motivated.Supervision is limited.Author concludes best care given in a home with a family or social quality.Community involvement is important.Cultural homogeneity contributes Higher number of rewards given to nurse aides resulted in lower incidence of pressure ulcers.Nurse aides who had more influence resulted in on characteristics & management of aggressive behaviour.Aggression occurs more often in the morning, during dressing.Soothing, using comfort measures and reasoning were commonly used by aides to reduce aggression.organized hierarchically, aides receive few rewards for performance, aides have few opportunities to feel successful, aides minimally involved in care planning, aides are mostly African American or Hispanic and supervisors are mostly White, residents are primarily White.experience racism on the job.Job characterized by low wages, few or no benefits, low opportunity for advancement, job instability, some serious repercussions: over-involvement, disagreements about care strategies, divisions in nursing team, lack of communication, weakening of the team as a nurse aides and residents are an essential determinant of quality of care.Adequate staffing is essential to allow NAs to nurture relationships with residents.necessarily quit because of hard work or poor pay.Rather, it is the way aides are treated by their employers that accounts for their leaving.Dismissing experiences will override positive experiences.Managers must develop a culture of respect, instead of demeaning or humiliating aides.
related to intent to leave and turnover.Training, rewards and workload are important aspects of nurse aide work Aides who experience greater workload are more likely to feel burdened.Social support at work does not relieve the effect of workload.Aides who receive support from family and friends are less likely to burnout.Aides who have family supportive of their work experience less job pressure.Fewer family members at home results in less job pressure.about caring for demented patients on a continuum from rational to intuitive, in part because of the working environment.Some decisions are not good decisions and may lead to decreased quality of care.turnover: increases in pay reduce turnover.Job satisfaction, satisfaction with co-workers are negatively related to turnover.Age, tenure, number of dependents negatively related to turnover.Women more likely to leave than men.care, low quality work environments.Much of the work is invisible and not documented or measured.Training minimal.Supervision inadequate.Little information is shared.Many aides choose this work despite poor working conditions.to physical aggression and the effects of physical aggression on caregivers and on nursing practice.Showering is the activity most likely to provoke patient aggression.social environment of the nursing home is as important as attitudes to job benefits in accounting state with highest nursing home staffing levels: 3.9 hours per resident per day.A trend across the USA towards higher staffing levels.33 states have minimum staffing levels for NAs.No federal minimum standards for NA staffing levels.less than a living wage.91% of all California nursing homes report nurse aide hours below the recommended 2.8 hours per resident per day.Average facility reported 2.2 hours per resident per day.Average annual turnover rate is 78%.work support in nursing aides compared to RNs.Aides are significantly less hardy than RNs and more vulnerable to occupational resonated / perceived nurse aide empathy (measured by empathy subscale), expressed empathy (supervisors) with self rated depressive symptoms of residents Negative nurse aide behaviour is related to USA negative psychological outcomes for residents.to guide decision making.A major barrier to giving care is the organization of care itself.Not enough time to give adequate care.Aides not monitored or supervised.Aides not informed properly.Aides perform "invisible work".how staff conceptualized and dealt with "problem" behaviours.Staff were cognizant of the ever-present threat of assault.Violent, serious disruptive behaviour is a serious problem.Staff resorted to informal and author offers a set of characteristics similar to both lay-caring and professional caring relationships and offers case studies to illustrate care-the nurse aide working in partnership with the RNs (as a dyad) resulting in cost savings.Suggestion to pass cost savings on to the RN in a form of salary increase. of residents are diagnosed with a serious mental illness.Residents with a serious mental illness and without dementia exhibit more verbal disruption than residents with dementia.No differences in physical aggression or socially intervention: investigator designed education program (relationship enhancing).Care providers taught how to enhance relational skills without added staff.Residents report significant positive effects: more empathetic and more reliable.work extra shifts just to cover basic expenses.77.7% of aides experience discriminatory language and racist behaviours.Slurs hurt, early warning systems.Managers create their own reality.Dismissal is based on attitudes and competence, not on business expertise or technical skills.Managers need training in social skillsfor becoming a nurse aide Like helping and working with people.Like feeling needed, wanted, valued.Want to receive recognition.Work is physically demanding, tiring.Continue to work because need the money.not a fully insured health service in any Canadian province or territory.Provides demographics and useful facts.Monthly charges.Guaranteed income supplement (GIS), low income.System failing to provide many Canadians affordable care.Many forced to pay for medical and personal care, forced to spend assets.Poor staffing, the greatest impact on satisfaction with supervision (family, financial, health concerns).Personal stressors of NAs require attention from supervisors because they affect Most satisfied with closeness to residents, their affect on residents, belief that the job is important, and own competence in providing resident care.Dissatisfied with insufficient input into decision-making, pay, benefits, recognition, aides working in acute care settings.Educators need to make an effort to assess, organize, and plan activities for aides in acute care.threatened by increasing demand for aides (support workers).RNs exercise control over aides by delegating tasks to support workers., African American women with health and pension benefits.Wages and working environments play a major role in turnover.Should recruit older welfare to work clients and students.Focus screening on questionnaires about skills, motivations and reliability.Relationships are important to job satisfaction and turnover.Aides require clear job descriptions.residents.Older, more racially diverse, more circulatory diseases and cognitive and mental disorders, more mental health issues, more help with ADLs, more incontinence, increased choices of care (home care) demanding, poor pay, work grounded in hostility and disrespect, lack of control and physical assaults by residents.Why aides stay in long term care: a sense of connection with families, residents and co-workers, pride, being recognized for their efforts, being conscientious about of care related to 27 different care processes (16 of the care processes typically implemented by aides…feeding, incontinence care, social engagement, repositioning etc.).Highest staffed homes perform better on 13 of the 16 care processes.Aides report lower care workers as a threat.Support workers perceived themselves as key players who support the work of the RNs

Table 1 .
The Full Contribution of the Different Sources to the Final Metasummary

Table 2 .
Abstraction and Grouping

Table 3 .
Formatting and Calculating Frequency Effect Sizes (ES) of Findings (total articles 138) ES%Aides collectively feel dissatisfied with organizational factors that inhibit them from providing excellent care 20.1%