*Article* **A Cross-Sectional Study on the Impacts of Perceived Job Value, Job Maintenance, and Social Support on Burnout among Long-Term Care Staff in Hawaii**

**Bum Jung Kim <sup>1</sup> and Sun-young Lee 2,\***


**Abstract:** Extensive research has demonstrated the factors that influence burnout among social service employees, yet few studies have explored burnout among long-term care staff in Hawaii. This study aimed to examine the impact of job value, job maintenance, and social support on burnout of staff in long-term care settings in Hawaii, USA. This cross-sectional study included 170 long-term care staff, aged 20 to 75 years, in Hawaii. Hierarchical regression was employed to explore the relationships between the key independent variables and burnout. The results indicate that staff with a higher level of perceived job value, those who expressed a willingness to continue working in the same job, and those with strong social support from supervisors or peers are less likely to experience burnout. Interventions aimed at decreasing the level of burnout among long-term care staff in Hawaii may be more effective through culturally tailored programs aimed to increase the levels of job value, job maintenance, and social support.

**Keywords:** burnout; job value; job maintenance; social support; care worker

#### **1. Introduction**

With rapid population aging, the importance of long-term care is growing in most countries affiliated with the Organization for Economic Co-operation and Development (OECD). In 2005, long-term care expenditures accounted for slightly more than 1% of the GDP of all OECD countries, but this number is expected to reach between 2% and 4% by 2050 [1]. Interest in long-term care is expected to grow even more. On the contrary, long-term care is labor-intensive, and its burden is increasing; thus, attracting long-term care staff is becoming more difficult. To respond to the increasing demand for long-term care, investment in policies to utilize the available labor force more efficiently is essential. In particular, the importance of non-financial benefits has recently emerged [2].

The shortage of long-term care staff is one problem occurring in many countries. In particular, the field's high turnover rate is often pointed out as a cause of the shortage of staff, while job dissatisfaction and burnout are identified as predictors of turnover among long-term care staff [3].

The older population in the US, including Hawaii, has been growing rapidly. Between 2015 and 2018, the proportion of the state's population aged 65 years and older increased from 22.6% to 24.2%, and the percentage of individuals aged 85 and older increased from 2.7% to 3.2% [4]. Given these demographic trends, the demand for long-term care services in Hawaii is expected to grow exponentially over the next few years.

Older people often experience chronically complex health conditions that require long-term treatment. With the increased demand for long-term care derived from the longer average life expectancy and aging population, the workload of staff is increasing. At the same time, the mental stress experienced by staff has attracted attention, and studies from multiple fields have been conducted to identify ways of reducing their mental burden.

**Citation:** Kim, B.J.; Lee, S.-y. A Cross-Sectional Study on the Impacts of Perceived Job Value, Job Maintenance, and Social Support on Burnout Among Long-Term Care Staff in Hawaii. *Int. J. Environ. Res. Public Health* **2021**, *18*, 476. https:// doi.org/10.3390/ijerph18020476

Received: 16 December 2020 Accepted: 6 January 2021 Published: 8 January 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

Therefore, this study examined the factors affecting burnout to develop practical measures for increasing job satisfaction and lowering turnover rates among staff in Hawaii.

#### *1.1. Burnout*

Burnout refers to the process in which energy related to a job is drained and leads to feelings of helplessness and cynicism in an individual; it largely comprises the sub-concepts of emotional burnout, depersonalization, and lack of personal achievement [5]. The term burnout refers to these and other aspects of job-related stress, which were identified in the 1970s among volunteers of the American Mental Health Center who had lost their motivation to care adequately for clients [6]. In particular, burnout is a negative phenomenon frequently seen in human service professionals, such as doctors, nurses, teachers, counselors, and social workers [7].

If burnout persists, it negatively affects physical and psychological well-being. For example, burnout causes disorders like anxiety and depression, decreases job satisfaction and job commitment, diminishes work motivation and productivity, and increases turnover and retirement intentions [8]. Additionally, individuals with a lack of emotional empathy due to burnout might be more inclined to tolerate the abuse of those in their care [9].

As mentioned earlier, research suggests that people who provide care services are more likely to experience burnout. Additionally, as the demand for care increases alongside the aging population, researchers' interest in exploring burnout issues has become more urgent. Maslach et al. [5] classified the factors related to burnout into personal and situational factors. Personal factors include demographic characteristics, personality, and work attitude. Situational factors are classified into job-related characteristics, occupationalrelated characteristics, and organizational characteristics. Many burnout-related studies have utilized these factors originally identified by Maslach et al. [5].

In summary, if burnout persists for an extended period among those who provide care services, they might experience exhaustion and a decrease in motivation to work, which might deteriorate the quality of the services provided and result in abusive behavior toward patients. Therefore, to develop practical support measures for reducing the burnout of staff, we examined factors affecting their burnout.

#### *1.2. Theoretical Background*

Among the research models that hypothesize the cause of burnout, the job demands– resources model can be applied as a theory that provides major implications for this study. This theory was proposed by Demerouti et al. [10] as a model of job burnout, applicable to various occupation groups, and was based on the theory of resource conservation [11]. Job resources, referred to herein, are all job-contextual functions that effectively respond to job demands required by the organization, contribute to reducing negative effects (such as jobrelated stress), and ultimately play a functional role in achieving job goals [10]. For example, they may include a number of individual job-related factors, such as participation in the decision-making process related to the job, diversification of job-related skills, and feedback on the degree of autonomy in performance, along with interpersonal factors, such as cooperative relationships with colleagues and supervisors, and organizational atmosphere [12].

Based on the job demands–resources model, it is assumed that as a variable that affects employees' burnout, employees' attitude toward their job—such as high job value, willingness to maintain their job and their relationship with co-workers—is an influential factor [13]. When an organization member experiences a depletion or shortage of job resources, they experience exhaustion due to a decrease in job performance and personal motivation toward achievement.

The direct influences of job attitudes and circumstances (namely, job value and social support) on burnout are well known. There are several studies that show that as the years of service increase, burnout decreases; however, there is a scarcity of studies exploring the inverse causal relationship, which establishes that a decrease in the number of years of service may lead to increased burnout [12,13].

As mentioned above, excessive job factors induce stress in staff; furthermore, they manifest as burnout, which consequently can negatively affect organizational effectiveness [14]. In particular, this study is focused on the existing job demands–resources model, but expands the scope to factors related to favorable work performance environments such as social support and internal motivations such as job value and service providers. According to the results of previous studies, even if job factors negatively impact staff, burnout is likely to decrease when social support is high; internal motivations such as job value and job maintenance are also likely to reduce burnout. Therefore, our analysis could contribute to broadening the scope of application of the job demands–resources model and thereby contribute toward finding ways to reduce burnout.

#### *1.3. Literature Review*

#### 1.3.1. Job Value and Burnout

Job value and burnout generally have an inverse relationship: individuals who have a positive emotional outlook regarding their jobs tend to experience a lower level of burnout. For example, in a study on social workers, the higher the value that social workers assigned to their jobs, the lower their levels of burnout were [15]. Similarly, a higher level of burnout was associated with a lack of occupational identity among occupational therapists [16]. Among staff, higher job values have been observed to contribute to a reduction in burnout [17]. In addition, high vocational awareness has been associated with a lower level of burnout among employees in other service sectors [18].

The aforementioned studies suggest that the level of burnout decreases as human service professionals perceive their jobs more positively. Several factors contribute to the positive perception of one's job, including social reputation and related benefits. Nevertheless, there is a lack of research that has analyzed the effects of individual attributes of job perception on burnout. Therefore, this study focused on and examined the perception of Hawaiian long-term care staff of the social value of their job and its various attributes.

#### 1.3.2. Job Maintenance and Burnout

In a study that examined the relationship between job maintenance and burnout, poor work environment factors, such as long working hours and a lack of regular rest hours, increased burnout among welfare facility workers [14]. Similarly, another study found that job stress and job satisfaction had a significant effect on burnout among nurses [19]. Yet, another study showed a significant relationship between job satisfaction and burnout among counselors. Additionally, many human service professionals continue to work in their respective jobs despite their burnout potential, which provides additional evidence of a relationship between job satisfaction and burnout [20]. Conversely, if job satisfaction decreases and the level of attachment and immersion also declines, workers' willingness to continue working in the same job also decreases [21]. Therefore, research indicating that as job satisfaction decreases burnout increases, highlights the necessity of examining the long-term impact of the human service profession on workers' burnout. Therefore, this study also aimed to verify the impact of being a long-term care provider, on burnout.

#### 1.3.3. Social Support and Burnout

All resources that satisfy one's physical, material, and emotional needs can be collectively referred to as social support, which reduces the harmful effects of stress, as well as psychological and social burdens [22,23]. Social support also plays a positive role in reducing the burnout of workers by helping them cope with stressful situations [24,25]. Research indicates that social support is a major factor that alleviates burnout by acting as a buffer between stress factors and tension [19,26]. One of the most important forms of social support that individuals have is their network of relationships with others. Studies conducted with social workers indicate that sufficient social support reduces burnout [27–29].

Prior studies have demonstrated that social support affects individuals' experiences of burnout. Additionally, the level of burnout varies among care providers who undergo the same level of stress. Therefore, this study examined the association between different factors (such as job-related social support and the long-term will of caregivers) and burnout, as this notion has not yet been adequately explored. *Hawaii.* **Hypothesis 3 (H3)**. *Social support is associated with burnout among long-term care staff in Hawaii.*

1.3.4. Purpose of the Study and Hypotheses

This study aims to examine the relationships between job value, job maintenance, social support, and burnout among long-term care staff in Hawaii, USA. The hypotheses (Figure 1) for the current study are as follows.

*Int. J. Environ. Res. Public Health* **2021**, *18*, x FOR PEER REVIEW 4 of 12

out, as this notion has not yet been adequately explored.

1.3.4. Purpose of the Study and Hypotheses

(Figure 1) for the current study are as follows.

reducing the burnout of workers by helping them cope with stressful situations [24,25]. Research indicates that social support is a major factor that alleviates burnout by acting as a buffer between stress factors and tension [19,26]. One of the most important forms of social support that individuals have is their network of relationships with others. Studies conducted with social workers indicate that sufficient social support reduces burnout [27–29].

Prior studies have demonstrated that social support affects individuals' experiences of burnout. Additionally, the level of burnout varies among care providers who undergo the same level of stress. Therefore, this study examined the association between different factors (such as job-related social support and the long-term will of caregivers) and burn-

This study aims to examine the relationships between job value, job maintenance, social support, and burnout among long-term care staff in Hawaii, USA. The hypotheses

**Hypothesis 2 (H2)**. *Job maintenance has an influence on burnout among long-term care staff in* 

**Figure 1.** The hypothesized model.

**Hypothesis 1 (H1).** *Job value is correlated with burnout among long-term care staff in Hawaii.*

**Figure 1.** The hypothesized model. **Hypothesis 2 (H2).** *Job maintenance has an influence on burnout among long-term care staff in Hawaii.*

**2. Method** *2.1. Design, Study Site, and Participants*  **Hypothesis 3 (H3).** *Social support is associated with burnout among long-term care staff in Hawaii.*

#### **2. Method**

#### The study used a cross-sectional survey design with data collected from a conven-*2.1. Design, Study Site, and Participants*

ience sample of 192 long-term care staff in Hawaii, US. The study sample was recruited from 23 long-term care agencies such as nursing homes, adult day care centers, and independent living facilities. Participants in the study were professionals working in longterm care facilities, including nurses, nursing assistants, social workers, physical therapists, and occupational therapists. Staff working at long-term care institutions in Hawaii include social workers, physical therapists, and occupational therapists, as well as nurses and nursing assistants. Social workers play a role in social care and case management, and therapists also play an important role in rehabilitation and dementia management at long-The study used a cross-sectional survey design with data collected from a convenience sample of 192 long-term care staff in Hawaii, US. The study sample was recruited from 23 long-term care agencies such as nursing homes, adult day care centers, and independent living facilities. Participants in the study were professionals working in long-term care facilities, including nurses, nursing assistants, social workers, physical therapists, and occupational therapists. Staff working at long-term care institutions in Hawaii include social workers, physical therapists, and occupational therapists, as well as nurses and nursing assistants. Social workers play a role in social care and case management, and therapists also play an important role in rehabilitation and dementia management at long-term care institutions. The research team first contacted program directors of long-term care centers and explained the purpose and procedure of the study to obtain their consent for participation. Once agency-wide consent was obtained, the authors identified potential research participants at each agency, obtained informed consent, and distributed self-administered questionnaires for completion. Of the 192 responses obtained, the data from 170 questionnaires were used (22 questionnaires were discarded due to missing data and incomplete responses), representing an acceptance rate of 88.5%. Each participant received USD 5 as compensation.

#### *2.2. Data Measures*

#### 2.2.1. Burnout

To measure burnout, the study used the Maslach Burnout Inventory (MBI). The MBI was developed by Maslach and Jackson [30]; it comprises three domains (depersonalization, attainment of personal fulfillment, and emotional exhaustion) and 17 items. Participants answered items using a 5-point Likert scale (1 = *almost always,* 2 = *sometimes,* 3 = *every once in a while,* 4 = *rarely,* and 5 = *never*). High scores indicated a high risk of burnout. The only survey item that required inverted calculation due to inverted response values was the attainment of personal fulfillment. The internal consistency reliability (Cronbach's alpha) for the MBI in this study was 0.91. In addition, confirmatory factor analysis (CFA) was conducted to verify the factor structure of a set of observed items. The CFA produced a chi-square of 5.61 (*p* = 0.47), a root mean square error of approximation (RMSEA) of 0.03, a comparative fit index (CFI) of 0.91, and a Tucker-Lewis index (TLI) of 0.92, all indicating the measure's reasonably good fit.

#### 2.2.2. Job Value

To measure the level of job value, we used the following item: "How much do you think your current job is valued by society?" Participants responded to the item on a 4-point Likert scale (*very much, somewhat, not much,* and *not at all*). A low score indicated that the participant perceived his or her job as highly valuable.

#### 2.2.3. Job Maintenance

To measure the possibility of participants maintaining their current job, we utilized the following item: "How long would you like to stay in your current workplace?" Participants responded to the item on a 4-point Likert scale (*I would like to quit my job right now, I would like to quit my job but not now, I would like to stay here for the time being,* and *I would like to stay here as long as possible*). A high score indicated a high level of job maintenance.

#### 2.2.4. Social Support

Social support was measured using the Social Support Measurement Tool by Poulin and Walter [31]. This 18-item scale contains five items to measure instrumental support from supervisors, six items to measure emotional support from supervisors, and seven items to measure emotional support from peers. Participants responded to the items using a 4-point Likert scale (*very agreeable, agreeable, almost not agreeable,* and *not agreeable*). A higher score meant stronger social support. In this study, the internal consistency reliability (Cronbach's alpha) for social support was 0.89. Moreover, CFA analysis produced a chisquare of 7.24 (*p* = 0.23), an RMSEA of 0.01, a CFI of 0.94, and a TLI of 0.97, all indicating the variable's good fit.

#### 2.2.5. Background Information

Sociodemographic variables were included in this study as follows: age (in years), gender (1 = female), marital status (1 = married), income (continuous variable), and education (continuous variable).

This study addressed the issue of common method bias. Usually, the concern is that when the same method is used to measure multiple constructs, it may result in spurious method-specific variance that can bias observed relationships between the measured constructs [32]. In order to reduce common method bias, this study used two methods. By adding a time delay, thereby increasing temporality of the items, the study could reduce participants' tendency to use previous answers to inform subsequent answers. In addition, ambiguous items increase participants' reliance on their systematic response tendencies as they are unable to rely on the content of the ambiguous item [33]. The study reduced ambiguity by keeping questions as simple and specific as possible.

#### *2.3. Ethical Considerations*

The authors clearly informed potential participants that their participation was voluntary, that the study adhered to a rigorous protocol for research ethics (guaranteeing participants' anonymity and confidentiality), and that collected data were to be used for research purposes only. The study design was approved by the Institutional Review Board of the University of Hawaii (CHS #22473) on 9 October 2014.

#### *2.4. Data Analysis*

There were three procedures for data analysis. First, the study used descriptive statistics to explain the main study variables in terms of frequencies, percentages, and means. Next, the study used bivariate analysis (Pearson's correlation) to examine the correlational relationships between the independent variables and the dependent variable. Finally, the study performed a robust hierarchical regression analysis with the outlier downweighting algorithm using STATA version 13.0 software. Four sets of independent variables were regressed on burnout in successive order as follows: (1) sociodemographic characteristics, (2) job value, (3) job maintenance, and (4) social support. Additionally, variance inflation factors were assessed to determine multicollinearity.

To investigate burnout, we first added the sociodemographic variables as a group (age, gender, marital status, education, and income) to control how these factors affect the dependent variable (burnout). Through a hierarchical regression analysis, the change in the R-squared value at each step provided insight into the predictive power of each cluster while controlling the variables in the previous model. To overcome this problem, a robust regression procedure was used to repeatedly reduce or correct outliers.

#### **3. Results**

#### *3.1. Sample Characteristics*

Demographic characteristics of the sample and descriptive data of the following study variables are shown in Table 1: age (range, mean age), gender ratio, marital status ratio, educational level spectrum, average monthly income, the mean scores of job value, job maintenance, social support, and burnout level.

**Table 1.** Participants' characteristics.



**Table 1.** *Cont.*

#### *3.2. Bivariate Correlations with Burnout*

Imputed correlations between variables from the predicted model are shown in Table 2. Since no correlation coefficient values were over 0.06, multicollinearity was considered nonexistent among the study variables [34]. There was a significant positive correlation between job value (*r* = 0.38, *p* < 0.01) and burnout, indicating that increased negative job value was related to higher levels of burnout. Moreover, there were significant negative correlations between job maintenance (*r* = −0.49, *p* < 0.01), social support (*r* = −0.33, *p* < 0.01), and burnout, indicating that a longer intended stay in the current job and increased levels of social support were associated with lower levels of burnout.


\* *p* < 0.05. \*\* *p* < 0.01.

#### *3.3. Hierarchical Regression*

A hierarchical regression analysis was conducted to examine the impact of job value, job maintenance, and social support on burnout, controlling for the selected demographic variables. Table 3 displays the results of the analysis for the four models. Model 1 included participants' age, gender, marital status, education, and income; it explained 4% of the total variation in burnout. Of the five demographic predictors, only gender had a significant relationship with burnout (*p* < 0.05). Job value, included in Model 2, explained 18% of the total variation and was positively associated with the level of burnout (*p* < 0.01). Job maintenance was added in Model 3 and explained 35% of the total variance in burnout (*p* < 0.01). Finally, by adding social support to Model 4, it explained 39% of the total variance in burnout. Interestingly, in Model 3, education was a significant variable at the *p*-level < 0.05; however, it was not significant in Model 4. In Model 4, the effect of social support was large, therefore the influence of education was reduced. It can be seen that the level of burnout changes depending on the degree of social support regardless of the educational background. In summary, the results indicated that perceived job value was positively associated with burnout, whereas both job maintenance and social support were negatively associated with burnout.


**Table 3.** Standardized coefficients from robust hierarchical regression on burnout.

\* *p* < 0.05, \*\* *p* < 0.01.

#### **4. Discussion**

This study examined the association between burnout and job value, job maintenance, and social support among 170 long-term care staff in Hawaii, US. Several implications for clinicians are provided below based on the major findings of the study.

This study found that job value was negatively associated with burnout among longterm care staff, which supports our first hypothesis. In other words, care staff with a higher perception of job value are more likely to experience a low level of burnout. This is consistent with the findings of earlier research [15–18]. Long-term care service jobs are often seen as undesirable and difficult, characterized by long work hours, requiring minimal skills, providing low wages, and having high labor intensity [35]. As a result, treatment for longterm care staff tends to be poor, despite the considerable physical, mental, and emotional burden associated with their job, while financial compensation is commensurate with that of a low-quality job. If long-term care staff feel they are not appreciated, their job satisfaction and pride in their work decrease, while stress and burnout are likely to increase.

Efforts are required at the individual, institutional, and government/social levels to increase the extent to which staff value their jobs in long-term care settings. First, staff themselves must recognize that their work helps maintain the human dignity of older adults and the socially disadvantaged. It should be recognized that their assistance as official caregivers does not only increase the independence and life satisfaction of older clients, but also eases families' care burden and helps family caregivers maintain their social life. Second, it is necessary to provide education and training programs for the professional development of long-term care staff at the institutional level. Specifically, staff should be provided with job training opportunities that require complex skills (such as body care, physical therapy, and rehabilitation), thereby enabling care work to gain acceptance as a viable career choice. In particular, there is a need to expand specialized education on dementia in line with the increasing number of patients with dementia [27]. Additionally, wages and treatment of workers should also be improved to mitigate the negative image of care work. Third, support for long-term care staff should be strengthened at the governmental and societal level. An institutional mechanism is needed to increase the budget support of the central government and to develop policies to improve the treatment of workers by local governments. In particular, it is necessary to actively consider the introduction of public long-term care insurance and to make efforts to facilitate the care of older adults from a public policy standpoint.

This study found a significant negative relationship between job maintenance and burnout among long-term care staff, confirming our second hypothesis. In other words, staff who expressed a willingness to continue working in the same job are more likely to have a low level of burnout. This finding is consistent with earlier research [14,19–21]. Having a willingness to work longer means that you are proud and satisfied with your

work, and that you are rewarded for your job. Research generally shows that the more employees express a willingness to change their job, the more likely it is that they are unsatisfied with their current job, experience higher levels of stress, and have a higher level of burnout [36]. Thus, it is necessary to improve the work environment, foster the organizational culture of the organization, and adjust the work intensity so staff can stay at their jobs in the long-term.

Additionally, our study revealed that social support was significantly correlated with burnout among staff at long-term care agencies, thus supporting our third hypothesis. Specifically, staff with strong social support from supervisors or peers are less likely to experience burnout; this is consistent with earlier research [19,22–29].

The job demands–resources model posits that burnout is influenced by individual job-related factors, such as participation in the decision-making process related to the job, diversification of job-related skills, and feedback on the degree of autonomous performance, but also interpersonal factors, such as social support and cooperative relationships with colleagues and supervisors [12]. Our findings are in concordance with the aforementioned model.

Long-term care staff play a role in helping older people who experience difficulties with activities of daily living as well as instrumental activities of daily living during working hours. Due to the deterioration in physical functioning and cognitive ability of older adults, it is sometimes difficult to communicate with them; consequently, job stress in staff is higher in such cases. In this situation, if the relationship between staff and their supervisor is not productive, the workers' level of satisfaction with their work will be lower. Conversely, if staff communicate frequently with their supervisors and receive emotional support from them, their mental stress will be reduced. Additionally, if a supervisor provides good supervision and allows staff to discuss their job-related difficulties, the care worker will have a more organized work environment. If relationships with colleagues involve understanding and listening to each other, and staff receive emotional support in a caring attitude, their work life will be easier and more productive. Likewise, staff who receive social support from their supervisor or colleagues will have a lower level of burnout resulting from reduced job stress. In addition, to strengthen the social support for staff, a line of dialogue must be established between staff and supervisors, to allow them the opportunity to communicate openly with each other through meetings and employee training, thereby creating an open organizational culture for solving problems.

This study has a few limitations. First, the study used cross-sectional survey data, which limits our ability to identify causality and time order. Accordingly, future research needs to examine causal relationships among the variables because social support, job value, and job maintenance are time-varying variables, which means they may improve or deteriorate over time. Second, because the participants were recruited from territories in Hawaii from various long-term care facilities (based on non-probability convenience sampling), the findings cannot be generalized to other contexts. Future studies need to recruit study participants from various geographic locations and broaden the applicability of the survey. Third, it is necessary to diversify the questions used in the survey. For example, job value was measured using only one question. Therefore, it is necessary to further subdivide the construct and measure job value as is perceived by the staff themselves and by their family members and acquaintances. Additionally, consideration should be given to including other variables that affect burnout (e.g., physical health, mental health, and job satisfaction) so that it is possible to provide practical policy implications for dealing with burnout by addressing a wider range of influencing factors. Finally, the study did not examine the group differences among staff (e.g., nurses, nursing assistants, social workers, physical therapists, occupational therapists) because the majority of study participants in this study were nurses or nursing assistants and other staff groups are quite small to carry out comparisons. For future study, it is recommended to include an extended number of staff besides the nursing workers.

#### **5. Conclusions**

The present study contributes toward an understanding of the effect of job value, job maintenance, and social support on burnout by examining the understudied group of long-term care staff in Hawaii. The higher the value of a worker's job, the more rewarding and positive it will be. Moreover, as workers remain longer in their position, the relationship with their clients will deepen and close relationships will be formed. Additionally, mutual support between workers and supervisors will increase job satisfaction and reduce work stress, which will eventually improve the quality of services provided to clients.

Even though previous studies indicate that job value, job maintenance, and social support are significantly associated with the level of burnout, there are limited studies on burnout among staff at long-term care settings in Hawaii. In particular, the relationship between burnout and job value, job maintenance, and social support has not been examined in the previous literature. This study fills the gap by emphasizing the significance of a culturally specific approach. Interventions aimed at decreasing the level of burnout among long-term care staff in Hawaii may be more effective if the levels of job value, job maintenance, and social support are increased through culturally tailored programs. It is necessary to develop a community-friendly and emotional value-oriented program that considers the cultural characteristics of Hawaii. In particular, practitioners can help attenuate burnout among long-term care staff by informing the leaders of long-term care facilities about the importance of job value and social support, to ensure improved quality of care.

**Author Contributions:** Conceptualization, B.J.K. and S.-y.L.; methodology, B.J.K.; software, B.J.K.; validation, B.J.K., and S.-y.L.; formal analysis, B.J.K.; investigation, B.J.K. and S.-y.L.; resources, B.J.K.; data curation, B.J.K.; writing—original draft preparation, B.J.K. and S.-y.L.; writing—review and editing, B.J.K.; visualization, B.J.K.; supervision, S.-y.L.; project administration, B.J.K.; funding acquisition. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study design was approved by the Institutional Review Board of the University of Hawaii (CHS #22473) on 9 October 2014. The study was conducted according to the guidelines of the Declaration of Helsinki.

**Informed Consent Statement:** "Informed consent was obtained from all subjects involved in the study." The authors clearly informed potential participants that their participation was voluntary, that the study adhered to a rigorous protocol for research ethics (guaranteeing participants' anonymity and confidentiality), and that collected data were to be used for research purposes only.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical reason.

**Conflicts of Interest:** The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

#### **References**


### *Article* **Personal and Work-Related Factors Associated with Good Care for Institutionalized Older Adults**

**Javier López \*, Gema Pérez-Rojo, Cristina Noriega and Cristina Velasco**

Department of Psychology, School of Medicine, Universidad San Pablo-CEU, CEU Universities, 28925 Alcorcón, Madrid, Spain; gema.perezrojo@ceu.es (G.P.-R.); cristina.noriegagarcia@ceu.es (C.N.);

cristina.velascovega@ceu.es (C.V.)

**\*** Correspondence: jlopezm@ceu.es; Tel.: +34-913724700

**Abstract:** Despite efforts to promote good care, many institutionalized older adults (IOA) experience elevated neglectful conditions and reduced person-centered care approaches. Based on the job demand–control model, this study aimed to analyze the relationship between nursing home professionals' personal and organizational factors and good care provided to institutionalized older people. Data was collected through a self-administered survey completed by 208 nursing home staff members. Three dimensions of personal factors (i.e., personal accomplishment, depersonalization, and negative old age stereotypes) were significant predictors of good care. Depersonalization and negative old age stereotypes were negatively associated with IOA, and both good care and personal accomplishment were positively associated with good care in nursing homes. Only one work-related factor (i.e., management support) was positively associated with good care. Personal factors may play a significant role in good care. Management support offers a promising mechanism to promote good care among nursing home professionals. The findings support the need to change the focus on entirely completing care tasks to providing good care of residents in nursing homes that promotes management support, personal accomplishment, personalization and positive old age consideration, attitudes, and behaviors. Policies and interventions should be developed to address in a more humanized way.

**Keywords:** elder abuse; good treatment; humanization; institutions; long-term care; mistreatment; nursing homes; staff; person-centered treatment; residential aged care

#### **1. Introduction**

Residents in nursing homes often have many physical and cognitive problems, and the occurrence of dementia is quite frequent [1]. Most studies found that 50% of IOA have dementia [2]. Nursing homes can be a difficult environment for professionals because of the complex health and cognitive status of the residents. Family caregivers experience high levels of anxiety and depression [3]. In most occasions, family caregivers decide to institutionalize their older relative after a period of deep reflection and various consultations with specialists [4].

The poor pay and working conditions of care workers such as overwhelming workloads, lack of respect, and lack of support are well-documented, especially for nursing assistants [5–7]. These issues present challenges to provide good care in nursing homes. Kayser-Jones (1990) suggested a conceptual framework about quality of care in long-term institutions and described four essential aspects: personalization, humanization, no infantilization, and no victimization [8]. Quality of care among nursing staff and residents is a crucial issue to promote good care. Good care for IOA not only implies avoiding abuse (no victimization) but also promoting person-centered care (personalization, humanization, and no infantilization) [9]. Good care not only focuses on avoiding abuse. It also promotes good daily care practices, such as respect, humanization, and ethical values [10,11]. Conse-

**Citation:** López, J.; Pérez-Rojo, G.; Noriega, C.; Velasco, C. Personal and Work-Related Factors Associated with Good Care for Institutionalized Older Adults. *Int. J. Environ. Res. Public Health* **2021**, *18*, 820. https:// doi.org/10.3390/ijerph18020820

Received: 27 December 2020 Accepted: 15 January 2021 Published: 19 January 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

quently, good care includes avoiding elder abuse but is not only this, and good care also includes person centered care but it is more than this too.

#### *1.1. Person-Centered Care*

While the traditional long-term care model is focused on tasks and professionaldirected (institution-centered perspective), the person-centered care perspective targets older people's preferences and needs. [12]. It reflects the move from a biomedical approach based on clinical quality and quality of care to a biopsychological approach based on people´s quality of life and quality of care. The latter consists of a humanistic perspective that has been extensively used in gerontology settings in the last few decades.

Person-centered care affirms that the person should be the focus of care delivery and not their disease, frailty, deficits, nor their illnesses [13]. This perspective recognizes the importance of considering older adults, their family and staffs' well-being and quality of life. However, different authors use the term person-centered care to refer to a variety of different concepts and there is no standard definition yet [12]. WE-THRIVE, an international consortium of long term care researchers, prioritized the following concepts within the person-centered care domain: relationship (among residents, professionals, and relatives), knowing the elder, paying attention to what is important for the person and providing a positive context in which the person can engage meaningfully. As can be observed, this consortium enhances the importance of setting caregiving goals that ensure residents´ quality of life. Considering this, there is an important international debate about what the construct good care refers to [14].

Person-centered care has found positive outcomes in nursing home staff, including organizational and personal factors. Some organizational conditions related with a higher person-centered care are a higher staff-to-resident ratio [14], a lower job turnover [14,15], better equipment and facilities [14,16], better organizational climate [17], and higher management support [12,14,18,19].

There are also individual factors related with a higher Person-Centered Care such as lower burnout [15,17,20,21], less work overload [15,21–23], higher intrinsic motivation [24], and less stereotypes towards ageing [14,20].

#### *1.2. Elder Abuse*

Different gerontologists have tried to develop theoretical models to explain a bad and good care approach. However, there is still no consensus. The difficulty in defining the causes of elder abuse in institutions and the factors associated with IOA´s good care has been pointed out [25].

Elder abuse is a common problem, commonly missed in the aging services network. It is often viewed as a 'hidden issue' or 'inner affair'. In fact, elder abuse is an interpersonal violence less reported than other types of violence conducted in institutions. It is a violation of human rights that not only affects the victims but also the relatives and society in its totality. Research regarding elder abuse is still in its infancy [26,27].

Only a few studies deal with elder abuse in residential care since the trailblazing research of Pillemer and Moore (1989) [28]. Some reasons why older people are more vulnerable to suffer elder abuse in institutions are not being able to report the abuse because of their cognitive or physical difficulties, being worried about the negative consequences that may take place if they report the abuse (e.g., revenge) or feeling hopeless and believing that no one would help them [29,30]. Staff may be reluctant to admit their own or colleagues abuses for fears of reprisal [31] and they tended to condone abusive behaviors toward elderly residents [32]. Therefore, IOA and staff members are unable or unwilling to seek help.

The direction of the abuse is varied: resident-to-staff, residents-to-residents, family-toresidents, and staff-to-residents. The last one is the most prevalent. However, a resident who experiences resident-to-resident abuse may become more vulnerable to suffer abuse by a staff member or vice versa [29]. Furthermore, studies from United States of America and

European countries elder abuse is more likely to take place in a shared living environment, specifically for physical and financial abuse [33].

Ho et al. (2017), in the first meta-analysis on the global prevalence of community and institutional elder abuse estimated a prevalence of 10%. Nevertheless, this study mixed abuse in community-dwelling older people and IOA abuse [34]. Yon et al. (2019) analyzed only nine studies finding the physical and psychological abuse as the most prevalent types based on data provided by the nursing home staff. Although caution should be taken when self-reported elder abuse data is used, nearly 64% of nursing home staff acknowledges that they have abused IOA. This review estimates that there is a 33.4% prevalence of psychological abuse, 14.1% of physical abuse, 13.8% of financial abuse, 11.6% of neglect, and 1.9% of sexual abuse. All of these percentages are higher than those experienced by community-dwelling older adults [26]. However, Pillemer et al.(2016, p. 195) affirm that the prevalence of IOA abuse is not covered because of "the lack of research in this area; no reliable prevalence studies have been conducted of such mistreatment in nursing homes or other long-term care facilities" [33].

There are only a few studies that have analyzed the risk factors of elder abuse in nursing homes, and the research conducted to date on this topic is inconclusive [35]. More research analyzing the underlying risk factors is needed considering the different levels of the ecological framework. Literature has supported the role played by organizational and personal factors in elder abuse perpetrated by staff working in nursing homes. Some organizational conditions related with higher abuse are poorer working condition, particularly staffing shortages, time pressures, and lack of equipment [36–40], as well as lower management support, and a lack of guidance and support; a service isolated within the organization [38]. Regarding individual factors, burnout is a strong predictor of abuse [28,36,39,41]. Nursing home staff often rated work overload perception as a reason for abuse and neglect [39,40]. Abusers did not feel sufficiently motivated [37] and showed more negative attitudes towards residents [28,41].

#### *1.3. Good Care*

The WHO global strategy and action plan on ageing and health (2016–2020) stresses the need to provide a better long-term care to prevent elder abuse [42]. The European roadmap on healthy ageing (2012–2020) also includes strategies to improve the quality of services in nursing homes [43]. Furthermore, the European Commission suggested that desired good care levels include not only encouraging quality but also counteracting elderly abuse. Governments have the responsibility to protect vulnerable IOA and set the framework underpinning oversight of good care. Monitoring nursing homes quality has been growing in importance but needs further development. Good care implies, on the one hand, effectiveness and care safety, and on the other, patient-centeredness, responsiveness, and care coordination [11]. Professionals should work multidisciplinary and must be trained in good practices and the promotion of good care. Good care implies humanization, no infantilization, respect, and IOA empowerment.

Good care for IOA implies humanization. Dehumanization is a subtle form of mistreatment that violates basic human rights and it is even more devastating than depersonalization. Humanization follows when IOA are treated sensitively and amicably. Humane care recognizes the human attributes such as compassion, understanding and kindness. Humanization promotes sensitivity to IOA needs, especially to those with high dependency levels. Interactions are personal, where individuals are spoken to rather than spoken at [8].

Good care for IOA also implies the absence of infantilization, establishing an 'adult– adult' relationship instead of a 'parent–child' one among nursing home staff and older adults. IOA must be treated as adults, taking their life-long accomplishments into consideration. This includes such behaviors as avoiding scolding incontinent IOA, addressing IOA in respectful terms and dressing them in adult attire. Non-infantilization increases independency, role, and status. It also promotes and maintains a sense of dignity and self-worth. Because of the vulnerability of many IOA, there is a high risk of conducting

paternalist practices in nursing homes. Being especially significant those practices related to infantilization [8].

Good care for IOA is related to respect [6,44]. Nursing home professionals' practice implies respect for intrinsic dignity, worth, and uniqueness of each person. Respect enhances a person's sense of dignity and pride in nursing homes [8,44,45].

The nursing–IOA interaction is positive and respectful. Nursing home staff culture promotes the interest in paying attention to and understanding older people's deepest needs [46]. The staff also respected the family's wishes [47]. Privacy and space are necessary so that IOA can have time with their relatives and bring closure to their lives. IOA and their families want and deserve respect and dignity [48]. Disrespect is linked, to a violation of human rights such as dignity, privacy, or autonomy [29].

Good care for IOA is related to empowerment [6]. The resident empowerment approach is well suited to helping IOA make self-selected changes. Empowerment is related with meaning, competence, and self-determination. Therefore, listening to residents empower them [49]. As a result, older people feel more meaningful, confident, and satisfied [45].

Drawing upon the job demand-control (JDC) model [50], which highlights the relevance of demands (stressors that are present in the work environment, i.e., work-related factors) and control (the potential of workers of regulating their tasks and behavior at work, i.e., personal factors), these being resources for understanding the differences in job impact between individuals, the present study aims to answer the following main research question: What is the relationship of nursing home good care with the position in the facility, work stressors (better organizational conditions and more management support) and personal variables? The hypotheses were the following: (1) team technicians (i.e., psychologists, physiotherapists, social workers, occupational therapists, nurses) will show better good care than nursing assistants; (2) The lower the levels of turnover and ratios, the more adequate the equipment and facilities, and the higher the management support, the more they will hold good care attitudes and behaviors; and (3) those professionals with less burnout, work overload, stereotypes towards ageing and more intrinsic motivation, will have a greater tendency to develop good care in nursing homes.

#### **2. Materials and Methods**

#### *2.1. Sample and Data Collection*

We used a cross-sectional design study. A convenience sample of nursing home professionals participated. Before gathering data, the Institutional Review Board of CEU San Pablo University approved the study. We contacted several nursing homes to recruit participants. They were required to be working as a front-line care nursing home professional (staff directly involved in care). The inclusion criterion of being directly involved in care was selected because they have a close daily interaction with residents and are the largest group of professionals in nursing homes [7]. The survey was self-administered. However, trained interviewers (i.e., psychology postgraduate students and the authors of this study) assisted participants in case they needed help. Before completing the survey, interviewers explained the aims of the study, the types of questions and response options, data confidentiality, and their rights. All participants signed the informed consent. A total of 231 nursing home professionals participated in the study. Twenty-one participants did not meet the inclusion criteria (being a front-line care nursing home professional) and two participants did not complete the questionnaires and were excluded. The final sample included 208 nursing home staff members directly involved in care.

#### *2.2. Measures*

Questionnaires collected information on sociodemographic outcomes and the good care of the nursing home staff, as well as assessed perceived personal and work-related factors in their caregiving experiences. The sociodemographic information included was age, sex, marital status, highest education qualification attained, position in facility (nursing assistants versus interdisciplinary team technicians), nursing home equipment and facilities, non-consistent assignment of staff (turnover), and staff-to-resident ratio.

Good care was assessed using the good care scale in nursing homes (GCS-NH) [51]. Initially, this instrument was composed of 32 items (reverse-scored and direct scored) grouped in four dimensions: humanization (9 items; bonding, connection, tenderness and closeness), non-infantilization (10 items; consideration of older people as adults, avoiding overprotection), respect (7 items; respect and avoid stigmatization by staff), and empowerment (6 items; promotion of older people´s decision-making and choices and control over their lives). The items are scored on a five-point Likert scale (from 0 = nothing to 4 = a lot). This scale is based on the perspective of centered care by including practices in line with avoiding mistreatment and power relationships as well as providing individualized care, considering older people's singularity. This scale is focused on protecting from disrespect (violation of human rights such as dignity, privacy, or autonomy). Internal consistency for this scale in this study was 0.714 (Cronbach's α).

Burnout (personal variable) was assessed using the Maslach Burnout Inventory (MBI) [52]. It is a 22-item measure grouped in three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Research conducted in nursing homes and other healthcare contexts has extensively supported its validity and reliability [52,53]. Participants had to indicate the frequency they experienced 22 statements of 'job-related' feelings on a seven-point Likert scale ranging from 0 ('never experienced such a feeling') to 6 ('experience such feelings every day'). The EE domain has nine items, the DP domain five items, and the PA domain eight items. High levels of EE and DP scores, and low levels of PA are associated with more burnout. Subscales internal consistency were as following: 0.866 for the EE scale, 0.728 for the DP scale, and 0.736 for the PA scale (Cronbach's α). Internal consistency for this scale in this study was 0.710 (Cronbach's α).

Professional quality of life was assessed using the PQL-35 Questionnaire [54]. It is a 35-item measure of the professional quality of life with three domains: work overload (WO), intrinsic motivation (IM), and management support (MS). This questionnaire is based on Karasek´s demand-control model formulated [50]. Professional quality of life was related to the balance between work demands and the perceived ability to carry them out. WO and IM are personal variables and MS is a work-related variable. Professional quality of life was assessed in a 10-point scale from 1 ('none) to 10 ('a lot'). The WO domain has 11 items, the IM domain has 9 items, and the MS domain 13 items. The final item that measures global quality of life and the item that measures ability to disconnect from work were excluded in line with previous studies [55,56]. Subscales internal consistency were as following: 0.845 for the WO scale, 0.815 for the IM scale and 0.918 for the MS scale (Cronbach's α). Internal consistency for this scale in this study was 0.765 (Cronbach's α).

Negative old age stereotypes (personal variable) were assessed using the Negative Stereotypes Towards Ageing Questionnaire [57]. This scale has 15 items. Response options range from 1 ('strongly disagree') to 4 ('strongly agree'). Higher scores show high levels of negative stereotypes towards older people. In the present study we found a global internal consistency index for this scale of 0.897 (Cronbach's α)

#### *2.3. Data Analysis*

Hierarchical multiple regression was used to assess the contribution of position in facility indicators; personal and work-related factors to IOA good care scores. Variables were entered into the regression equation in three blocks: position in facility (nursing assistants versus interdisciplinary team technicians) was entered first, followed by four work-related factors and then followed by six personal factors, using the SPSS software (version 24, IBM Corp. Armonk, NY, USA). We controlled the effects of position in facilities (nursing assistants versus interdisciplinary team technicians) by entering them in the first step of the hierarchical multiple regression analysis.

#### **3. Results**

#### *3.1. Sample Characteristics*

Participants were 208 staff members at 11 different nursing homes in Spain (about 19 professionals at each institution). As shown in Table 1, the mean age of participants was 39.28 years. Most participants were female, nursing assistants and had at least a high school degree and a little less than half were married.

**Table 1.** Sample characteristics (N = 208).


Data are presented as mean (SD), or *n* (%). Professional quality of life = Professional quality of life, PQL-35 Questionnaire; Burnout = Maslach Burnout Inventory; Negative old age stereotypes = Negative Stereotypes Towards Ageing Questionnaire; Good Care = Good Care Scale in Nursing Homes.

Regarding organizational factors, the mean score for management support was 6.05. Overall, about 72.6% of respondents considered adequate nursing home equipment and facilities but only 24.5% considered adequate staff-to-resident ratios. In terms of nonconsistent assignment of staff, almost 80% of participants experienced turnover.

Regarding individual or personal factors, the mean score for the burnout dimension was 10.78 for emotional exhaustion, 5.03 for depersonalization, and 40.52 for personal accomplishment. Applying the cut points, only the mean score of personal accomplishment implies high levels of this dimension. The mean score of 4.84 for work overload and 8.63 for intrinsic motivation, on a 1–10 scale, indicates a relatively high tendency to experience intrinsic motivation. Mean scores for negative old age stereotypes and good care indicated a medium level of experienced stereotypes and good care behaviors and attitudes.

#### *3.2. Role of Organizational and Personal Factors on Good Care*

The hierarchical regression results are displayed in Table 2. In step one, position in facility explained 6.1% of the variance (Adjusted R<sup>2</sup> ) in good care. Position in facility and organizational factors in step two accounted for 20% of the variance (Adjusted R<sup>2</sup> ); an increase of 14% from step one. In the final step, position in facility, organizational and personal factors explained 31.1% of the variance (Adjusted R2); an increase of 11% from step two.


**Table 2.** Hierarchical regression analysis examining the associations between assessed variables and good care

\* *p* < 0.05. \*\* *p* < 0.01. \*\*\* *p* < 0.001.

Higher levels of management support were related to higher levels of good care (β = 0.259, *p* ≤ 0.01). Similarly, personal accomplishment was positively associated with good care (β = 0.243, *p* ≤ 0.001). Higher depersonalization was associated with lower levels of good care (β = −0.186, *p* ≤ 0.05). Additionally, higher negative old age stereotypes was significantly related to lower levels of good care (β = −0.242, *p* ≤ 0.001).

#### **4. Discussion**

We aimed to examine the association between personal and work-related factors and the good care provided to residents by nursing home staff. As predicted, many personal or individual factors were related to good care levels in the expected directions. Nevertheless, only one work-related variable was positively related to good care: management support.

Good care models [8,9] were linked with the job demand–control model because they highlight the relevance of demands (work-related factors) and control (personal factors) as factors that seem responsible for good care, avoiding elder abuse and promoting personcentered care. Our results confirm the relevance of demands and control for good care.

Our findings also show that personal variables can have significant effects on good care. Previous studies have supported the negative effects of personal variables on personcentered care [15,17,20,21] and on risk of abuse [28,39]. The novelty of this study lies in the more in-depth description of the potentially harmful effects of personal variables on abuse and the potentially beneficial effects on person-centered care to an under-studied variable; good care. In this regard, this study stresses the importance of promoting personal variables and, more specifically, good care within the nursing home staff.

An interesting finding was that lower depersonalization and higher personal accomplishment predicted IOA good care, whereas emotional exhaustion did not. This result may be related to the importance of connectedness and empathy in nursing homes. Personal accomplishment is connected with empathy, attitudes, and behavior towards IOA care. Professionals reporting more personal accomplishment also showed more staff–resident interactions [58,59]. Depersonalization was negatively related to willingness to help [59].

Moreover, our results agree with a previous study in which only some burnout factors were predictive of person-centered Care [17]. Also, some good care trainings among professional caregivers in nursing homes had no effect on emotional exhaustion [19,21].

Supporting our hypothesis, a negative association between old age stereotypes and good care was observed. Lower levels of old age stereotypes were found to be associated with reporting higher levels of good care among the assessed individual factors. In line with these results, other studies have shown a use of stereotypes in disrespect or generally

treated older adults [45], that may be related to a less effective IOA abuse recognition ability among nursing home professionals [35], and that involves more nursing home mistreatment [41]. Furthermore, there is evidence for a dysfunctional nursing home caregiving type, named rough handling care, in which professionals behave impatiently, ignoring and treating IOA as objects, or even threatening them. Moreover, nurses´ negative stereotypes affect negatively the delivery of IOA care [30]. Because of the important role played by professionals´ negative self-perceptions of aging explaining good care in this study, it should be considered as a key dimension. Given that negative stereotypes can reduce the potential IOA good care, more research and interventions should be developed among front-line professionals working in nursing homes. Institutions supporting continued education and care about reducing nursing staff´s negative old-age stereotypes, have the potential to impact on IOA good care and ameliorate ageism.

Furthermore, management support (i.e., being thanked for a job well-done; receiving support in the form of feedback on work performance) is the only work-related factor analyzed significantly associated with good care. Consistent with previous research, supporting capacities of supervisors towards their subordinates, plays a role of major importance [19]. Sufficient support for professionals and colleagues should be guaranteed in a friendly and reinforcing work atmosphere [18]. Practically, our results support the notion that researchers, chairs, supervisors, and nursing home professionals may need to focus on social support. Collective support (managerial and coworker social support) may provide the individual with more opportunities to perceive improved control, thereby improving good care.

Most nursing assistants take this employment because of not finding a job in their original occupation [32]. Workplace stress can be especially problematic for nursing aides or nursing assistants [32,60]. Contrary to our hypothesis, there were no differences on the good care ratings on the GCS-NH among positions in facilities. No association was found between good care and both being a nursing assistant or being a technician in the last step of the regression analysis. The correlation of good care with being a nursing assistant is no longer significant when work-related and personal resources are considered. These results may be explained by mediation effects. For example, being a technician may lead to receiving higher management support, and higher personal resources (i.e., more personal accomplishment and less depersonalization, and negative old age stereotypes). Previous studies have found less management support in nursing assistants [60]. Nursing assistants experienced higher levels of burnout and negative stereotypes [32,60] that may be related to less effective good care ability, involving less use of humanization, no infantilization, respect, and empowerment strategies.

This is one of the first studies to analyze the impact of personal and work-related resources on IOA good care. However, the different effects of management support, depersonalization, personal accomplishment, and negative old age stereotypes on good care for IOA should be studied further.

The results of the present study should be interpreted in light of its limitation involved in cross-sectional designs. We cannot make causal inferences because a cross-sectional study can only test associations between the variables. Further longitudinal research is needed to analyze this model of IOA good care. Moreover, intervention studies targeting workrelated and personal resources might help to determine causality between work-related and personal resources and good care.

In addition to the cross-sectional design, this study has the following limitations. First, regarding the data-collection method through a self-reported survey, social desirability may have affected nursing staff´s answers by showing what the employer expects them to respond instead of their true feelings or impressions. Second, our findings cannot be generalized because of the use of a non-probability sample. A more representative sample of nursing home professionals should be included in future studies to provide a more complex view of good care, thereby advancing our knowledge. Third, data on residents and their relatives' impressions were not collected. Future studies could be based on our

results and go further by examining residents' and their relatives' concepts about nursing home professionals' good care. Fourth, even though the regression model explained 31% of good care, this means that there are still additional factors influencing the IAO good staff that remain to be explored.

#### **5. Conclusions**

Despite these limitations, this study provides relevant information about the effect of personal and work-related variables on good care in front-line care nursing home professionals. In summary, in addition to management support, some personal issues such as personal accomplishment, depersonalization, and negative old age stereotypes seem to be relevant for explaining good care for IOA at nursing homes.

Good care seems to be related to work related factors and personal resources that may have to do with a negative view of aging, such as perceiving older adults as less capable, and with burnout feelings and management support. The data from this study suggests that it is not mainly work-related factors themselves but having positive perceptions of aging and less burnout perceptions that are related to good care for IOA. Nursing staff with positive perceptions of aging develop a better IOA care. Furthermore, nursing staff with engagement—characterized by energy, implication or commitment, and efficiency—may be regarded as the opposite to burnout, and seem to be more connected to IOA good care.

Policymakers and practitioners could consider the following aspects. First, promoting good care in nursing homes should begin by working on personal variables. The aim would be reducing staff burnout, a highly prevalent variable in nursing assistants working in long-term facilities for older people [32]. Professionals´ burnout should be sanctioned at the policy levels. Increasing the levels of personal accomplishment, and improving personalization attitudes may contribute to tackling burnout, which may, in turn, influence their good care to the residents. Second, modifying professionals´ attitudes towards older people can prevent negative old-age stereotypes. Burnout and negative stereotypes are modifiable through support, education, supervision, and other well-established means. Third, management support is a key point when changing the organization in the nursing home. It is also essential to assess the effect of these changes in IOA good care. Each nursing home should have clear policies to report and promote good care for its residents. Person-centered care and good care are wide constructs with relevant joint points. However, they are not exactly the same [61]. Good care is everyone's business [44]. The theory of 'doing good care' involves anticipatory caring, and momentary caring [62]. Good care conveys to IOA that they are important. Individually, each good care behavior could have a positive impact. Collectively, they have the potential to result in a sense of strengths, optimism, and self-esteem [45]. Good care is both value reinforcing (it allows nursing home professionals to support the value of personhood) and an ethical expression (it is good to work with residents who are dependent and fragile). The essential test of this care is recognizing the uniqueness of the other. All of this, assuming that a holistic approach considers also factors associated with quality of life in IOA (control and autonomy, pleasure, and self-realization) [63].

The recent COVID-19 pandemic has shown the importance of having a well-organized health system, enough flexible to adapt to the people´s needs not only to respond to emerging threats, but also to cope with chronic diseases. COVID-19 outbreak had a limited impact on older adults' psychological wellbeing [64]. However, IOA do not have usually an alternative home (the long-term center is their home), making the nursing homes an essential service and a priority for the whole of society. The preventive measurements of the lockdown of residences, sectorization of spaces, and isolation of residents has affected to good care during COVID-19 outbreak. The present study highlights the influence of nursing staff personal factors (a positive perception of aging and personal accomplishment and personalization) on good care. Nursing staff with lower levels of old age stereotypes and depersonalization will probably inform residents, and their relatives, with understandable language, answer all questions, and repeat information when necessary, about the

emergency of exceptional situations and the existing COVID's protocols (i.e., regarding referrals to health services, test for COVID-19, visit conditions). Furthermore, nursing staff with higher levels of personal accomplishment will probably discover new forms of working during COVID-19 outbreak (i.e., identify circuits in nursing homes that allow the development of routines basic mobility for IOA; guarantee the monitoring of educational and social work activities to the IOA). Nevertheless, more research is needed on this topic.

**Author Contributions:** Conceptualization, J.L. and G.P.-R.; Methodology, J.L.; Formal analysis, J.L.; Investigation, J.L., G.P.-R., C.N., and C.V.; Writing—original draft preparation, J.L.; Writing—review and editing, G.P.-R., C.N., and C.V.; Project administration, J.L. and G.P.-R.; Funding acquisition, J.L. and G.P.-R. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the Spanish Ministry of Economy and Competitiveness (grant no. PSI2016-79803-R).

**Institutional Review Board Statement:** All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Spanish Ministry of Education and the Ethical Committee of the San Pablo CEU University (Madrid, 30 December 2016).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Upon reasonable request, data used for this publication can be reanalyzed under the terms and conditions of the Spanish data protection laws. The datasets used and/or analyzed during the current study are available from the senior author at jlopezm@ceu.es.

**Acknowledgments:** We give our thanks to all the nursing home staff involved in this study and also to their institutions: Alcorcón—Amavir; Almedralejo—Grupo Comser; Coslada—DomusVi; Fuenlabrada—Villa Elena; Hospitalet de Llobregat—RPark; Leganés—Valdeluz; Santa Pola—DomusVI; Torrejón de Ardoz—Amavir; Torres de la Alameda—La Alameda; Valdebernardo—Amavir; Villanueva de la Cañada—Amavir.

**Conflicts of Interest:** The authors declare no conflict of interest.

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