Work stress/strain, low job satisfaction, and intent to leave home health care nursing among Home Health Care Registered Nurses (HHC RNs)

Paxson Barker, PhD, MS, RN

Purpose

The purpose of this study was to explore the work stress/strain reported by HHC RNs that may influence job satisfaction and “intent to leave” their positions and/or profession.

Background

Home Health Care (HHC) services enable people to remain at home rather than use residential, long-term, or institutional-based nursing care.

By 2020, the greatest demand increase will be 109% for HHC nurses (HRSA, 2004) with a resultant 36% shortfall of HHC nurses (U.S. Department of Labor, 2007).

The most recent national average of turnover rates among HHC RNs is estimated to be 22% and an estimated 25-33% of HHC RNs report an “intent to leave” their current position.

Strategies to improve or remove the work environment factors that negatively influence the nurses may improve retention.

Statement of the Problem Effort-Reward Imbalance (ERI) due to work stress/strain measured

in other occupations results in low job satisfaction, which is recognized as an antecedent to Home Health Care (HHC) RNs “intent to leave” their current position and/or profession in the published literature.

HHC RNs, as caregivers, can experience disequilibrium between the amount of effort they invest in their care-giving in relation to the rewards and benefits they receive for those efforts.

If a lack of reciprocity occurs between the nurses’ efforts expended and the rewards received, then this imbalance can result in work strain/stress leading to low job satisfaction for the HHC RN.

Significance

This secondary analysis of HHC RNs responses is the first to apply the ERI model to calculate their ERI ratio/score from reported work stress/strain.

Acknowledging the specific issues reported by HHC RNs will help frame and develop the needed interventions required to improve the work environment of HHC nurses.

Research has demonstrated that latent conditions, such as inadequate staffing and the nurses’ work environment, are the primary sources of threats to patient safety and health care errors.

Study Aims 1. To identify categories of work stress/strain reported by the HHC RNs

via the narratives contained within their 2006 questionnaire response.

2. To examine the association between the two Organization Of Work (OOW) components (effort, and reward) and “intent to leave” as well as examine the association between the two OOW components and job satisfaction, while controlling for personal characteristics.

3. To explore differences in the ERI scores between two sets of groups: (1) RITL respondents as compared to the NRITL respondents as well as (2) the respondents without a narrative as compared to the respondents with a narrative.

Literature Review Recurring themes regarding sources of work strain in the published

research studies include unreasonable administrative demands/expectations, excessive paperwork, low wages and benefits, lack of professional advancement, lack of autonomy, difficult work characteristics, lack of cohesive co-worker relationships, and emotional strain of the job (Ellenbecker, 2004; Navaie-Waliser et al., 2004; Flynn, 2005, Ellenbecker & Byleckie, 2005).

The literature review noted 17 published research studies exploring the HHC nurses’ job satisfaction and intent to leave but none of the studies included the ERI theory measuring work strain/stress among HHC nurses.

The ERI model was used to study burnout among 204 hospital nurses in Germany that noted nurses with reported effort reward imbalances had significantly higher emotional exhaustion and

depersonalization scores measuring burnout. (Bakker et al., 2000).

ERI theory

The Effort Reward Imbalance (ERI) theory is a psychosocial model that incorporates external and internal components of work characteristics to assess levels of job strain/stress associated with job satisfaction.

The model assumes that work contracts are not always balanced in reciprocity of rewards for the efforts requested.

This imbalanced reciprocity of “high costs” and “low gains” results in work strain/stress that may impair successful self-regulation and this sustained strain/stress may result in an “intent to leave” among nurses

Conceptual FrameworkANTECEDENTS ATTRIBUTES

JOB SATISFACTION

INTENT TO LEAVE

REPORTED NOT REPORTED

HIGH/LOW ERI SCORE Job stress/strain

Personal Characteristicsageracegendereducationyrs in HHCyrs with HHC employer

COPSOC Items

1,5,6,8*,9*,11*,12*,13*,14,15,17*,18*,19*,20,21*,23*,25*,26*,28*,29*,31*,32,33*,35,38*,39*,40,43*,44*

ERI Items

2,3,4*,9*,11*,12*,13*,17*,18*,19*,22*,23*,24,25*,27,28*,31*,34*,36*,37,38*,39*,45*

JCQ Items

8,*9*,11*,13*,22*,28*,29*,33*,36*

FOCUS GROUP Items 4*,7,10,16,21*,26*,30,31*,42,43*,44*,45*,46,47,48,49

Negative organizational traits

Inadequate financial compensation

Overwhelming paperwork

Work stress Fatigue

Study Narratives

Exhaustion

Burnout

Co-worker support

Study Narratives

* Overlap of item sources

Study Narratives

Parent Questionnaire one OOW item

Supervisor support

Aim 1 Results

Top 6 issues reported in narratives:

1. negative organizational traits 69.4% (n=143)

2. work stress 63.6% (n=131)

3. love homecare 50.0% (n=103)

4. overwhelming paperwork 43.7% (n= 90)

5. inadequate financial compensation 42.7% (n= 88)

6. nurse attrition 40.3% (n= 83)

27.2% of eligible 206 sample specifically stated that they had left or were leaving homecare work

Aim 2 Results Logistic Regression final model for respondents with (206)and without narratives (572) for job satisfaction (n=772)

Scales B S.E. Wald df Exp(B) 95% CI pvalue

Lower Upper

Effort

Reward

Overcommitt-ment

-.089

.104

-.026

.034

.026

.018

6.781

15.695

1.981

1

1

1

.914

1.110 .974

.855

1.054

.940

.978

1.169

1.010

.009*

<.001*

.159

* Significant p<.05

Aim 3 Results Proportion of high and low ERI scores by narrative group, respondents with narratives (206) and respondents without narratives (572).

Variable N= 206 n (%)

N= 572 n (%)

Low ERI scorea 117 (56.8) 402 (70.3)

High ERI scoreb 89 (43.2) 170 (29.7)

Low OCERIc score 122 (59.2) 405 (70.8)

High OCERIc score 84 (40.8) 167 (29.2)

a Low ERI score (.01 – 1.00) b High ERI score (1.01 – 4. c Overcommittment scale included in the ERI scores

Aim 3 Results cont.’

Mean scores of ERI and OCERI scores with t test results for respondents with and without narratives.

* statistically significant p <.05

SCALE n= 206 n=572

N min max m sd n min max m sd t(df), p

ERIscore

206 1.12 3.88 1.45 .35 572 .17 1.12 .80 .19 54.31(565), <.001*

OCERIscore

206 .72 3.92 1.40 .40 571 .10 1.36 .80 .20 32.29(511), <.001*

Conclusions The qualitative results were consistent and supported by published literature

on HHC nurses and their work environment. 27.2% (56) of respondents with narratives reported intent to leave. 30.4% (17) of those 56 respondents with narratives specifically stated that

they loved homecare. Negative organizational traits (69.4%)was the most frequently reported

issue among the respondents with narratives. Work stress (63.6%) was the next most frequently reported and is also

supported by the literature. Respondents with and without narratives (n=778)

The effort scale (subscales of exhaustion and cognitive stress) and reward scale (subscales of autonomy and rewards) were statistically significant for job satisfaction

43.2% of the 206 HHC RNs with narratives reported elevated ERI scores 35.0% of the 572 HHC RNs without narratives reported elevated ERI scores The surprising result was that the group without narratives reporting

elevated ERI scores, only 18.5% (n= 37) of this group (n=200) reported low job satisfaction despite the evidence of elevated work stress/strain

65% (n=372) respondents without narratives reported no/low effort-reward imbalance and 97.8% reported experiencing good job satisfaction.

Implications for Policy A place to begin is to establish federal standards for HHC nurses’ work

environment including but not limited to work hours, physical hazards, overtime (paid and unpaid), workload, and safety so that all nurses are protected regardless of geographic location or employer.

The OASIS paperwork, (federal documentation requirements), and being grossly underpaid (federal reimbursement issue) are issues resulting in unpaid overtime for HHC RNs. The need for HHC RNs to use their uncompensated private family time to conduct business for their HHC agencies is an unreasonable expectation of employers and the federal government.

CMS reimbursement for patient services should be based on total hours worked including travel time to provide care versus only face time with patients.

The reported level of elevated effort-reward imbalance increases the responsibility and burden of management to identify the sources of job stress/strain in the work environment for their employees and intervene appropriately.

Policy makers need better data to improve the reimbursement of homecare nursing.

Implications for Practice HHC agencies must balance their number of admissions to the

amount of resources available to provide safe, quality care to the clients they serve.

The voices of these HHC RNs provides key information for the development of interventions that reduce and/or eliminate these work environment hazards.

Employers must address and resolve work hazards including unsupportive employer behavior, work stress, and unreasonable/excessive hours worked by HHC RNs to improve the retention of these highly qualified nurses.

Almost 50% of the 794 HHC RNs responding to this study reported elevated effort reward imbalances with 27% having left or planning to leave homecare. These results should capture the attention and response of decision-makers.

The employer can resolve many of the issues through improved “organization of work” policies.

Implications for Research Quantitative analysis alone does not provide comprehensive results

and interpretation of the HHC RNs lived experience and requires the inclusion of qualitative analysis to capture relevant data.

Additional research using the ERI model is indicated to assess levels of work strain/stress among HHC RNs.

Hazards in the HHC RNs workplace persist despite published literature identifying these hazards due to a disconnect between research and practice. This disconnect indicates that improved dissemination of research results to federal policy and decision makers is needed.

The nurse’s voice must be respected, heard, and responded to appropriately for resolution of practice errors and problems in the health care delivery system of homecare.

Qualitative research is required with quantitative methods to achieve an in-depth understanding of the phenomena of workplace issues among HHC RNs.

Homecare employers need research findings to identify and implement needed changes in homecare documentation and compensation to retain nurses.

References Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital

nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987-1993.

Anthony, A., & Milone-Nuzzo, P. (2005). Factors attracting and keeping nurses in home care. Home Healthcare Nurse, 23(6), 372-377.

Apker, J., Propp, K., & Ford, W. (2009). Investigating the effect of nurse-team communication on nurse turnover: Relationships among communication processes, identification, and intent to leave. Health Communication, 24(2), 106-114.

Armstrong-Stassen, M., & Cameron, S. (2005). Concerns, satisfaction, and retention of Canadian community health nurses. Journal of Community Health Nursing, 22(4), 181-194. doi:10.1207/s15327655jchn2204_1

Bakker, A., Killmer, C., Siegrist, J., & Schaufeli, W. (2000). Effort-reward imbalance and burnout among nurses. Journal of Advanced Nursing, 31(4), 884. Retrieved from: http://search.ebscohost.com.proxy-hs.researchport.umd.edu/login.aspx?direct=true&db=hch&AN=6059291&site=ehost-live

Borkowski, N., Amann, R., Song, S., & Weiss, C. (2007). Nurses' intent to leave the profession: Issues related to gender, ethnicity, and educational level. Health Care Management Review, 32(2), 160-167.

References

Bourbonnais, R., Comeaux, M., Vezina, M., Dion, G., (1998). Job strain, psychological distress, and burnout in nurses. American Journal of Industrial Medicine, 34(1), 20-28.

Buerhaus, P. (2008a). Current and future state of the US nursing workforce. JAMA : The Journal of the American Medical Association, 300(20), 2422-2424. doi:10.1001/jama.2008.729

Buerhaus, P. (2008b). The potential imposition of wage controls on nurses: A threat to nurses, patients, and hospitals. Nursing Economics, 26(4), 276279.

Caers, R., Du Bois, C., Jegers, M., De Gieter, S., De Cooman, R., & Pepermans, R. (2008). Measuring community nurses' job satisfaction: Literature review. Journal of Advanced Nursing, 62(5), 521-529. doi:10.1111/j.1365-2648.2008.04620.x

Camerino, D., Conway, P., Van der Heijden, B., Estryn-Behar, M., Consonni, D., Gould, D., Hasselhorn, H. (2006). Low-perceived work ability, ageing, and intention to leave nursing: A comparison among 10 European countries. Journal of Advanced Nursing, 5 (5), 542-552.

References Canton A., Sherman M., Magda L., Westra L., Pearson J., Raveis

V., et al. (2009). Violence, job satisfaction, and employment intentions among home healthcare registered nurses. Home Healthcare Nurse, 27(6), 364-373.

Coomber, B., & Barriball, K. (2007). Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: A review of the research literature. International Journal of Nursing Studies, 44, 297-314.

Creswell, J., Plano Clark, V. (2007). Designing and conducting mixed methods research. Thousand Oaks, CA.: Sage Publications.

Cushman, M., & Ellenbecker, C. (2008). Home care nurse shortage 2007. Caring : National Association for Home Care Magazine, 27(1), 42-7, 3.

Cushman, M., Ellenbecker, C., Wilson, D., McNally, M., & Williams, K. (2001). Home healthcare nurses--why they leave and why they stay. Caring : National Association for Home Care Magazine, 20(10), 62-67.

References

Dillman, D. (2007). Mail and internet surveys. the tailored design method. second edition. Hoboken, NJ: John Wiley & Sons.

Ellenbecker, C. (2001). Home health care nurses job satisfaction: A system indicator. Home Health Care Management and Practice, 13, 462-467.

Ellenbecker, C. (2004). A theoretical model of job retention for home health care nurses. Journal of Advanced Nursing, 47(3), 303-310. doi:10.1111/j.1365-2648.2004.03094.x

Ellenbecker, C., Boylan, L., & Samia, L. (2006). What home healthcare nurses are saying about their jobs. Home Healthcare Nurse, 24(5), 315-324.

Ellenbecker, C., & Byleckie, J. (2005a). Agencies make a difference in home healthcare nurses' job satisfaction. Home Healthcare Nurse, 23(12), 777-84; quiz 785-6.

References Ellenbecker, C., & Byleckie, J. (2005b). Home healthcare nurses'

job satisfaction scale: Refinement and psychometric testing. Journal of Advanced Nursing, 52(1), 70-78. Retrieved from: http://search.ebscohost.com.proxy-hs.researchport.umd.edu/login.aspx?direct=true&db=c8h&AN=2009339346&site=ehost-live

Ellenbecker, C., Byleckie, J., & Samia, L. (2008). Further psychometric testing of the home healthcare nurse job satisfaction scale. Research in Nursing & Health, 31(2), 152-164. doi:10.1002/nur.20241

Ellenbecker, C., Porell, F., Samia, L., Byleckie, J., & Milburn, M. (2008). Predictors of home healthcare nurse retention. Journal of Nursing Scholarship : An Official Publication of Sigma Theta Tau International Honor Society of Nursing / Sigma Theta Tau, 40(2), 151-160. doi:10.1111/j.1547-5069.2008.00220.x

Ellenbecker, C., Samia, L., Cushman, M., & Porell, F. (2007). Employer retention strategies and their effect on nurses' job satisfaction and intent to stay. Home Health Care Services Quarterly, 26(1), 43-58.

References Estryn-Behar, M., Van der Heijden, B., Oginska, H., Camerino, D.,

Le Nezet, O., Conway, P., Fry, C., Hasselhorn, H. (2007). The impact of social work environment, teamwork characteristics, burnout, and personal factors upon intent to leave among European nurses. Medical Care, 45(10): 939-950.

Estryn-Behar M., van der Heijden B., Fry C., Hasselhorn H., (2010). Longitudinal analysis of personal and work-related factors associated with turnover among nurses. Nursing Research, 58(3), 166-177.

Flynn, L. (2003). Agency characteristics most valued by home care nurses: Findings of a nationwide study. Home Healthcare Nurse, 21(12), 812-817.

Flynn, L. (2005). The importance of work environment: Evidence-based strategies for enhancing nurse retention. Home Healthcare Nurse, 23(6), 366-71; quiz 385-7.

Flynn, L. (2007). Extending work environment research into home health settings. Western Journal of Nursing Research, 29(2), 200-212. doi:10.1177/0193945906292554

References Flynn, L., & Deatrick, J. (2003). Home care nurses' descriptions of

important agency attributes. Journal of Nursing Scholarship : An Official Publication of Sigma Theta Tau International Honor Society of Nursing / Sigma Theta Tau, 35(4), 385-390.

Geiger-Brown, J., Trinkoff, A., Nielsen, K., Lirtmunlikaporn, S., Brady, B., & Vasquez, E. (2004). Nurses' perception of their work environment, health, and well-being: A qualitative perspective. AAOHN Journal : Official Journal of the American Association of Occupational Health Nurses, 52(1), 16-22.

Hasselhorn, H., Conway, P., Widerszal-Bazyl, M., Simon, M., Tackenberg, P., Schmidt, S., Camerino, D., Muller, B. (2008). Contribution of job strain to nurses' consideration of leaving the profession: Results from the longitudinal European Nurses' Early Exit study. Scandinavian Journal of Work and Environmental Health 6, 75-82.

Hasselhorn, H., Tackenberg, P., & Peter, R. (2004). Effort-reward imbalance among nurses in stable countries and in countries in transition. International Journal of Occupational & Environmental Health, 10(4), 401-408.

References

Hayes, L., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., et al. (2006). Nurse turnover: A literature review. International Journal of Nursing Studies, 43(2), 237-263. doi 10.1016/j.ijnurstu.2005.02.007

Health Resources and Services Administration (HRSA). (2004). The registered nurse population: National sample survey of registered nurses. Washington DC: US. Department of Health and Human Services, Health Resource s and Services Administration.

Health Resources and Services Administration (HRSA). (2002). Projected supply, demand, and shortage of registered nurses: 2000-2020. National Center for Health Workforce Analysis, Bureau of Health Professions. Retrieved from:http://bhpr.hrsa/gov/healthworkforce/rnproject/default.htm

Hwang, J., & Chang, H. (2009). Work climate perception and turnover intention among Korean hospital staff. International Nursing Review, 56(1), 73-80.

References Institute of Medicine. (2004). Keeping patients safe: Transforming

the work environment of nurses. Washington DC: National Academies Press.

Jasseron, C., Estryn-Behar, M., Le Nezet, O., & Rahhali, I. (2006). Factors linked to premature leaving of the nursing profession. Confirmation of the impact one year later. Longitudinal analyses of nurses. PRESST/NEXT study. Rech Soins Infirm., 85, 46-64.

Jorgensen R. (2008) Chronic fatigue: an evolutionary concept analysis. Journal of Advanced Nursing 63(2), 199–207.

Kankaanranta, T., & Rissanen, P. (2008). Nurses' intentions to leave nursing in Finland. European Journal of Health Economics, 9(4), 333-342.

Karasek, R. (1996). Job strain and the prevalence and outcome of coronary artery disease. Circulation, 94(5), 1140-1141.

Kluska, K., Laschinger, H., Kerr, M., (2004). Staff nurse empowerment and effort-reward imbalance. Canadian Journal of Nursing Leadership, 17(1), 112-128.

References Lavoie-Tremblay,M., Burbonnais, R., Viens, C., Vezina, M., Durand,

P., Rochette, L., (2005). Improving the psychosocial work environment. Journal of Advanced Nursing, 49(6), 655-664.

Ledue, C. (2009). Globally, patients pay the price for insufficient nursing staff, large workloads. Retrieved July 9,2009 from: http://www.healthcarefinancenews.com/news/globally-patients-pay-price-insufficient-nursing-staff-large-workloads

Leiter, M., & Maslach, C. (2009). Nurse turnover: The mediating role of burnout. Journal of Nursing Management, 17(3), 331-339.

Li, J., Galatsch, M., Siegrist, J., Muller, B., Hasselhorn, H. (2011). Reward frustration at work and intention to leave the nursing profession: Prospective results from the European longitudinal NEXT study. International Journal of Nursing Studies, 48, 628-635.

Lipscomb, J., Sokas, R., McPhaul, K., Scharf, B., Barker, P., Trinkoff, A., et al. (2009). Occupational blood exposure among unlicensed home care workers and home care registered nurses: Are they protected? American Journal of Industrial Medicine, 52(5), 563-570.

References Maslach, C., & Schaufeli, W. (1993). Historical and conceptual

development of burnout. In W. B. Schaufeli, C. Maslach & T. Marek (Eds.), Professional burnout: Recent developments in theory and research (pp. 1-16). New York: Taylor & Francis.

Maslach C., Schaufeli W., Leiter M. (2001). Job Burnout. Annual Review of Psychology, 52:397-422.

McVicar, A. (2003). INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES workplace stress in nursing: A literature review. Journal of Advanced Nursing, 44(6), 633-642. doi:10.1046/j.0309-2402.2003.02853.x

Mensik, J. (2007b). The essentials of magnetism for home health. The Journal of Nursing Administration, 37(5), 230-234. doi:10.1097/01.NNA.0000269742.40137.a6

Mensik, J. (2007c). Impact of organizational attributes on nurse satisfaction in home health. Home Health Care Management & Practice, 19(6), 456-459.

National Institute for Occupational Safety and Health. (2008). Exposure to stress: Occupational hazards in hospitals. Department of Health and Human Services (NIOSH) Publication no. 2008-136,

References National Institute for Occupational Safety and Health. (2009).

Engineering controls. Retrieved June 15, 2009, from: http://www.cdc.gov/niosh/topics/engcontrols

National Research Center for the Working Environment. (2009). The scales of the long COPSOQ questionnaire. Copenhagen, Denmark. Retrieved from:

http://www.arbejdsmiljoforskning.dk/en/publikationer/spoergeskemaer/~/media/Spoergeskemaer/copsoq/uk/scales-of-the-long-copsoq-ii-questionnaire.pdf#

Navaie-Waliser, M., Lincoln, P., Karuturi, M., & Reisch, K. (2004). Increasing job satisfaction, quality care, and coordination in home health. The Journal of Nursing Administration, 34(2), 88-92.

Nogueras, D. (2006). Occupational commitment, education, and experience as a predictor of intent to leave the nursing profession. Nursing Economics, 24(2), 86-93.

O'Brien-Pallas, L., & Hayes, L. (2008). Challenges in getting workforce research in nursing used for decision-making policy and practice: A Canadian perspective. Journal of Clinical Nursing, 17, 3338-3346.

References Occupational Safety and Health Administration.(2001). Revision to

OSHA's blood borne pathogens standard: Technical background and summary. Retrieved from: http://www.osha.gov/needlesticks/needlefact.html

Sauter, S., Brightwell, W., Colligan, M., Hurrell, J., Katz, T., LeGrande, D., et al. (2002). The changing organization of work and the safety and health of working people, publication NO. 2002-116. No. 2002-116). Cincinnati, OH: Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), Department of Health and Human Services (DHHS).

Schaufeli, W., Van Dierendonck, D., & Van Gorp, K. (1996). Burnout and reciprocity. Work and Stress, 10, 225-237. Siegrist, J. (1996). Adverse health effects of high-Effort/Low-reward conditions. Journal of Occupational Health Psychology, 1(1), 27-41.

Siegrist, J. (2005). Social reciprocity and health: New scientific evidence and policy implications. Psychoneuroendocrinology, 30(10), 1033-1038. doi 10.1016/j.psyneuen.2005.03.017

References Siegrist, J., Starke, D., Chandola, T., Godin, I., Marmot, M.,

Niedhammer, I., et al. (2004). The measurement of effort–reward imbalance at work: European comparisons. Social Science & Medicine, 58(8), 1483-1499. doi 10.1016/S0277-9536(03)00351-4

Siegrist, J., (2008). Effort-reward imbalance and health in a global economy. Scandinavian Journal of Work and Environmental Health, Suppl. (6), 163-168.

Smith-Stoner, M., & Markley, J. (2007). Home healthcare nurse recruitment and retention: Tips for retaining nurses: One state's experience. Home Healthcare Nurse, 25(3), 198-205. doi:10.1097/01.NHH.0000263438.15685.dd

Stone, P., Mooney-Kane, C., Larson, E., Pastor, D., Zwanziger, J., & Dick, A. (2007). Nurse working conditions, organizational climate, and intent to leave in ICUs: An instrumental variable approach. Health Research and Educational Trust, 42(3), 1085-1104.

Stone, P., Pastor, D., & Harrison, M. (2006). Organizational climate: Implications for the home healthcare workforce. Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality, 28(1), 4-11.

References Stone, P., Mooney-Kane, C., Larson, E., Pastor, D., Zwanziger, J., &

Dick, A. (2007). Nurse working conditions, organizational climate, and intent to leave in ICUs: An instrumental variable approach. Health Research and Educational Trust, 42(3), 1085-1104.

Stone, P., Pastor, D., & Harrison, M. (2006). Organizational climate: Implications for the home healthcare workforce. Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality, 28(1), 4-11.

Smith-Stoner, M., & Markley, J. (2007). Home healthcare nurse recruitment and retention: Tips for retaining nurses: One state's experience. Home Healthcare Nurse, 25(3), 198-205. doi:10.1097/01.NHH.0000263438.15685.dd

Tsutsumi, A., & Kawakami, N. (2004). A review of empirical studies on the model of effort–reward imbalance at work: Reducing occupational stress by implementing a new theory. Social Science & Medicine, 59(11), 2335-2359. doi 10.1016/j.socscimed.2004.03.030

Tullai-McGuinness, S., Madigan, E., & Anthony, M. (2005). Exercise of autonomous home care practice: The relationship with nurse characteristics. Home Healthcare Nurse, 23(6), 378-384.

References• Tullai-McGuinness, S. (2008). Home healthcare practice

environment: Predictors of RN satisfaction. Research in Nursing & Health, 31(3), 252-260. Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=2009933359&site=ehost-live

U.S. Bureau of Labor Statistics. (2007). Occupation employment statistics., 2009, from: http://www.bls.gov/oes/current/naics4_621600.htm#b00-0000.

U.S. Bureau of Labor Statistics. (2008). Occupational outlook handbook, edition 2008-2009: Registered nurses. Retrieved 6/15/2009 from:http://www.bls.gov/oco/ocos083.htm

U.S. General Accounting Office. (2004). Nursing workforce: Emerging nurse shortages due to multiple actors. GAO 01-944., 2009, from: http://www.gao.gov/news.items/d01944.pdf

Vaeth, M. (2004). A simple approach to power and sample size calculations in logistic regression and Cox regression models. Statistics in Medicine, 23, 1781-1792.

References

Zeytinoglu, I. U., Denton, M., Davies, S., & Plenderleith, J. M. (2009). Casualized employment and turnover intention: Home care workers in Ontario, Canada. Health Policy, 91(3), 258-268. doi10.1016/j.healthpol.2008.12.004

Zurmehly, J., Martin, P., & Fitzpatrick, J. (2009). Registered nurse empowerment and intent to leave current position and/or profession. Journal of Nursing Management, 17(3), 383-391.