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20 Volume 39 | Number 1 www.homehealthcarenow.org

Jose Abelardo Garza, DHA, MBA, and Donna Taliaferro, PhD, RN, COI

Job Satisfaction Among Home Healthcare Nurses

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Understanding the experiences of home healthcare nurses and exploring the factors

that influence job satisfaction is important in reducing costly staff turnover. The purpose

of the qualitative case study was to describe experiences related to job satisfaction

among home healthcare nurses. Herzberg’s Two Factor theory was used to frame the

study. Twelve home healthcare nurses from an agency in South Texas volunteered to

participate in in-depth interviews. Four themes emerged from the data: 1) patients

contribute to job satisfaction, 2) autonomy promotes job satisfaction, 3) occupational

stressors negatively influenced job satisfaction, and 4) leadership impacts job satisfac-

tion. Home healthcare leadership should take safety concerns seriously and explore in-

novative ways to promote communication between field nurses and physicians. Further

research is needed with a larger and more diverse sample of home healthcare nurses in

order to be able to generalize findings.

January/February 2021 Home Healthcare Now 21

strategy to increase job satisfaction (Baljoon et al., 2018; Mohammed et al., 2017).

Method and Sample After institutional review and facility approval, a purposeful sample of RNs were recruited from a for-profit home healthcare agency in South Texas. Inclusion criteria included: a) working at least part- time as an RN, b) an associate degree in nursing or higher, and c) at least 1 year of experience as a home healthcare nurse. Potential participants were contacted by email. The study was explained and interviews were scheduled with interested participants.

Data Collection The in-depth interviews were conducted in a pri- vate office within the home healthcare agency and lasted 30 to 60 minutes. Participants were assured of confidentiality. A textual instrument (Supplemen- tal Digital Content http://links.lww.com/HHN/A139) was used to guide the in-depth interviews, which were audio-recorded and transcribed verbatim. The interview guide questions were divided in three broad categories—defining job satisfaction, work- ing conditions, and organizational factors. Audio recordings and transcriptions were kept in a locked office, and computerized data were password- protected. Field notes were used to document ob- servations during the interviews. Document re- views of monthly turnover rate reports and exit interview surveys were examined during data col- lection as a method of data triangulation.

Data Analysis This qualitative study used a thematic analysis approach to describe experiences related to job satisfaction among RNs working in home health- care. A general inductive approach was used dur- ing the analysis, which consisted of multiple steps, as described by Vaismoradi et al. (2013). First, interviews were transcribed verbatim. Sec- ond, data collected were organized using De- doose, a qualitative analysis tool. Third, tran- scriptions and observational field notes were organized into smaller components to give the data meaning and formulate emerging themes. Fourth, validating ensured that the information collected was through ethical and accepted qual- itative approaches. Triangulation strengthened the study’s confirmability originating from multi- ple sources of evidence. In addition, trustworthi- ness was reached by continuously ensuring the

J ob dissatisfaction is one of the main predic- tors of burnout and turnover among regis- tered nurses (RNs; Fatemi et al., 2019). The consequences for high RN turnover are

costly, and the quality of care provided to the pa- tients can be affected (Kieft et al., 2014; Nei et al., 2015). Healthcare organizations spend between $44,000 and $63,000 to replace an RN who resigns (Yarbrough et al., 2017). Nurse job satisfaction has received national recognition, particularly focusing on hospital settings. The most common reasons cited by nurses in hospitals for job dissatisfaction are: heavy workload, pay, irregular schedules, lack of opportunity for promotion, and leadership styles of managers (Andrioti et al., 2017; Halcomb et al., 2018; Lee & Jang, 2019).

Tourangeau et al. (2017) conducted a cross- sectional survey to integrate nurse job satisfac- tion factors and intent to remain employed in a home healthcare setting. Surveys were mailed to 1,582 nurses who met the inclusion criteria of being employed as a home healthcare RN, either full-time or part-time, and more than 5 years away from retirement. Forty-six percent of the surveys were returned. The authors concluded that work environment, supervisor relationship, and pay were characteristics related to satisfaction and intent to remain employed.

Baljoon et al. (2018) used Herzberg’s Two Factor theory to present the conceptual analysis of work motivation and the factors that affect a nurse’s job performance. The study focused on intrinsic and extrinsic motivation factors and the relationship the factors had on job performance. Intrinsic fac- tors such as self-interest and job pleasure were established as motivational factors that affected job performance. Rewards, job pay, fringe benefits, and bonuses were identified as extrinsic factors that affected job performance among nurses. The theory was used to support the idea that motiva- tion can affect a nurse’s job performance and level of satisfaction in both negative and positive ways.

Little is known about job satisfaction of home care nurses. The aim of this descriptive qualita- tive study was to describe experiences related to job satisfaction among RNs working in home healthcare. Herzberg’s Two Factor theory was used as the theoretical framework, which helped provide a broader perspective on factors that in- fluence nurse job satisfaction in home health- care. The theory emphasizes the importance of both preventing an unfavorable work environ- ment and using encouragement as a motivating

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alignment of the study with the research design and method, bracketing, and authenticating the data sources.

Results The recruitment of participants continued until data saturation occurred at 12 participants. Age was collected by decades, with three participants were in their 20s, four in their 30s, two in their 40s, and three in their 50s. Only one participant was male. Seven participants held a bachelor’s de- gree and five held an associate degree. See Table 1 for additional demographic information.

Major Themes Four major themes emerged during analysis of the data: (1) patients contribute to job satis- faction, (2) autonomy promotes job satisfaction, (3) occupational stressors negatively influenced job satisfaction, and (4) leadership impacts job satisfaction.

Theme 1: Patients contribute to job satisfac- tion. All 12 of the participants stated that patients and patient care contribute to job satisfaction and were personally rewarding. Answers such as “I enjoy helping people,” and “patients make the job satisfying” were provided when describing their relationship with their patients. For example, Par- ticipant 3 stated the following:

The best part of my job is the patients. I have always been passionate about nursing and helping people. I find this type of work so rewarding and motivational. I could be having such a crappy day, and it only takes one of my precious patients to cheer me up. I love when I get to their house, and their face lights up. Most of the time, these people are lonely and do not have family, so when I show up, I make their day.

Theme 2: Autonomy promotes job satis- faction. Participants mentioned that a feeling of autonomy in their daily work promoted job satis- faction because they were able to make their own decisions about patient care, and have the flexibil- ity they loved. Participants felt that making their own decisions made them feel confident and

trusted. This statement by Participant 1 is repre- sentative of this theme:

I think there are many elements that would in- fluence job satisfaction. For example, one would be the time or length of work experience, for example, do you have years of experience or days of experience. That would definitely affect the confidence or autonomy in the care you provide, which I think highly influences your level of job satisfaction. I make the deci- sions and my supervisor supports me, which gives me the confidence and trust that I need.

Flexibility was often mentioned as one of the ele- ments that positively influenced job satisfaction. The participants said they enjoyed the flexibility because they were able to schedule their patients around other commitments. Four of the nurses spe- cifically mentioned flexibility as it relates to their families—they were able to drop their children off at school and pick them up at the end of the day. The other three nurses said they enjoyed the flexi- bility because they were able to work on their own time and finish early or late. This statement by Participant 2 reflects the importance of flexibility:

I would say that the best parts are that I am on my own most of the time. I’m not having to be in the office all day, so I’m not restricted to one single area. Also, the scheduling flexi- bility, most of the time, it’s pretty good, like I said, if I have a doctor’s appointment or

Table 1. Study Participants Demographics

Participant Age Group Gender Race Years of

Experience Level of

Education FT/ PT

Participant 1 30s Female Hispanic 6 BSN PT

Participant 2 20s Female White 7 BSN PT

Participant 3 50s Female White 2 ½ ADN FT

Participant 4 30s Female Hispanic 6 ADN PT

Participant 5 20s Female Black 5 BSN FT

Participant 6 40s Male White 1 ½ BSN FT

Participant 7 50s Female White 10 ADN FT

Participant 8 40s Female Asian 2 ADN PT

Participant 9 20s Female White 10 ADN FT

Participant 10 30s Female Hispanic 5 BSN PT

Participant 11 50s Female White 12 BSN FT

Participant 12 30s Female Black 2 BSN FT

Note. BSN = Bachelor of Science in Nursing, ADN = Associate’s Degree in Nursing, FT = full-time position, PT = part-time position.

January/February 2021 Home Healthcare Now 23

their job satisfaction. Participant 10 related that a “simple thank you” makes her feel good:

What I mean by that is that a simple thank you for a job well done or thank you for mak- ing that extra home visit when a nurse can- cels or when you pick up a patient. Any of that, I mean, it is part of your job. Yes, that is our job, and we do our job but a simple rec- ognition, just a simple thank you just makes you feel good. It makes you feel like you’re appreciated for what you do. It’s not just an actual job. Yes, you’re getting paid to do it, but management is actually recognizing the job that you do. That goes a long way.

Nurses who expressed a lack of leadership sup- port described this in terms such as “unhappy,” “negative,” and “overwhelmed” related to job sat- isfaction, whereas nurses who felt supported by leadership used terms such as “happy,” “positive,” and “teamwork” related to job satisfaction.

Discussion The purpose of this study was to describe experi- ences that affect job satisfaction of RNs working in home healthcare. The participants expressed sat- isfaction with their jobs, especially when describ- ing positive patient encounters. They described building relationships and connections with the patients as a vital aspect of their satisfaction with their jobs. Wälivaara et al. (2013) also concluded that good relationships with patients influence job satisfaction. Furthermore, the professional rela- tionship the home healthcare nurses build with the patients influences the nurse’s experience and the quality of care delivered (Wälivaara et al.). Morrow (2017) discussed how relationship build- ing and the journey of patient recovery is one of the most rewarding aspects of home healthcare.

Outcomes from the study revealed that the participants felt autonomy was a vital factor that led to job satisfaction. Autonomy was described as integral to performing job duties as a home healthcare nurse. Irani et al. (2018) also found that the home healthcare nurses in their study valued the autonomy and flexibility they felt when creat- ing their schedules. Han et al. (2015) concluded that the nurses in their study who were dissatis- fied at work had lower levels of autonomy.

The participants in our study pointed to occu- pational stressors they face while providing care to patients in their homes. Findings from a re-

something in the morning I can go to that and then go see my patients the rest of the day.

Theme 3: Occupational stressors negatively influenced job satisfaction. The third theme that emerged was related to the occupational stress- ors that home healthcare nurses encounter on a day-to-day basis. These occupational stressors were considered elements that the participants associated negatively in relation to job satisfac- tion. All participants mentioned documentation as one of the occupational stressors that nega- tively influenced their job satisfaction. They de- scribed the documentation process as “tedious,” “repetitive,” and “time-consuming.” Eight out of 12 nurses described the challenges they face with insufficient staffing. Participant 12 expressed her concern with the high turnover rate:

Some of the worst parts are the high turnover rate of the employees. A lot of the nurses don’t stay very long in home health. I have been there for about four years, and I have trained several other nurses. They may stay a month or five months, and then they leave. It is not a very steady thing for most people, and I am not sure why. But when our census is high, and we have a lot of turnover at the same time, it gets very challenging. The nurses who are left have to pick up the slack for those who left and see extra patients.

The participants voiced their concerns regarding the work environment while in the field. They de- scribed the connection between the patient’s socio- economic status and the work environment, noting that some patients reside in areas where the nurse feels safe and protected, whereas other patients re- side in what they described as “high crime” areas. Some of the participants recalled unsafe encounters with pets, family members, and unsanitary homes. The participants voiced much frustration with is- sues related to trying to reach the patient’s physi- cian, with some concluding that the best way to contact a physician is through a third party, such as the secretary or medical assistant. Nurses described communication with some physicians as “difficult,” “obnoxious,” and “an act of God” when successful.

Theme 4: Leadership impacts job satisfaction. The fourth theme that emerged from data analysis was the impact leadership has on job satisfaction. Eleven out of the 12 participants indicated that recognition by leadership positively influenced

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The authors declare no conflicts of interest.

Address of correspondence: Jose A. Garza, DHA, MBA, 2001 Hol-

combe Blvd., Unit 604, Houston, TX 77030 ([email protected]).

DOI:10.1097/NHH.0000000000000921

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cal practices. International Journal of Caring Sciences, 10(1), 76–87. Baljoon, R., Banjar, H., & Banakhar, M. (2018). Nurses’ work

motivation and the factors affecting it: A scoping review. Inter- national Journal of Nursing & Clinical Practices, 5(1). https://doi. org/10.15344/2394-4978/2018/277

Fatemi, N. L., Moonaghi, H. K., & Heydari, A. (2019). Perceived chal-

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Halcomb, E., Smyth, E., & McInnes, S. (2018). Job satisfaction and

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integrative review. BMC Family Practice, 19(1), 136. https://doi. org/10.1186/s12875-018-0819-1

Han, K., Trinkoff, A. M., & Gurses, A. P. (2015). Work-related factors,

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Irani, E., Hirschman, K. B., Cacchione, P. Z., & Bowles, K. H. (2018).

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tive descriptive study. Journal of Clinical Nursing, 27(21–22), 4066–4076. https://doi.org/10.1111/jocn.14548

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(2014). How nurses and their work environment affect patient experi-

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Lee, M., & Jang, K. (2019). Nurses’ emotions, emotional labor, and

job satisfaction. International Journal of Workplace Health Manage- ment, 13(1), 16–31. https://doi.org/10.1108/ijwhm-01-2019-0012

Mohammed, A., Shahwan-Akl, L., & Maude, P. (2017). Herzberg’s

two-factor theory. Life Science Journal, 14(5), 12–16. http://www. lifesciencesite.com/lsj/life140517/03_32120lsj140517_12_16.pdf

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care nurse. Home Healthcare Now, 35(8), 456–457. https://doi. org/10.1097/nhh.0000000000000587

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search study by Irani et al. (2018) concluded that high productivity and staffing factors influenced home healthcare nurses. Weerdt and Baratta (2015) examined working conditions for home healthcare workers with similar findings—the home healthcare nurses described unsanitary homes and unfavorable working conditions, which affected their job satisfaction. Additionally, previ- ous studies have found that the relationship with physicians is essential, and healthy collegial rela- tionships were associated with higher job satisfac- tion levels (Scruth et al., 2018; Wargo-Sugleris et al., 2018; Yarbrough et al., 2017).

Finally, the nurses described the impact of lead- ership and recognition by leadership on job satis- faction. Baljoon et al. (2018) conducted a study to understand nurses’ work motivation and the fac- tors that influence motivation. They concluded that a supportive leadership environment increased the nurses’ motivation in the workplace. Additionally, the authors stated that recognition and apprecia- tion were high motivators for the nurses.

Limitations The small sample of 12 participants from a single home healthcare agency in South Texas limits gen- eralizability, although the findings can be used as a resource for future studies of nurse job satisfac- tion in home healthcare. Additionally, only one participant was male, so future research would benefit from a more diverse sample.

Conclusion A sense of autonomy over work, flexibility in scheduling, and positive feedback from leadership were found to positively influence nurse satisfac- tion with home care. On the other hand, documen- tation mandates, safety concerns in the field, and difficulty communicating with physicians were factors associated with dissatisfaction. Although the sample size of this study was small, findings can be used to further study job satisfaction and turnover among home healthcare nurses. Home healthcare leadership should take safety concerns seriously and explore innovative ways to promote communication between field nurses and physi- cians. Further research is needed with a larger and more diverse sample of home healthcare nurses in order to be able to generalize findings.

Jose Abelardo Garza, DHA, MBA, Houston, Texas.

Donna Taliaferro, PhD, RN, COI, is Lead Faculty Area Chair, Methodologist, University of Phoenix, Phoenix, Arizona.