Health and Social Care in the Community (2014) 22(5), 461–468
doi: 10.1111/hsc.12084
The importance of leadership style and psychosocial work environment to staff-assessed quality of care: implications for home help services Kristina Westerberg
PhD
and Susanne Tafvelin
PhD
Department of Psychology, Ume a University, Ume a, Sweden Accepted for publication 4 October 2013
Correspondence Kristina Westerberg Department of Psychology Ume a University 901 87 Ume a, Sweden E-mail: kristina.westerberg@psy. umu.se
What is known about this topic
•
•
•
Working conditions in home help services are characterised by solitude, a high workload, little influence and lack of peer and leader support. Relations between leadership styles, psychosocial work environment and positive and negative employee outcomes have been established. A transformational leadership style is associated with more positive job satisfaction and staff well-being.
What this paper adds
•
• •
Transformational leadership style is mediated by perceived organisational and peer support, workload and job control with regard to its effect on quality of care. When indirect effects were taken into consideration, there were no direct effects of leadership style on quality of care. A high workload, little influence and lack of peer and leader support have a negative impact on quality of care in home help services.
© 2013 John Wiley & Sons Ltd
Abstract Work in home help services is typically conducted by an assistant nurse or nursing aide in the home of an elderly person, and working conditions have been described as solitary with a high workload, little influence and lack of peer and leader support. Relations between leadership styles, psychosocial work environment and a number of positive and negative employee outcomes have been established in research, but the outcome in terms of quality of care has been addressed to a lesser extent. In the present study, we aimed to focus on working conditions in terms of leadership and the employee psychosocial work environment, and how these conditions are related to the quality of care. The hypothesis was that the relation between a transformational leadership style and quality of care is mediated through organisational and peer support, job control and workload. A cross-sectional survey design was used and a total of 469 questionnaires were distributed (March–April 2012) to assistant nurses in nine Swedish home help organisations, including six municipalities and one private organisation, representing both rural and urban areas (302 questionnaires were returned, yielding a 65% response rate). The results showed that our hypothesis was supported and, when indirect effects were also taken into consideration, there was no direct effect of leadership style on quality of care. The mediated model explained 51% of the variance in quality of care. These results indicate that leadership style is important not only to employee outcomes in home help services but is also indirectly related to quality of care as assessed by staff members. Keywords: home help services, leadership style, psychosocial work environment, quality of care
Many countries are facing a growing number of elderly individuals in need of assistance while at the same time as the social systems need to contain costs (Keefe et al. 2011). Home help services that provide care and support to elderly people in their homes are an important part of the care social system. The structure and organisation of home help services show large local and regional variations both within and between countries (Trydeg ard & Thorslund 2001, Hammar et al. 2008, Savla et al. 2008, Rostgaard 2012). In Sweden, public care has the formal responsibility for home help services, although the work can be conducted by private contributors. Home help resources have increasingly been concentrated on elderly people with the greatest needs (Meinow et al. 2005, Savla et al. 2008) and it has been argued that this concentration, along with organisational changes, has resulted in a more strenuous and stressful work situation (Brulin et al. 2000). However, when it comes to working conditions, there are certain features common across comparative countries. The work 461
K. Westerberg & S. Tafvelin
is typically conducted by an assistant nurse or nursing aide in the home of the elderly person and the working conditions have been described as solitary with a high workload, little influence and lack of peer and leader support (Elovainio & Sinervo 1997, Brulin et al. 2000, Arts et al. 2001, Samia et al. 2012). Relationships between various aspects of the psychosocial work environment in home help services and a number of employee outcomes have been established. Low wages and minimal benefits add to the picture of poor working conditions (Denton et al. 2012) and the elderly care sector suffers from high turnover and high sick leave rates and low formal education (The Swedish Board of Health and Welfare 2003, Trydeg ard 2005). In the present study, we aimed to focus on working conditions in terms of leadership and employee psychosocial work environment and how these conditions are related to the quality of care. Leadership style and psychosocial work environment A solitary working environment with no access to manager or colleagues during the working day can result in a perceived lack of support. It has been shown that lack of support from colleagues, leaders and the organization has negative consequences, but also that perceived support has positive effects. Arts et al. (2001), in a review on working conditions in home help services, found that working solo and having a high workload were related to higher levels of burnout, stress and absenteeism among employees. Estryn-Behar et al. (2007), in a large European hospital sample, found that a serious lack of teamwork was associated with turnover intention among nurses and nursing aides. When investigating specific working conditions in terms of working in clients’ homes, it has been shown that organisational support, control over work and peer support are associated with better health among home-care workers (Denton et al. 2012). In addition, a transformational leadership style, mediated by followers’ perception of their working environment, has been associated with more positive job satisfaction and staff wellbeing in elderly care (Nielsen et al. 2008), and with job satisfaction, job involvement and propensity to remain with the organisation in home healthcare (Smith et al. 1994). Transformational leadership is a vision-based leadership where the leader acts as a role model to inspire and motivate employees to perform beyond expectations. By stimulating new ways of thinking and showing individual support, the leader stimulates participation and creativity (Bass & Riggio 2006). A recent review also concludes that 462
transformational leadership is associated with reduced employee stress and increased levels of wellbeing (Skakon et al. 2010). It has been shown that a transformational leadership style is common in public services (Dumdum et al. 2002), and it has been argued that this is of specific importance in elderly care and healthcare because of the responsibility and relationship that employees have with the patients (Nielsen et al. 2008). Leadership, psychosocial work environment and quality of care Even though relations between leadership styles, psychosocial work environment and a number of positive and negative employee outcomes have been established, the outcome in terms of quality of care has been addressed to a lesser extent. In studies of hospital care (Aiken et al. 2002) and geriatric care (Lapointe McKenzie et al. 2011), nurse assessment of the quality of care is used as an indicator of patient outcome. Purdy et al. (2010) found that an improved work environment exerted a positive effect on nurseassessed quality of care and fewer falls among hospital patients, as well as better employee job satisfaction. A study on Swedish home help services indicated that clients’ perceptions of the caring climate were influenced by the work group climate (Olsson & Ingvad 2001). However, these relationships between quality of care and work environment, as assessed by clients, staff, or both, have not always been found in other studies, indicating that the relationships are complex (Hannan et al. 2001, Hasson & Arnetz 2009). In a review of relationships between job satisfaction, work stress, quality of care and care recipients’ well-being, Hannan et al. (2001) reported divergent findings. Methodological differences and shortcomings in these studies make comparisons uncertain, however. Nevertheless, it was found that management style seems to have a strong influence, and organisational factors and group cohesiveness might play an important role in the relationship between work environment and quality of care. In addition, the authors found that workload was a factor influencing quality of care, although few studies have considered this relationship. Taken together, leadership style and support are considered important factors in employees’ psychosocial work environment. Some research findings indicate that the effect of a transformational leadership style on employee well-being in elderly and social care is mediated through various aspects of the psychosocial work environment (Nielsen et al. 2008, Tafvelin et al. 2011). As mentioned above, manage© 2013 John Wiley & Sons Ltd
Home help services to elderly people
ment style has been suggested as a key factor that influences the relationship between employee wellbeing and stress and care quality (Hannan et al. 2001). Thus, there is support for direct as well as indirect effects of leadership style. To implement transformational leadership, the leader needs to meet the employees. Therefore, it is of particular importance to understand the impact of leadership style on the quality of care and how it can be mediated through key factors of the psychosocial work environment such as support, control and workload in a solitary work environment such as the home help service. Aim and hypothesis The aim of the present study was to explore the relationship between transformational leadership style and care quality, mediated by perceived support from colleagues and organisation, job control and workload in Swedish home help services. The hypothesis was that the relationship between leadership style and quality of care is mediated by peer and organisational support, job control and workload.
Methods Procedure and participants A cross-sectional survey design was used, with a total of 469 questionnaires distributed in March–April 2012 to assistant nurses in nine home help organisations, including six municipalities and one private organisation in the north of Sweden. The organisations were selected to represent different organisational sizes and rural and urban areas in one larger county. Background descriptions from earlier projects in these organisations have shown that access to work colleagues and leaders varies between and within organisations, but morning meetings and regular staff meetings are common. The questionnaire was distributed to all employees in home help services by first-line managers in each organisation. All participants received written information that their responses would only be used in a research project concerning leadership and changes in home help services. They were also informed that all presentations of data would be at a group level and that participation was voluntary. Therefore, no formal informed consent was required. The research design was in accordance with the APA (American Psychological Association) ethical standards and the local field research unit in the largest participating municipality. © 2013 John Wiley & Sons Ltd
Measurements Leadership behaviour (in terms of transformational leadership) was measured using the Multifactor Leadership Questionnaire (MLQ). The scale was developed by Bass and Avolio (1995) and consists of four subscales, which operationalised the four dimensions of transformational leadership: idealised influence, inspirational motivation, intellectual stimulation and individualised support. The MLQ is the most commonly used measure of transformational leadership (Yukl 1998), and employees are asked to rate how often their supervisor engages in behaviour specific to each dimension on a 5-point Likert scale. The reliability of this 20-item scale was a = 0.95 (Cronbach’s alpha). The perception of organisational support was measured using three items from Guest et al. (2010). These items reflect respondents’ trust in the management and the organisation, and are used as a subscale to describe employment relationships. It has been shown that trust mediates the effects of a transformational leadership on the performance of followers (Jung & Avolio 2000, Bartram & Casimir 2007). One item was, ‘To what extent do you trust senior management to look after your best interests?’. The five response alternatives were graded from 1 (not at all) to 5 (totally), and the reliability of the scale was a = 0.80. Peer support was measured on a three-item scale (Hauer et al. 2012) derived from earlier organisational research (e.g. Karasek & Theorell 1990, Dallner et al. 2000). One item was, ‘When I need it, I can get support and help from my colleagues’, with five response alternatives graded from 1 (very seldom or never) to 5 (very often or always). The reliability of the scale was a = 0.72. Job control was measured on a three-item scale (Hauer et al. 2012) derived from earlier organisational research (e.g. Karasek & Theorell 1990). One item was, ‘I have freedom to decide how I do my work’, with five response alternatives graded from 1 (very seldom or never) to 5 (very often or always). The reliability of the scale was a = 0.77. Workload was measured on three items reflecting work demands (Karasek & Theorell 1990) such as working hard, working fast, and excessive workload. The five response alternatives were graded from 1 (very seldom or never) to 5 (very often or always). The reliability of the scale was a = 0.84. Quality of care can be defined in various ways. Items related to quality of care were presented by Aiken et al. (2002) and used as single items in several studies of hospital care (Purdy et al. 2010). Poghosyan et al. (2010) used a nurse-assessed single item in a cross-national investigation, arguing that single-item 463
K. Westerberg & S. Tafvelin
measures show associations with indicators of quality and patient outcomes. One example of a nurseassessed item is: In general, how would you describe the quality of nursing care delivered to patients on your unit? (Aiken et al. 2002, p. 193)
In the present study, five statements were constructed, based on earlier research, to form a measure of quality of care as assessed by staff. Three statements concerned how often the respondent felt satisfied with the way in which the clients were treated, kept informed and their wishes respected. One statement concerned how well the help and support provided met the client’s needs, while another concerned the overall satisfaction with care work. The five response alternatives were graded from 1 (very seldom or never) to 5 (very often or always). The items yielded a Cronbach’s alpha value of 0.86, which was considered sufficient. Time with leader: In addition, the participants were asked to estimate the time (in hours) spent with their leader every week. The estimates were ordered in five groups ranging from 0 to 4 (0 = no time with leader; 1 ≤1 hour; 2 = 1–2 hours; 3 = 2.5–6 hours; 4 ≥6 hours) for the purpose of analysis. Data analysis The hypothesis was tested using structural equation modelling (SEM) with maximum-likelihood estimation in AMOS 18 (IBM SPSS, Chicago, IL, USA). Goodness of fit between the model and observed data was tested using a number of goodness-of-fit indices. There is broad consensus that no single measure of model overall fit should be relied on exclusively (Marsh et al. 1988). In this study, v2, root mean square error of approximation (RMSEA), Comparative Fit Index (CFI) and Tucker–Lewis Coefficient (TLI) are reported. It is generally agreed that RMSEA values of
doi: 10.1111/hsc.12084
The importance of leadership style and psychosocial work environment to staff-assessed quality of care: implications for home help services Kristina Westerberg
PhD
and Susanne Tafvelin
PhD
Department of Psychology, Ume a University, Ume a, Sweden Accepted for publication 4 October 2013
Correspondence Kristina Westerberg Department of Psychology Ume a University 901 87 Ume a, Sweden E-mail: kristina.westerberg@psy. umu.se
What is known about this topic
•
•
•
Working conditions in home help services are characterised by solitude, a high workload, little influence and lack of peer and leader support. Relations between leadership styles, psychosocial work environment and positive and negative employee outcomes have been established. A transformational leadership style is associated with more positive job satisfaction and staff well-being.
What this paper adds
•
• •
Transformational leadership style is mediated by perceived organisational and peer support, workload and job control with regard to its effect on quality of care. When indirect effects were taken into consideration, there were no direct effects of leadership style on quality of care. A high workload, little influence and lack of peer and leader support have a negative impact on quality of care in home help services.
© 2013 John Wiley & Sons Ltd
Abstract Work in home help services is typically conducted by an assistant nurse or nursing aide in the home of an elderly person, and working conditions have been described as solitary with a high workload, little influence and lack of peer and leader support. Relations between leadership styles, psychosocial work environment and a number of positive and negative employee outcomes have been established in research, but the outcome in terms of quality of care has been addressed to a lesser extent. In the present study, we aimed to focus on working conditions in terms of leadership and the employee psychosocial work environment, and how these conditions are related to the quality of care. The hypothesis was that the relation between a transformational leadership style and quality of care is mediated through organisational and peer support, job control and workload. A cross-sectional survey design was used and a total of 469 questionnaires were distributed (March–April 2012) to assistant nurses in nine Swedish home help organisations, including six municipalities and one private organisation, representing both rural and urban areas (302 questionnaires were returned, yielding a 65% response rate). The results showed that our hypothesis was supported and, when indirect effects were also taken into consideration, there was no direct effect of leadership style on quality of care. The mediated model explained 51% of the variance in quality of care. These results indicate that leadership style is important not only to employee outcomes in home help services but is also indirectly related to quality of care as assessed by staff members. Keywords: home help services, leadership style, psychosocial work environment, quality of care
Many countries are facing a growing number of elderly individuals in need of assistance while at the same time as the social systems need to contain costs (Keefe et al. 2011). Home help services that provide care and support to elderly people in their homes are an important part of the care social system. The structure and organisation of home help services show large local and regional variations both within and between countries (Trydeg ard & Thorslund 2001, Hammar et al. 2008, Savla et al. 2008, Rostgaard 2012). In Sweden, public care has the formal responsibility for home help services, although the work can be conducted by private contributors. Home help resources have increasingly been concentrated on elderly people with the greatest needs (Meinow et al. 2005, Savla et al. 2008) and it has been argued that this concentration, along with organisational changes, has resulted in a more strenuous and stressful work situation (Brulin et al. 2000). However, when it comes to working conditions, there are certain features common across comparative countries. The work 461
K. Westerberg & S. Tafvelin
is typically conducted by an assistant nurse or nursing aide in the home of the elderly person and the working conditions have been described as solitary with a high workload, little influence and lack of peer and leader support (Elovainio & Sinervo 1997, Brulin et al. 2000, Arts et al. 2001, Samia et al. 2012). Relationships between various aspects of the psychosocial work environment in home help services and a number of employee outcomes have been established. Low wages and minimal benefits add to the picture of poor working conditions (Denton et al. 2012) and the elderly care sector suffers from high turnover and high sick leave rates and low formal education (The Swedish Board of Health and Welfare 2003, Trydeg ard 2005). In the present study, we aimed to focus on working conditions in terms of leadership and employee psychosocial work environment and how these conditions are related to the quality of care. Leadership style and psychosocial work environment A solitary working environment with no access to manager or colleagues during the working day can result in a perceived lack of support. It has been shown that lack of support from colleagues, leaders and the organization has negative consequences, but also that perceived support has positive effects. Arts et al. (2001), in a review on working conditions in home help services, found that working solo and having a high workload were related to higher levels of burnout, stress and absenteeism among employees. Estryn-Behar et al. (2007), in a large European hospital sample, found that a serious lack of teamwork was associated with turnover intention among nurses and nursing aides. When investigating specific working conditions in terms of working in clients’ homes, it has been shown that organisational support, control over work and peer support are associated with better health among home-care workers (Denton et al. 2012). In addition, a transformational leadership style, mediated by followers’ perception of their working environment, has been associated with more positive job satisfaction and staff wellbeing in elderly care (Nielsen et al. 2008), and with job satisfaction, job involvement and propensity to remain with the organisation in home healthcare (Smith et al. 1994). Transformational leadership is a vision-based leadership where the leader acts as a role model to inspire and motivate employees to perform beyond expectations. By stimulating new ways of thinking and showing individual support, the leader stimulates participation and creativity (Bass & Riggio 2006). A recent review also concludes that 462
transformational leadership is associated with reduced employee stress and increased levels of wellbeing (Skakon et al. 2010). It has been shown that a transformational leadership style is common in public services (Dumdum et al. 2002), and it has been argued that this is of specific importance in elderly care and healthcare because of the responsibility and relationship that employees have with the patients (Nielsen et al. 2008). Leadership, psychosocial work environment and quality of care Even though relations between leadership styles, psychosocial work environment and a number of positive and negative employee outcomes have been established, the outcome in terms of quality of care has been addressed to a lesser extent. In studies of hospital care (Aiken et al. 2002) and geriatric care (Lapointe McKenzie et al. 2011), nurse assessment of the quality of care is used as an indicator of patient outcome. Purdy et al. (2010) found that an improved work environment exerted a positive effect on nurseassessed quality of care and fewer falls among hospital patients, as well as better employee job satisfaction. A study on Swedish home help services indicated that clients’ perceptions of the caring climate were influenced by the work group climate (Olsson & Ingvad 2001). However, these relationships between quality of care and work environment, as assessed by clients, staff, or both, have not always been found in other studies, indicating that the relationships are complex (Hannan et al. 2001, Hasson & Arnetz 2009). In a review of relationships between job satisfaction, work stress, quality of care and care recipients’ well-being, Hannan et al. (2001) reported divergent findings. Methodological differences and shortcomings in these studies make comparisons uncertain, however. Nevertheless, it was found that management style seems to have a strong influence, and organisational factors and group cohesiveness might play an important role in the relationship between work environment and quality of care. In addition, the authors found that workload was a factor influencing quality of care, although few studies have considered this relationship. Taken together, leadership style and support are considered important factors in employees’ psychosocial work environment. Some research findings indicate that the effect of a transformational leadership style on employee well-being in elderly and social care is mediated through various aspects of the psychosocial work environment (Nielsen et al. 2008, Tafvelin et al. 2011). As mentioned above, manage© 2013 John Wiley & Sons Ltd
Home help services to elderly people
ment style has been suggested as a key factor that influences the relationship between employee wellbeing and stress and care quality (Hannan et al. 2001). Thus, there is support for direct as well as indirect effects of leadership style. To implement transformational leadership, the leader needs to meet the employees. Therefore, it is of particular importance to understand the impact of leadership style on the quality of care and how it can be mediated through key factors of the psychosocial work environment such as support, control and workload in a solitary work environment such as the home help service. Aim and hypothesis The aim of the present study was to explore the relationship between transformational leadership style and care quality, mediated by perceived support from colleagues and organisation, job control and workload in Swedish home help services. The hypothesis was that the relationship between leadership style and quality of care is mediated by peer and organisational support, job control and workload.
Methods Procedure and participants A cross-sectional survey design was used, with a total of 469 questionnaires distributed in March–April 2012 to assistant nurses in nine home help organisations, including six municipalities and one private organisation in the north of Sweden. The organisations were selected to represent different organisational sizes and rural and urban areas in one larger county. Background descriptions from earlier projects in these organisations have shown that access to work colleagues and leaders varies between and within organisations, but morning meetings and regular staff meetings are common. The questionnaire was distributed to all employees in home help services by first-line managers in each organisation. All participants received written information that their responses would only be used in a research project concerning leadership and changes in home help services. They were also informed that all presentations of data would be at a group level and that participation was voluntary. Therefore, no formal informed consent was required. The research design was in accordance with the APA (American Psychological Association) ethical standards and the local field research unit in the largest participating municipality. © 2013 John Wiley & Sons Ltd
Measurements Leadership behaviour (in terms of transformational leadership) was measured using the Multifactor Leadership Questionnaire (MLQ). The scale was developed by Bass and Avolio (1995) and consists of four subscales, which operationalised the four dimensions of transformational leadership: idealised influence, inspirational motivation, intellectual stimulation and individualised support. The MLQ is the most commonly used measure of transformational leadership (Yukl 1998), and employees are asked to rate how often their supervisor engages in behaviour specific to each dimension on a 5-point Likert scale. The reliability of this 20-item scale was a = 0.95 (Cronbach’s alpha). The perception of organisational support was measured using three items from Guest et al. (2010). These items reflect respondents’ trust in the management and the organisation, and are used as a subscale to describe employment relationships. It has been shown that trust mediates the effects of a transformational leadership on the performance of followers (Jung & Avolio 2000, Bartram & Casimir 2007). One item was, ‘To what extent do you trust senior management to look after your best interests?’. The five response alternatives were graded from 1 (not at all) to 5 (totally), and the reliability of the scale was a = 0.80. Peer support was measured on a three-item scale (Hauer et al. 2012) derived from earlier organisational research (e.g. Karasek & Theorell 1990, Dallner et al. 2000). One item was, ‘When I need it, I can get support and help from my colleagues’, with five response alternatives graded from 1 (very seldom or never) to 5 (very often or always). The reliability of the scale was a = 0.72. Job control was measured on a three-item scale (Hauer et al. 2012) derived from earlier organisational research (e.g. Karasek & Theorell 1990). One item was, ‘I have freedom to decide how I do my work’, with five response alternatives graded from 1 (very seldom or never) to 5 (very often or always). The reliability of the scale was a = 0.77. Workload was measured on three items reflecting work demands (Karasek & Theorell 1990) such as working hard, working fast, and excessive workload. The five response alternatives were graded from 1 (very seldom or never) to 5 (very often or always). The reliability of the scale was a = 0.84. Quality of care can be defined in various ways. Items related to quality of care were presented by Aiken et al. (2002) and used as single items in several studies of hospital care (Purdy et al. 2010). Poghosyan et al. (2010) used a nurse-assessed single item in a cross-national investigation, arguing that single-item 463
K. Westerberg & S. Tafvelin
measures show associations with indicators of quality and patient outcomes. One example of a nurseassessed item is: In general, how would you describe the quality of nursing care delivered to patients on your unit? (Aiken et al. 2002, p. 193)
In the present study, five statements were constructed, based on earlier research, to form a measure of quality of care as assessed by staff. Three statements concerned how often the respondent felt satisfied with the way in which the clients were treated, kept informed and their wishes respected. One statement concerned how well the help and support provided met the client’s needs, while another concerned the overall satisfaction with care work. The five response alternatives were graded from 1 (very seldom or never) to 5 (very often or always). The items yielded a Cronbach’s alpha value of 0.86, which was considered sufficient. Time with leader: In addition, the participants were asked to estimate the time (in hours) spent with their leader every week. The estimates were ordered in five groups ranging from 0 to 4 (0 = no time with leader; 1 ≤1 hour; 2 = 1–2 hours; 3 = 2.5–6 hours; 4 ≥6 hours) for the purpose of analysis. Data analysis The hypothesis was tested using structural equation modelling (SEM) with maximum-likelihood estimation in AMOS 18 (IBM SPSS, Chicago, IL, USA). Goodness of fit between the model and observed data was tested using a number of goodness-of-fit indices. There is broad consensus that no single measure of model overall fit should be relied on exclusively (Marsh et al. 1988). In this study, v2, root mean square error of approximation (RMSEA), Comparative Fit Index (CFI) and Tucker–Lewis Coefficient (TLI) are reported. It is generally agreed that RMSEA values of
