Journal of Occupational Health
Online ISSN : 1348-9585
Print ISSN : 1341-9145
ISSN-L : 1341-9145
Field Study
Risk factors for work-related stress and subjective hardship in health-care staff in nursing homes for the elderly: A cross-sectional study
Carole Pélissier , Michel Vohito, Emmanuel Fort, Brigitte Sellier, Jean Pierre Agard, Luc Fontana, Barbara Charbotel
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Keywords: Health-care staff in nursing homes, Subjective hardship, Work-related stress, Working conditions
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2015 Volume 57 Issue 3 Pages 285-296

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Abstract

Objectives: This study aimed to explore potential risk factors for work-related stress by, detailing working conditions and subjective hardship according to occupational category in health-care staff working with elderly patients. Methods: A cross-sectional descriptive survey was conducted in 105 nursing homes for the elderly in France. Data on nursing home working conditions were collected by occupational physicians. The study population was limited to those in direct contact with the elderly, who were divided into 3 occupational groups defined by qualifications and tasks: housekeepers (HKs), nursing assistants (NAs) and nurses (Ns). Employees answered a questionnaire on their perceived working conditions and vocational training courses. Psychosocial stress was assessed with the Siegrist questionnaire. Results: The subjects included 706 HKs, 1,565 NAs and 378 Ns, and the findings showed confusion of tasks and responsibilities in the study population. Verbal abuse by residents was reported by 60.9% of HKs (versus 76.2% of NAs and 76.7% of Ns, p<0.001). Physical attack by residents was more frequently reported by NAs (59.1%) than Ns (52.8%) or HKs (38.0%) (p<0.001). Nearly 10% of employees reported clear effort/reward imbalance (10.4% of NAs, 9.2% of Ns and 7.0% of HKs, p=0.059). Great hardship related to proximity to death was reported by 40.5% of HKs (versus 37.3% of NAs and 22.6% of Ns; p<0.001). Conclusions: To prevent stress related to insufficient ability, nursing home workers should be encouraged to attend job training courses, which should cover knowledge of the specific care needs of elderly patients and of the authority/responsibility required to do their job.

(J Occup Health 2015; 57: 285–296)

Introduction

The increase in the number of elderly persons with multiple chronic conditions including neuropsychiatric disorders and high levels of dependence entails increased demand for professional care workers in long-term residential care settings, such as nursing homes, in many countries1–3).

In France, medical retirement or nursing homes are designated “establishments for the accommodation of dependent elderly persons” (Etablissements d'Hébergement pour Personnes Agées Dépendantes: EHPAD). They provide collective accommodation and overall management for the elderly, including lodging, health care and dependence-related aid. Management is founded on a qualified multidisciplinary team notably comprising nurses, nursing assistants and housekeepers, who are under the supervision of physicians. Nurses usually ensure technical care and coordinate the work of the nursing assistants. As well as catering and accompaniment, nursing assistants are in charge of hygiene, comfort and preventive and curative care and are under the supervision of a nurse. Housekeepers carry out cleaning tasks, catering tasks and sometimes care tasks such as helping with meals.

Like other health-care workers, these workers are exposed to a variety of occupational risks4). Working with the elderly, however, may give rise to specific form of stress, such as having to deal with elderly persons suffering from behavioral disorders or confrontation with the death of their patients and caring for dying patients5–7). This stress may cause hardship at work and have a negative emotional and psychosocial impact. Thus, care-workers in nursing homes are exposed to potential risk factors for work-related stress8, 9).

Before developing prevention plans to improve working conditions and reduce stress levels for nonmedical nursing-home staff, working conditions need to be better identified, in particular according to occupational groups, such as nurses, nursing assistants and housekeepers.

For these reasons, we carried out a descriptive cross-sectional survey of 2,649 workers in 105 nursing homes for the elderly located in Rhône-Alpes, a region of France.

The main focus of this study was exploration of the potential risk factors for work-related stress by studying: perceived tasks and working conditions. A second aim was to identify any differences between 3 job categories: nurses, nursing assistants and housekeepers.

Materials and Methods

Sampling

The target population for the survey was employees working with elderly patients in nursing homes in the Rhône-Alpes Region of France. The region has a population of over 6 million (10% of the population of France). At the time of the survey, there were 677 nursing homes for the elderly, with a capacity of 50,535 residents.

The regional occupational physicians were asked to participate by the Regional Department of Businesses, Competition, Consumption, Work and Employment (DIRECCTE), a state organization providing control, advice and intervention for businesses. Volunteer occupational physicians were allowed to include the employees of only 1 or 2 of the nursing homes they oversaw; if they were involved in several establishments, only 2 study centers were selected, by randomization. The occupational physicians filled out a working conditions assessment questionnaire, and asked all employees meeting the inclusion criteria in the nursing homes which they oversaw to take part.

New recruits were excluded to avoid attributing problems that had more to do with a previous job to the nursing home.

Only employees who had been working with the elderly for at least 6 months on at least a half-time basis were included. Questionnaires were not allowed to be sent back late to the occupational physician, so as to avoid differences in data collection.

Ethical issues

Employees were free to agree or decline to participate. They were given an information leaflet explaining the study objectives. Approval by the French Ministry of Research (Comité consultatif pour le traitement de l'information en matière de recherche dans le domaine de la santé) was obtained before starting the study.

Survey variables

Between October 2009 and September 2010, socio-occupational data were collected from volunteer employees by self-administered questionnaire, including personal (age, gender, marital status and number of children) and occupational items (job title, relevant professional qualifications, perceived match between qualifications and job held, position, seniority in the establishment with years of experience, duration of experience of working with the elderly, number of elderly care facilities worked in, tasks and perception of job, job-related hardship, situations of physical assault, situations of verbal abuse, interpersonal relations at work, and vocational training). The questionnaire included visual analog hardship scales (1=no hardship, to 10=great hardship) related to premises (disrepair, stairs, clutter), lifting and carrying the elderly, patients' mental deterioration and physical deterioration, and proximity of death10–12). The choice of these particular categories was based on the literature13). Each hardship scale variable was recoded into three categories: slight hardship (score less than or equal to 3), moderate hardship (score between 4 and 7) and high hardship (score more than or equal to 8).

Quantitative seniority was transformed into an ordinal qualitative variable for statistical purposes. Two main models are currently used to evaluate psychosocial factors at work: the job strain model developed by Karasek, and the effort-reward imbalance (ERI) model using the Siegrist questionnaire12). Siegrist allowed a free access to the Siegrist questionnaire10,12).

Psychosocial demands at work were assessed with the Siegrist questionnaire, comprising 3 scales: 2 measuring the extrinsic components “effort” (6 items) and “reward” (11 items covering the aspects of earnings, esteem and job security) and 1 scale measuring the intrinsic component “overcommitment” (6 items), scored according to the 2004 ERI model; the higher the extrinsic and intrinsic effort scores, the greater the effort, whereas the higher the rewards score, the lower the rewards10,12,14). The rationale of the ERI model is that a working situation associating great effort to low reward will induce emotional and physiological reactions that may jeopardize health15). The French version of the Effort-Reward Imbalance model validated by Niedhammer et al., was used in this study10).

Data analysis

A descriptive step was performed to characterize the population of employees according to training, work organization and working conditions.

For statistical purposes, the study population was limited to those in direct contact with the elderly, who were divided into 3 occupational groups defined by qualifications and tasks: housekeepers (mainly household and catering tasks and delivery of meals), nursing assistants (mainly non-nursing care), and nurses.

Frequencies were compared on chi2 test. Depending on cross analyses performed, chi2 trend tests were also performed. Mean values were compared between pairs of groups with the Student's t-test and between more than 2 groups by analysis of variance (ANOVA). All statistical analyses were performed with the SAS software, version 9.3. The standard level of significance was used to justify a claim of a statistically significant effect: i.e., 0.05.

The binary response of ERI was modeled in two steps:

  • • Firstly, all independent variables underwent univariate analysis;
  • • Secondly, variables with a p value ≤0.05 were included in a multivariate model by a step-forward procedure: the variable with the lowest p value was included in the model first, followed by the next lowest, and so on. Variables with p values ≤0.05 remained in the model, and the other variables were excluded.

We performed multivariate analysis in order to study links between the 3 occupational groups and several variables. Logistic regressions were used when the variable of interest was dichotomous, and polytonic logistic regressions with a cumulative logit model were used when a variable presented 3 responses categories. Regressions were adjusted based on age, work contracts and duration of work with elderly persons.

Results

The 78 occupational physicians recruited 2,649 employees in 105 nursing homes in the 8 administrative départements of the Rhône-Alpes Region. Of them, 229 workers who matched the inclusion criteria were ultimately excluded, and 61 workers refused to participate in the study, leading to a participation rate of 90.7%.

The subjects included 706 housekeepers, 1,565 nursing assistants and 378, and most of them were female (94.6, 92.9 and 92.3%, respectively). Significant differences between groups were found for the following items: age, seniority in the establishment and duration of work with elderly persons (see Table 1).

Table 1. Socio-occupational data by occupational group
Housekeepers Nursing assistants Nurses p-value
n % n % n %
Gender Men 38 5.4 111 7.1 29 7.7 0.23 
Women 668 94.6 1,454 92.9 349 92.3
Age <30 years 137 19.4 371 23.7 67 17.7 <0.001
30–39 years 129 18.3 348 22.2 87 23.0
40–49 years 228 32.4 500 32.0 99 26.2
>50 years 211 29.9 345 22.1 125 33.1
Perception of match between qualifications and job heldby employees Yes 506 76.1 1,351 89.4 367 98.6 <0.001
No 159 23.9 161 10.6 5 1.4
Work contract Probationer 24 3.5 62 4.0 13 3.4 <0.001
Permanent work contracts 457 66.1 1,197 77.0 324 85.7
Short-term work contracts 174 25.2 257 16.5 41 10.8
Other work contracts 36 5.2 38 2.5 0 0
Seniority in the establishment (years of experience) <1 year 96 13.9 252 16.4 69 18.5 <0.001
1 year 77 11.2 182 11.8 59 15.8
2.4 years 164 23.8 311 20.2 94 25.2
5–9 years 144 20.9 341 22.1 80 21.5
≥10 years 208 30.2 455 29.5 71 19.0
Duration of work with elderly persons <1 year 47 5.8 76 4.9 24 6.4 0.001
1–4 years 230 32.8 413 26.5 130 34.6
5–9 years 167 23.8 386 24.8 96 25.3
10–19 years 176 25.1 429 27.5 88 23.4
≥20 years 87 12.4 253 16.2 38 10.1

% column: For each item, the sum of the percentages for each column is equal to 100%.

Tasks and working conditions

Household tasks were performed by housekeepers (89.9%), but also by nursing assistants (56.3%) and nurses (11.3%) (p<0.001), as were catering tasks (83.6, 67.3 and 15.8%, respectively; p<0.001). Nursing assistants were involved in feeding residents most frequently (87.4%), although housekeepers (76.6%) and nurses (66.8%) (p<0.001) were also involved in this task. A large majority of nurses (97.3%) provided technical care (bed sore treatment, massage, anal bags, probes), but 78.0% of nursing assistants and 35.9% of housekeepers (p<0.001) also provided this kind of care. Almost all nursing assistants (95.8%) provided personal care (washing, dressing, bathing, toileting), although 72.1% of nurses and 67.8% of housekeepers (p<0.001) also did so. Residents were put to bed and helped to get up mainly by nursing assistants (95.4%), followed by housekeepers (70.5%) and nurses (62.6%) (p<0.001). Administrative tasks were performed by 93.9% of nurses compared with 18.4% of housekeepers and 25.1% of nursing assistants (p<0.001). Preparation of medications was performed by 91.7% of nurses, although 4.3% of nursing assistants and 1.4% of housekeepers also performed this task (p<0.001). Delivery of medication was performed by 96.0% of nurses, 67.7% of nursing assistants and 31.5% of housekeepers (p<0.001). Organization of activities for residents was performed by 73.3% of nursing assistants, 57.9% of housekeepers and 17.16% of nurses. Nurses, on average, routinely performed a greater variety of tasks per day (mean=7.0, SD=1.8) than nursing assistants (mean=6.3, SD=1.7) or housekeepers (mean=5.0, SD=2.2) (p<0.001). Housekeepers made more beds (mean=8.9, SD=6.8) than nursing assistants (mean=8.2, SD=4.8) or nurses (mean=2.9, SD=4.4) (p<0.001). Nursing assistants more frequently washed residents (mean=8.67 per day, SD=4.66) than housekeepers (mean=7.60, SD=3.54) or nurses (mean=1.89, SD=1.35) (p<0.001).

Perception of work

The workforce was thought to be sufficient for the job by 20.8% of the respondents (independent of occupational group), and 71.1% of nurses, 75.3% of nursing assistants and 77.9% of housekeepers felt their work met the needs of the residents (p=0.048).

Aggression

Nearly three-quarters of the respondents reported verbal abuse from residents, although this was reported less frequently by housekeepers (60.9%) than nursing assistants (76.2%) or nurses (76.7%) (p<0.001). Nurses more frequently reported verbal abuse from residents' family members (46.9%, versus 20.2% for nursing assistants and 10.6% for housekeepers; p<0.001) and colleagues (28.8%, versus 23.7 and 18.71%, respectively; p=0.007). Physical attack by residents was more frequently reported by nursing assistants (59.1%) than nurses (52.8%) or housekeepers (38.0%) (p<0.001); physical aggression by colleagues (0.9%) did not significantly differ between occupational groups. When verbal or physical abuse had occurred, 1,813 respondents (68.4%) reported sympathy on the part of colleagues.

Interpersonal relations

Most respondents (82.7%) were satisfied with their relations with the team (independent of group), and 74% were satisfied or very satisfied with their relations with management, although this percentage was lower for nurses (69.3%, versus 73.0% for nursing assistants and 79.5% for housekeepers; p=0.001). The percentage of respondents dissatisfied with their relations with management was highest in nursing assistants (9.3%), followed by nurses (8.2%) and housekeepers (5.6%) (p=0.001).

Siegrist effort-reward imbalance model

Extrinsic and intrinsic effort and rewards differed significantly according to occupational group. Extrinsic and intrinsic effort scores were significantly higher in nursing assistants (respectively, mean=16.2, SD=4.3; mean=15.6, SD=3.9) than nurses (mean=14.5, SD=4.6; mean=14.9, SD=3.9) or housekeepers (mean=13.6, SD=4.5; mean=14.5; SD=3.9) (p<0.001; p<0.001). Reward scores were significantly higher for nurses (mean=20.4, SD=7.5) than nursing assistants (mean=19.1, SD=6.7) or housekeepers (mean=20.0, SD=7.3), (p<0.05). Nearly 10% of employees reported clear effort/reward imbalance: 10.4% of nursing assistants, 9.2% of nurses and 7.0% of housekeepers (p=0.059).

Table 2 presents the relationship between effort-reward imbalance -and other occupational factors by univariate analysis and multivariate analysis.

Table 2. Relations between prevalence of effort-reward imbalance and working conditions
Prevalence of effort-reward imbalance Univariate analysis Multivariate analysis
n/N % RR 95% CI RR 95% CI
Gender▿ Men 8/155 5.16 0.53 0.27–1.06 — —
Women 209/2,164 9.66 1 — — —
Age <30 years 45/516 8.72 1 — —
30–39 years 52/507 10.26 1.18 0.80–1.72 — —
40–49 years 75/728 10.30 1.18 0.83–1.68 — —
≥50 years 44/566 7.77 0.89 0.60–1.33 — —
Occupational group▿ Housekeepers 42/598 7.02 1 — —
Nursing assistants 144/1,384 10.40 1.48 1.06–2.06 — —
Nurses 31/338 9.17 1.31 0.84–2.04 — —
Work contract Probationer 5/86 5.81 1 — — —
Permanent work contracts 175/1,745 10.03 1.72/ 0.73–4.08 — —
Non permanent work contracts 35/469 7.46 1.28 0.52–3.18 — —
Seniority in the establishment (years of experience)▿ <1 year 24/358 6.70 1 — —
1 year 18/280 6.43 0.96 0.53–1.73 — —
2–4 years 55/513 10.72 1.60 1.00–2.53 — —
5–9 years 56/499 11.22 1.67 1.06–2.65 — —
≥10 years 59/642 9.19 1.37 0.87–2.16 — —
Duration of work with elderly persons* <1 year 4/124 3.23 1 — —
1–4 years 51/679 7.51 2.31 0.85–6.26 — —
5–9 years 67/573 11.69 2.50 1.30–9.43 — —
10–19 years 63/608 10.36 3.10 1.15–8.37 — —
≥20 years 31/327 9.48 2.87 1.04–7.95 — —
Verbal abuse**** No 16/536 2.99 1 1
Yes 201/1,784 11.27 3.78 2.29–6.22 2.53 1.47–4.33
Physical assault* No 72/1,155 6.23 1 1
Yes 145/1,165 12.45 1.99 1.52–2.62 1.36 1.03–1.79
Subjective hardship related to
Mental deterioration of elderly residents**** Slight 24/569 4.22 1 — —
Moderate 48/761 6.31 1.50 0.93–2.41 — —
Great 144/964 14.94 3.54 2.33–5.40 — —
Physical deterioration of elderly residents**** Slight 16/493 3.25 1 1
Moderate 38/771 4.93 1.52 0.86–2.69 1.22 0.68–2.19
Great 163/1,035 15.75 4.86 2.93–8.02 3.12 1.82–5.36
Proximity to death* Slight 37/699 5.29 1 1
Moderate 60/775 7.74 1.46 0.98–2.17 1.05 0.70–1.57
Great 120/829 14.48 2.73 1.92–3.90 1.51 1.03–2.20

Relative risk, RR; confidence interval, CI.

▿  p-value<0.1

*  p<0.05

**  p<0.01

***  p<0.001

****  p≤.10−4.

Hardship related to working conditions (see Tables 3, 4)
Table 3. Subjective hardship related to working conditions according to occupational group
Subjective hardship related to Occupational groups p-value *Adjusted p-value
Housekeepers Nursing assistants Nurses
n % n % n %
Handling of residents Slight 206 31.8 245 15.8  99 26.7 <0.001 <0.0001
Moderate 225 34.7 523 33.8 148 39.9
Great 217 33.5 781 50.4 124 33.4
Workplace Slight 346 50.4 761 49.4 160 43.0 0.178 0.002
Moderate 216 31.5 463 30.1 113 30.4
Great 124 18.1 316 20.5  99 26.6
Mental deterioration of elderly residents Slight 198 29.2 347 22.5  99 26.4 0.002 0.002
Moderate 225 33.2 501 32.4 129 34.4
Great 255 37.6 697 45.1 147 39.2
Physical deterioration of elderly residents Slight 186 27.3 290 18.7 90 23.9 < 0.001 <0.0001
Moderate 221 32.5 501 32.4 144 38.3
Great 274 40.2 758 48.9 142 37.8
Proximity to death Slight 207 30.5 451 29.1 130 34.6 <0.001 <0.0001
Moderate 197 29.0 522 33.6 161 42.8
Great 275 40.5 579 37.3  85 22.6
*  Adjusted based on age, work contracts and duration of work with elderly persons.

% column: For each item, the sum of the percentages for each column is equal to 100%.

Table 4. Hardship related to work factors
Hardship related to proximity to death p-value
Slight Moderate Great
n % n % n %
Attachment of health-care staff to elderly residents Very often 128 24.48 140 26.77 255 48.76 <0.001
Often 447 29.05 549 35.67 543 35.28
Several times 165 37.41 155 35.15 121 27.44
Seldom or never   4 47.62  27 32.14  17 20.24
Palliative care training over the previous 5 years No 506 29.42 565 32.85 649 37.73 0.039
Yes 282 31.79 315 35.51 290 32.70
Desire for training in palliative care No 490 32.47 516 34.20 503 33.33 0.039
Yes 298 27.14 364 33.15 436 39.71
Hardship related to mental deterioration of elderly residents p-value
Slight Moderate Great
n % n % n %
Desire to work in another establishment No 460 26.21 584 33.28 711 40.51 0.019
Yes 173 22.24 246 31.62 359 46.14
Verbal abuse by residents No 275 37.62 243 33.24 213 29.14 <0.001
Yes 369 19.76 612 32.78 886 47.46
Previous training in psychological approaches for elderly residents No 427 26.28 541 33.29 657 40.43 0.217
Yes 217 22.30 314 32.27 442 45.43
Hardship related to physical deterioration of elderly residents p-value
Slight Moderate Great
n % n % n %
Desire to work in another establishment No 410 23.27 594 33.71 758 43.02 0.002
Yes 145 18.64 244 31.36 389 50.00
Desire for training in psychological approaches for elderly residents No 391 23.26 551 32.78 739 43.96 0.035
Yes 175 18.92 315 34.05 435 47.03
Desire for palliative care training No 356 23.64 485 32.20 665 44.16 0.020
Yes 210 19.09 381 34.64 509 46.27

% line: the sum of the percentages for each line is equal to 100%.

Hardship related to handling of residents, residents' mental deterioration, proximity to death and residents' physical deterioration differed significantly according to occupational group without and with adjustment on age, work contracts and duration of work with elderly persons.

Hardship related to proximity to death was reported as being great, moderate and slight by 36.2, 33.7, and 30.1% of respondents, respectively. Hardship related to proximity to death was considered great by 40.5% of housekeepers, versus 37.3% of nursing assistants and 22.6% of nurses (p<0.001). Housekeepers most frequently reported becoming often or very often attached to residents (85.1%, versus 78.9% for nursing assistants and 73.9% for nurses; p<0.001).

Respondents who rarely became attached to residents more often reported only slight hardship related to proximity to death. Respondents desiring training in palliative care and accompaniment of the dying reported elevated hardship related to proximity to death significantly more often than those who had received such training. Great hardship related to residents' mental deterioration was significantly more often reported by victims of verbal abuse from residents and by workers desiring to work in another establishment. Hardship related to residents' physical deterioration was associated with desire to work in another establishment, and was more frequently considered great by respondents desiring training in psychological approaches for elderly subject or in palliative care.

Training over the previous 5 years and desire for training (see Table 5)
Table 5. Training over the previous 5 years and desire for training differed significantly according to occupational group
Training over the previous 5 years Occupational group p-value *Adjusted p-value
Housekeepers Nursing assistants Nurses
n % n % n %
Receiving the elderly and activities No  547 77.4 1,018 65.0 286 75.7 <0.001 <0.0001
Yes 160 22.6   547 35.0  92 24.3
Psychological approaches for elderly residents No 524 74.1   919 58.8 227 60.0 <0.001 <0.0001
Yes 183 25.9   646 41.2 151 40.0
Hygiene No 393 55.6   990 63.3 294 77.8 <0.001 <0.0001
Yes 314 44.4   575 36.7  84 22.2
Palliative care and accompaniment of the dying No 566 80.1   974 62.2 216 57.1 <0.001 <0.0001
Yes 141 19.9   591 37.8 162 42.9
Handling of residents No 360 50.9   632 40.4 213 56.3 <0.001 <0.0001
Yes 347 49.1   933 59.6 167 43.7
Other training No 686 97.0 1,495 95.6 355 93.9 0.048 0.037
Yes  21  3.0    70  4.5  23  6.1
Desire for training Housekeepers Nursing assistants Nurses p-value *Adjusted p-value
n % n % n %
Receiving the elderly and activities No 566 80.1 1,274 81.4 230 87.3 0.009 0.004
Yes 141 19.9   291 18.6  48 12.7
Hygiene No 613 86.7 1,452 92.8 356 94.2 <0.001 <0.0001
Yes  94 13.3   113  7.2  22  5.8
Palliative care and accompaniment of the dying No 446 63.1   888 56.7 208 55.0 0.007 0.006
Yes 261 36.9   677 43.3 170 45.0
Handling of residents No 521 73.7 1,176 75.1 304 80.4 0.043 0.014
Yes 186 26.3   389 24.9  74 19.6
Other training No 669 94.6 1,417 90.6 325 86.0 <0.001 <0.0001
Yes  38  5.4   148  9.5  53 14.0
*  Adjusted based on age, work contracts and duration of work with elderly persons.

(% column: For each item, the sum of the percentages for each column is equal to 100%).

Training over the previous 5 years and desire for training differed significantly according to occupational group and depending on the training module without and with adjustment based on age, work contracts and duration of work with elderly persons.

Discussion

In spite of increased demands on nursing home workers and a growing need for the care they provide to so many elderly persons, to our knowledge, data on their working conditions, some aspects of which may constitute risk factors for work-related stress, are sparse. In response to this situation, the present large-scale survey investigated various aspects of working conditions for 2,649 French nursing home workers in three occupational categories in daily contact with residents: nurses, nursing assistants and housekeepers.

Study of the task distribution according to the 3 occupational groups showed confusion of tasks and responsibilities in the study population. Several studies have found that competence and work tasks are mismatched in nursing home care16–18). In France, as in many countries, confusion of tasks and responsibilities might be explained by the fact that the proportion of nurses in the workforce in nursing homes is different from that found in other care settings, such as acute hospital care: nursing homes tend to have fewer registered nurses and a higher proportion of support workers. It may be also explained by the low absolute staffing levels, especially for nurses, usually observed in French nursing homes for the elderly; thus, only 20.8% of respondents in the present study thought the workforce was sufficient for the job. For some authors, it is not necessarily the case that more staff (i.e., more staff hours per resident day) would mean better care. There are wide-ranging professional and policy debates about what constitutes “nursing” care and who is able to carry out nursing duties19).

Delegation of complicated tasks to staff without formal nursing training is common, and is reported to be associated with feelings of uncertainty in nursing staff17). Insufficient and inadequate competence regarding work tasks has been shown to be a source of strain and stress for nursing personnel20). However, the confusion of tasks and responsibilities described by the present respondents did not seem to be a source of hardship: the majority were satisfied with the match between qualifications and job held.

Nurses, on average, routinely performed a great variety of tasks per day, including them administrative tasks. In previous studies, care staff for the elderly reported lacking time to perform their care tasks, which may lead to a feeling of guilty conscience and to work stress16–18, 21–23).

Most respondents were satisfied with their relations with their team, independently of the occupational group. These findings agree with those of Castle et al. for two rest homes in the USA, where care staff were satisfied with their work and relations with colleagues24). A care setting is an environment in which employees work and interact daily25). The present results may be explained by people working in geriatric settings forming close ties because they share common issues at work, such as frequent death, low staff levels and uncooperative residents. Thus, most victims of verbal or physical abuse reported receiving sympathy from colleagues. Working on the same ward with the same team of colleagues for a long time may favor close relationships; about 60% of respondents had worked in the same establishment for 5 years or more. Many were also satisfied or very satisfied with their relations with management, although this percentage was lower for nurses than the other two groups; this finding is not consistent with those usually reported in other studies, in which good relationships have been found mainly with direct peers and others working in the same ward24). In a study of work stressors affecting nurses' aides in long-term care facilities and the factors related to work stressors, Lin et al found that, of the six types of work stressor distinguished, relationships with supervisors were the least stressful26)

In the present study, psychosocial demands at work were assessed with the Siegrist questionnaire12); the rationale of this ERI model is that a work situation associating great effort with low reward will induce emotional and physiological reactions that may jeopardize health.15). Siegrist's ERI model is based on the assumption that there should ideally be a reciprocal relationship between work done and socially defined rewards27). The employee's health is viewed in relation to work done and rewards received (salary, recognition, job security and promotion prospects). If there is an imbalance, associating high performance with low rewards, Siegrist regards it as a stressful situation, which increases the risk of stress-related disorders if it persists for some time (ERI hypothesis). Nearly 10% of respondents, and especially nursing assistants (10.4%), reported a clear effort/reward imbalance in our study. These results are similar to those observed in other European countries. The French SAMOTRACE study of 3,117 men and 2,229 women in a variety of job sectors found that 2.8% of men and 3.0% of women claimed effort/reward imbalance28). The prevalence of ERI is higher in French care givers (8.8%)29). In several European countries, effort and reward and the resulting imbalance differ substantially between different types of health-care institution. The European PRESST-NEXT study showed that, in German nursing homes, as many as 26.5% of employees were exposed to a high effort/reward imbalance, mainly due to an extremely high level of effort associated with low reward in terms of esteem30). In France, nurses in nursing homes were at relatively high risk of ERI (12.5%), attributable to high levels of effort30). In Italian nursing homes, a high rate of ERI (21.3%) was due to high levels of effort and low reward on all three reward components: esteem, status control and financial reward. In our survey, ERI was related by multivariate analysis to verbal abuse, physical assault, proximity to death, and physical deterioration for elderly residents.

Nearly three-quarters of respondents reported verbal abuse from residents. This especially concerned nurses, whereas nursing assistants were more frequently exposed to physical attack by residents than the other two groups. The geriatric setting has been recognized as one of the most frequent sites of workplace violence in the health-care sector, including hospitals and other institutions providing health services. The risk of frequent violence against care workers, in homes, day-hospitals or consultation settings in 7 European countries, was highest in psychiatry (adjusted odds ratio (OR)=4.89 [3.82–6.25]), followed by emergency departments (adjusted OR=2.68 [2.1–3.44]) and long-stay geriatric facilities (adjusted OR=1.32 [1.05–1.65])31). According to Estryn-Behar, staff in nursing homes for the elderly are more often confronted by aggressive patients than in hospitals or facilities for the disabled32). Nursing assistants in long-stay facilities experience the highest incidence of assault of all employees in the USA31). According to Camerino et al., violence by patients or their families in a variety of care structures targets nursing assistants (24%) more often than nurses (22%) or chief nurses (21%)33). This higher exposure of nursing assistants to risk of physically violent acts by patients observed in the present study and in the literature may be explained by closer and more personal contact (for example, during transfer to and from chairs, toilets, etc.) than is the case for other workers34).

In the present study, proximity to death caused particular hardship for housekeepers (40.5%) as compared with nursing assistants (37.3%) and nurses (22.6%). This may seem surprising, inasmuch as housekeepers are basically supposed to perform household and catering tasks31). It was also noteworthy that, in all 3 groups, respondents from who rarely became attached to residents more often reported only slight hardship related to proximity to death. One of the major concerns of nursing home staff is emotional attachment to residents35). Approaching death is a source of hardship for those working with the elderly and may contribute to increased stress36). The need for training most frequently mentioned by nursing-home staff is how to manage end-of-life care, and training opportunities have been found to be an important factor for job satisfaction in these workers35).

The physical and mental deterioration of elderly patients was more often perceived as a source of great hardship by nursing assistants, who spend most of their working hours in direct contact with the patients. Hardship related to mental deterioration was greater in those who had not had training in psychological approaches for elderly subjects; that related to physical deterioration showed a significant association with a desire for training in psychological approaches for elderly subjects or in palliative care, but not with a desire for training in lifting and carrying. Having to take care of residents with mental deterioration who exhibit combative, uncooperative behavior and sometimes abuse workers was frequently mentioned as contributing to stress in the work environment. Consistent with this stress factor, the most frequently mentioned training need concerned managing dementia behavior37). Ripich et al. found that nursing assistants frustrated by the difficulty of communicating with Alzheimer patients reported a definite benefit from communication training38). In a study of 67 nursing assistants, some of whom had received training in feeding dementia patients and some of whom had not, Chang et al. found that the training provided benefited not only the personnel (improved knowledge and behavior) but also the patients39). Moreover, poor or nonexistent training in areas such as managing residents with a memory disorder has been identified as a key factor in certified nursing assistant job dissatisfaction40). These findings combined indicate a positive impact of such training on both job satisfaction and the conditions and quality of work with elderly patients showing mental deterioration.

There are some limitations to this study. First, extrapolation should be performed with caution. Care workers in nursing homes are not a homogeneous professional group, as in different countries, organization and tasks differ. Second, it is important to emphasize that the present study did not measure objective indicators in the work environment: e.g., to assess physical and emotional strain. Third, although this applies to most questionnaires, it is critical to note that our study described participants' perceptions of given indicators in their work, mostly via closed questions. Finally, the cross-sectional design of this study precludes any cause-and-effect conclusions regarding the study variables. Nevertheless, our sample size of nursing homes and workers was relatively large, and was representative of the population of Rhone-Alpes Region nursing homes, so the study provides a large amount of information about the working conditions of the three main occupational groups involved in nursing home residential care.

This study highlighted some potential risk factors for work-related stress in the care of elderly people among care workers working in nursing homes. Future research needs to further examine the relationship between effort-reward imbalance and working conditions.

The results showed that there was substantial confusion of tasks between the three occupations categories and that nursing home workers were exposed to verbal abuses and physical assaults, and experienced hardships, particularly when there was a lack of training in an area (such as when caring for residents approaching death). We suggest that necessary measures have to be initiated and implemented by nursing home administrators. To prevent insufficient ability stress, nursing home workers should be encouraged to attend job training courses, which should cover knowledge of elderly patient-specific care needs and the authority/responsibility to do this job. To reduce heavy workload stress of nurses, adequate staffing should be considered of utmost importance. To prevent stress due to resident violence, resident death, dying or provision of end-of-life care, a section on caring and coping skills to deal with residents and a course aimed at managing aggression and preventing violence should be added to job training. Faced with the trend of an elderly population and increased care demand year after year consideration of nursing home workers' needs is essential for managers to keep their personnel on the job in the nursing home. Hence, appropriate measures, consisting of education and support, might facilitate nursing home workers' feelings of work satisfaction.

Funding statement: This study received funding from the “Department of Businesses, Competition, Consumption, Work and Employment” (DIRECCTE).

Acknowledgments: The authors thank all of the occupational physicians who agreed to cooperate with them in performance of this study:

Drs Alric, Aragnou, Bados, Basbous, Barthelemy, Berticat, Bressot-Perrin, Briatte, Brotel, Bund-Dauffer, Cayot, Chabanis, Chalaye, Chardon, Chavatte, Chenevaz, Couprie, Decoster, Delaygue, Deries, Dubreuil, Dumont, Ehrmann, Etaix, Etienne-Millier, Faure, Fontenoy, Fouilly, Fustier, Glerant, Granier, Girer, Guilhaudin, Habrard, Huboud-Peron, Hugues, Jaussaud, Julien, Lafarge, Lafon, Lasseron, Locci, Locher, Loubet-Deveaux, Luci Bello, Lusamvuku, Martaresche, Manaou, Martelain, Megerie, Neyra, Panchairi, Perrier, Philippe, Pruvot. Religieux, Renaud, Ribella, Rosati, Royer, Sabbagh, Sellier, Seys-Bedu, Tercinier, Thiriet, Thomassin, Thoviste-Boutrand, Traynard, Vaugeois, Viossat, Vitrolles.

Conflict of interest: The authors declare that they have no conflicts of interest.

References
 
2015 by the Japan Society for Occupational Health
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