This article was downloaded by: [The Aga Khan University]On: 24 November 2014, At: 22:45Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: MortimerHouse, 37-41 Mortimer Street, London W1T 3JH, UK

Aging & Mental HealthPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/camh20

Dementia care and labour market: The role of jobsatisfactionMyrra J. Vernooij-Dasssen a , Marjan J. Faber a , Marcel G. Olde Rikkert b , RaymondT. Koopmans b c , Theo van Achterberg a , Didi D. Braat d e , Gerda P. Raas e & HubWollersheim aa Scientific Institute for Quality of Healthcare, Radboud University Medical centre ,Nijmegen, The Netherlandsb Department of Primary and Community Care Centre for family Medicine , GeriatricCare and Public Health Radboud University, Kalorama foundation Nijmegen MedicalCentre , Nijmegen, The Netherlandsc Department of Primary and Community Care , Radboud University Nijmegen MedicalCentre , Nijmegen, The Netherlandsd Department of Obstetrics and Gynaecology , Radboud University Nijmegen MedicalCentre , Nijmegen, The Netherlandse Council for Public Health and Health Care , The Hague, The NetherlandsPublished online: 29 May 2009.

To cite this article: Myrra J. Vernooij-Dasssen , Marjan J. Faber , Marcel G. Olde Rikkert , Raymond T. Koopmans , Theovan Achterberg , Didi D. Braat , Gerda P. Raas & Hub Wollersheim (2009) Dementia care and labour market: The role ofjob satisfaction, Aging & Mental Health, 13:3, 383-390, DOI: 10.1080/13607860902861043

To link to this article: http://dx.doi.org/10.1080/13607860902861043

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose ofthe Content. Any opinions and views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be reliedupon and should be independently verified with primary sources of information. Taylor and Francis shallnot be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and otherliabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to orarising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Aging & Mental HealthVol. 13, No. 3, May 2009, 383–390

Dementia care and labour market: The role of job satisfaction

Myrra J. Vernooij-Dasssena*, Marjan J. Fabera, Marcel G. Olde Rikkertb, Raymond T. Koopmansbc,Theo van Achterberga, Didi D. Braatde, Gerda P. Raase and Hub Wollersheima

aScientific Institute for Quality of Healthcare, Radboud University Medical centre, Nijmegen, The Netherlands;bDepartment of Primary and Community Care Centre for family Medicine, Geriatric Care and Public Health RadboudUniversity, Kalorama foundation Nijmegen Medical Centre, Nijmegen, The Netherlands; cDepartment of Primary and

Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; dDepartment of Obstetricsand Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; eCouncil for Public Health

and Health Care, The Hague, The Netherlands

(Received 12 December 2008; final version received 3 March 2009)

Objectives: A labour shortage in the dementia care sector is to be expected in the near future in the Netherlandsand in many other European states. The objective of this study is to analyse why people quit or avoid jobs indementia care.Method: An integrative analysis was used to study reports, articles, and Website information on the dementiacare labour market.Results: The main reason for quitting a (dementia) care job was the lack of job satisfaction. Job satisfaction wasreduced by a lack of appreciation and professionals’ own dissatisfaction about the quality of care they were ableto provide. Effects of staff training on job satisfaction, quality of dementia care, and patient functioning arepromising.Conclusion: Job satisfaction is the main cause of quitting (dementia) care jobs. It might also be the key to solvingproblems in the dementia care labour market. Considering health-care workers as precious capital and takingadequate measures to enhance job satisfaction might contribute to a better image of dementia care. The followinghypothesis has been derived from our results: enhancement of job satisfaction will prevent professional caregiversfrom quitting jobs and improve the quality of care and patient outcomes.

Keywords: job satisfaction; labour market; health care; quality of care; image of care

Introduction

Dementia care is labour intensive and therefore costintensive. It is a great challenge for governments toprovide adequate care at an acceptable cost level.Both financial and human resources are needed toprovide optimal dementia care.

Financial resources facilitate or impede adequatecare. The costs of dementia care are considerable.The average annual costs per dementia patient in theUK are estimated as follows: for a patient in thecommunity with mild dementia, E1985; with moderatedementia, E2797; with severe dementia E3919.Accommodation accounted for 41%, informal carefor 36%, social services for 15%, and National HealthService (NHS) for 8% of the total costs (Knapp &Prince, 2007). Dementia is one of the top three areas ofhealth-care costs in the Netherlands (Meerding,Bonneux, Polder, Koopmanschap, & van der Maas,1998; Slobbe et al., 2006), in 2003 5.3% of the totalhealthcare budget was spent on dementia (Slobbeet al., 2006).

Since accommodation is a major cost driver, there isa tendency in many European governments to stimulatepersons with dementia to live at home as long aspossible. The proportion of people with dementia livingat home ranges from 61.5% in France to 85.0% in Italy

(Vernooij-Dassen et al., 2005). In the Netherlands, 65%

of people with dementia lives at home (Health Council,

2002). It should be noted that dementia care is mainly

provided by the family, and that professional dementia

services are usually additional to family care.The average time during which people with

dementia live at home is 4.5 years, and in a nursing

home, 2.5 years; the average disease period is 7 years

(Koopmans & Ekkerink, 2001).Nearly all European states provide home care and

have nursing homes, but the availability of dementia

services varies greatly (Vernooij-Dassen et al., 2005).

In some states such as the Netherlands, UK, Ireland

and Belgium a wide range of services is available on

a large scale, while other states like Portugal and parts

of Italy lack services (Vernooij-Dassen et al., 2005).The advanced economies allow an increase of the

labour force in dementia care in times of economic

growth. This is an opportunity to improve the quality

of care. However, in these periods, fewer people choose

to work in dementia care. In the near future, the labour

shortage in the health-care sector, including nursing

home care, home care and mental health care is

expected to be 4.8% in the Netherlands (van der Windt

& Talma, 2005). Similar problems are expected in other

European Union states according to the Secretary

*Corresponding author. Email: M.Vernooij-Dassen@iq.umcn.nl

ISSN 1360–7863 print/ISSN 1364–6915 online

� 2009 Taylor & Francis

DOI: 10.1080/13607860902861043

http://www.informaworld.com

Dow

nloa

ded

by [

The

Aga

Kha

n U

nive

rsity

] at

22:

45 2

4 N

ovem

ber

2014

General of the European Federation of Public(van Caelenberg, 2006). Knowledge on why peoplequit or avoid jobs might help to prevent people fromquitting jobs. The objective of this study is to analysewhy people quit or avoid jobs in dementia care.

Methodology

We conducted a literature study to answer the researchquestion. The conventional review methodology didnot produce an answer, since many relevant publica-tions have not been reported as articles, but as reportsand on-line publications. For instance, there was onlyone PubMed hit for ‘dementia’ combined with ‘labourmarket’, which was not suitable for inclusion.Therefore, we chose an integrative review methodthat summarizes past empirical or theoretical literatureto provide a more comprehensive understanding of thedementia labour market problem (Whittemore &Knafl, 2005). The method requires the use of at leasttwo strategies. We used a general literature review anda systematic review. In Table 1 we compare thesereview sources. An invitational conference was used todiscuss the results of the reviews and to derive newinformation on recent developments in the dementiacare labour market. In order to get a more compre-hensive understanding, we analysed the resultsacquired from these sources for patterns.

General literature review

Electronic databases (PubMed and the CochraneLibrary) and extensively searched grey literature data-bases were used for the general literature study. Thefollowing search terms were used: dementia, disability,health-care utilization, informal care, formal care andcaregivers. Included are all qualitative and descriptivestudies on the subject, as well as correlation orcomparative designs. Grey-literature search was studiedin databases and on Websites of stakeholder organiza-tions (health-care research institutes and governmentalboards within the Netherlands). The sources usedincluded reports of the Ministry of Health, the DutchHealth Council, the Social and Cultural Planning Officeof the Netherlands, and included Websites of StatisticsNetherlands and the National Institute for PublicHealth and the Environment (Council for PublicHealth and Health Care, 2006).

Systematic review

The overarching theme found in the general review was

studied in a systematic review. In a PubMed search, the

term ‘dementia’ was combined with ‘job satisfaction’.

Correlation studies and studies using a comparative

design were included, while studies using a qualitative

design and opinion articles were excluded.

Invitational conference

An invitational conference was set up to check our

literature findings and to add new information about

developments in dementia care in relation to the

developments in the labour market. Therefore, 38 senior

representants of the Dutch Health council, the Council

for Public Health and Health Care, researchers of five

Dutch universities, three research institutes, the Dutch

Alzheimer patient organization, the expertize centre for

informal care, geriatric nursing, mental health care

organizations, integrated care network and insurance

companies were invited. Statements were used to

structure the discussion. An example of such a statement

is, ‘The image of dementia care can be improved by

improving the quality of care.’ The participants agreed

on the notes of the invitational conference (Council for

Public Health and Health Care, 2006).

Analysis

We used a grounded theory approach, and hypothe-

sized inductively from the data (Mays, Pope, & Popay,

2005). Therefore, we used a constant comparison

method for qualitative analysis, which facilitated

placing the extracted data into systematic categories

for distinguishing themes, variations, relationships and

patterns (Corbin & Strauss, 1990).This method was applied to the results of the

reviews and the notes of the invitational conference.

The results of all multi-source data were then analysed

again to find patterns.

Results

The data sources used in the reviews are described in

Table 1.The general literature review uses resources that

provide a broader perspective, while the systematic

review only uses peer reviewed journals and strict

inclusion criteria.

Integrated review

In order to achieve comprehensive understanding of

the research problem, the following themes were

considered in relation to quitting or avoiding jobs in

dementia care: labour market developments, image of

dementia care and job satisfaction (Council for Public

Health and Health Care, 2006).

Table 1. Sources general literature review and systematicreview.

General literature review Systematic review

Health policy advisereports (Dutch)

Articles in peer-reviewedjournals

Website: non-profitorganization in Europe

Articles in peer-reviewed journalsArticles in journals forHealth care professionals (Dutch)

384 M.J. Vernooij-Dasssen et al.

Dow

nloa

ded

by [

The

Aga

Kha

n U

nive

rsity

] at

22:

45 2

4 N

ovem

ber

2014

General literature review

Labour market developments

The economic development, shifts in governmentpolicies, and the composition of the labour force mayinfluence labour market developments.

Economic development. The labour market in the caresector (nurses, welfare workers, nursing aids andunqualified occupational workers) fluctuates simulta-neously with the economic fluctuations. The number ofvacancies in the care sector diminished in theNetherlands between 2001 and 2003 from almost24,000 to 17,000 (i.e. approximately a surplus of1.5%) (Ott, Paardekooper, & van der Windt, 2005).The vacancy rate stabilized between 2003 and 2005 anddropped to no vacancies in 2006. The shortage ofhealth-care workers in Dutch care sector is expected tobe 4.8 – 6.1% in 2010. The reduction of vacanciesin the health-care sector between 2003 and 2005 wascaused by economic decline. As a result, there werefewer jobs available and people did not leave their ownjobs (Ott et al., 2005). However, the economic revivalsince 2005 has reversed some tendencies. For example,turnover rates increased, which might reduce thequality of care. A significant relationship was foundbetween high employee turnover and poor residentoutcomes (Bostick, Rantz, Flesner, & Riggs, 2006).

Government policies. Government policies can alsoinfluence the dementia care labour market. Shifts inhealth-care policy, such as the introduction of themarket principle and budget cuts, might have pro-found effects on choices to be made in care to bedelivered. Such effects may affect the health-carelabour market both directly and indirectly (Schut &van de Ven, 2005). Moreover, the need for competitionamong services might compete with the urgent need forcollaboration in complex dementia care.

Composition of the labour force. The composition ofthe labour forces is another striking problem, and itwas found to be related to labour market shortages.

A major problem in dementia care is the decline inthe level of education of health-care workers.Especially in Dutch nursing home care, the numberof highly qualified nurses declined from 1989 to 2004,while the number and complexity of problems ofpatients increased (Health Care Inspectorate, 2004).In 2004 the composition of occupational caregivers innursing homes (not only dementia care) was: nurses11%, nursing aids 71% and unqualified workers 18%.In home care the level of education was even lower:nurses 13%, nursing aids 37% and unqualified workers50% (van der Windt & Talsma, 2005). The importanceof the staffing level is underlined by the positiveassociation found between higher total staffing levels(especially licensed staff ) and improved quality of care(Bostick et al., 2006). Conversely, the lack of available

staff knowing how to deal with dementia care reducesthe quality of care and job satisfaction.

Due to economic growth after 2004, the educationlevel will become even more problematic becauseyoung people with a drive to study will probablychoose other professions. Thus, a serious reduction ofrecently graduated nurses and nurse assistants after2007 is to be expected (van der Windt & Talma, 2006).

Demographic developments might also requireaction. In many countries, the population of elderlypeople who need health care is growing, while thepopulation of younger people who can help them isshrinking (van Caelenberg, 2006).

In conclusion, the labour market in dementia carestruggles with problems caused by the economicfluctuation, governmental policy introducing themarket principle and low education level of staff.

Image of dementia

There is a negative image of dementia and dementiaquality of care. Even in a state with a wealth offacilities such as the Netherlands, the Health CareInspectorate, medical and nursing staff, press, andpublic all report deficits in quality of dementia care.The Dutch Health Care Inspectorate concluded in2004 that only one-fifth of the nursing homes compliedwith minimum standards (Health Care Inspectorate,2004). Staff working in nursing homes is critical aboutthe quality of care delivered due to shortages of staffand equipment, and they do not dare to communicateabout this, fearing a negative impact on the patient(Messchendorp, Blok, Koopman, Wansink, & vanVliet, 2004). They feel frustrated by often doing theirutmost and yet not doing enough. They cannot beproud of their achievements under these difficultcircumstances. Yet, many professionals are verydedicated to their jobs (The, 2005). There is a lot ofnegative publicity about the quality of nursing homes,for example, the so-called ‘pyjama days’ (i.e. a personhas to stay in bed all day because of a lack ofpersonnel). This causes their relatives to fear inade-quate care (Health Council, 2002). An internationalreview reveals that organization, teamwork, commu-nication and leadership were all indeed critical to bothresident and staff outcomes (Scott-Cawiezell &Vogelsmeier, 2006).

Serious efforts are now being made to improve thequality of dementia care both at home and ininstitutions. Guidelines have been developed, andthey include chapters on caregiving (NationalInstitute for health and clinical excellence (NICE),2006; Scottish Intercollegiate Guidelines Network(SIGN), 2006), and on collaboration between generalpractitioners and nurse practitioners (Boomsma et al.,2005).

The image of dementia care also suffers from theimage of dementia. Iliffe et al. (2005) and Sartorius(2003) report a negative image of dementia.This negative image is clearly described in a Dutch

Aging & Mental Health 385

Dow

nloa

ded

by [

The

Aga

Kha

n U

nive

rsity

] at

22:

45 2

4 N

ovem

ber

2014

survey among 961 people in the general population.Fifty six percent said that life would not be worthliving if dementia caused them to become totallydependent. However, when it was stated that adequatecare could be arranged this proportion dropped to30% (Jansen van Doorn, 2003).

Since there is no cure for dementia at present, thereis a strong feeling that nothing can be done to improveor sustain the patient’s condition, which in itself givesrise to the societal stigma that dementia carries. It hasbeen suggested that it is impossible to communicateadequately with people with dementia (Chapman,Williams, Strine, Anda, & Moore, 2006; Vernooij-Dassen et al., 2005). Nonetheless, there are feasible andeffective ways of communicating with people withdementia. Knowing how to communicate with them,how to use their remaining capacities, and how tocompensate for deficits might change a task initiallyperceived as hopeless into a challenging job.

Job satisfaction

Not surprisingly considering the context of dementiacare, job satisfaction is under pressure. Lack of jobsatisfaction is a major reason for quitting a care job innursing homes and home care for persons withdementia and persons with long term disabilities.Exit interviews in the Netherlands funded by theMinistry of Health indicate that 64% of the jobs left bynurses, home care workers and nursing home aids areperceived as preventable in residential and nursinghomes, and 55% in the home care sector. Somepreventable reasons for leaving jobs in residential andnursing homes are: poor contact with heads of staff(13%), dissatisfaction with the quality of delivered care(12%), insufficient career perspectives (12%), and highwork pressure (11%) (Ott et al., 2005). In home care,the main reasons for preventable leave are: insufficientcareer perspectives (12%) and insufficient personaldevelopment (10%) (Ott et al., 2005). Other Europeanstudies confirm the results of this Dutch study.Job satisfaction is negatively influenced by the fewpromotional opportunities, negative contacts withsuperiors (Castle, Degenholtz, & Rosen, 2006), andinsufficient nursing capacity in relation to the indivi-dual demand for care (Rathert & May, 2007).

In the care sector, labour was perceived to be aphysical burden by 62% in 2005, with 25% experien-cing high work pressure (Ott et al., 2005). Satisfactionwith wages might also influence job satisfaction.In 2004, the raise in wage percentage in the caresector (0.4%) was lower than that in the total economy(1.3%). Twenty-eight percent of the employees in thehealth-care sector consider the wage reasonably highor high, while this is 38% in the total economy(Ott et al., 2005).

The findings about the relationship between work-related strain and job satisfaction are contradictory.Strain was mentioned as a reason for quitting the job,but correlation studies find that job satisfaction scores

were relatively independent of the results of the

burnout inventory and work-related strain. It hasbeen suggested that positive work experience andnegative work experience are not opposites (Hansson,Hallberg, & Axelsson, 1995). These results seem toindicate that a certain amount or kind of burden doesnot interfere with job satisfaction. There are alsoindications of a relationship between staff attitudesand patient outcomes. Increased hope among the staffis associated with a better resident quality of life(Spector & Orrell, 2006).

Job satisfaction in health care is expected to dependon intrinsic pleasure and social incentives (Lynn,Redman, & Zomorodi, 2006; Venturato, Kellett, &Windsor, 2006). Factors contributing to intrinsic pleasurein nursing homes are a good spirit sharedwith co-workers(Castle et al., 2006), having the perception or reward ofdelivering care of good quality (Castle et al., 2006;Messchendorp et al., 2004), and being able to deliverpatient-centred care (Rathert & May, 2007).

The results of this general literature review provideessential information about the context of the labourmarket problems in dementia care. Job satisfactionseems to be a main problem since it is directly related tochoosing or quitting dementia care jobs, and otherthemes are related to job satisfaction. Therefore, wesystematically searched for information about therelationship between job satisfaction and dementia care.

Systematic review

Two researchers (MVD, MF) independently searchedfor data about the relationship between dementiacare and job satisfaction. We identified 45 studies,of which four were correlation studies and seven useda comparative design. Thirty-three studies were

excluded: 11 were not related to the research question,22 had no comparative or correlation design, and onehad no job satisfaction outcome.

The correlation studies reveal that job satisfactionin dementia care is positively related to involvement in

patient-centred care (Drebing, McCarty, & Lombardo,2002) and professionals’ feelings of personal growth(Drebing et al., 2002). The extent of burden onprofessionals is negatively associated with job satisfac-tion (Drebing et al., 2002). Job satisfaction scores arerelatively independent of the results of the burnoutinventory and of the work-related strain (Brodaty,Draper, & low, 2003; Hansson et al., 1995). Nursingstaff with more negative attitudes reported lower levelsof strain and less job satisfaction (Brodaty, Draper, &Low, 2003).

Interventions that allow professionals to acquiremore skills in caring for people with dementia improvejob satisfaction. Specific interventions such as snoeze-len (van Weert, van Dulmen, Spreeuwenberg, Bensing,& Ribbe, 2005) and emotion-oriented training(Finnema, Droes, Ribbe, Van, 2000), validation(Nooren-Staal, Frederiks, & te Wierik, 1995), as well

386 M.J. Vernooij-Dasssen et al.

Dow

nloa

ded

by [

The

Aga

Kha

n U

nive

rsity

] at

22:

45 2

4 N

ovem

ber

2014

as interventions using training and application of

individualized care plans (Lyne et al., 2006), staff

training in assisted living residences (STAR); (Teri,

Huda, Gibbons, Young, & van, 2005), and compre-

hensive staff training (Alfredson & Annerstedt, 1994)

improve job satisfaction or tend to do so (Nooren-

Staal et al., 1995; Teri et al., 2005). Another effective

intervention that improves job satisfaction is the use of

information technology (IT) support in dementia care

(Engstrom, Ljunggren, Lindqvist, & Carlsson, 2005).Staff training also positively influences satisfaction

with the quality of care, contacts with residents (van

Weert et al., 2005), and the confidence in the caring

role (Lyne et al., 2006). Those who perceive improve-

ment of skills are less stressed (Finnema et al., 2005).Studies in which effects on patients were evaluated

show positive effects on the reduction of affective and

behavioural distress in patients (Teri et al., 2005), in

maintaining emotional balance and preserving a posi-

tive self-image (Finnema et al., 2005), reduction of

depression (Lyne et al., 2006), and some improvement

of behaviour of residents (Nooren-Staal et al., 1995).The designs used were the randomized controlled

trial (Finnema et al., 2005; Teri et al., 2005), non-

randomized, controlled design (Alfredson &

Annerstedt, 1994; Engstrom et al., 2005), quasi-

experimental (Nooren-Staal et al., 1995) or pre-post

measurement (Lyne et al., 2006; van Weert et al.,

2005). A variety of job satisfaction measures were used

including Swedish Satisfaction with Nursing Care and

Work Assessment Scale by Brodaty and the Maastricht

Work Satisfaction Scale for Healthcare (MAS-GZ) by

van Weert.

Invitational conference

The participants of the invitational conference organized

by the Dutch Health Council were 15 representatives

from organizations working in the field of dementia care

in the Netherlands. The main conclusions are:

(a) Expertise is lacking on several levels and

dementia-specific education for formal occupa-

tional caring groups is needed.

(b) Care should meet the patient’s needs for care.(c) Care plans should include both care for the

patient and the informal carer.(d) Cure and care should be integrated.(e) Career perspectives for formal occupational

caring can be used to improve the image of

dementia care.(f) The image of dementia can be changed by

accepting that dementia is part of life.

Patterns

We re-analysed the results of our literature studies to

find patterns in the relationships between factors

improving or impeding job satisfaction and the

consequences of job satisfaction. This might help toformulate theoretical assumptions about the role of job

satisfaction in dementia care. The factors that increase

or decrease job satisfaction found in the literaturestudy are summarized in Table 2.

Some factors associated with job satisfaction are

directly related to good quality of care; for instance, the

preference of the professional occupational groups forpatient-centred care. Patient-centred care is one of the

main contributors to effective care (Brodaty et al., 2003).Improving job satisfaction by better education

might also be the key to improved quality of careand positive effects on patient outcomes.

There is a recognizable pattern in which staff

training improves skills and patient-centred care, and

this seems to increase job satisfaction, which in turnseems to contribute to improved quality of care and

patient outcomes.

Recommendations

An interrelated approach addressing labour market

participation, recruitment strategy, productivity andrequests for care might be most successful according to

the former Dutch Minister of Health (Hoogervorst,

2006). We consider the proposed Dutch measures whiletaking into account the factors influencing job

satisfaction found in the integrative review.

Table 2. Factors influencing job satisfaction in dementia care derived from three sources.

Factors increasing job satisfaction Factors decreasing job satisfaction

Skills training Lack of educationCareer perspectives Insufficient career perspectivesGood communication between staff

and executive personnelNegative contact with superiors

Showing respect Lack of collaboration skillsFinancial rewards Budget cutsPersonal growth Heavy workloadDelivery of patient-centred care Dissatisfaction with care delivered by oneselfConfidence in one’s own caring capacities Insufficient staff capacityDelivery of care of good quality Stigma related to dementia

Negative publicity

Aging & Mental Health 387

Dow

nloa

ded

by [

The

Aga

Kha

n U

nive

rsity

] at

22:

45 2

4 N

ovem

ber

2014

Labour market participation

Participation in the labour market can be increased byexpanding working hours for part-time workers, by

retiring employees from the labour market later, andby employing immigrants. However, working more

hours and more years might overburden some workers.Migration deprives other countries of their valuablework force and introduces specific problems because of

differences in cultural background (van Caelenberg,2006).

Another way of increasing participation in thelabour market is to reduce or prevent people quitting

jobs in dementia care. This can be done by addressingfactors negatively influencing job satisfaction such as

lack of respect and poor communication withsuperiors.

Enlarging recruitment

Recruitment can be enlarged by emphasizing aspectsrelated to job satisfaction, such as opportunities to

acquire more skills by job training. Facilities such asflexible working hours and skills training can be used

in recruitment campaigns (van Caelenberg, 2006).Interventions that allow professionals to acquiremore skills in caring for those with dementia were

found to improve job satisfaction. Adequate humanresource management can partially prevent lack oflabour satisfaction and poor labour conditions

(Hingstman et al., 2003; Mannaerts, 2005).The results of this integrative review seem to

indicate that adequate human resource management

and job training will improve both the quality of jobsatisfaction and the quality of care.

Another proposed measure, the delegation of tasksto people with less education offers opportunities, such

as the introduction of a nurse practitioner. Medicaldoctors can train nurse practitioners and delegate someof their work to them, and thus have more time for the

patient. However, within nursing homes and homecare, the limits of efficiency have been over-reached.

Too much work is delegated to nursing aids. Theinspectorate considers the decline in the percentage ofnurses as a threat for the quality of care in nursing

homes (Health Care Inspectorate, 2004).

Reduction of requests for care

The most obvious measure to be taken to reduce thedemand for care is prevention of dementia in order toslow down the increase of people with dementia

(Verghese et al., 2003). However, this is not the subjectof our study. Some measures, such as telecare, are

supposed to reduce the requests for care. Telecare hasthe potential to reduce the use of actual care and mighthelp patients, informal carers, and professionals, but

more research has to be done in order to find out whatare the effects on the actual reduction of care.

Greater productivity in connection with better qualityof care

Trying to increase productivity by just letting fewerpeople work harder might affect their health, reducejob satisfaction, induce the risk of outflow, andthreaten the quality of care.

Models such as the market model might endangerother measures by encouraging competition amongservices and putting pressure on productivity and costsat the expense of quality of care and health of workers.The market model should be carefully evaluated toconsider the pros and cons.

Greater productivity should only be striven for inconnection with better quality of care. Therefore, it isrecommended that the government at least set thestandards of responsible care in order to ensure safety,taking into account medication errors, malnutritionand decubitus as indicators, for example (Council forPublic Health and Health Care, 2006).

Discarding unnecessary rules and streamliningadministration can improve the efficiency. Greaterproductivity might be reached by improving jobsatisfaction.

Discussion

The main cause of quitting or avoiding jobs indementia care seems to be professionals’ job satisfac-tion. People quit or avoid dementia care for a varietyof reasons, which are often related to job satisfactionand are prevalent in several European states.

Job satisfaction is reduced by lack of resources toprovide adequate care, lack of support and apprecia-tion of the management and society, and feelings ofinability to deal with dementia-related problems.Job satisfaction is positively associated with involve-ment in personal care, being appreciated, acquiringmore skills and competence in caring, and profes-sionals’ feelings of personal growth. Staff training haspromising effects on professionals’ job satisfaction,quality of dementia care and patient functioning.Job satisfaction might, therefore, also be the key tosolving labour market problems. However, whilst stafftraining improves skills and patient centred care, thisresults in the overall costs of running the homeincreasing, sometimes making the home less competi-tive in the market. Moreover well-trained and skilleddementia care staff may then leave the home to moveonto better-paid posts. Whilst improving staff trainingand person centred care is clearly the way forward,these dynamics are a challenge for the care system.

Education is especially important in dementia care,because of a major difference between care for personswith dementia care and persons with other long-termdisabilities is the incomprehensible behaviour of peoplewith dementia. Education might help to understandand deal with this behaviour.

Job satisfaction can be improved by continuousstaff education, focussing on the complex needs of

388 M.J. Vernooij-Dasssen et al.

Dow

nloa

ded

by [

The

Aga

Kha

n U

nive

rsity

] at

22:

45 2

4 N

ovem

ber

2014

dementia patients, collaboration with other profes-sionals, respect from management, financial rewards,flexible working hours and career perspectives.

The integrative review methodology offered anopportunity to obtain better comprehension of pro-blems and chances in the complicated labour marketproblem of dementia care. This review method enabledthe use of several sources, including unconventionalsources such as exit interviews, Website informationand epidemiological results. The general literaturereview helped to define the key problem to be studiedin a systematic review: job satisfaction. This systematicreview was not limited to the study of controlled trials,randomized or not, but also included correlationstudies.

This study has its limitations because the efforts toportray empirical evidence and the proof of therelationship between labour market problems and jobsatisfaction might be incomplete and less rigorous thanconventional reviews. Studies used in the generalliterature review were often not specified to dementiacare. The search terms might not have identified all therelevant studies, the invitational conference might havefailed to include the full spectrum of ideas about thetopic, and the selection of best practices might havebeen incomplete. Nevertheless, this study constitutesan effective attempt to find and analyse the availableevidence.

A gap in the knowledge of job satisfaction is thelack of information about the relationship betweenprofessional caregivers and informal carers. Sinceinformal carers in fact do most of the dementia careand are the intermediaries with formal care, theirrelationship with professionals might also influence theprofessionals’ job satisfaction.

The situation in dementia care asks for urgentaction to reduce outflow from dementia care jobs andto attract new professional caregivers. Reduction oflabour market outflow by increasing recruitment andgreater productivity can be achieved by measures toincrease job satisfaction. Health-care policies canfacilitate this approach and create circumstances inwhich staff can adequately carry out their tasks.According to van Caelenberg (2006) the biggest capitalof the health-care sector consists of capable and well-motivated workers. Investment in health-care workersis an investment in the future of the health-care sector.

In conclusion, complex problems require compre-hensive investigation. The integrative review methodwas helpful in providing more rigors in the investiga-tion. Job satisfaction is the main problem and might bethe key to solutions. The following hypothesis can bederived from our results: enhancement of job satisfac-tion will prevent professional caregivers from quittingjobs and improve the quality of care and patientoutcomes. This hypothesis should be tested in futureresearch. Meanwhile, health-care services can test thishypothesis in their own daily practice. Consideringhealth-care workers, as precious capital and takingadequate measures to enhance job satisfaction will also

contribute to a better image of dementia care.Improvement of job satisfaction can improve thequality of care and reduce the labour market shortageat the same time.

Acknowledgements

This work was funded by the Dutch Council for PublicHealth and Health Care (RVZ).

References

Alfredson, B.B., & Annerstedt, L. (1994). Staff attitudes and

job satisfaction in the care of demented elderly people:

Group living compared with long-term care institutions.

Journal of Advanced Nursing, 20, 964–974.Boomsma, L.J., De Bont, M., Engelsman, C., Gussekloo, J.,

Hartman, C., Persoon, A., et al. (2005). Landelijke

Eerstelijns Samenwerkings Afspraak Dementie. Huisarts

en Wetenschap, 48, 124–126.Bostick, J.E., Rantz, M.J., Flesner, M.K., & Riggs, C.J.

(2006). Systematic review of studies of staffing and quality

in nursing homes. Journal of the American Medical

Directors Association, 7, 366–376.Brodaty, H., Draper, B., & Low, L.F. (2003). Nursing home

staff attitudes towards residents with dementia: strain and

satisfaction with work. Journal of Advanced Nursing, 44,

583–589.Brodaty, H., Green, A., & Koschera, A. (2003). Meta-

analysis of psychosocial interventions for caregivers of

people with dementia. Journal of the American Geriatric

Society, 51, 657–664.

Castle, N.G., Degenholtz, H., & Rosen, J. (2006).

Determinants of staff job satisfaction of caregivers in

two nursing homes in Pennsylvania. BMC Health Services

Research, 6, 60.

Chapman, D.P., Williams, S.M., Strine, T.W., Anda, R.F., &

Moore, M.J. (2006). Dementia and its implications for

public health. Preventing Chronic Disease, 3, A34.Corbin, J., & Strauss, A. (1990). Grounded theory research –

Procedures, canons and evaluative criteria. Zeitschrift fur

Soziologie, 19, 418–427.Council for Public Health and Health Care (2006). The

labour market and the demand for care. The Hague:

Council for Public Health and Health care.Drebing, C., McCarty, E.F., & Lombardo, N.B. (2002).

Professional caregivers for patients with dementia:

Predictors of job and career commitment. American Journal

of Alzheimer’s Disease and Other Dementias, 17, 357–366.

Engstrom, M., Ljunggren, B., Lindqvist, R., & Carlsson, M.

(2005). Staff perceptions of job satisfaction and life

situation before and 6 and 12 months after increased

information technology support in dementia care. Journal

of Telemedicine and Telecare, 11, 304–309.Finnema, E., Droes, R.M., Ettema, T., Ooms, M., Ader, H.,

Ribbe, M., et al. (2005). The effect of integrated emotion-

oriented care versus usual care on elderly persons with

dementia in the nursing home and on nursing assistants: A

randomized clinical trial. International Journal of Geriatric

Psychiatry, 20, 330–343.

Finnema, E., Droes, R.M., Ribbe, M., & Van, T.W. (2000).

The effects of emotion-oriented approaches in the care

for persons suffering from dementia: A review of

Aging & Mental Health 389

Dow

nloa

ded

by [

The

Aga

Kha

n U

nive

rsity

] at

22:

45 2

4 N

ovem

ber

2014

the literature. International Journal of Geriatric Psychiatry,15, 141–161.

Hansson, U.W., Hallberg, I.R., & Axelsson, K. (1995).Nurses’ satisfaction with nursing care and work at threecare units for severely demented people. Journal ofPsychiatric and Mental Health Nursing, 2, 151–158.

Health Care Inspectorate (2004). Verpleeghuizen garanderenminimale zorg niet. Den Haag: Health care Inspectorate.

Health Council (2002). Dementia (Report number 2002/04).

Den Haag: Health Council.Hingstman, L., Kenens, R.J., van der Windt, W., Talma, H.,Meihuizen, H.E., & Josten, E.J.C. (2003). Rapportage

Arbeidsmarkt Zorg en Welzijn 2003. Tilburg: Organisatievoor Strategisch Beleidsmarktonderzoek (OSA).

Hoogervorst, H. (2006). Arbeidsmarktbrief 2006. Den Haag:Ministerie van VWS.

Iliffe, S., De, L.J., Van, H.H., Kenny, G., Lewis, A., &Vernooij-Dassen, M. (2005). Understanding obstacles tothe recognition of and response to dementia in different

European countries: A modified focus group approachusing multinational, multi-disciplinary expert groups.Aging and Mental Health, 9, 1–6.

Jansen van Doorn, G. (2003). Living with dementia.Amsterdam: TNS NIPO.

Knapp, M., & Prince, M. (2007). Dementia UK. UK:

Alzheimer’s Society.Koopmans, R.T.C.M., & Ekkerink, J.L.P. (2001). Dementiein het verpleeghuis. In C. Jonker, F.R.J. Verhey, &J.P.J. Slaets (Eds.), Alzheimer en andere vormen van

dementie (p. 268). Houten: Bohn Stafleu Van Loghum.Lyne, K.J., Moxon, S., Sinclair, I., Young, P., Kirk, C., &Ellison, S. (2006). Analysis of a care planning intervention

for reducing depression in older people in residential care.Aging and Mental Health, 10, 394–403.

Lynn, M.R., Redman, R.W., & Zomorodi, M.G. (2006). The

canaries in the coal mine speak: Why someone should (andshould not) become a nurse. Nursing AdministrationQuarterly, 30, 340–350.

Mannaerts, H. (2005). CPB Memorandum. De arbeidsmarktvan de zorgsector: Data en modellen (Report number 124).Rijswijk: CPB.

Mays, N., Pope, C., & Popay, J. (2005). Systematically

reviewing qualitative and quantitative evidence to informmanagement and policy-making in the health field. Journalof Health Services Research and Policy, 10(Suppl. 1), 6–20.

Meerding, W.J., Bonneux, L., Polder, J.J., Koopmanschap,M.A., & van der Maas, P.J. (1998). Demographic andepidemiological determinants of healthcare costs in

Netherlands: Cost of illness study. BMJ, 317, 111–115.Messchendorp, H.J., Blok, A.J., Koopman, M.I., Wansink, O.,& van Vliet, M. (2004). Werk in Beeld, Branchrapport 2004.Utrecht: Prismant/Atos.

National Institute for health and clinical excellence (NICE)(2006). Dementia: Supporting people with dementia andtheir carers in health and social care. London: National

Institute for health and clinical excellence (NICE).Nooren-Staal, W.H., Frederiks, C.M., & te Wierik, M.J.(1995). Validation: Its effect in residents and staff in a

home for the aged. Tijdschrift voor Gerontologie en.Geriatrie, 26, 117–121.

Ott, M., Paardekooper, P., & van der Windt, W. (2005).

Arbeid in zorg en welzijn 2005. Utrecht: Prismant.

Rathert, C., & May, D.R. (2007). Health care workenvironments, employee satisfaction, and patient safety:

Care provider perspectives. Health Care ManagementReview, 32, 2–11.

Sartorius, N. (2003). Introduction: Stigma and discrimina-tion against older people with mental disorders.

International Journal of Geriatric Psychiatry, 18, 669.Schut, F.T., & van de Ven, W.P. (2005). Rationing andcompetition in the Dutch health-care system. Health

Economics, 14, S59–S74.Scott-Cawiezell, J., & Vogelsmeier, A. (2006). Nursing homesafety: A review of the literature. Annual Review of Nursing

Research, 24, 179–215.Scottish Intercollegiate Guidelines Network (SIGN) (2006).Management of patients with dementia. Edinburgh:Scottish Intercollegiate Guidelines Network (SIGN).

Slobbe L.C.J., Kommer G.J., Smit J.M., Groen J.,Meerding W.J., & Polder J.J (2006). Kosten vanziekten in Nederland 2003. Zorg voor’euro’s (Report

number 270751010). Bilthoven: Rijksinstituut voorvolksgezondheid en Milieu.

Spector, A., & Orrell, M. (2006). Quality of life (QoL) in

dementia: A comparison of the perceptions of people withdementia and care staff in residential homes. AlzheimerDisease and Associated Disorders, 20, 160–165.

Teri, L., Huda, P., Gibbons, L., Young, H., & van, L.J.(2005). STAR: A dementia-specific training program forstaff in assisted living residences. Gerontologist, 45,686–693.

The, A.-M. (2005). In de wachtkamer van de dood.Amsterdam: Theoris.

van Caelenberg, B. (2006). Invest in healthcare workers ¼

invest in the future of the healthcare sector. In 2050: Ahealth Odyssey (pp. 56–59). Brussels: Health First Europe.

van der Windt, W., & Talma, H. (2005). De arbeidsmarkt

voor verpleegkundigen, verzorgenden en sociaal-pedagogenin de zorgsector 2004—2008. Utrecht: Prismant.

van der Windt, W., & Talma, H. (2006). Dreigende

knelpunten in verpleging en verzorging. Feiten 2005. TvZTijdschrift voor Verpleegkundigen, 11, 10–15.

van Weert, J.C., van Dulmen, A.M., Spreeuwenberg, P.M.,Bensing, J.M., & Ribbe, M.W. (2005). The effects of the

implementation of snoezelen on the quality of working lifein psychogeriatric care. International Psychogeriatrics, 17,407–427.

Venturato, L., Kellett, U., & Windsor, C. (2006).Searching for value: The influence of policy andreform on nurses’ sense of value in long-term aged

care in Australia. International Journal of NursingPractice, 12, 326–333.

Verghese, J., Lipton, R.B., Katz, M.J., Hall, C.B., Derby, C.A.,Kuslansky, G., et al. (2003). Leisure activities and the risk of

dementia in the elderly. New England Journal of Medicine,348, 2508–2516.

Vernooij-Dassen, M.J., Moniz-Cook, E.D., Woods, R.T.,

De, L.J., Leuschner, A., Zanetti, O., et al. (2005). Factorsaffecting timely recognition and diagnosis of dementiaacross Europe: From awareness to stigma. International

Journal of Geriatric Psychiatry, 20, 377–386.Whittemore, R., & Knafl, K. (2005). The integrative review:Updated methodology. Journal of Advanced Nursing, 52,

546–553.

390 M.J. Vernooij-Dasssen et al.

Dow

nloa

ded

by [

The

Aga

Kha

n U

nive

rsity

] at

22:

45 2

4 N

ovem

ber

2014