Facilitators and Barriers Surrounding the Role of Administration in Employee Job Satisfaction in Long-Term Care Facilities: A Systematic Review

Previous literature has shown how associate engagement has positively impacted on productivity, job satisfaction, safety, retention, consumer sentiment, and financial performance in hospitals and healthcare systems. However, a lack of research showing the relationship between associate engagement and job satisfaction within the long-term care environment has existed. Our objective was to investigate characteristics within the long-term care environment that promote and detract from associate job satisfaction and extrapolate the best practices in maintaining job satisfaction and engagement. This systematic review queried CINAHL, PubMed (MEDLINE), and Academic Search Ultimate databases for peer-reviewed publications for facilitators and barriers commensurate with employee job satisfaction in long-term care facilities using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and the Kruse Protocols. The authors identified 11 facilitators for job satisfaction and 18 barriers to job satisfaction in the 60 selected articles. The top four facilitators were Supportive Leadership, Capable and Motivated Employees, Positive Organizational Values, and Social Support Mechanisms. The top four barriers were condescending management style, high job demands, lack of self-care, and lack of training with medically complex patients. The systematic review revealed the importance of maintaining satisfied employees in the long-term care workplace through am emphasis leadership and on the facilitators identified to best serve their associates and improve care for residents.


Rapid Growth of 65+ Population
The fastest growing segment of the national and world population is the 65 years and over age bracket. World Population Ageing 2019 [1] emphasizes that the current world population of individuals at 65 years or greater numbers 703 million, with a projection of 1.5 billion in 2050. In the United States, the population of age 65 and over is at 52 million, with a projection of a doubled population of 95 million by 2060 [2,3]. In addition, a greater percentage of our total population in the US and in the world is comprised of people aged 65 and older [1][2][3], with a projected increase of 1 in 5 persons in the US and 1 in 6 persons in the world by 2050 [1,4]. In the United States, the number of those aged 65 and over will rise from the current 16% of total population to 23% of the total population by 2060 [2,3].

Cost of Associate Disengagement
To further draw attention to the critical impact of job satisfaction and associate engagement, it is important to consider the impact of the disengaged and dissatisfied healthcare worker on Americans' pocketbooks. One source reported that 68% of employees from all industries are not engaged and that this disengagement costs US employers $400 billion annually [15].

Societal and Public Health Crises-Multiplier of Importance of Healthcare Associate Satisfaction
Crises such as public health pandemics (e.g.,  and natural disasters further exacerbate the sense of urgency in addressing morale and the satisfaction of healthcare team members in healthcare organizations. Recently, initial research findings and literature have emerged acknowledging the stress imposed by Covid-19 conditions on the healthcare workforce, impacting job satisfaction, morale, and risking the imposition of unintended negative impacts on patients and quality [17,18]. With the nursing home and other residential communities as epicenters of the Covid-19 pandemic, stress experienced by long-term care workers will certainly impact on patient satisfaction and quality of care.

Significance and Purpose
Given the quickly expanding over-65 population worldwide, an anticipated increased demand for nursing homes and residential care communities to care for the aging population, an increased burden on social and economic systems, an anticipated increase in need for nursing and care professionals, the relationship between nursing and healthcare professional's job satisfaction and engagement with patient and organizational outcomes, and the impact of public health crises and pandemics (e.g., , a sense of urgency exists to identify systems and practices that either facilitate or impede administrators in long-term care facilities to enhance job satisfaction and improve outcomes in quality of care and organizational effectiveness [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. Further to this point, the investigators' two key purposes in this study were to investigate characteristics within the long-term care environment that promote and detract from associate job satisfaction and extrapolate the best practices in maintaining job satisfaction and engagement, ultimately leading to best practices in creating a positive organizational culture for associates and a sound foundation for delivering resident-centered care within long-term care settings. The investigators used a systematic literature review method.
For the purposes of this study, the terms "associates", "employees", and "healthcare workers" were used synonymously. The investigators intentionally have utilized the word "associates" to be more inclusive, contemporary, and substantive in impacting culture. In addition, much has been written relating to job satisfaction with associate engagement. It is generally accepted that job satisfaction is a component and a contributing factor of overall associate engagement in the workplace. A number of published articles have substantiated this relationship [6,10,[12][13][14].

Materials and Methods
This study was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Kruse Protocol for writing systematic reviews [19,20]. The initial search was conducted using Pubmed (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Academic Search Ultimate. These databases were chosen due to their widespread use and availability. A Boolean search was conducted using a complex three-string search as included in Figure 1.

Significance and Purpose
Given the quickly expanding over-65 population worldwide, an anticipated increased demand for nursing homes and residential care communities to care for the aging population, an increased burden on social and economic systems, an anticipated increase in need for nursing and care professionals, the relationship between nursing and healthcare professional's job satisfaction and engagement with patient and organizational outcomes, and the impact of public health crises and pandemics (e.g., , a sense of urgency exists to identify systems and practices that either facilitate or impede administrators in long-term care facilities to enhance job satisfaction and improve outcomes in quality of care and organizational effectiveness [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. Further to this point, the investigators' two key purposes in this study were to investigate characteristics within the long-term care environment that promote and detract from associate job satisfaction and extrapolate the best practices in maintaining job satisfaction and engagement, ultimately leading to best practices in creating a positive organizational culture for associates and a sound foundation for delivering resident-centered care within long-term care settings. The investigators used a systematic literature review method.
For the purposes of this study, the terms "associates", "employees", and "healthcare workers" were used synonymously. The investigators intentionally have utilized the word "associates" to be more inclusive, contemporary, and substantive in impacting culture. In addition, much has been written relating to job satisfaction with associate engagement. It is generally accepted that job satisfaction is a component and a contributing factor of overall associate engagement in the workplace. A number of published articles have substantiated this relationship [6,10,[12][13][14].

Materials and Methods
This study was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Kruse Protocol for writing systematic reviews [19,20]. The initial search was conducted using Pubmed (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Academic Search Ultimate. These databases were chosen due to their widespread use and availability. A Boolean search was conducted using a complex threestring search as included in Figure 1.  The summary of the selected articles included the Population, Intervention, Comparison, and Outcome (PICO) requirements for Prisma guidelines [19]. The reviewers read and analyzed the complete articles and noted the facilitators and barriers indicated to influence job satisfaction in long-term care facilities. Each article was completely assessed by at least two reviewers and the reviewers met routinely to arrive at a consensus on the facilitators, barriers, and themes of each article. Weekly consensus meetings occurred throughout the systematic review analysis. The reviewers/authors sought to reduce the risk of bias in the analysis technique through having multiple reviews and weekly consensus meetings.

Inclusion Criteria
Authors reviewed articles yielded from the search, determined germane literature, and summarized themes based on consensus. Inclusion criteria included English language and peer-reviewed articles. Articles must have been published in academic journals to be included. The dates of inclusion were 1 January 2014 through to 30 September 2019. To be included, articles must have explored the effects of administration/organizational culture on job satisfaction, employee satisfaction, or employee engagement in long-term care facilities.

Exclusion Criteria
Articles were only included in the study if they were determined to be germane by all authors. Trade industry reports were excluded. Poster presentations were excluded. Any works without a clear peer review process were excluded. Articles which were not specific to long-term care environments were excluded. Bias was not considered when reviewing research for this study. The final sample of articles after meeting exclusion criteria was analyzed and yielded a kappa statistic (k = 1), which showed perfect interrater agreement [21].

Study Selection
The initial search resulted in 4288 results. All duplicates were removed, leaving 3675 articles. Publication time frame was limited to between 2014 and 2019, leaving 1407 articles. Additionally, only academic journals and articles in the English language were included, leaving 1349 articles. Duplicates and non-germane articles were then removed from the results, leaving 60 articles for use in this qualitative analysis and review. Authors retained articles that only occurred within long-term care facilities and included facilitators or barriers to job satisfaction of associates or employees. A summary of the articles chosen for inclusion is included in Appendix A Table A1.

Data Analysis
Narrative summaries related to factors that influenced job/employee satisfaction, retention, and engagement regarding administration or organizational culture in long-term care environments were extracted from each article. Summaries were then grouped into larger recurring themes that identified either key determinants or impediments to job/employee satisfaction, retention, and engagement. The themes were chosen by consensus of the authors and were chosen as they provided overarching summaries to the facilitators and barriers extracted from the articles. Themes were then summarized via two affinity matrix tables, one for facilitators and one for barriers. Tables 1 and 2 document the themes, their citation occurrence, their frequency sum, and frequency percentages.

Results
The 60 articles included in the qualitative analysis are summarized in Appendix A Table A1, with the most recent publications listed first by their primary authors. The 60 articles yielded 162 instances of facilitators and 97 instances of barriers relative to job satisfaction in long-term care facilities.

Discussion
This study provided a more comprehensive and extensive review in comparison to studies over the previous 5 years than previous studies in long-term care. Because of the extensive nature of this particular review, leaders had the opportunity to prioritize best practices and systems to enhance their own organizations and facilities. Focusing on the top categories of both facilitators and barriers will help long-term care facilities and organizations provide environments that promote both associate and resident satisfaction, while reducing costs associated with unhappy associates and residents.
The top four "barrier" themes (condescending management style, high job demands, lack of selfcare, and lack of training with the medically complex patients) represented 45.92% of the total occurrences for barriers. An example of condescending management style included the withholding of information by supervisors or coworkers that leads to negative work performance [46]. An example of high job demands included heavy workload, which leads to higher stress levels and lower levels of job satisfaction [49]. Lack of self-care can affect job satisfaction through issues such as brief lunch breaks, low access to healthy foods at work and "working to the point of exhaustion" that can cause employees to be tired and too exhausted to exercise or cook a heathy meal after work [30]. Lack of training with medically complex patients can include young nurses with "less knowledge and experience with elderly care", which can lead to unrealistic expectations, leading to burnout and decreased engagement [25]. Additional examples of themes in the analyzed articles can be found in Appendix A. If the themes of lack of leadership training and prohibitive environmental characteristics were added to the top four themes, the top six "barrier" themes accounted for 61.22% of the occurrences. Administrators have the opportunity to further demonstrate their commitment to supportive leadership, empowerment of team members, positive organizational values, and social support mechanisms through managing the barriers in long-term care facilities. The 98 occurrences of barriers noted in this study fell into 18 categories, including condescending management style [27,34,35,38,41,42,48,51,66,71,77], high job demands [25,38,40,43,46,65,67,71,72,77,78], lack of self-care by employees [30,32,33,46,47,54,59], lack of training with medically complex patients [22,24,25,65,75,79], lack of leadership training [22,24,[27][28][29]31], prohibitive environmental characteristics [22,32,54,68,78], high coworker conflicts [34,35,46,47,76], perception of business aspects interfering with care [24,80,81], negative perceptions about leadership style [31,35,39,72], lack of access to management [22,35,41,47], stress [27,30,42,67], lack of peer support [22,48], patient morbidity [50,59], poor compensation and benefits [38,39,78], limited communication opportunities with leadership and team members [22], language barriers [59], non-profit ownership [77], and patient complexity [32]. The top themes are displayed in Table 2 and Figure 3.
The top four "barrier" themes (condescending management style, high job demands, lack of self-care, and lack of training with the medically complex patients) represented 45.92% of the total occurrences for barriers. An example of condescending management style included the withholding of information by supervisors or coworkers that leads to negative work performance [46]. An example of high job demands included heavy workload, which leads to higher stress levels and lower levels of job satisfaction [49]. Lack of self-care can affect job satisfaction through issues such as brief lunch breaks, low access to healthy foods at work and "working to the point of exhaustion" that can cause employees to be tired and too exhausted to exercise or cook a heathy meal after work [30]. Lack of training with medically complex patients can include young nurses with "less knowledge and experience with elderly care", which can lead to unrealistic expectations, leading to burnout and decreased engagement [25]. Additional examples of themes in the analyzed articles can be found in Appendix A. If the themes of lack of leadership training and prohibitive environmental characteristics were added to the top four themes, the top six "barrier" themes accounted for 61.22% of the occurrences. Administrators have the opportunity to further demonstrate their commitment to supportive leadership, empowerment of team members, positive organizational values, and social support mechanisms through managing the barriers in long-term care facilities.

Most Impactful Categories of Themes
The researchers noted how the themes grouped into three broad categories pertaining either to the organizational leadership, systems, or processes; to the attributes of team members, associates, or employees; and lastly to the environmental characteristics of long-term care or the nature of the work; depicted in Figure 4a

Organizational Leadership
Nine of the 12 "facilitator" themes (80.25% of the occurrences in the literature) and 10 of the 18 "barrier" themes (71.14% of the occurrences in the literature) represented organizational leadership, systems, or processes. Administrators and organizational leaders have the most control over these organizational themes' attributes. Within the category of which administrators have the most influence, supportive leadership accounted for 31.48% of the occurrences of facilitators. The findings of this study relative to the long-term care environment  reinforced the importance of leaders providing positive and empowering guidance, setting up systems to support team members, providing robust orientation and training on the specific needs of the medically complex population,

Most Impactful Categories of Themes
The researchers noted how the themes grouped into three broad categories pertaining either to the organizational leadership, systems, or processes; to the attributes of team members, associates, or employees; and lastly to the environmental characteristics of long-term care or the nature of the work; depicted in Figure 4a

Most Impactful Categories of Themes
The researchers noted how the themes grouped into three broad categories pertaining either to the organizational leadership, systems, or processes; to the attributes of team members, associates, or employees; and lastly to the environmental characteristics of long-term care or the nature of the work; depicted in Figure 4a

Organizational Leadership
Nine of the 12 "facilitator" themes (80.25% of the occurrences in the literature) and 10 of the 18 "barrier" themes (71.14% of the occurrences in the literature) represented organizational leadership, systems, or processes. Administrators and organizational leaders have the most control over these organizational themes' attributes. Within the category of which administrators have the most influence, supportive leadership accounted for 31.48% of the occurrences of facilitators. The findings of this study relative to the long-term care environment  reinforced the importance of leaders providing positive and empowering guidance, setting up systems to support team members, providing robust orientation and training on the specific needs of the medically complex population,

Environmental Attributes
The least influential of the broad categories of themes was environmental attributes, aspects of providing care in long-term care facilities with the clinical complexity of the population. None of the "facilitator" themes were classified as environmental attributes and 4 of the 18 (24.49%) "barrier" themes were classified as environmental. Patient morbidity [50,59], limited communication opportunities with leadership and team members [22], and patient complexity [32] were included in a few of the articles reviewed as posing barriers to associate satisfaction. Considering how an administrator best manages environmental attributes relative to overcoming these barriers, one could posit again that creating a positive supportive leadership style, establishing positive organizational values, and providing social support mechanisms will most influence how associates react to the environment. Interventions such as including training in techniques to cope with patient morbidity in order to better communicate and gain competence with managing patient complexity, represent examples of how an administrator can best provide support mechanisms for employees [7][8][9][10][11][12][13][14][15].

Implications for Future Success in Long-Term Care and in Times of Crisis and Rapid Change
The secondary purpose of the current study was to determine a best-practice checklist for establishing a long-term care setting, which promotes associate engagement and in turn creates a care environment focused on quality care. The study's findings suggest the best practices that could facilitate such an environment. Through the findings of this study, leaders in long-term settings are guided to engage in establishing supportive leadership. Supportive leadership, the most frequently cited facilitator in the study, results from the career and professional leadership development of administrators, leaders, and staff, the provision of adequate job resources, orientation, and ongoing training, specifically in terms of the medically complex. All the components that contribute to establishing a supportive leadership style were identified as facilitators.
In addition, the second-most cited facilitator of associate engagement is the presence of a capable and motivated healthcare workforce in long-term care. The secret of empowering and motivating associates comes through such facilitators as establishing social support mechanisms (the third most frequent facilitator theme), rewarding patient-centered care and philosophy, and celebrating associates' enjoyment of their professional relationships with residents, patients, and clients, all of which were identified in this study as best practices.
Positive organizational values were identified as the third contributing facilitator, which occurs through the establishment of organizational systems and processes and a patient-centered philosophy. Organizational leaders have the responsibility and the opportunity to include all four key facilitators by tapping into the contributions of other facilitators or building blocks for success in quality, resident-centered care.
The reader is encouraged to view from the study, results of what not to do to promote associate satisfaction and perception of quality care through the list of 19 barriers or detractors of care. Many of the barrier themes that emerged could be considered as symptoms of a non-supportive or "condescending" management style, the opposite spectrum of a positive, supportive leadership style.

Limitations and Future Research
The present study provided an extensive systematic review for the facilitators and barriers of the promotion of associate satisfaction of recent literature in long-term care facilities. Although the study met the objectives of identifying useful information relative to facilitators to further promote engagement and satisfaction and suggests the best practices for administrators, limitations existed in the present study. Our study did not categorize or quantify the types of long-term settings with each article review. This was beyond the scope of our study. From a counter perspective, not categorizing the settings lends itself to the generalizability of the results in a variety of long-term settings, including nursing homes, assisted living, community settings providing day services, and other service companies. In addition, our study did not collapse all facilitator and barrier themes, which could also be considered a limitation. Some of the themes could have been considered as sub-components of a broader theme. The reviewers set out to identify as many facilitators and barriers so as to lead to as many insights on best practices and systems to promote associate satisfaction, ultimately leading to resident and family satisfaction.
The current study was qualitative in methodology and although the articles themselves and the authors considered relationships, an opportunity exists to further quantify the relationships between facilitators and barriers. One would speculate that administrators and leaders using positive supportive leadership, creating a culture based on positive organizational values, empowering associates, and providing support mechanisms for employees will decrease the likelihood and influence of detractors or barriers such as condescending management styles, high job demands, and lack of self-empowerment. With that said, the current study did not quantify the relationship of the themes or study the correlation or regression of the themes. Thus, the results of this study provide opportunities for such studies in the future, relating to the strength of the relationship between organizational leadership characteristics and associates' capabilities and motivation.
A related limitation of the current study is that the authors did not have access to specific associate satisfaction data to make further discoveries on the significance of relationships of various themes within the data. Herein lies a future opportunity for additional studies.

Conclusions
This study resulted in outlining key components to set in place for the promotion of associate satisfaction. The single most important facilitator of associate satisfaction was establishing supportive leadership, followed by empowering and developing employees, and establishing positive organizational values and support mechanisms. From the opposite perspective, administrators and managers using a condescending management style, setting high job demands, not supporting work-life balance or employees' self-care, and not providing adequate training to staff on how best to care for the medically complex clients promotes dissatisfaction in their associates. Administrators and leaders have the opportunity to utilize and grow the best practices in order to engage their associates, ultimately increasing the perception of the quality of care for their clients and residents. All of the considerations in this study have been become even more critical in the current situation with fighting the Covid-19 pandemic.  A survey was used to collect data. Path analyses and descriptive statistics were conducted.
This study found that a positive work environment promotes job satisfaction.

F Enjoyment of Relationships with Patients
A low perception of support and tension between facilities and healthcare service workers were found to be barriers to job satisfaction.

B High Coworker Conflicts
Malagon-Aguilera/2019 [23] To analyze the sense of coherence among RNs 2 and its relationship with health and work engagement.
109 Nurses working in an LTC setting.
In a cross-sectional study, 109 registered nurses working in an LTC setting responded to a self-administered questionnaire. Multiple linear regression models were used to analyze social support, work-related family conflicts, sense of coherence, self-reported health status, and work engagement variables.  30-day inpatient mortality and failure-to-rescue were the measured outcomes.
Higher professional support and support from colleagues were found to be facilitators to job satisfaction.

F Career/Professional Development and Supportive Leadership and Management
Desveaux/2019 [52] To qualitatively determine whether, how, and why an academic detailing intervention could improve evidence uptake, and to identify changes that occurred to advise outcomes for quantitative evaluation.
11 clinical and administrative leaders, 10 physicians, 6 direct care providers, and 2 pharmacists across 13 nursing homes.
A qualitative evaluation of 29 interviews with nursing home staff, which were analyzed using the framework method.
A flexible approach, active knowledge dissemination, and in-person engagement are key components required to drive change.

F Capable and Motivated Employees
Hartmann/2018 [73] To improve resident engagement. Six Veterans Health Administration nursing homes.
A mixed-methods study. The intervention was implemented by using evidence-based tactics for implementing quality improvement and combining CLC-based staff facilitation with researcher-led facilitation. Intervention success was assessed via structured observations and resident and staff surveys collected pre-and post-intervention.
The study found that staff job satisfaction was related to positive meaningful engagements with residents and professional development opportunities.  This study suggests that employees with a stronger passion and sense of trust had an increased job satisfaction.

F Capable and Motivated Employees and Positive Organizational Values
Management's inability to resolve problems was a barrier to job satisfaction.

B Condescending Management Style
Keisu/2018 [36] Estimate the potential associations between employee-perceived transformational leadership style of their managers, and employees' ratings of effort and reward within geriatric care work.
RNs, occupational therapists, physiotherapists, and assistant nurses across 9 elderly care facilities in Sweden.
Questionnaires were distributed to participants during an on-site visit. The focus was on balance at work, rather than imbalance.
This study suggests that motivating, inspirational, coaching, and intellectually stimulating managers are facilitators of job satisfaction.

F Supportive Leadership and Management
Bernstein/2018 [35] To identify ways to minimize turnover by keeping staff happy in LTC.   [44] Examine the relationship between supervisory support and intent to turn over amid personal support workers in LTC homes and identifying whether the association is influenced by job satisfaction and the possible effect of happiness.

personal support workers in 398 LTC homes in Ontario Canada
Cross-sectional survey data from the sample was obtained and analyzed through a series of multilevel regression models.
Supervisory support on intent to turn over is mediated by job satisfaction.

F Supportive Leadership and Management
Yepes-Baldó/2018 [62] Examine the effects of job crafting activities of elder care and nursing home employees on their perceived well-being and quality of care.

elderly care and nursing home employees in Spain and Sweden
Questionnaires on the Job Crafting, the General Health, and the Quality of Care were administered to participants. Correlations and hierarchical regression analyses were also performed.
A positive relationship was found between job crafting and well-being.   [27] To examine the quality of manager-subordinate relationships using Leader-Member Exchange Theory (LMX) as a predictor to turnover among low-wage earners in the LTC environment.
Participants were from a large vertically integrated southeastern LTC organization.
A cross-sectional method was used to gather survey data over two periods. At time one, LMX, demographic information and job satisfaction was measured. At time two, turnover was measured.
This study suggests teamwork, support systems, versatility of foreigners, adequate work time, and working for larger organizations are associated with a higher job satisfaction. A forced linear regression model was used, while controlling for age and job title, higher physical activity levels, fewer symptoms of depression, stress, and/or anxiety, less back pain, stronger social support, and reports of low work demands were assessed.
The study found that the main factor associated with job satisfaction was mood, followed by interventions to increase employees' coping mechanisms and receiving affirmation from management.

F Capable and Motivated Employees, Social Support Mechanisms and Supportive Leadership and Management
Barriers to job satisfaction included short lunch breaks and minimal access to nutritious meals.

B Lack of Self-Care
Pung/2017 [68] To examine elements of job satisfaction, their demands of immigration score, explore any relationship between job satisfaction and demands of immigration, and determine the predictors of job satisfaction among international nursing staff working in LTC.
International nursing staff group, including those who are non-Singaporean, worked a minimum of one year, and nursing staff who provided direct patient care.
A cross-sectional design was used, and participants were chosen using a convenience-sampling technique.
This study found a positive workplace climate, comprehensive orientation programs, and having the proper resources to succeed were indicators of job satisfaction.

F Initial Orientation and Training, Social Support Mechanisms, and Adequate Job Resources
A barrier of job satisfaction is the lack of understanding on the migration demands of nurses and job satisfaction.

B Prohibitive Environmental Characteristics
Harding/2017 [43] To determine why staff in care settings are unhappy and understand the benefits of a happier staff.
Long-term care settings and employees in the United Kingdom.
Observations from field experts were included in the study.
This author/expert found that staff development opportunities, supportive managers, and recognition from management increased job satisfaction.

F Career/Professional Development and Supportive Leadership and Management
A barrier to job satisfaction was the feeling of the inability to complete tasks in each time frame.

B High Job Demands and Stress
Boscart/2017 [74] Changing the impact of nursing assistants' education in seniors' care by implementing the Living Classroom (LC) approach.
A Canadian college and nursing home group.
A collaborative approach to integrated learning was conducted where nursing assistant students, college faculty, NH teams, residents, and families engage learning together. This approach placed the student in the nursing home where knowledge, team dynamics, behaviors, relationships, and inter-professional practices are modeled.
Nursing assistant students were highly satisfied with the LC and intention to seek employment in nursing homes have increased. Nursing home teams, residents, and families exhibited positive attitudes towards educating students via LC.

F Initial Orientation and Training
Chamberlain/2017 [54] Examine organizational context, care aide characteristics, and frequency of dementia-related resident responsive behaviors associated with burnout.
1194 care aides from 30 urban nursing homes in Canada.
A mixed-effects regression analysis was used to assess care aide characteristics, dementia-related responsive behaviors, unit and facility characteristics, and organizational context predictors of care aide burnout. Burnout was measured using the Maslach Burnout Inventory form.
Unit culture and environmental resources were predictors of professional efficacy, which was associated with increased care aide job satisfaction.

F Positive Organizational Values, Capable, and Motivated Employees and Adequate Job Resources
Predictors of emotional exhaustion included English as a second language, medium facility size, organizational slack-staff, organizational slack-space, personal health, and dementia-related behaviors.

B Prohibitive Environmental
Characteristics, Lack of Self-Care To examine an expanded demand-control-support model that included justice perceptions to determine its impact on multiple types of psychological and organizational well-being outcomes.
173 aged care nurses. A self-report survey was used to collect and analyze data using hierarchical multiple regression.
This study found job control, high quality training, exceptional health benefits, and professional development opportunities increase job satisfaction. A questionnaire was used to gather data on the job satisfaction, motivation, and job characteristics of nursing staff working in small-scale and traditional care environments. Descriptive statistics were used to analyze data, and multilinear regression analysis was used to test the differences between job satisfaction, motivation, and job characteristics.
In small-scale nursing homes, job satisfaction and job motivation were significantly higher compared to those in traditional nursing homes. Job autonomy and social support were also higher, while job demands were lower in small-scale nursing homes. Social support was the most notable predictor of job motivation and job satisfaction in both types of nursing home. Employee patience and motivation was a factor when determining cases where there was an intention to switch care environments.  Semi-structured interviews were conducted to collect a realist evaluation process. An interpretive data analysis unpacks interactions between managerial leaders and internal facilitators.
This study suggests that building relationships, encouragement from management, and a sense of being valued promote job satisfaction.

F Social Support Mechanisms
A lack of commitment from management was a barrier to job satisfaction. Burnout, job satisfaction, and job demands were measured before the implementation, in the middle of the program, and after every unit implemented in the care program. The Dutch version of Maslach burnout inventory was used to measure burnout. Job satisfaction and demands were measured using subscales of the Leiden Quality of Work Questionnaire. Effects were determined using mixed model analyses.

B Condescending Management Style
Notable positive effects of using the grip on challenging behavior care programs were found on job satisfaction, without an increase placed on job demands.

F Initial Orientation and Training and Capable and Motivated Employees
Thompson/2015 [80] To consider the influence of multiple-source care funding issues on nursing-home nurses' job satisfaction.
13 nurses from seven nursing homes in North-East England.
Hermeneutic phenomenology was used in this study. Participants were interviewed in a sequence of five interviews, and the data were analyzed using a literary analysis method.
This study found that tension between funding and care, the feeling of "selling beds," multiple-source care funding, and difficulty coping with self-funding residents was a barrier to nurses' job satisfaction in the LTC setting.  A longitudinal survey design was used to track CNAs completing training for one year.

B Business Aspects Interfering with Care
The first 6 months of employment most impacted retention; 53.7% CNAs were retained after one year; and the CNAs leaving cited pay as being the number one reason for leaving.

B High Job Demands and Poor Comp and Benefits
Heavy workloads were found to be a barrier to job satisfaction

Prohibitive Environmental Characteristics
McGilton/2014 [42] Describe the organizational, unregulated nurse and resident outcomes associated with effective supervisory performance of regulated nurses in LTC homes.
Regulated nurses working in LTC homes.
Six databases were utilized to gather articles between 2000 and 2015. Twenty-four articles were selected, and an integrative interview was performed.
Nurse supervisor performance left employees feeling empowered, increasing job satisfaction.

F Supportive Leadership and Management
Poor supervision over nurses was a barrier to job satisfaction.

B Condescending Management Style
Chu/2014 [41] Describe the relationship between nursing staff turnover in LTC homes and organizational factors (i.e., leadership practices and behaviors, supervisory support, burnout, job satisfaction and work environment satisfaction).
LTCF administrators. A stress process model was used. Surveys were distributed to LTC administrators to measure organizational factors and to regulated nurses to measure sources of stress and workplace support; 324 surveys were used in a linear regression analysis to examine factors related to high turnover rates.
This study identified greater support from management, empowering work environments, and employee assistance programs as contributors to job satisfaction.

F Supportive Leadership and Management and Social Support Mechanisms
Lack of supervisory support, poor leadership, administration turnover, and poor work environments were barriers to job satisfaction.  Explore the mediating effects of job satisfaction on work stress and turnover intention among LTC nurses.
LTC nurses in Taiwan.
The study used a cross-sectional survey and a correlation design. Multistage linear regression was utilized to test the mediation model.
Low stress levels among LTC employees lead to a higher job satisfaction.

F Social Support Mechanisms
Barriers to job satisfaction include high stress levels, unfair working hours, and lack of supportive leadership.

B High Job Demands
Jungyoon/2014 [79] To examine the relationship between organizational structure and HR practices on job satisfaction and turnover intent.
50 LTC facilities across five states.
A latent class analysis was used to group facility characteristics into three sets of combinations. A multivariate regression was used to test the relationship between groups on job satisfaction and turnover intent.
This study found low levels of job training and communication to be barriers to job satisfaction.