Do Worker Cooperatives Promote Job Satisfaction? An Empirical Analysis Among Home Health Care Aides.

1. DO WORKER
COOPERATIVES
PROMOTE JOB
SATISFACTION?
AN EMPIRICAL ANALYSIS
AMONG HOME HEALTH
CARE AIDES
JULIA GORLOVETSKAYA

2. A THESIS SUBMITTED IN
PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR
THE DEGREE OF
BACHELOR OF ARTS IN
PUBLIC POLICY,
DECEMBER 2018

3. ABSTRACT
While the anticipated growth in demand for home health care has led to
projections of roughly 1.3 million new jobs, low retention rates threaten the
industry’s progress and cast doubt on the quality of the home health care
aid profession. Seeking to ameliorate the shortcomings of the industry, ten
worker cooperative home health care agencies have sprung up across the
nation. As intrinsically democratic enterprises, these agencies work to offer
higher wages, better benefits, job training, full-time hours, and, above all,
employee support. This study reviews the effects of these proposed
advantages on job satisfaction by running linear regressions using data from
the 2007 National Home Health Aide Survey. It finds the particular
characteristic of feeling valued by an organization as the strongest predictor
of job satisfaction. A strong, positive impact of feeling trusted, receiving
clear instructions from supervisors, and receiving both paid sick days and
health insurance were observed as well. Additionally, using data gathered
from surveys of current employees at home health care cooperatives, this
study offers a descriptive comparison between cooperative and non-
cooperative models. Although it finds that cooperative home health care
agencies neither had higher job satisfaction rates nor differed significantly
from non-cooperative agencies, it is the first of its kind to offer a snapshot of
current home health care cooperative employment sentiments. This study is
inconclusive regarding the determinants of job satisfaction in worker
cooperatives due to its small sample size; nonetheless, it finds good reasons
for the expansion of knowledge in the field of cooperatives and provides
suggestions for future research.

4. TABLE OF
CONTENTS

5. Current trends in home
health care
Problems facing the industry and
home health care workers
Different types of home health care
agencies
What are worker cooperatives?
The current state of worker
cooperatives in the U.S.
The viability of worker cooperatives in
our present economy
The necessity for the expansion of
worker cooperatives
Examining home care worker
cooperatives
Participating cooperatives
LITERATURE REVIEW
Importance of focusing on job
satisfaction of the home care industry
Factors influencing job satisfaction in
traditional home health care firms
The relationship between job
satisfaction and employee ownership
Drawing Conclusions
Measures
Description of Variables
BACKGROUND REVIEW2
18
Data
FRAMEWORK29
RESULTS AND
DISCUSSION
44
Hypothesis 1
Hypothesis 2
Limitations
CONCLUSION58
Further research
BIBLIOGRAPHY61

6.
BACKGROUND REVIEW
I. CURRENT TRENDS IN HOME HEALTH CARE
Home care is defined as “an array of services which enables clients
incapacitated in whole or in part to live at home, often with the effects of
delaying, or substituting for long term care or acute care alternatives”
(Denton et.al., 2002). The industry is multifaceted, including workers providing
professional services, like nursing and therapy, and/or home support services,
like homemaking, personal care, housekeeping, and transportation; as well as
office workers that manage, supervise or coordinate. This paper will focus on
the non-office workers. While most scholars cite the Bureau of Labor
Statistics estimate of a home care workforce comprised of 600,000 - 800,000
workers nationally (Delp et.al., 2010; Lund, 2012). Paraprofessional Healthcare
Institute (PHI) recently found the number to be closer to 2.2 million workers
once independent providers that are employed directly by consumers
through publicly funded consumer-directed programs are accounted for
(PHI, 2017).
PAGE 2

7. The Bureau of Labor Statistics estimates that from 2014 to 2024, home
care occupations are projected to add more jobs than any other single
occupation, with an additional 633,100 new jobs (U.S. Bureau of Labor
Statistics, 2012). However, PHI points out that this number is likely an
underestimate of actual future employment growth, as it does not account
for projected population growth. More likely, the number of new health
workers needed to meet demand by 2024 will be well over 1.3 million.
There are many reasons for this magnified demand for home care
workers: the aging population (by 2050, the population of people over the age
of 65 will nearly double, from 47.8 million to 88 million), consumer preference,
expansion of Medicare Home Health programs, reductions in admissions and
lengths of stays in hospitals, and advances in medical technology that allow
increasingly complex care to be provided in the home (Bureau of Labor
Statistics, 2012; Denton, 2002). In many ways, the business opportunities for
expansion in the home care market exceed those in almost any other
industry (Lund, 2012).
PROBLEMS FACING THE INDUSTRY AND HOME HEALTH CARE WORKERS
While the future of home health care appears ripe for growth and
progress, its current state is strikingly grim and stagnant. Home care worker
inflation-adjusted wages have decreased from $10.21 in 2005 to $10.11 in 2015.
Because of this, home care workers earn a median annual income of $15,100
PAGE 3

8. today. 24 percent of home care workers live in households below the federal
poverty line and rely on some form of public assistance, compared to 9
percent of all U.S. workers (PHI, 2017). Paradoxically, these providers of
healthcare are often left uninsured. Before the implementation of the
Affordable Care Act (ACA), 26 percent did not have health insurance. After, the
rate of health coverage for home care workers increased by 14 percent.
Nonetheless, even this hopeful statistic is jeopardized by a political climate
that may reduce funding for and/or replace ACA.
Given the current state of home health care, experts predict a crisis
defined by the “ home care gap” (Lund, 2012). Despite the almost doubled
demand for home health care workers, the labor force is experiencing little
growth. Labor force participation among women ages 25 to 64, who currently
make up 73 percent of the home care workforce, will increase by only 2
million in the next decade, compared to 6.3 million in the previous decade
(PHI, 2017). Job quality is one of the main forces hindering increased
workforce participation. Aside from the physically and emotionally
demanding nature of the job itself, low wages, poor benefits, inconsistent
hours, insufficient training, lack of opportunities for advancement, and lack of
agency-level employee support have caused many workers to instead seek
jobs in other low-skill industries like retail (Butler et. al., 2013; Ellenbecker et.al.;
2008; Chou & Robert, 2008; Castle, 2007; Denton et. al., 2002).
PAGE 4

9. DIFFERENT TYPES OF HOME HEALTH CARE AGENCIES
Zeytinoglu et.al. correlate the growing job dissatisfaction and turnover
rates with the current restructuring and organizational change in the home
care sector. Their study provides evidence that the transformation to a
market-based model of homecare, also known as “managed competition,”
has contributed to the cultivation of a business-like work environment and
consequently taken a toll on homecare workers (Zeytinoglu et. al., 2007).
Since most home health care agencies “provide part-time, low-wage jobs for
unskilled women in the urban labor force, with little chance for advancement”
(Rowe, 1990), they are similar to temp agencies that provide both temporary
workers and deviate from traditional, in-house hiring and employment
practices, losing in the process the many elements that contribute to job
satisfaction. Home care agencies are present in both the for-profit and
non-profit sectors. However, Zeytinoglu et. al. finds little promising
differences in the working conditions of the two, other than for-profit
homecare workers seemingly experiencing fewer structural impacts of
healthcare restructuring. Rowe, on the other hand, finds two favorable
alternatives to the traditional business model of home health care outside the
non-profit/for-profit debate. The first is a “service credit” movement that
functions as a time-barter in which seniors in good health volunteer to lend
assistance to other seniors in poor health, building up credit to claim if and
when they need it. The second is the employee cooperative. (Rowe, 1990). Yet,
PAGE 5

10. before exploring the home health care cooperative alternative, the central
focus of this paper, it is important to examine recent trends in the cooperative
movement altogether.
II. WHAT ARE WORKER COOPERATIVES?
The International Cooperative Alliance (ICA) defines a cooperative
(co-op) as “an autonomous association of persons united voluntarily to meet
their common economic, social, and cultural needs and aspirations through a
jointly-owned and democratically-controlled enterprise” (ICA, n.d.). Although
cooperatives often largely differ by industry, they generally adhere to seven
common principles outlined by the International Cooperative Alliance: 1)
voluntary and open membership, 2) democratic member control, 3) member
economic participation, 4) autonomy and independence, 5) education,
training and information, 6) cooperation among cooperatives, and 7) concern
for community. As social economy organizations, worker co-ops value the
employee and socio-economic development of the community over
profit-making. While economic growth is still valued, the generated surplus is
divided among members of the co-op, rather than outside stockholders and
investors. Thus, co-ops are able to function in a capitalist society where
employees are subject to the bare minimum of free-market rules. This
independence and control over decision making is inherent in the
democratic structure of the cooperative. In line with cooperative bylaws, each
PAGE 6

11. member is granted one vote, thus maintaining equality among all employees
regardless of hierarchical status, like salary or position. First and foremost, this
vote guarantees members control over the composition of the board of
directors. Usually, the board is comprised mainly of direct work employees,
rather than investors, office managers or supervisors. Nevertheless, all
members annually vote on board representation, committees, and managers.
This structure eliminates the traditional top-bottom business model in which
the board of directors and managers have final firing and hiring power, which
has often lead to an abuse of power and unfair treatment of workers. Instead,
through a system of checks and balances, a constant stream of information
exchange is evident between members, as they hold voting power in all
major decisions brought up by the board. By having a long-term financial
stake in the company, employees are actively concerned and engaged in
aspects that while not directly affecting their employment, may impact the
welfare and longevity of the company. These guiding principles of voluntary
adhesion and collective deliberation ultimately protect workers from the
moral hazard often attached to management decisions over investment,
strategy, and even human resource policies. Additionally, through
involvement in profit and in decisions on wages and pay, cooperatives are
able to effectively respond to demand shocks (Pérotin, 2006).
PAGE 7

12. THE CURRENT STATE OF WORKER COOPERATIVES IN THE U.S.
Worker cooperatives are quite rare in the United States. In contrast with
other Western countries, like Italy with 40,000 cooperatives and France with
21,000 (LaSalle, 2012), the United States has only approximately 300
democratic worker cooperatives. Yet, even this number is a rough estimation;
currently, very little research has been conducted in the field and a
cooperative census examining longevity is still in the works (Democracy at
Work Institute, n.d.). Compared to other cooperatives, like consumer,
producer, and purchasing cooperatives, worker co-ops are the most scarce
and have the lowest average revenue, membership, and employment levels (
Artz & Kim, 2011). 70% of the worker cooperatives are located in just seven
states. At the same time, 20 states do not have any cooperatives at all
(Democracy At Work Institute, 2016). This telling statistic describing stark
differences among states is suggestive of the fundamental importance of
state-by-state policy support, favorable tax structures, and availability of
resources in instituting and expanding cooperatives. Despite the dearth,
worker co-ops are gradually increasing in size and number. This expansion is
stimulated by the substantial growth of employee-ownership in the U.S. over
the past 40 years, due to legislative changes in the 1970s that created and
gave favorable tax treatment to Employee Stock Ownership Plans (ESOPs)
and a change in 1984 that eliminated capital gains taxes for business owners
who sold at least 30% of their firm to their employees (Artz & Kim, 2011). It is
PAGE 8

13. important to clarify that ESOP firms differ substantially from worker co-ops
by lacking an institutional democratic foundation; some might share many
cooperative principles, but they do not abide by strict cooperative bylaws.
Nonetheless, their growth has given rise to research and support for the
advancement of return rights (having a financial stake in a firm) and control
rights (having the ability to make decisions regarding management and
business prospects) in the workplace (Artz & Kim, 2011; Hansmann, 2000). This,
in turn, prompted a greater evaluation of the viability of worker co-ops that
intrinsically encompass these rights and function to empower employees.
THE VIABILITY OF WORKER COOPERATIVES IN OUR PRESENT ECONOMY
Opinion on worker cooperatives is marred by preconceived notions that
cooperatives are unlikely to work because they radically alter the traditional,
hierarchical, profit-oriented structure of firms. Despite the cooperative model
operating for longer than a century, with many firms created in the late
nineteenth and twentieth century still trading today, they are still considered
minority forms of business and often reasoned to be less efficient and less
viable (Pérotin, 2006). Moreover, many authors have suggested that allowing
worker participation introduces inexperienced or ill-qualified participants into
decision making which results in bad, slowly made decisions. (Artz & Kim,
2011).
PAGE 9

14. However, through an extensive literature review of all recent empirical
evidence on the performance and success factors of employee-owned
cooperatives, Pérotin draws several fundamental conclusions about their
apparent efficiency and necessity. She finds that “contrary to popular
thinking and to the pessimistic predictions of some theorists, solid, consistent
evidence across countries, systems, and time periods shows that worker
cooperatives are at least as productive as conventional firms, and more
productive in some areas” (Pérotin, 2016). Studying cooperatives through the
frameworks of job preservation, survival, and institutional sustainability,
Pérotin highlights that the elements that make cooperatives so unique, such
democratic participation and an unusual distribution of capital, in fact
contribute significantly to their viability, strength, and efficiency. Additionally,
co-ops have been found to have higher retention rates among
employee-owners. Through longer job commitment, employees develop
more skills, thus improving productivity, profitability, and their own wages.
Kruse et. al. even found that by embracing participation in workplace
decisions, having job security, and maintaining freedom from supervision,
employees report higher job satisfaction (Kruse et.al., 2010).
THE NECESSITY FOR THE EXPANSION OF WORKER COOPERATIVES
While there is a growing interest in the profitability attained by
supporting workers’ rights, particularly through return and control rights, one
PAGE 10

15. might question whether there is an ethical concern or a truly pressing need
for policy support of worker cooperatives. An analysis of the alarming current
state of income inequality answers this question straightforwardly: yes.
Without going into detail on the many patterns of wealth inequality in the
U.S., it is important to summarize several growing trends that would be
reversed by a growth in worker cooperatives. Firstly, CEOs today make almost
300 times more than they pay their average worker (Mishel, et.al., 2015) While
there is no research on this ratio in worker cooperatives, CHCA, the nation’s
biggest worker cooperative, hit its highest ratio of CEO to minimum wage
employee at just 11:1 (Flanders, 2014). Smaller pay ratios ensure that a
company’s profits are split among employees, thus promoting their
economic inclusion and increasing their capacity to participate in the
economy (Rieger, 2012). A second important trend worth examining is the
racial wealth gap. The disparities are disturbing: on average, black households
possess just 6 percent the amount of wealth that white households do, and
Latino households have 8 percent the amount of wealth that white
households possess (Sullivan, et. al., 2015). Worker cooperatives are already
altering this trend, as between 2012 and 2013, about 60 percent of people in
emerging worker cooperatives were people of color (Democracy at Work
Institute, 2016). Chief program and policy officer of the Federation of
Protestant Welfare Agencies (an organization that promotes the social and
economic well-being of greater New York), Wayne Ho, thoroughly
PAGE 11

16. summarizes the necessity of worker cooperatives: “Making sure that a safety
net exists is not enough to help New Yorkers have satisfying lives. We needed
a new approach to workforce development that would not only reduce
poverty but also promote upward mobility, and that’s where co-ops can be an
anchor” (Flanders, 2014).
Additionally, there is a necessity for a reallocation of resources from the
promotion of ESOPs towards the furthering of worker cooperatives. While
ESOPs, like worker cooperatives, tend to also draw employee satisfaction rates
above the national average employee (McQuaid, 2012), its structure does not
ensure the protection of workers’ rights nor reverse wealth inequality. Unlike
worker cooperatives, the allocation of profits in ESOPs is based on the
number of shares owned, rather than the number of hours worked or wages
earned, thus maintaining a wealth status quo and hindering upward mobility.
Moreover, voting rights rest within the trust fund (and the trustees), or a one
share/one vote model, rather than the employee, or one member/one vote
model. Because of this, ESOPs do not inherently promote democratic
self-determination nor challenge the traditional, capitalist property rights that
uphold wealth inequality. Here, power and control over the workplace still
remains in the hands of the select few (Ellerman, 1985). In conclusion, ESOPs
should not be embraced as the solution for increasing employee satisfaction
and decreasing the wealth gap.
PAGE 12

17. III. EXAMINING HOME CARE WORKER COOPERATIVES
Coinciding with the general cooperative movement, worker ownership
in-home care agencies is a growing trend. The first home health care
cooperative, Cooperative Home Care Associates (CHCA) emerged in the Bronx
in 1985. Since then, not only has its workforce increased to over 2,000
employees, it is, in fact, the largest worker cooperative in the United States.
Home care cooperatives benefit from management accountability, member
governance and involvement, and the maximization of income, hours and
benefits (Whitaker, 2005). Studying home care cooperatives 13 years ago,
Whitaker found several unique commonalities among home care co-ops.
First, many integrate cooperative members into the governance of the
organization through sub-committees, like those on policy action, marketing,
and social events and organizing. Additionally, direct care staff at these
co-ops have consistent hours and competitive wages. However, since the
home care industry operates on slim profit margins, the little additional
aggregated revenue is often used to benefit consumer care and business
expansion. Nonetheless, these decisions are agreed upon by direct care staff.
Although Julie Whitaker offers the only research available on home
health care cooperatives, her study is largely outdated and insufficient. Of the
eight cooperatives studied, only three are still functioning as worker
cooperatives, or operating at all (Cooperative Care, Cooperative Home Care
Associates (CHCA), and Home Care Associates (HCA)). To expand on
PAGE 13

18. Whitaker’s research and fill its incompletions, I collected data on seven
cooperatives through extensive phone interviews and research. An overview
of the participating cooperatives follows.
PARTICIPATING COOPERATIVES
Of the 12 currently existing home care worker cooperatives in the U.S.,
seven cooperatives participated in this study: CHCA, HCA, Cooperative Care,
Peninsula Home Care (PHC), Heart is Home (HIH), Capital Home Care, and
Circle of Life. Speaking with office managers, human resources, and/or
founders on the phone, I found that each cooperative engendered its own
distinctive way of operating that stemmed from a unique story of its
founding, the number of years its been functioning, the region, source of
funding, and the number of member-owners present in the company.
Unfortunately, a majority of these worker cooperatives have less than 50
employees, and, within the context of low response rates, it proved impossible
to separate the data based on each cooperative alone. Instead, to ensure a
large enough dataset, responses from all seven cooperatives were
aggregated to produce an overarching snapshot of the average home health
care cooperative. To reflect the nature of this data, I will use two of Whitaker’s
cooperative model categories instead of examining each cooperative
individually. Additionally, this bifurcation acknowledges the large variability
between CHCA and HCA and the rest of the cooperatives in their size and
PAGE 14

19. longevity that may influence the results of the study through
heteroskedasticity. Understanding their distinctiveness will allow for a clearer
reading of the survey results.
Whitaker presents four individual home care cooperative models in
order to encompass the variation among cooperatives. Only two of her
categories are relevant to this study: 1. job training cooperative model 2.
independent caregiver model.
1. The job training cooperative model encompasses agencies that prioritize
providing exceptional, often free, job training to low-income and unemployed
people. This training encompasses both a primary caregiving and home
health caregiving certification. CHCA boasts that its 4-week training goes
beyond Medicare requirements, while HCA has an award-winning 12-week
training program. Cooperative Care, too, now has the Direct Care Competency
(DCC) training program. While Whitaker places Cooperative Care in the
second category since it’s program is non-medical, moving it to the first best
encompasses its similarities in size and longevity to CHCA and HCA.
Cooperative Care is the third oldest home care cooperative and third-biggest,
as it was established in 2001 and has 40 employees, compared to HCA in 1993
with 138 employees, and CHCA in 1985 with over 2,000 employees. Compared
to the second category, job training cooperatives tend to have fewer
employee-members, with HCA and CHCA garnering 40% membership
(although Cooperative Care differs with 90%). The lower rates of membership
PAGE 15

20. can be attributed to the size of the cooperative and the structure of the free
training programs that guarantee employment and may encourage
temporary employment for people that are not interested in a long-term
involvement in the agency.
Both HCA and CHCA employ a large share of women, especially those
that previously received public assistance. Additionally, they target inner-city
neighborhoods given their Philadelphia and New York City, respectively,
location. They provide medical care and post-surgery care, as well as respite
services like personal care and personal assistance. Although Cooperative
Care does not hire nurses, it partners with other agencies that specialize in
hospice and skilled nursing services in order to offer 24/7 care. Structurally, all
three are identical, with a seven-member board of directors, elected by
cooperative members, that meets monthly and an annual meeting for the
entire membership. Regarding employee benefits, they claim to provide
above-average wages, health insurance and other benefits, opportunities for
career advancement, full-time hours, and extensive employment support.
2. The independent caregiver model consists of Circle of Life in Washington,
Capital Home Care in Washington, Heart is Home (HIH) in New Mexico, and
Peninsula Homecare Cooperative (PHC) in Washington. They differ from the
previous category mainly by not providing medical services or medical care,
centering instead on meeting the basic needs of seniors, such as cleaning,
PAGE 16

21. bathing, companionship, cooking, and other duties. Aside from Circle of Life
with 50 caregivers, they are relatively small: PHC has 19 employees, HIH has 10,
Capital Homecare has 8. Additionally, they are not well established and
embody a structure closer to that of a startup. HIH began operating in 2016. It
is still not a licensed Home Health Agency but has begun the membership
process for employees. PHC reports being inspired by a cooperative “social
and economic revolution” to establish the agency in 2016, yet is currently
experiencing a low spirit and morale as it undergoes sweeping changes in the
composition of the board of directors. Nonetheless, there is promising
precedent for a successful home care cooperative startup model, as Circle of
Life, now on its 9th operational year, boasts a large net surplus (of $97,640)
that is split among members. In fact, the Northwest Cooperative
Development Center highlights Circle of Life as a model for success through a
financial and structural analysis of the agency (Northwest Cooperative
Development Center, n.d.). Unfortunately, as is typical of literature on worker
cooperatives, the report does not hone in specifically on the employees
themselves, such as their actual ability to effect change in the cooperative or
their satisfaction rates.
While, independent caregiver cooperative agencies parallel job training
cooperatives in their 7 member board of directors with annual membership
meetings, they limit the board to caregivers only, thus excluding office
managers and supervisors. Additionally, their services are limited to primarily
PAGE 17

22. rural and suburban counties and private-pay customers. Given their startup
natures and the bureaucratic difficulties in securing Medicaid funding
(Northwest Cooperative Development Center, n.d.), it is no surprise that they
do not serve lower-income communities or provide free training programs.
Nonetheless, several cooperatives express interest in pursuing Medicare
funding and created a structured training program to serve lower-income
communities once they reach a higher net surplus and a bigger employment
force.
LITERATURE REVIEW
IMPORTANCE OF FOCUSING ON JOB SATISFACTION OF THE HOME CARE
INDUSTRY
While there are several reasons why researchers should be concerned
with job satisfaction when studying the home health care industry, the first
and foremost is the ethical concern for promoting a work environment where
caregivers are safe, respected, and treated fairly. Job satisfaction is a reflection
of good treatment (Bhatnagar & Srivastava1, 2012). A high level of job
satisfaction is a necessary component of an optimal state of health, especially
in a highly competitive modern society with mounting requirements for
commitment and self-efficacy from employees (Castel, 2011). In this context, a
PAGE 18

23. denial of dissatisfaction and the absence of a commitment to address and
reform current problems leads to unjust suffering.
Additionally, care work is a “dyadic relationship between the provider and
recipient of care” (Delp, 2010), encompassing a highly personal and intimate
scope of work that depends on the provider’s well being to administer good
care. As adult healthcare shifts from the public, hospital domain to the
unregulated, private, community, the obligation to be attentive to employee
health is often lost in the administrative concern for profit-making. Compared
to traditional employment structures, home health care providers are
nowadays forced to rely on support from friends, family, and the clients they
attend to, as opposed to support from coworkers and supervisors (Chou and
Robert, 2008). Instead of measuring the satisfaction of employees, the focus
has shifted to retention and intent to leave rates, as these most closely predict
economic productivity and efficiency. However, studies show that caregivers
are far more likely to endure the agonies of low quality work. They may be
more attached to their jobs and display less willingness to quit because of the
overwhelming satisfaction they get from “their calling” (Singh, 2010), thus
proving that intent to leave rates do not account for the weight of intrinsic
values of satisfaction and easily conceal factors that may have a mental or
physical toll on caregivers.
Rather than examining health care through a consumer-directed
model that measures the efficiency of an exchange of services, we must see
PAGE 19

24. care work as a social interaction compounded by a wide range of factors that
influence well-being. Since job satisfaction is a significant predictor of the
overall level of happiness of an individual (Argyle, 2001), it is imperative that
the discussions on home health care shift away from studying factors that
affect turnover rates and towards those that makeup job satisfaction.
Without a doubt, high turnover rates plague the home health care
industry and deserve some kind of attention. With Home Health Pulse
reporting the percentage of caregivers who quit or are terminated per year
higher than ever (a soaring 66.7% in 2017, the highest since 2013) (Marcum A.,
2018), managers scurry to counteract these rates with better recruitment
strategies and more appealing benefit packages and pay. While a plethora of
research supports the direct relationship between pay dissatisfaction and
intent to leave, there are reasons to expect different outcomes from different
professions, such as from social work and health care, where pay may not be
the driving reason for employment. Singh and Loncar (2010) conducted a
multidimensional regression to find that compensation alone may not be
sufficient to decrease turnover, as caregivers are “more motivated by their
jobs, versus their pay.” Their research supports the findings of Shields and
Ward (2001) who observe that satisfaction with the daily work environment is
a more important determinant of the intention to quit. Similarly, a recent
survey on home care by the Canada Home Care Association, which included
input from more than 1,000 people from home care organizations, advocacy
PAGE 20

25. groups, caregiver organizations, health associations, trade unions, and
research groups, found that the number one concern of home care work is
employee support through human resources, with inadequate funding
placing second. Studies focusing on the relationship between job satisfaction
and intent to leave all found negative correlations among direct care workers
(Castle, 2006; Decker, 2009) and home care workers (Sherman, 2008). While it
is true that job satisfaction alone is not a consistent predictor of work
performance (Schermerhorn, 2000), focusing on this measurement, instead of
a quantitative, economic analysis on the effects of pay and financial benefits,
reflects the multidimensional nature of home health care work.
Certainly, the concern for the clients receiving home health care and
the need to measure the quality of their care remains. However, it is widely
known in the human resources field that satisfied workers are more
productive and efficient, are happier, and provide better quality services
(Tullai-McGuiness, 2008). Specifically, in healthcare, research supports the
theory that caregiver satisfaction is linked to both improved client outcomes
(Aiken et. al., 1994) and client satisfaction (Rondeau & Wager, 2005). Thus it
can be concluded that job satisfaction is the most in-depth and pervasive
measurement, as it directly impacts both turnover rates and customer
satisfaction rates. In comparing home health care cooperatives to
non-cooperative agencies, the job satisfaction variable enables a more
PAGE 21

26. thorough understanding of intrinsic and extrinsic differences between the
two.
FACTORS INFLUENCING JOB SATISFACTION IN TRADITIONAL HOME
HEALTH CARE FIRMS
Although numerous definitions of job satisfaction are outlined in
literature, this study will focus on the frequently cited definition of John
Locke, who explains it as a “pleasurable and positive emotional state resulting
from the appraisal of one’s job or job experiences” (Locke, 1969). This
definition highlights the importance of both extrinsic (structural/job) and
intrinsic (experiential/job experiences) factors.
The distinction between extrinsic and intrinsic rewards, factors, and
needs is a useful tool for studying the extent of job satisfaction. Herzberg et al
(1957) first elucidated this distinction in his “two-factors theory.” Extrinsic work
factors focus on issues that are external to the job itself, such as pay, working
conditions, work schedules, relationships with management and coworkers,
safety, and job prestige. On the other hand, intrinsic factors refer to a job’s
inherent features and affective reactions to integral features of the work itself,
such as occupational accomplishment, recognition, work interest,
responsibilities, promotion, autonomy, work usefulness, self-efficacy in work,
and skills use.
To best characterize the qualities of the home health care occupation,
focus groups and interviews are held to establish key attributes valued by
PAGE 22

27. caregivers. Reviewing such literature, Ellenbecker (2004) establishes the most
common extrinsic factors in home health care to be: stress and workload,
autonomy and control of work hours, autonomy and control of work activities,
perceived and real job opportunities, and lastly, salary and benefits.
Additionally, the most prominent intrinsic characteristics are autonomy and
independence in client relationships, and autonomy in the profession, group
cohesion with peers and with physicians or nutritionists, and organizational
characteristics. Not only are these variables commonly cited in homecare
literature, they all prove to be directly related to job satisfaction, intent to stay,
and retention (Ellenbecker, 2004).
While a plethora of variables may significantly correlate with job
satisfaction, the strength of the effects vary largely. Chou and Robert (2008)
consider this dynamism of job satisfaction to examine the varying degrees to
which different sources and types of support influence satisfaction. Results
from their hierarchical linear modeling regressions indicate that institutional
support, supervisor instrumental and emotional support, coworker emotional
support, and role overload are each independently associated with job
satisfaction. Moreover, their study is the first to confirm that institutional
support, in the form of providing human resources, material resources, and
problem-solving mechanisms, is more strongly related to job satisfaction than
either supervisor or coworker instrumental support.
PAGE 23

28. Given the multidimensionality of job satisfaction that is difficult to
capture numerically, through extensive surveys, it is not surprising that most
research in home health care focuses instead on the effects of workplace
characteristics on retention rates or intent to stay. The most prominent and
impactful characteristics are wages, health insurance, paid leave, pension
fund, the degree of care worker empowerment, respect from supervisors,
potential for injuries or violence, exposure to abuse, union involvement, and
travel to dangerous neighborhoods (Chou & Robert, 2008; Delp et al, 2010;
Butler et al, 2013). Given the correlation of intent to stay with job satisfaction
(Sherman, 2008), it may be intuitive to assume that characteristics impacting
one will impact the other. However, Stone (2004) in studying workplace
characteristics that impact worker empowerment, finds that feeling
undervalued by the organization and feeling uninvolved in challenging work
were only correlated with an intent to leave when job satisfaction was
removed from the model, proving that job satisfaction may be mediating
their effects.
Individual demographic characteristics of caregivers have been studied
in both intent to stay and job satisfaction. Tai et al (1998) found that tenure,
defined as number of years in present job, and age are both not only
positively related to intent to stay but also have the strongest effect on
retention compared to family income, marital status, gender, race and
PAGE 24

29. ethnicity. On the other hand, Stone (2004) found that the strongest
demographic variable on intent to leave is being African American.
Contrary to Tai et.al. (1998) and Stone (2004), Ejaz et. al. (2008) found
several stressors far more important than all demographics of direct care
workers for predicting job satisfaction. Using two levels of data (empirical and
interview driven), their study centers on the correlation between the
independent variables of backgrounds, personal sources of stress, job-related
sources of stress, workplace support, and organization level characteristics
and the dependent variable of direct care worker job satisfaction. Opposing
previous research, their findings conclude that race and financial
backgrounds were significant, yet not very important in predicting job
satisfaction. Instead, personal stressors, such as depression, and job-related
factors, like training and experiencing discrimination or racism from staff,
were far more impactful.
Adding context to the study of job satisfaction, Denton et. al. (2002)
explores the effects of health care restructuring on health care workers.
Observing the organizational changes in Ontario’s health care system,
Denton found that rapid change both increases job stress and decreases job
satisfaction, stemming from a lack of control over structural changes, loss of
autonomy, and strain of readjustment. Furthermore, Zeytinoglu et. al. (2007)
confirms these findings in the home care sector. Their study finds that
“restructuring and organizational change in the homecare sector has
PAGE 25

30. contributed to both mental and physical health problems, job dissatisfaction,
and retention problems. Considering the current and ongoing structural
changes in Affordable Health Care and Medicare, Denton and Zeytinoglu et.
al’s studies shed light on the often overlooked, underlying sources of job
stress.
THE RELATIONSHIP BETWEEN JOB SATISFACTION AND EMPLOYEE
OWNERSHIP
While there is no research examining the factors influencing job
satisfaction in home health care cooperatives, the relationship between
satisfaction and employee ownership has been well documented.
Lukomskaya (2014) summarizes this relationship by looking at intrinsic,
instrumental, and extrinsic routes. Intrinsically, ownership has a greater effect
on
attitudes and behavior “when employees feel it brings greater financial
returns or a
greater sense of control over workplace decision making.” Instrumentally,
management recognizes employees as investors and firm owners, and in
turn, promotes a culture of shared information and participation in decision
making at all levels of the firm. Extrinsically, Lukomskaya found several
studies in agreement on the positive effect of receiving a clear scope of their
work and financial returns from ownership on satisfaction rates of employees.
PAGE 26

31. Just as structural elements of home health care agencies impact job
satisfaction of caregivers, the unique structural organization of cooperatives
and employee-owned firms have a similar influence on satisfaction. While
Klein (1987) diverges from Lukomskaya (2014) and fails to examine support for
intrinsic satisfaction of employee-owned firms (ESOP), his study outlines
several influential structural elements of employee ownership on satisfaction.
When ESOPs provide substantial financial benefits to employees, when
management is highly committed to employee ownership and when the
company maintains an extensive ESOP communications program,
organizational commitment and satisfaction are high while average company
turnover intention is low.
Filling in the gap left by Klein (1987) in examining intrinsic satisfaction,
Castel et. al. (2011) conducted the first and only qualitative analysis of job
satisfaction and intrinsic motivation in worker cooperatives. Fundamentally,
their research is grounded on findings that “autonomy-supportive (rather
than controlling) work environments and managerial methods promote basic
need satisfaction, intrinsic motivation, and full internalization of extrinsic
motivation, and these, in turn, lead to persistence, effective performance, job
satisfaction, positive work attitudes, organizational commitment, and
psychological well-being.” Castel et. al.’s study confirmed that when
worker-owned cooperatives adhered to principles of the social economy,
there was a positive effect on workers’ job satisfaction. When workers
PAGE 27

32. intrinsically valued sustainability over profits, universal autonomy, democratic
decision-making, and a reduction in the gap between the conception and
execution of tasks, they were more likely to have a positive attitude toward
work. Castel’s study is interesting in that it clarifies that simply being in a
worker cooperative and an employee-owner does not imply a higher job
satisfaction. Instead, the correlation rests upon the individual’s personal
adaptation of these values and not on the adoption of a cooperative form of
enterprise.
DRAWING CONCLUSIONS
Although research in the field of home health care is limited, existing
studies elucidate the varying perspectives to which job satisfaction can be
studied. In relation to the particular effect of the cooperative model on job
satisfaction, literature strongly suggests a multidimensional approach,
studying intrinsic, extrinsic, and demographic variables that reflect the
complexities of the profession. Job training model cooperatives, like CHCA,
HCA, and Cooperative Care, claim to offer above-average wages, health
insurance and other benefits, opportunities for career advancement, full-time
hours, and extensive employment support. While literature suggests all of
these variables to affect job satisfaction in varying health care professions, no
one study examines these effects in the home health care setting. Thus,
PAGE 28

33. this study will first examine the effect of the advantages cooperatives offer
(due to their inherently democratic structure and equitable distribution of
capital) on job satisfaction in non-cooperatives. This approach can also serve
to prove whether or not cooperatives offer unique characteristics that can be
adapted in non-cooperatives to better serve employees. Secondly, this study
will test the hypothesis that employees at home health care worker
cooperatives have higher satisfaction rates than non-cooperatives. Kruse et.
al. (2010) suggests that job commitment leads to higher retention and higher
satisfaction. Additionally, Artz & Kim (2011) argue for the benefits of return
rights and control rights in improving employee well-being. Combining Kruse
et. al. and Artz & Kim’s suggestions, this study’s survey will attempt to capture
the extent to which cooperative employees are motivated by their
commitment, financial investment, and feeling of being valued and in
control.
FRAMEWORK
This study’s research framework was inspired by Denton et.al (2002)’s
participatory action research project. Elevating the purpose of educating and
taking action to effect social change, their project is the product of a
collaborative union between researchers, managers, and supervisors from
agencies affected by the problem studied. As a result, those affected by the
problem researched, in this case, the effects of home health care
PAGE 29

34. restructuring, directed aspects of the project, rather than simply acting as
subjects of interviews. Overall, “the goal of this project was to improve the
work-related health of home care workers at the three agencies” (Denton, et
al, 2002), thus solidifying a reciprocal relationship in which both the
researcher and the subjects benefit from the study.
I, too, hoped to engage in reciprocity and the collective production of
knowledge in my study. Although the subjects of my study were the direct
care workers, I spoke with administrators over the phone as well. Our lengthy
conversations touched upon the structure of the cooperatives, the story
behind their foundings, the current problems facing the cooperatives, and
any suggestions they might have for the framework of my research.
Moreover, a draft of my survey was distributed to all administrators to offer
them more control over the structure of my survey. For agencies with a large
number of Spanish speakers, I offered a Spanish version of the survey. By
doing so, I hoped to reverse the limitations of Jang et al’s research, whose
survey was offered only in English and “may indicate a systematic exclusion of
non-White workers, particularly those with limited English proficiency” (Jang
et al, 2017). Given the fact that more than a quarter of home healthcare
employees spoke a language other than English at home (Montgomery et al.
2005, Jang et al., 2017), a Spanish version not only allows for greater inclusion
and more accurate results, but also increases response rates.
PAGE 30

35. I approached the idea of a participatory research project with a broad
view of the actors involved in the production and effects of my research. Since
my project aims to contribute evidence and data to the under-researched
field of worker cooperatives, I found it imperative to consider the roles of
people outside the home health care cooperative industry and their
relationship to my study. My paths crossed with Carolee Colter, a consultant
for cooperatives whose expertise lies in employee surveys, human resources
systems, and tools and training. An individual involved in the cooperative
movement and concerned about the underrepresentation of worker
cooperatives in academia and American businesses, Colter offered
consultation about the format of my survey. She advised me on the wording
of my cooperative specific questions and the content they touched upon,
shedding light on the effects of tone to garner more truthful responses.
Additionally, I received invaluable help from her through conversations about
the nature of cooperatives and the ways in which a survey can capture the
“cooperative spirit.”
DATA
My study examines the effect of home health care cooperatives on job
satisfaction by comparing them to traditional home health care agencies. In
order to create a point of comparison, I researched job satisfaction data sets
for traditional agencies. Three surveys stood out: 2007 National Home Health
PAGE 31

36. Aide Survey (NHHAS), Ellenbecker’s Home Health Nurses’ Job Satisfaction
survey (HHNJS), and Ejaz’s Direct Care Worker Job Satisfaction Scale
(DCWJSS). Carefully analyzing means and standard deviations of the collected
data from each, and comparing them with the 2005 Census on Home
Healthcare workers, NHHAS stood out as the most reliable survey. Although
DCWJSS is short, user-friendly, and has the most accurate descriptive
characteristics, it has significant shortcomings in the lack of cross-sectional
data, as results were confined to the state of Ohio. HHNJS drew strengths in
the multidimensional and psychometrically validated scale for measuring job
satisfaction; however, it focused on nurses rather than all home health aides,
had the smallest number of respondents, and had a demographic of
participants with a family income substantially higher than that of the home
health workers reported in the U.S. Census (Montgomery et al., 2005). NHHAS,
too, faced limitations in the underrepresentation of non-whites (Jang et al.,
2017), 10 year outdatedness, and exclusion of privately hired workers.
Nonetheless, NHHAS offered the largest data set with the most abundant
questions to perform a cross-sectional analysis.
Conducted by the National Center of Health Statistics in 2007, the
NHHAS is a national, two-stage probability survey of home health workers.
Designed to provide nationally representative information regarding home
health aides who work at home health and hospice care agencies, it utilized
computer-assisted telephone interviewing system in English to garner 3,377
PAGE 32

37. responses from aides. Included in this sample were home health workers,
certified nursing assistants, hospice aides, and home care aides/personal care
attendants (Stone, 2017).
Jang et. al (2017), Stone et al. (2017), and Yoon et al. (2016) all study the
factors and determinants of job satisfaction using data from the NHHAS
survey. Although sharing the same dependent variable (job satisfaction based
on a 4-point Likert scale), and overlapping in many independent variables, the
results of their studies largely varied. For the most part, Yoon et al. and Jang
et al. found a majority of their independent variables statistically significant in
their multivariable analyses. Their findings were also largely in agreement
with literature on the effects of job stressors, work characteristics, work
demands, and work support on satisfaction rates. On the other hand, Stone et
al. arrived at findings that refuted earlier assumptions. Contrary to Yoon et al. ,
Jang et. al. , and previous home health care literature using other surveys,
Stone et. al.’s study found that consistent assignment, empowerment of the
aide, benefits, and desire for more hours had no statistically significant effect
on job satisfaction.
Perhaps at the core of these differences are the varying statistical
analysis models used that elucidated different, possibly incomparable,
aspects of the relationship between job satisfaction and other factors. Yoon et
al. perform a one-way ANOVA to study the variance between population
characteristics, job characteristics, and job satisfaction. By simply capturing
PAGE 33

38. mean differences, their model lends itself to an observation of the cause and
effect relationship between job satisfaction and the independent variable. It
identifies a positive or negative relationship, but does not measure the size of
these effects, like a beta coefficient in a regression would. Thus, it is no
surprise that the effect of every independent variable on job satisfaction was
confirmed in Yoon et al’s study.
Jang et al. took on a more complex approach in their analysis and first
studied bivariate correlations to eliminate the possibility of multicollinearity.
He confirmed that all variables were correlated in the expected direction
(paralleling Yoon’s findings). Next, a linear multivariate regression was run to
discover the factors that predicted job satisfaction. This model arrived at a
narrower selection of statistically significant factors, eliminating training,
agency affiliation, and marital status.
Stone et. al. concluded that being encouraged to speak with the
patient’s family, job training, pension/retirement plan, feeling valued,
challenged, and trusted, wanting fewer hours, and agency affiliation were all
statistically significant. Notice that job training and agency affiliation were
previously found insignificant in Jang’s study. Although also conducting
descriptive and bivariate analyses to better understand the data in the
beginning, Stone et al. ran a multinomial logistic regression to identify
statistical significance. This type of regression allows them to assess the effect
of the independent variable on the log-odds of being “extremely satisfied” or
PAGE 34

39. “somewhat satisfied” as opposed to the reference group of “dissatisfied.” In
this way, job satisfaction was no longer a metric, but rather a nominal
characteristic. “Extremely dissatisfied” was not taken into account.
Additionally, Stone et al. created two models, the first excluding variables that
were suspected of being endogenous to job satisfaction: feeling involved in
challenging work, feeling trusted, feeling confident, feeling satisfied with
hours, and feeling respected. By doing so, the researchers avoided problems
with simultaneity. However, because excluding relevant variables can lead to
bias in the estimated coefficients, they presented the endogenous variables
in a second model. Both models produced discrepancies over the statistical
significance of variables, thus rendering less findings of significant
relationships. Yoon et al. also considered the effects of endogenous variables.
However, they mitigated these effects by computing job satisfaction as a 12
point score of 4 aspects of job satisfaction that contribute to the dependent
variable: feeling satisfied with challenging work, salary, benefits, and learning
new skills. Thus, these endogenous variables were captured by the
dependent variable. Overall, while both researchers eliminate the problem of
simultaneity, they also arrive at incomparable dependent variables, which
further explains the great degree of variation within their findings.
Analyzing all three works, I concluded that no one model presented the
most straightforward approach for determining the most relevant
determinants of job satisfaction. Nonetheless, each clarified important
PAGE 35

40. considerations for me in developing an approach that explores the impact of
mutable factors, that is the factors under the control of an agency or
influenced by policy, in the job satisfaction rates of both traditional and
worker cooperative firms.
MEASURES
DEPENDENT VARIABLE
Agreeing with Yoon et. al. (2016), I computed the dependent variable of job
satisfaction by using responses to the NHHAS question: “How satisfied are
you with the following aspects of your current job?: challenging work, salary,
benefits, and learning new skills.” Each item was rated on a 4-point Likert
scale with 0 meaning extremely dissatisfied and 3 meaning extremely
satisfied. An average was then computed to produce a score that ranged
from 0 to 3. Relying on just one question, “How satisfied are you with your
job,” to determine job satisfaction is dangerous, as often times, we rely on
hindsight rather than experiential memory to answer questions about our
sentiments (Kahneman, 2015). Thus, participants may instead answer the
question as “How satisfied was I with my job today or yesterday,” capturing
their current mood or mental state of being, rather than their satisfaction
with all the daily aspects of the job thus far. Asking four specific questions
instead not only engages participants in using their experiential memory, but
also provides a more multidimensional scale to job satisfaction.
PAGE 36

41.
INDEPENDENT VARIABLES
Since I could not simply use all the variables gathered in the extensive NHHAS
survey, literature advises for the selection of independent variables based on a
theoretical model. For example, Chou and Robert (2008) adapt the job
demand-control/support (JDC/S) model that examines variables related to
job-related stress through the categories of job demands, control, and
support. Jang et. al. (2017) use a similar model, shifting focus on demands and
resources (JD-R). Delp et. al. (2010), too, focus on demand, control and support
through a job stress model. Ellenbecker et al. (2008), on the other hand,
approached job satisfaction through the two categories of extrinsic and
intrinsic variables. Denton et. al. (2002) used a job stress model like previous
authors, yet at the same time, also differentiated the dependent variable of
job satisfaction into intrinsic and extrinsic job satisfaction.
Taking all these different models into account, I structure my study
around the variables most relevant to a comparison between worker
cooperatives and traditional health care agencies. Assuming that the
demands of home health care professions are similar in both types of
agencies, I focus on control and support variables. CHCA, along with other
cooperatives within the job training co-op model category, points to “above
average wages, health insurance [and other benefits], career advancement,
full-time hours, and extensive employment support” as the five main reasons
PAGE 37

42. for joining a cooperative. Because my survey did not garner many responses
from the independent caregiver models, the advantages that job training
co-ops advertise become my independent variables of interest: hourly wages
[HOURLY], receiving insurance [INSURE], receiving training [TRAIN], working
enough hours [FTHOURS], receiving paid sick days [PSICK], receiving paid
holidays [PHOLIDAY], receiving retirement funds or pensions[RETIRE],
receiving paid childcare [PCHILD], multidimensional supervisor support
[SUPCLEAR, SUPSUPPOR, SUPLISTEN, SUPTELLS], respect from
agency[RESPECT], feeling trusted [TRUST], feeling confident [CONFIDEN], and
feeling valued [VALUE]. Conveniently, these independent variables
encompass both intrinsic and extrinsic variables, thus providing a
multifaceted assessment of cooperatives. Additionally, to better understand
sentiments in cooperatives, variables of employment control are introduced.
Although these questions were not originally asked in the NHHAS survey, and
will not be used as points for comparison, their inclusion better illuminates
the cooperative aspect of the home care agency, specifically in its distribution
of power and empowerment of the employee. Below is a table outlining the
variables, corresponding survey questions, response categories, and
supporting literature previously reviewed in my study.
PAGE 38

43. TABLE 1: Description of Variables Included in the Study
VARIABLE
INCLUDED
QUESTION ASKED RESPONSE
CATEGORIES
NHH
AS
Que
stion
#
Literatu
re
Review
Dependent
Variable
Job
Satisfaction
AVGSAT
“How satisfied are you with the
following aspects of your
current job?”
a. Doing challenging work?
b. The benefits?
c. The salary or wages?
d. Learning new skills?
1. Extremely
satisfied
2. Somewhat
satisfied
3. Somewhat
dissatisfied
4. Extremely
dissatisfied
H4 Yoon
et. al.
(2016)
Demographic
s
(Control)
Race
MINOR
“Do you consider yourself…”
a. White
b. African American or black
c. American Indian or Alaska
native
d. Asian
e. Native Hawaiian or pacific
islander
F. Hispanic or Latino/Latina
1. Non-Hispanic
White
2. Non-White
K4 -Stone
et al.
,2004
-Ejaz et
al.,
2008
Education
EDUC
“What is your highest level of
education?”
1. No diploma or
GED
2. HS diploma or
GED
3. At least some
college
Yoon
et al.
Time
working at
agency
TENURE
Since you first became a home
health aide, how long have you
been doing this kind of work?
1. <2 years
2. 2-5
3. 6-10
4. >10 years
B4 Yoon
et al.
Personal
health
In general would you say that
your health is. . . excellent, very
1 Excellent
2 Very good
K7b Jang
et al.
PAGE 39

44. HEALTH good, good, fair, or
poor?
3 Good
4 Fair
5 Poor
Extrinsic
Variables
Full Time
Hours
FTHOURS
“Would you prefer to work more
or fewer
hours on this job, or is the
amount of hours
you work about right?”
1 More hours
2 Fewer hours
3 About right
Ellenbe
cker,
2004
Salary
HOURLY
“What is your hourly rate of
pay?”
[Although respondents were
asked for their exact hourly pay,
responses were recoded for the
OLS regression to avoid
heteroskedasticity and decoded
for the descriptive analysis]
1. $0-9
2. $10-13
3. $14-20
D6a
2
Jang
et al.
Benefits
PSICK
PHOLIDAY
RETIRE
PCHILD
“Does your agency offer you…”
“Does your agency offer you…”
a. paid sick leave?
b. Paid holidays off?
c. Retirement or pension
plan?
d. Paid child care or child care
subsidies or assistance?
1. No
2. Yes
D19 Jang
et al.
INSURE “Is there health insurance
coverage available to you”
1. No
2. Yes
D13
Career
Advanceme
nt
/Training
TRAIN
Did you receive any classroom
or formal
training to become a home
health aide?
1. No
2. Yes
C1a Jang
et al.
Yoon et
al.
Intrinsic
Variables
PAGE 40

45. Employment
Support
SUPCLEAR
SUPSUPPOR
SUPLISTEN
SUPTELLS
Please tell me if you strongly
agree,
somewhat agree, somewhat
disagree, or
strongly disagree with each
statement.
a. (My supervisor) provides clear
instructions when assigning
work
b. (My supervisor) is supportive
of progress in my career, such as
further training
c. (My supervisor) listens to me
when I am worried about a
patient’s care
d. (My supervisor) tells me when
I am doing
a good job”
1 Strongly agree
2 Somewhat agree
3 Somewhat
disagree
4 Strongly
disagree
F1 - Chou
&
Robert,
2008
- Stone
et al.
ORGVALUE How much do you think the
organization at {AGENCY} values
or appreciates the work you do
as a home health aide?
1 Very much
2 Somewhat
3 Not at all
I4
RESPECT
CHALLEN
TRUST
CONFIDEN
“tell me
whether you strongly agree,
somewhat
agree, somewhat disagree, or
strongly
disagree.
a. I am respected by my agency
for my work
b. I am involved in challenging
work
c. I am trusted to make patient
care decisions
d. I am confident in my ability to
do my job
1. Strongly agree
2. Somewhat
agree
3. Somewhat
disagree
4. Strongly
disagree
I1
DISCRIM On your current job, have you
ever been
discriminated against because
of your race
or ethnic origin? This could be
from
your employer, client or client’s
1. No
2. Yes
I8
PAGE 41

46. family.
Cooperative
only
variables
Employment
control
CONTROL
POWER
INVOLVE
“Tell me
whether you strongly agree,
somewhat
agree, somewhat disagree, or
strongly
Disagree.
a. I have control over the
work that I do
b. I have the power to
generate change in
organizational policy at
the agency where I work
c. I am very involved at my
cooperative
1. Strongly agree
2. Somewhat
agree
3. Somewhat
disagree
4. Strongly
disagree
EMPLOMEM Are you an employee-member
of the cooperative?
1. No
2. Yes
BOARD Are you currently or have you
ever been on the Board of
Directors?
1. No
2. Yes
PAGE 42

47. RESULTS AND DISCUSSION
This study seeks to test two hypotheses:
Hypothesis 1: Wages, benefits, training, full-time hours, and employment
support are significant determinants of job satisfaction
Hypothesis 2: Cooperatives have more satisfied employees than
non-cooperatives
HYPOTHESIS 1: RESULTS AND DISCUSSION
While cooperatives boast putting the employee first by offering a better
workplace environment, the advantages of these improvements, specifically
their relation to job satisfaction, are largely contested. To confirm the
statistical significance of these variables of interest, I ran an OLS regression
using data from the NHHAS survey, as presented in Table 1. After removing
individuals with data missing and men for lack of variance (since they
constituted just 3% of the respondents), a total of 2,202 individuals were
included in the study. The R2
of the regression was 0.42, indicating that the
independent variables account for 42% of the variation of job satisfaction. This
R2
is well within the range reported by other home health care studies, like
Jang et. al.’s 0.27, Denton et. al.’s 0.345, and Ejaz et al.’s 0.51. Because all
variables were recoded and of constant variance, heteroskedasticity is
PAGE 43

48. avoided. The statistical significance of each variable is considered strong on
the 0.01 level.
Table 2. Results of OLS Regression
Demographics
Of the significant demographic variables, a negative correlation is
noted between higher job satisfaction and higher educational attainment.
Given that home health care aides have an average $11.29 pay, it is no surprise
PAGE 44

49. that college-educated workers are dissatisfied with their jobs. Moreover, this
relationship has been previously confirmed (Jang et.al, 2017). Additionally
significant was personal health, which positively correlated with higher job
satisfaction. This relationship highlights the necessity that home health care
agencies prioritize the well-being of their workers, either by offering health
insurance, sufficient pay, or support for job stresses. Contrary to (Ejaz et.al.,
2008; Stone, 2017; and Jang et.al (2016)) minority race was not a predictor of
job satisfaction. While previous literature found that race correlated with
intent to leave (Stone, 2017; Ejaz et. al. 2008), this relationship should not imply
that all minority aides are dissatisfied. Clearly, other factors, not captured in
the study, lead these workers to quit. Additionally, tenure was not a
statistically significant predictor. While Denton et. al. (2002) and Jang et al
(2017) found age to be significant, my study dismisses age as a variable due
to the possibility of a tautological association between age and tenure.
Intrinsic Variables
Among the intrinsic variables, feeling that one’s supervisor tells them
they are doing a good job (SUPTELLS), receiving clear instructions from a
supervisor (SUPCLEAR), and receiving support for career progress through
job training from a supervisor (SUPSUPPORT) were significant predictors of
job satisfaction. The significance of SUPSUPPORT yet insignificance of TRAIN
was surprising, as the two seem to reflect similar aspects of the job, albeit one
PAGE 45

50. through an intrinsic perspective and another through an extrinsic. Perhaps
home health aides do not expect to be trained at the job and therefore are
not less satisfied when training is not offered. Nonetheless, there remains an
expectation for some kind of means of support for professional development
and attentiveness from the supervisor. This finding suggests that agencies
should reevaluate the structure of professional development, approaching it
not only as an extrinsic, financial investment in a rigid training program but
also as an intrinsic relationship of consistent support developed between
supervisors and employees.
In addition to the variables of supervisor support, feelings valued
(ORGVALUE), trusted (TRUST), confident in one’s abilities (CONFIDEN) and
respected (RESPECT) by an agency as a whole are significant predictors of job
satisfaction. In fact, compared to all other significant variables in the study,
ORGVALUE had the greatest effect on job satisfaction, accounting for a .24
standard deviation increase in job satisfaction when controlling for all other
variables -- twice as much as the second most impactful variable, PSICK.
Ultimately, these variables encompass the general ambiance of a workplace
and many factors influence the extent to which employees feel valued,
trusted, and respected by all the staff in an agency. Moreover, encouraging a
compassionate workplace will “enhance trust and fuel generosity, which in
turn can have a cascade effect in organizations” (Suttie, 2017). To do so, Worlin
and Dutton recommend creating smaller sub-groups that allow people with
PAGE 46

51. shared duties to develop a strong connection, formally recognizing acts of
compassion at work, and encouraging employees to speak about mistakes as
much as achievements without repercussions at weekly meetings (Worlin &
Dutton, 2017). In promoting this kind of environment, employees feel that the
organization not only values their good work, but also their well-being. This
relationship can significantly mediate the stresses they experience inherent
in their work with clients. As seen by the high statistical effect of ORGVALUE
on job satisfaction, organizations are encouraged to embrace a
compassionate work environment as their highest priority.
Moreover, discrimination has a significant, inverse relationship with job
satisfaction. Ejaz et al. (2008) delve deeper into this relationship and show
that racism and discrimination from staff were significant predictors of job
satisfaction, while racism from residents were not. These findings suggest
that discrimination can be mitigated on the administrative level by
promoting a no-tolerance policy and encouraging, or mandating, sensitivity
training for all employees (Ejaz et.al, 2008).
Extrinsic Variables
Extrinsic variables ultimately consist of structural characteristics, all of
which require a financial investment. Although agencies are not always able
to provide many benefits or high pay, it must not be ignored that these
variables significantly predict job satisfaction. For example, although hourly
PAGE 47

52. wage is a significant predictor of job satisfaction, when controlling for other
variables, a one standard deviation in hourly wage will increase job
satisfaction by .10 standard deviations. However, other benefits, like paid sick
days, paid child care, and health insurance, have a larger effect on job
satisfaction. Additionally significant is retirement or pension benefits,
although its effect is smaller (β = 0.0577). These findings are crucial for
employers to consider when planning financial models and budgeting for
each fiscal year. Evidently, employees, on average, prefer the benefit of paid
sick days over a raise in hourly wage.
Discussion
Table 3 displays the statistically significant variables in the study, listed
based on the magnitude of their effect on job satisfaction as interpreted by
the standardized regression coefficient. To specifically answer the hypothesis
“wages, benefits, training, full time hours, and employment support are
significant determinants of job satisfaction,” my OLS regression finds that
only wages, benefits, and employment support are significant predictors.
Nonetheless, training and providing full time hours should not be
disregarded, as their insignificance simply suggests that given the variables
controlled no significant linear dependence of the mean of both variables on
job satisfaction was detected. However, further studies should be conducted
examining the correlation between training and full time hours with
PAGE 48

53. statistically significant variables like ORGVALUE or HOURLY. Perhaps, lack of
training or frustrations over inadequate opportunities to work more hours are
mediated by the degree to which the employee feels valued by the agency or
they pay they receive.
Table 3. Statistically Significant Variables of OLS, organized by beta coefficient
Variable β p Characteristic
ORGVALUE .2374 0.000 Intrinsic
PSICK .1334 0.000 Extrinsic
TRUST .1199 0.000 Intrinsic
SUPCLEAR .1091 0.000 Intrinsic
INSURE .1077 0.000 Extrinsic
HOURLY .1006 0.000 Extrinsic
EDUC -.0986 0.000 Demographic
RESPECT .0981 0.000 Intrinsic
DISCRIM -.0681 0.000 Intrinsic
HEALTH .0665 0.000 Demographic
SUPTELLS .0618 0.003 Intrinsic
PCHILD .0577 0.001 Extrinsic
RETIRE .0578 0.005 Extrinsic
SUPSUPPORT .0541 0.009 Intrinsic
CONFIDEN .0496 0.006 Intrinsic
PAGE 49

54. HYPOTHESIS 2: RESULTS AND DISCUSSION
The second part of this study centers on drawing comparisons between
satisfaction rates in cooperative and non-cooperative home health care
agencies. In order to create the most accurate point of comparison, I used the
same exact questions as the 2007 NHHAS survey in my survey on
cooperatives (with the addition of cooperative-specific questions). However,
my survey is substantially narrower, follows a different sequence of questions,
has fewer responses, and focuses on employees in cooperative agencies now,
a decade after the NHHAS survey. Additionally, NHHAS was conducted over
the phone, while my survey uses Google Forms through a mass email.
Research shows that diction, sequence, and methodology are especially
important in the collection of accurate survey results (Schuman & Presser,
1977), thus suggesting that the results must be interpreted with caution. To
mitigate these shortcomings, I draw a comparison between cooperatives and
non-cooperatives based on a descriptive statistics analysis only. These results
are in no means representative of all home health care cooperatives.
Nonetheless, they provide a snapshot, albeit imperfect, of current home
health care cooperative, the first-ever of its kind. Table 4 presents the
descriptive statistics of variables in cooperatives and non-cooperatives, listing
the mean, standard deviation, and range.
Despite the differences in response rates (26 from cooperatives and
3,377 from non-cooperatives), cooperatives do not significantly diverge from
PAGE 50

55. non-cooperatives. Near identical means are reported in education
attainment, full time hours, paid child care, training, supervisor support,
supervisor appraisal, respect, confidence, and discrimination. Most
importantly, average job satisfaction is equal between the two, showing that
cooperatives do not necessarily have more satisfied workers.
Among the extrinsic variables of interest, cooperatives seem to lack the
advantages they advertise over non-cooperatives. For example, on average
they offer less benefits, like paid sick days, paid holidays, pension and
retirement plans, and insurance. Nonetheless, they own up to promised
higher wages, averaging at $12.28, a dollar increase over non-cooperatives.
Among the intrinsic variables of interest, employees at cooperatives feel less
(although not to a great degree) supported and praised by their supervisors,
respected by the agency, involved in challenging work, and trusted to make
patient decisions. Yet at the same time, they feel more valued by the
organization and confident in their ability to perform well, perfectly aligning
with the intentions of a cooperative model to account for the well-being of
the employee as much as the client. Given that feeling valued by an
organization is the greatest predictor of job satisfaction, this advantage
provides good reason for employees to join cooperatives over
non-cooperatives.
PAGE 51

56. Table 5: Descriptive Characteristics of the Cooperative (N=26) and
Non-Cooperative Samples(N=3,377)
VARIABLE COOPERATIVE MEAN,
STANDARD DEVIATION.
RANGE
NON-COOPERATIVE
MEAN, STANDARD
DEVIATION, RANGE
AVGSAT M= 2.317308
SD= .3908816
R= 1.75-3
M= 2.26258
SD= .5375025
R= 0-3
MINOR M= .3461538
SD= .4851645
R= 0-1
M= .2793679
SD= .4487555
R= 0-1
EDUC M= 1.230769
SD= .6516252
R= 0-2
M= 1.240597
SD= .6602837
R= 0-2
TENURE M= 1.423077
SD= 1.238485
R= 0-3
M= 2.329582
SD= 1.196135
R= 0-4
HEALTH M= 2.384615
SD= .8978607
R= 1-4
M= 2.855652
SD= .9230759
R= 0-4
FTHOURS M= 1.192308
SD= .4914656
R=0-2
M= 1.182035
SD= 4565614
R= 0-2
HOURLY M= 12.27826
SD= 2.429872
R=10-18
M= 11.29172
SD= 2.548227
R= 0-20
PSICK M= .5384615
SD= .5083911
R= 0-1
M= .7595245
SD= .4374374
R= 0-1
PHOLIDAY M= .5
SD= .509902
R= 0-1
M= .7364155
SD= .4406427
R= 0-1
RETIRE M= .2692308
SD= .4523443
R= 0-1
M= .7880691
SD= .4087403
R= 0-1
PCHILD M= 0.0384615
SD= .1961161
R= 0-1
M=.0945518
SD=.2926464
R=0-1
PAGE 52

57. INSURE M= .4230769
SD= .5038315
R= 0-1
M= .8718255
SD=.3343339
R= 0-1
TRAIN M= .8461538
SD= .3679465
R= 0-1
M=.8485926
SD= .3584987
R= 0-1
SUPSUPPOR M= 2.576923
SD= 0.5038315
R= 2-3
M= 2.73744
SD= .6113574
R= 0-3
SUPTELLS M= 2.423077
SD= .6433088
R= 1-3
M= 2.753289
SD= .5984984
R= 0-3
ORGVALUE M= 1.884615
SD= .4314555
R= 0-2
M= 1.692584
SD= .5054226
R= 0-2
RESPECT M= 2.692308
SD= .5491252
R=1-3
M= 2.822004
SD= .4731805
R= 0-3
CHALLEN M= 2.346154
SD= .5615911
R= 1-3
M= 2.659186
SD= .693065
R= 0-3
TRUST M= 2.461538
SD= .5817745
R= 1-3
M= 2.805489
SD= .5022121
R= 0-3
CONFIDEN M= 2.768231
SD= .4296689
R= 2-3
M= 2.673042
SD= .6643401
R= 0-3
DISCRIM M= 0
SD= 0
R= 0
M= .1080597
SD= .3105021
R= 0-1
CONTROL M= 2.5
SD= .7071068
R= 1-3
/
POWER M= 2.269231
SD= .7775702
R= 1-3
/
INVOLVE M= 2
SD=.8485281
R= 0-3
/
EMPLOMEM M= 1.230769 /
PAGE 53

58. SD= 0.6516252
R= 0-2
BOARD M= .84
SD= .3741657
R= 0-1
/
LIMITATIONS
This study is a worthy first step in expanding the research on home
health care cooperatives, and cooperatives in general. That being said, it faces
several limitations. While assessing NHHAS data to test my first hypothesis, I
found that the same size is biased against minorities. Aides were not given a
survey in languages other than language, despite the U.S. Census reporting a
large amount of home health aides to be speaking a language other than
English at home. Additionally, this study is only cross-sectional and does not
capture the effects of change over time. As Ejaz et.al. (2008) recommend, a
longitudinal study is imperative to assess the cause and effect between
variables in the model. Moreover, a longitudinal study will be more relevant to
policy makers and health agencies, as NHHAS is more than a decade old and
does not reflect noteworthy changes in the healthcare industry since the
2008 recession, expansion of Medicare programs, and the introduction of the
PAGE 54

59. Affordable Care Act that sets requirements on the employee health
insurance.
In regards to the second part of my study, hypothesis 2, I ran into
several problems that elucidate the difficulties in studying worker
cooperatives and may explain the reason so little research exists in the field.
Firstly, although a total of 2,262 potential respondents were contacted, only 26
responded. Responses were primarily aggregated from Cooperative Care and
CHCA. The 1% response rate can be attributed to several factors. Firstly, the
survey was voluntary and sent by administrators through email. Although
warned that responses were anonymous and administrators would not have
access to the data, employees may have been hesitant to respond out of fear
that their identity will somehow be detected. Secondly, it is unclear whether
all administrators dispersed the survey. Although initially receptive to phone
calls and interested in the study, several administrators clearly did not share
the survey link as a number of cooperatives has zero responses. It is possible
that administrators and those serving on the board of directors fear that low
job satisfaction rates may negatively reflect their organization and hinder
potential employees from applying. They may instead wish to conduct a
survey similar to mine on their own accord. Thirdly, the method for collection
of data, in and of itself, may not be ideal. For example, Ellenbecker et al. (2008)
call into question the validity of self-reported data and the degree to which an
online survey accurately measures the constructions of job satisfaction. To
PAGE 55

60. mitigate these limitations, surveys should be conducted in a more personable
manner, either over the phone or distributed by hand, especially for those
individuals without access to the internet or ability to check their emails daily.
Fourthly, although the descriptive analysis between cooperatives and
non-cooperatives showed results that did not substantially diverge from one
another and raise concerns for bias, the descriptive statistics for
cooperative-only variables did. The BOARD variable showed that 42% of
cooperative respondents had served on the board of directors. Considering
that the 7 chair board of directors is an elite position seated by the most
involved and invested employees, it is highly unlikely that of the 2,262 aides
approached to fill out the survey, 42% of them had served or are serving on
the board. This large number of board respondents calls into question to
whom the survey was sent out. Bias of the responses must be taken into
account, as board members represent the most involved and invested
employees that possess the greatest power to generate change and may
have skewed perceptions of the workplace.
Finally, my inability to collect at least 100 responses, or 4% of the total
number of employees in home health care worker cooperatives may
elucidate a hidden, less studied, nature of cooperatives: stress from
cooperative involvement. As employee-members, workers are not only
encouraged to invest money, but also time through attendance at meetings
or commitment to serving on the board. This increasingly stressful
PAGE 56

61. involvement may be further exacerbated in the healthcare industry, as
“response rates for all groups of healthcare professionals has been declining
over the last 20 years, due in part to increasingly busy work schedules”
(Ellenbecker et. al., 2008).
CONCLUSION AND FURTHER RESEARCH
In summary, my study contributes to the growing evidence that worker
cooperatives provide an advantageous model for increasing job satisfaction.
Combining results from empirical comparative tests on both hypotheses, I
found that the greatest impact of the cooperative model lies not in its
extrinsic, financially supported benefits, like its intent to offer more flexible
hours or provide training, but in fact in its intrinsic employment support.
Seeing as being valued by an organization is notably the strongest predictor
of job satisfaction, as well as the current advantage that home health care
cooperatives have over non-cooperatives, this study provides reason for
agencies to dedicate substantial efforts to creating a culture of
compassionate and supportive leadership. Moreover, these findings
recommend that potential employees consider worker cooperatives if they
prioritize feeling valued by the organization. Additionally, it supports a
plethora of research on intrinsic characteristics of home health care,
commonly overlooked for more concrete strategies for increasing job
retention through benefits and management (Ellenbecker et.al., 2008). Often
PAGE 57

62. misunderstood, increasing the quality of a workplace does not require a
financial investment. Brannon et. al. (2007) recommends supervisors to
participate in care planning, provide consistent patient assignments, reward
and recognize employees, and train in employment support, as these are
viable methods for enhancing the values of direct caregiving tasks.
Overall, this study is inconclusive about whether or not current home
health care worker cooperatives significantly impact or lead to higher job
satisfaction. Since low response rates did not allow for OLS regression results
to be compared between the two types of agencies, research in the field of
home care worker cooperatives remains insubstantial. Nonetheless, the
findings that cooperatives do in fact embody characteristics proven to
increase satisfaction rates of home health aides provide good reason for the
continued research in the field.
FURTHER RESEARCH
The following are recommendations for further research:
1. How does a home health care cooperative compare with an
non-cooperative agency of the same size and location?
a. A comparison between CHCA and another home health agency
in New York City ( of similar size, roughy 2,000 employees), using
identical surveys to examine variables of employment control,
involvement, and employee-membership on job satisfaction.
PAGE 58

63. 2. Do return rights and control rights lead to greater job satisfaction?
a. Artz & Kim (2011) note that having a financial stake in a firm and
the ability to make decisions regarding management and
business prospects is a key component of worker cooperatives.
However, in current research on home health agencies, these two
characteristics have not been studied. It is important to examine
first, whether or not these aspects predict higher job satisfaction
and then to examine their role in mediating the job stresses of
home health aides.
3. Does withholding information correlate with lower job satisfaction?
Does this missing data hold a significant key to understanding the
complex dynamics of employee happiness?
a. Missing data plays an impactful role in regression analyses.
NHHAS garnered 3,377 respondants, yet only 2,202 full responses
were considered in my study. A new study would compare the job
satisfaction of individuals that withheld responses to at least 20%
of the questions with those that answered entirely. Additionally,
given that many employees at worker cooperatives did not fill out
the survey or declined from answering specific questions,
particularly those relating to their finances, it is also important to
note the cause and effect, as well as the psychology, behind these
decisions. Perhaps, this study will elaborate the reasons for the
PAGE 59

64. lack of data and participation in voluntary research of worker
cooperative employees
4. Does job satisfaction lead to job retention? A ten year longitudinal
study examining job satisfaction and retention rates in home health
care cooperatives and non-cooperatives.
a. The current shortage on home health aides sheds light on the
complex relationship between job satisfaction and turnover rates.
While job satisfaction appears somewhat high, agencies see an
average of two-thirds of their employees leave every year. Clearly,
the empirical assumption that higher job satisfaction leads to
lower intent to leave ( Butler et. al., 2013; Shields, 2001) does not
translate to imply a correlation with job retention as well. To
better understand this paradox, a longitudinal study isolating the
effects of home health worker cooperatives should be conducted
because they statistically face substantially lower turnover rates.
This is partly due to employee-members making an initial
financial investment in the company, making them more likely to
stay to collect their money’s worth of benefits, such as shares
from the surplus each year (Kruse, 2010).
PAGE 60

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