Background
Nursing assistants, the workers on the front lines in nursing homes, frequently interact with the residents [1]. They play a key role in molding the life experiences of older people, as their interactions and care techniques directly influence the well-being and contentment of the residents [2]. This profession usually encounters challenges such as high labor intensity, low remuneration, and minimal social recognition. This leads to reduced appeal within the industry, significant staff turnover, and increased work pressure and caregiving responsibilities, which are more likely to result in negative repercussions [3]. Based on the researchers’ previous grounded theory results [4], the quality care behavior of nursing assistants in nursing homes is defined as follows: quality care behavior involves personalized care, respect, positive interaction, empowerment, and a holistic approach to the physical and mental well-being of residents. Person-centered care (PCC), which includes a variety of qualities like empathy, respect, effective communication, and the capacity to address the unique needs of older adults, is also regarded as the gold standard of high-quality care [5]. Studies demonstrate that negative behaviors shown by nursing assistants, including apathy, abuse, and contempt, can result in adverse effects for residents, such as increased feelings of isolation, anxiety, and deterioration of physical health [6]. Therefore, verifying the elements associated with nursing assistants’ quality care behavior is essential to lower unfavorable occurrences and increase senior occupancy and well-being in nursing homes.
According to the Capability, Opportunity, Motivation-Behavior (COM-B) model, “capability”, “opportunity”, and “motivation” are the essential determinants of a “behavior” outcome [7]. Capability consists of both physical and psychological components. Studies have shown that nursing assistants in nursing homes who are untrained or receive little training are more likely to abuse older adults [8, 9], yet this group of staff is also the largest group of staff in nursing homes. Hollingsworth pointed out that residents’ quality of life in long-term care setting is directly affected by the professional knowledge and skill level of nursing assistants and that certified nursing assistants may significantly improve their assisted feeding care capabilities through consistent and ongoing professional skills training [10]. Nursing students’ professional attitudes and caring behavior were correlated considerably in previous studies [11]. Furthermore, research has shown that both positive and bad contact experiences can influence care workers’ attitude towards elderly residents in eldercare homes and even cause discrimination against other senior populations [12]. Therefore, it is essential to understand caregivers’ attitude towards older people in long-term care settings to improve care behavior [13].
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Opportunity refers to social and physical contextual elements. It has been demonstrated that a positive organizational climate that fosters collaboration and communication can significantly enhance the delivery of high-quality care [14]. Insufficient staffing levels and increased care demands might result in substandard care practice, perhaps causing residents to feel ignored or neglected in long-term care facilities [15]. A continuous process of social support involves constant communication with others and using social networks to get affirmative feedback and support, including financial and emotional assistance from friends, family, co-workers, and society [16]. Family members’ recognition and support for the profession of nursing staff can help them work without worry [17]. Despite some literature investigating the influence of the organizational environment and social support on care behavior, the mechanisms of influence remain ambiguous.
Motivation has been regarded as a mediated component in behavioral change, as opportunity and capability may also indirectly impact behavior by influencing motivation. According to this study, self-efficacy and work need satisfaction may be regarded as automatic and reflective drivers of nursing assistants’ quality care behavior. Self-efficacy pertains to an individual’s belief in their ability to perform a specific task or behavior successfully [18]. Previous research has indicated potential associations between the self-efficacy of care staff in long-term care facilities and the quality of end-of-life care [19]. The study by Park Winqust also showed that high self-efficacy was a hindrance factor for abusive behavior among hospital nurses [20]. Furthermore, nursing assistants who with high reflective motivation (work need satisfaction) can exhibit quality care behavior. Motivation is induced by the stimulation of the nursing assistants’ requirements, which subsequently leads to the occurrence of behavior. In the Iranian study, hospital nurses’ sense of self-worth and capacity to deliver helpful treatment were considered essential elements influencing nursing quality [21].
Some studies offer substantial evidence for the mediation function of work needs satisfaction and self-efficacy as motivational factors among capability, opportunity, and behavior. According to social exchange theory [22], in organizational settings, when employers offer resources, support, and developmental opportunities, employees often experience a sense of obligation to reciprocate by enhancing their job performance. A study has demonstrated that increased perceived organizational support and self-efficacy among long-term care assistants correlate with elevated core competencies [23]. Low YS indicated that the organizational environment could influence job satisfaction, safeguard residential aged care staff from burnout, and allow them to concentrate on caring for elderly individuals [24]. Further studies have validated that Chinese nursing students’ perceived social support can enhance their health literacy via the mediation of self-efficacy and felt pressure, hence improving the quality of healthcare services they deliver [25]. Chen discovered that the intrinsic learning motivation and self-efficacy of health professional students partially and collectively regulate the association between social support and learning behavior [26].
This study aims to measure nursing assistants’ quality care behavior and explore latent influencing mechanisms based on the COM-B model. Few studies have examined the relationships between nursing assistants’ care knowledge and skills, attitude toward older people, organization climate, social support, work need satisfaction, self-efficacy, and quality care behavior. The following hypotheses were examined in this study (Fig. 1): (H1) Quality care behavior is linked to care knowledge and skills, attitude toward older people, organization climate, social support, work need satisfaction, and self-efficacy; (H2) The relationship between care knowledge and skills, attitude toward older people, and quality care behavior is mediated by work need satisfaction and self-efficacy; (H3) The relationship between organization climate, social support, and quality care behavior is mediated by work need satisfaction and self-efficacy.
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Fig. 1
Hypothetical model of this study
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Methods
Design
A cross-sectional study was conducted at 18 nursing homes across three central Chinese regions. Using stratified convenience sampling, six nursing homes were selected from the three central Chinese provinces (Henan, Hunan, and Hubei). The researchers find nursing homes with the help of the Department of Civil Affairs. This study continues a previous grounded theory study [4]. The STROBE Statement checklist for cross-sectional studies was followed in the writing of this manuscript. After conducting a field investigation, the researchers discovered that seven nursing homes did not fit the inclusion requirements of the 30 initially invited, 25 of which consented to participate in the study. Figure 2 displays the flowchart for sampling. The structural equation model (SEM) requires a sample size of 10–20 times the observed variables. The study incorporated a total of 20 observable factors. The theoretical sample size is 200 to 400 nursing assistants. The sample size of this study was 1,028, above the minimum threshold of 200 participants for SEM analysis [27].
Fig. 2
Flowchart of sampling procedures
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Participants
Nursing homes were included in this study if they (1) obtained the qualification recognized by the Department of Civil Affairs and (2) were medium or large nursing homes with 100 beds or more. Exclusion criteria: (1) refusal to participate in this study. Nursing assistants were eligible for inclusion in this study if they (1) possessed a valid nursing assistant qualification certificate, (2) had delivered direct care to residents for a minimum of 1 year, and (3) consented to participate in the study. The nursing assistants were excluded from this study if they could not understand the purpose of this study.
Instruments
Demographic characteristics
Following a thorough literature analysis, the researchers developed the demographic data. Gender, age, years of employment, average daily work duration, educational attainment, married status, religious beliefs, highest professional qualification certificate, type of work, monthly salary, availability of nursing assistants, and frequency of geriatric care training were all included. Each question was self-reported.
Quality care behavior
The quality care behavior scale for nursing assistants (QCBS-NA) was developed by Liao [28] for nursing assistants in nursing homes. There are 26 items reflecting five dimensions: (a) holistic care, (b) personalized care, (c) respect for older people, (d) positive interaction, and (e) empowerment and enabling (the 5-level Likert scale, out of a possible 130 points). Each item is answered as never (1), rarely (2), sometimes (3), generally (4), or always (5). A higher score reflects better care behaviors. The overall Cronbach’s alpha coefficient of the questionnaire was 0.948. Each question was self-reported.
Care knowledge and skills
The core competency questionnaire for nursing assistants (CCQ-NA), produced by Han (2017), was used to assess the care knowledge and skills of nursing assistants [29]. This tool was developed and validated in a Chinese population, which contained 27 items and was classified into five dimensions: (a) personal qualities, (b) communication ability, (c) ethical law knowledge, (d) care knowledge, and (e) care skills. Only 2 out of 5 dimensions were selected. The scale consists of 11 items, with the response scale from 1 (not capable) to 5 (very capable). Composite scores range from 11 to 55. A higher score indicates superior knowledge and skills in geriatric care among nursing assistants. The Cronbach’s α value in this study was 0.744.
Attitude toward older people
The attitude toward older people was reflected through Kogan’s Attitude toward Older People Scale (KAOPS), which was translated by Yen [30]. The KAOPS has 34 items divided into two subscales: positive and negative attitudes. A 7-point Likert scale, with 1 denoting “total disagreement” and 7 denoting “total agreement”, was used to ask nursing assistants to score each item. The intermediate assignment value of 4 has been eliminated. The Cronbach’s α value obtained in this study was 0.766.
Organization climate
The organization climate was reflected through the Gallup Workplace Audit (GWA) [31]. This scale was compiled by Gallup and applied by Zheng in the working environment of nursing staff in 2019 [32], including basic work needs (2 items), leadership support (4 items), team cooperation (4 items), self-growth (2 items), and 12 items in 4 dimensions. The Likert 5-level scoring method was utilized, with responses ranging from completely disagree to agree, assigned values from 1 to 5 points, resulting in a total score range of 12 to 60 points. The Cronbach’s α value for this scale in this study was 0.931.
Social support
The Social Support Rating Scale (SSRS) was used to measure social support. The scale was compiled by Xiao et al. [33], including 3 dimensions of subjective support, objective support, and utilization of support, and 10 items. The total score varies between 12 and 66, with elevated scores reflecting increased levels of social support. The Cronbach’s α coefficient for this scale in the study was 0.745.
Work need satisfaction
The work need satisfaction was reflected through the Chinese version of the work need satisfaction scales (WNSS-C) [34]. Autin et al. (2019) developed a Work Need Satisfaction Scale (WNSS) consistent with the framework of the Psychology of Working Theory (PWT) [35]. The dimensions are as follows: survival needs, social contribution needs, competence needs, relatedness needs, and autonomy needs, for a total score of 100. A higher score indicates a greater level of work need satisfaction in the research subject. The Cronbach’s α coefficient for this scale was 0.714.
Self-efficacy
Self-efficacy was reflected through General Self-Efficacy Scale (GSES) to understand the belief status of nursing staff in nursing institutions about their ability to deal with and overcome difficulties in life,), which was translated by Wang in China [36]. The scale comprises one dimension and ten items, using the Likert4 scoring method, which allocates points from 1 to 4, corresponding to “completely disagree” through “completely agree”. The total score comprises the aggregation of ten items. A higher score indicates a greater level of self-efficacy in the research subject. The Cronbach’s α coefficient for the general self-efficacy scale in this study was 0.886.
Data collection
The data was collected through face-to-face self-completion questionnaires data collection technique. Participant recruitment occurred from June to July 2024. This study disseminated recruitment posters via the provincial Civil Affairs Department, outlining the facility and participant criteria. Before the survey, consent and cooperation were secured from the nursing homes. The research subjects were fully informed about the purpose of the study and the method of filling it out. The formal questionnaire was filled out after the research objectives were agreed upon. Respondents must fill out the survey as much as possible on their own, but if they have trouble writing or are unwilling to do so, the researchers will read it to them one-on-one to help them fill it out based on their understanding. After filling in the questionnaire, the researcher immediately recovered, checked, and assisted the participants in completing the questionnaire if missing items were found.
Statistical analysis
Amos 26.0 and IBM SPSS Statistics 27.0 were used to analyze the data. Regular response questions or those with many incomplete answers were eliminated. The regression interpolation approach can fill in the missing data if the percentage of missing data is less than 10%. The data were double-checked before being statistically examined in IBM SPSS27.0. The P–P plots demonstrate that the data demonstrated a roughly normal distribution, except for gender and marital status. Descriptive statistics were employed to characterize categorical and continuous variables; an independent sample t-test and ANOVA were used to assess group differences. Non-parametric tests were employed for non-normally distributed data. The correlation between two continuous variables was evaluated using Pearson correlation analysis. The SEM was employed to examine the mediating effect of the chain. Amos 26.0 was applied to assess the SEM of the variables care knowledge and skills, attitude toward older people, organizational climate, social support, work need satisfaction, self-efficacy, and the quality care behavior of nursing assistants. The degree of model fit was evaluated by using the following indicators: chi-square/df (χ2/df<3.000), the goodness-of-fit index (GFI > 0.900), the adjusted goodness-of-fit index (AGFI > 0.900), the comparative fit index (CFI > 0.900), the normed fit index (NFI > 0.90), the relative fit index (RFI > 0.900), the incremental fit index (IFI > 0.900), Tucker-Lewis index (TLI > 0.900), and the root mean square error of approximation (RMSEA < 0.050) [37]. The indirect impact was deemed statistically significant if the 95% Confidence Interval (95% CI) of the mediation path did not contain 0; the path was considered non-significant if the CI contained 0. The threshold for statistical significance is p < 0.05 (two-tailed).
Ethical considerations
The Research Ethics Committee approval was obtained from the Institutional Review Board of the University (project No.2023-S098). All methods were carried out according to the Helsinki Declaration guidelines and recommendations. The project’s information is shown to the participants before the start of the study. Every person included in this study signed informed written consent. The number of registered clinical trials was not applicable.
Results
Demographic characteristics
A total of 1,105 questionnaires were distributed. Upon eliminating invalid surveys, characterized by consistent response patterns and incompleteness, 1,028 valid questionnaires were acquired. The final effective response rate was 93.03%. Of the 1,028 nursing assistants, the majority were female (90.86%), had completed junior middle school (59.34%), were married (92.22%), and held fixed-term contracts (83.95%). Female nursing assistants who finished high school or technical secondary school worked as senior nursing assistants, made over ¥4,000 per month, thought that there should be a fairly sufficient number of nursing assistants in nursing homes, and received training once or twice a month were more likely to exhibit higher-quality geriatric behavior. Table 1 shows nursing assistants’ quality behavior scores with their complete demographic characteristics.
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Table 1
Participants’ demographic characteristics and the scores of the quality behavior (N = 1,028)
Variable | Classification | N (%) | Quality behavior of nursing assistants | |
|---|---|---|---|---|
Mean ± SD | P | |||
Gender[M(P25,P75)] | Male | 94(9.14) | 107.00(101.00,114.00) | 0.012* |
Female | 934(90.86) | 110.00(104.00,116.00) | ||
Age(years) | <30 | 20(1.95) | 108.65 ± 7.78 | 0.064 |
30 ~ 39 | 157(15.27) | 109.89 ± 9.84 | ||
40 ~ 49 | 379(36.87) | 109.00 ± 13.31 | ||
50 ~ 59 | 450(43.77) | 107.05 ± 12.53 | ||
≥ 60 | 22(2.14) | 107.95 ± 7.23 | ||
Hours per day | Mean (SD) | 10.52(1.49) | - | - |
Range | 8–14 | - | - | |
Years of elderly care a | 1 ~ 5 | 787(76.56) | 108.18 ± 12.56 | 0.004** |
6 ~ 10 | 198(19.26) | 109.05 ± 12.20 | ||
>10 | 43(4.18) | 106.00 ± 9.73 | ||
Number of older people cared for by nursing assistants b | 1 ~ 5 | 353(34.34) | 107.31 ± 11.24 | 0.003** |
6 ~ 10 | 646(62.84) | 108.81 ± 12.79 | ||
>10 | 29(2.82) | 107.38 ± 14.27 | ||
Highest professional qualification certificate | Primary | 496(48.25) | 107.23 ± 12.76 | <0.001** |
Middle | 326(31.71) | 106.80 ± 10.93 | ||
Senior | 195(18.97) | 113.43 ± 12.37 | ||
Technician | 11(1.07) | 105.55 ± 7.84 | ||
Marital status[M(P25,P75)] | Unmarried | 22(2.14) | 110.50(103.00,114.00) | 0.050 |
Married/Remarried | 948(92.22) | 110.00(104.00,115.00) | ||
Divorced | 25(2.43) | 114.00(108.50,120.50) | ||
Death of a spouse | 33(3.21) | 111.00(107.00,117.00) | ||
Educational level | Primary school and below | 198(19.26) | 106.74 ± 11.94 | 0.002** |
Junior middle school | 610(59.34) | 107.40 ± 12.52 | ||
High school/ technical secondary school | 195(18.97) | 112.43 ± 11.75 | ||
Higher vocational /junior college | 25(2.43) | 108.56 ± 8.16 | ||
Religious beliefs | No | 956(93.00) | 108.24 ± 12.42 | 0.952 |
Yes | 72(7.00) | 108.43 ± 11.17 | ||
Nature of work | Officially formal | 14(1.36) | 108.93 ± 7.88 | 0.017* |
Fixed-term | 863(83.95) | 108.46 ± 12.73 | ||
Temporarily employed | 151(14.69) | 107.00 ± 10.10 | ||
Monthly income (Yuan) | 1000 ~ 1999 | 165(16.05) | - | <0.001** |
2000 ~ 2999 | 639(62.16) | 107.13 ± 10.52 | ||
3000 ~ 3999 | 224(21.79) | 106.58 ± 12.50 | ||
≥ 4000 | 165(16.05) | 113.85 ± 11.48 | ||
Whether the number of nursing assistants is sufficient | Very insufficient | 90(8.75) | 107.38 ± 11.71 | <0.001** |
Slightly insufficient | 463(45.04) | 106.50 ± 11.61 | ||
Average | 327(31.81) | 109.33 ± 13.24 | ||
Fairly sufficient | 143(13.91) | 111.99 ± 11.96 | ||
Very sufficient | 5(0.49) | 109.00 ± 8.97 | ||
Frequency of geriatric care training | No | 0(0.00) | - | <0.001** |
1 ~ 2/per week | 47(4.57) | 109.40 ± 9.73 | ||
1 ~ 2/per month | 561(54.57) | 109.60 ± 11.90 | ||
1 ~ 2/semiannually | 277(26.95) | 105.44 ± 11.59 | ||
1 ~ 2/per year | 143(13.91) | 108.04 ± 15.05 | ||
QCBS-NA scores
The mean total on the QCBS-NA score was 108.25 ± 12.33. The scoring rate of nursing assistants in the empowerment and enabling dimension is the lowest (76.94%) and the highest in the dimension of respect for the elderly (87.88%) (Table 2).
Table 2
Total scale and dimension scores of QCBS-NA (N = 1,028)
Dimension | Range | \(\:\stackrel{-}{\varvec{X}}\)±s | Scoring rate (%) |
|---|---|---|---|
Holistic care | 5–25 | 20.72 ± 2.80 | 82.86 |
Personalized care | 5–25 | 20.16 ± 3.07 | 80.65 |
Respect the elderly | 6–30 | 26.36 ± 3.17 | 87.88 |
Positive interaction | 5–25 | 21.78 ± 2.75 | 87.11 |
Empowerment and enabling | 5–25 | 19.23 ± 2.82 | 76.94 |
Total dimension | 26–130 | 108.25 ± 12.33 | 83.27 |
Correlations between variables
Table 3 displays the study variables’ mean, standard deviations, and correlations. Care knowledge and skills (r = 0.508, P < 0.001), attitude toward older people (r = 0.782, P < 0.001), organization climate (r = 0.753, P < 0.001), social support (r = 0.657, P < 0.001), work need satisfaction (r = 0.762, P < 0.001), and self-efficacy (r = 0.629, P < 0.001) were all significantly positively connected with nursing assistants’ quality care behavior.
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Table 3
Means, standard deviations, and correlation between care knowledge and skills, attitude toward older people, organization climate, social support, work need satisfaction, self-efficacy, and quality care behavior of nursing assistants (N = 1,028)
\(\:\stackrel{-}{\varvec{X}}\)±s | 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
|---|---|---|---|---|---|---|---|---|
1. QCB | 108.25 ± 12.33 | 1.000 | ||||||
2. CKAS | 33.16 ± 4.74 | 0.508** | 1.000 | |||||
3. ATOP | 122.50 ± 14.88 | 0.782** | 0.419** | 1.000 | ||||
4. OC | 49.18 ± 7.52 | 0.753** | 0.423** | 0.742** | 1.000 | |||
5. SS | 36.58 ± 6.12 | 0.657** | 0.378** | 0.601** | 0.570** | 1.000 | ||
6. WNS | 74.99 ± 7.72 | 0.762** | 0.476** | 0.699** | 0.693** | 0.676** | 1.000 | |
7. SE | 26.03 ± 5.86 | 0.629** | 0.385** | 0.502** | 0.481** | 0.608** | 0.650** | 1.000 |
Structural equation modeling results
An SEM was used to investigate the association between care knowledge and abilities, attitudes toward older people, workplace atmosphere, social support, job satisfaction, self-efficacy, and quality care behavior. The model fitting of the interaction effect of job need fulfillment, self-efficacy in the care knowledge and abilities process, attitude toward older people, workplace atmosphere, and social support to quality care behavior was adequate throughout the sample (see Fig. 3). The fitting values were χ2/df = 2.956, GFI = 0.998, AGFI = 0.977, CFI = 0.999, NFI = 0.998, RFI = 0.987, IFI = 0.999, TLI = 0.991, RMSEA = 0.044. Care knowledge and skills, attitude toward older people, organization climate, and social support directly and positively influenced quality care behavior. Furthermore, these factors indirectly affected quality care behavior through work need satisfaction and self-efficacy. It is important to note that in addition to social support influencing quality care behavior through self-efficacy, care knowledge and skills, attitude toward older people, and organizational climate cannot indirectly affect quality care behavior through self-efficacy alone. Table 4 displays the breakdown of the direct and indirect effects of each factor in the structural model. Quality care behavior was positively impacted by care knowledge and skills, and attitude toward older people, organizational climate, social support, work need satisfaction, and self-efficacy. The standardized path coefficients were β = 0.103 (t = 5.832, P = 0.001), β = 0.318 (t = 12.648, P = 0.001), β = 0.230 (t = 9.299, P = 0.001), β = 0.083 (t = 3.691, P = 0.001), β = 0.175 (t = 6.425, P = 0.001), β = 0.156 (t = 7.365, P = 0.001) respectively. The path coefficient and the hypothesis test results are shown in Table 5.
Fig. 3
Structural equation modeling results. The structural model fits the data adequately. All the coefficients in this figure are standardized and significant at level 0.01. Note: *** indicates the significance level is 0.01
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Table 4
Decomposition of mediating effects of variables for the structural model (N = 1,028)
Independent variable | Dependent variable | Direct effect | Indirect effect | Total effect |
|---|---|---|---|---|
Care knowledge and skills | Quality care behavior | 0.103 | 0.033 | 0.136 |
Attitude toward older people | Quality care behavior | 0.318 | 0.061 | 0.379 |
Organization climate | Quality care behavior | 0.230 | 0.065 | 0.295 |
Social support | Quality care behavior | 0.083 | 0.127 | 0.210 |
Work need satisfaction | Quality care behavior | 0.175 | 0.068 | 0.243 |
Self-efficacy | Quality care behavior | 0.156 | 0.000 | 0.156 |
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Table 5
Model path coefficient and hypothesis testing results (N = 1,028)
Paths | Path coefficient | S.E. | C.R.(t) | P | Standardized path coefficient | 95% CI [Lower, Upper] |
|---|---|---|---|---|---|---|
Attitude toward older people→Work need satisfaction | 0.130 | 0.015 | 8.451 | 0.001 | 0.251 | [0.099,0.160] |
Organization climate→Work need satisfaction | 0.273 | 0.030 | 9.200 | 0.001 | 0.267 | [0.219,0.324] |
Care knowledge and skills→Work need satisfaction | 0.222 | 0.034 | 6.459 | 0.001 | 0.136 | [0.159,0.291] |
Social support→Work need satisfaction | 0.405 | 0.031 | 13.255 | 0.002 | 0.321 | [0.337,0.462] |
Social support→Self-efficacy | 0.298 | 0.029 | 10.151 | 0.001 | 0.311 | [0.239,0.356] |
Work need satisfaction→Self-efficacy | 0.334 | 0.023 | 14.332 | 0.001 | 0.440 | [0.285,0.384] |
Self-efficacy→Quality care behavior | 0.327 | 0.044 | 7.365 | 0.001 | 0.156 | [0.213,0.457] |
Attitude toward older people→Quality care behavior | 0.264 | 0.021 | 12.648 | 0.001 | 0.318 | [0.216,0.321] |
Organization climate→Quality care behavior | 0.376 | 0.040 | 9.299 | 0.001 | 0.230 | [0.293,0.462] |
Work need satisfaction→Quality care behavior | 0.279 | 0.043 | 6.425 | 0.001 | 0.175 | [0.163,0.407] |
Care knowledge and skills→Quality care behavior | 0.268 | 0.046 | 5.832 | 0.001 | 0.103 | [0.191,0.351] |
Social support→Quality care behavior | 0.167 | 0.045 | 3.691 | 0.001 | 0.083 | [0.074,0.258] |
Discussion
The care behavior of nursing assistants has drawn more and more attention. Based on the COM-B model, this is the first study to explore the pathway among care knowledge and skills, attitude toward older people, social support, organizational climate, work need satisfaction, self-efficacy, and quality care behavior of Chinese nursing assistants. The mediation path through work needs satisfaction predominates among the different paths from care knowledge and skills, attitudes, social support, and organizational climate to quality care behavior.
This research showed that the QCBS-NA score of nursing assistants was 108.25 ± 12.33, and the overall scoring rate was 83.27%, which indicated that nurse assistants’ care behaviors are higher than medium. This is in line with previous findings in nursing assistants [38], which used the person-centered care assessment Tool (P-CAT) questionnaire to evaluate the level of PCC and provided a relatively high degree of PCC (3.82 ± 0.46). A different study assessing the quality of professional care in nursing homes indicated that nursing staff achieved an average score of 2.93 ± 0.42 out of a maximum of 4 [39]. A possible explanation is that this study investigated the nursing assistants in medium and large nursing homes; the supervision facilities are relatively perfect, and many of their practices are performed under the supervision of nurses with more specialized clinical experience [40]. However, it is noteworthy that the scoring rate on the item regarding empowerment and enabling was lower. One possible explanation is that, in contrast to other aspects, it demands nursing assistants to actively encourage older people’s autonomy and engagement, which calls for more awareness and expertise. In practice, they may be more likely to provide services as caregivers, ignoring the rights of older people as decision-making subjects, and may conflict with Chinese traditional “caregiving” culture [41], which is difficult for them to implement in high-pressure work environments. Situational simulation and role-playing can improve nursing assistants’ ability and self-confidence to deal with older people’s autonomy [42].
These findings supported the hypotheses that the capability of nursing assistants (care knowledge and skills, attitude toward older people) has both a direct and indirect effect on care behavior, which is consistent with previous evidence [43‐45]. Nursing assistants demonstrating elevated attitude scores can significantly improve self-esteem and trust among older adults while providing care devoid of age discrimination fosters effective communication and interaction [46]. Research indicates that nursing assistants’ insufficient nutrition knowledge and adverse attitudes can impact their nutritional practices [47]. Furthermore, it has been suggested that social recognition and respect for the profession of nursing assistants can improve their work attitude toward the elderly [48]. Through media publicity and policy support, it is necessary to raise social awareness of the professional value of nursing assistants and improve their working attitude.
The physical and social environment, including the organizational climate and social support, served as predictors of nursing assistants’ care behaviors. This finding is significant for low-status nursing assistants, as their career development involves acquiring skills and knowledge and the importance of social support and the work environment in fostering confidence and facilitating professional growth. Firstly, a supportive and friendly work environment provides them with sufficient opportunities to familiarize themselves with the various situations of older people and alleviates their pressure, similar to the outcomes for nurses [49]. Furthermore, promoting a harmonious working environment can enhance caregivers’ recognition of the significance of delivering high-quality services and motivate them to implement more personalized care practices [50]. Furthermore, research indicates that family caregivers with limited social support experience heightened psychological stress, feelings of worthlessness, and a decreased awareness of belonging. This situation leads to increased work-related pressure and negative behaviors, including abuse and neglect [51]. A supportive atmosphere fostering trust and belonging for nursing assistants is essential. Clear learning objectives must be established, and a psychologically healthy work and life environment should be developed [52].
According to the study’s findings, care knowledge and skills, attitudes toward older people, organization climate, and social support can directly affect the quality care behaviors of nursing assistants, and can also indirectly affect care behaviors through self-efficacy and work need satisfaction. Other elements must be satisfied by work need satisfaction or the chain mediation of work need satisfaction and self-efficacy, except for direct impact of social support on quality care behavior through self-efficacy. This result contradicts previous study findings that attitudes and organization climate were closely related to self-efficacy [23, 53], possibly due to the working environment in this study. In high-stress nursing homes, the emotional requirements of nursing assistants become more significant. Therefore, fulfilling work needs serves as a crucial mediator in modulating the impact of other variables on care behavior. The professional knowledge and attitudes of nursing assistants, while important, can only play a greater role if the work needs are met. Self-efficacy, which reflects an individual’s self-confidence and sense of control, may be effectively enhanced only through adequate fulfillment of needs [54]. Therefore, self-efficacy is located after work need satisfaction to promote nursing assistants’ quality care behaviors further.
However, this study also had some limitations. First, the generalizability of our findings may be limited, as our sample exclusively consists of nursing assistants from nursing homes in central China. The sample’s demographic features were primarily female, reflecting the caregiving population in nursing homes in central China and aligning with the overall demographic profile of nursing assistants in the country. This consistency supports the relevance of our findings in similar long-term care settings in China. Second, because the study design is cross-sectional, care should be taken when interpreting causal links. Future research may consider experimental or longitudinal approaches to ascertain the causal relationships between these variables. Third, although our study investigates the factors influencing nursing assistants’ care behavior through the COM-B model while accounting for demographic variables, certain potential risk factors for behavioral change were not included, owing to the complexity of behavior change. Fourth, this study did not incorporate covariates into the path model. Future research may employ multi-group analysis to investigate the impact of various group variations on quality care behavior. Finally, the data used in this study were exclusively self-reported by nursing assistants, which may introduce reporting bias. Future researchers are encouraged to integrate objective methods with subjective tools to measure study variables more comprehensively.
Implication of research
Facility managers must understand the significance of nursing assistants’ care practices. Implementing quality care behavior is facilitated through the organization’s support, developing a positive work atmosphere, and enhancing the nursing assistants’ intrinsic motivation. To further maximize resident satisfaction, it is recommended to establish assessment criteria for nursing assistants’ care behavior from the perspective of the residents.
Conclusions
This study indicated that capability (care knowledge and skills, attitude) and opportunity (organization climate and social support) might directly or indirectly affect the care behavior of nursing assistants through work need satisfaction. This information suggests that providing professional training and enhancing external recognition and support for nursing assistants can improve their care behaviors. Improving their professional identities and caring behaviors may also require the development of a supportive environment. Further empirical research on focused training for improving nursing assistants’ quality care behavior based on the COM-B model is required.
Acknowledgements
We acknowledge all the nursing assistants in this survey, we also thank to the Civil Affairs Department of Hubei Province, Hunan Province, Henan Province for the help and support.
Declarations
Ethics approval and consent to participate
This research was reviewed and approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (NO.2023-S098). All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki) and informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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