Factors influencing home care workers’ loyalty in long-term nursing services

The study addresses the growing global challenge of population ageing and the corresponding increase in long-term care needs. Home care workers are central to enabling elderly individuals to remain at home, yet the sector faces severe labor shortages, unstable income, stressful and isolated working conditions, and limited supervisory contact. In Taiwan, these challenges impede institutional oversight and achievement of organizational goals, making workforce stabilization and retention critical. Leadership style, particularly transformational leadership, is posited to influence workers’ satisfaction, engagement, organizational citizenship behavior (OCB), and ultimately loyalty, which is essential for organizational performance and service quality. Prior research on home care workers has emphasized stress and turnover intention, with limited attention to employee loyalty and its antecedents. The purpose of this study is to investigate factors influencing home care workers’ employee loyalty—specifically job satisfaction, work engagement, OCB, and transformational leadership—and to test whether employee motivations mediate the relationship between transformational leadership and loyalty. The research is framed by the Job Demands-Resources (JD-R) model, proposing that job resources (e.g., transformational leadership) enhance motivation (satisfaction, engagement, OCB) and thereby increase work willingness/performance (loyalty).

Employee loyalty is conceptualized as the intensity of an individual’s identification with and preference to stay with an organization, encompassing attachment, advocacy, willingness to learn and contribute, and pride. Loyalty reduces turnover costs and is linked to service quality and organizational performance. Organizational commitment is often integrated into the measurement of loyalty; the Organizational Commitment Questionnaire (OCQ) is noted for reliability and cross-national consistency. Grounded in the JD-R model, job resources enhance motivation (work engagement, job satisfaction) and can buffer job demands, thus improving outcomes. Job satisfaction: Higher satisfaction is associated with improved performance, intention to stay, and loyalty; home care workers’ satisfaction correlates with supervisor support, challenges, training, and benefits. A single-item global measure is justified by prior research. Hypothesis H1: Job satisfaction positively impacts employee loyalty. Work engagement: Defined as a persistent, positive state characterized by vigor, dedication, and absorption (UWES scale). Engagement is linked to meaningful work, commitment, reduced turnover, and loyalty. Hypothesis H2: Work engagement positively impacts employee loyalty. Organizational citizenship behavior (OCB): Discretionary, extra-role behaviors that support organizational effectiveness; facets include helping, initiative (OCB-O), civic virtue, loyalty, compliance, sportsmanship, and self-development. OCB enhances organizational performance and is associated with employee loyalty; measures from Ginsburg et al. (2016) and Lee & Allen (2002) are applied. Hypothesis H3: OCB positively impacts employee loyalty. Transformational leadership: Comprises idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; it influences followers’ attitudes/behaviors, enhances relationships and extra effort, and is a salient job resource in health care. Prior work suggests transformational leadership enhances loyalty and motivational states. Hypotheses H4: Transformational leadership positively impacts employee loyalty. H5: Job satisfaction, work engagement, and OCB mediate the relationship between transformational leadership and employee loyalty.

Design: Cross-sectional questionnaire survey. Sample and setting: Home care workers from seven long-term care service providers in Taiwan were invited; 455 surveys collected, 442 valid (97% valid response). Inclusion encompassed all home care workers regardless of experience. Ethics: Approved by National Taiwan University Research Ethics Committee (NTU-REC No. 202103ES009); anonymous, confidential, informed consent obtained. Measures: • Employee loyalty (13 items): Organizational commitment (8 items) and loyalty (5 items) adapted from Matzler & Renzl (2006) and Yee et al. (2010); 5-point Likert (1–5). • Job satisfaction: Single item “How satisfied are you with your current job?” (1–5), referencing Nielsen et al. (2009) and Lee (2012). • Work engagement: UWES-9 (vigor, dedication, absorption) from Schaufeli et al. (2006); 5-point Likert. • Organizational citizenship behavior (OCB): 12 items covering innovative/effective work behaviors and organization-benefiting behaviors from Ginsburg et al. (2016) and Lee & Allen (2002); 5-point Likert. • Transformational leadership: 4 items adapted from Lee (2012) aligned with Bass & Avolio (1990) dimensions; 5-point Likert. Reliability and validity: Cronbach’s alpha across loyalty, transformational leadership, work engagement, and OCB ranged 0.85–0.95. Factor analyses showed single-factor extraction for each construct with total variance explained 49.41%–73.22%; all loadings >0.50. KMO and Bartlett’s tests indicated suitability and significant correlations; constructs demonstrated good construct validity. Data collection: Self-administered structured questionnaires distributed during monthly returns to the institutions. Data analysis: Descriptive statistics; ANOVA for group differences; Pearson and partial correlations (controlling age, education, seniority in home care services, and seniority in current job); multiple regression with VIF diagnostics; hierarchical regression to test mediation; structural equation modeling (SEM) with bootstrap (N=2000) to assess indirect effects and Variance Accounted For (VAF). Key sample characteristics (N=442): 88.7% female; mean age 54.33 years; education concentrated at vocational high school (48%); home care seniority mean 7.86 years; current job seniority mean 7.01 years; 94.6% full-time.

- Descriptives/ANOVA: Significant differences in employee loyalty by age (F=12.848, p<0.001), education (F=2.902, p<0.05), seniority in home care (F=5.653, p<0.001), and seniority in current job (F=6.824, p<0.001); no significant differences by gender, marital status, or full-/part-time status. - Correlations: Positive correlations among job satisfaction, work engagement, OCB, transformational leadership, and employee loyalty (all p<0.01). Highest correlation was between OCB and employee loyalty. Partial correlations remained positive after controlling for age, education, and seniority variables; weak inter-correlations among independent variables indicated no collinearity. - Multiple regression (dependent variable: employee loyalty): VIFs < 10. Adjusted R2 = 65.6% (R2 = 66.3%); F = 94.777, p<0.001. Significant positive predictors: • OCB: β = 0.400, p<0.001 (largest effect). • Job satisfaction: β = 0.251, p<0.001. • Transformational leadership: β = 0.245, p<0.001. • Work engagement: β = 0.092, p<0.05. Control variables: Age β = 0.112, p<0.01 (older workers more loyal); education, seniority in home care, and seniority in current job not significant. - Hierarchical regression and mediation: Transformational leadership positively predicted the mediators and employee loyalty; inclusion of mediators reduced the direct effect, indicating partial mediation. - SEM with bootstrap (N=2000): Significant indirect effects (p<0.000). Path coefficients and effects: • TL → WE = 0.49; WE → EL = 0.27; indirect = 0.13; direct (TL → EL) = 0.55; total = 0.68; VAF = 19.39% (borderline/low partial mediation). • TL → JS = 0.69; JS → EL = 0.23; indirect = 0.16; direct = 0.51; total = 0.67; VAF = 23.73% (partial mediation). • TL → OCB = 0.46; OCB → EL = 0.83; indirect = 0.38; direct = 0.28; total = 0.66; VAF = 57.69% (stronger partial mediation). - Summary: All four hypothesized predictors (job satisfaction, work engagement, OCB, transformational leadership) significantly and positively influence employee loyalty (supporting H1–H4). Job satisfaction, work engagement, and OCB mediate the relationship between transformational leadership and loyalty (partial mediation; H5 partially supported with strongest mediation via OCB).

Findings affirm the JD-R model: transformational leadership operates as a job resource that enhances motivational states—job satisfaction, work engagement, and OCB—leading to higher employee loyalty. OCB emerged as the strongest predictor and mediator, suggesting that discretionary, organizationally oriented behaviors create stronger organizational attachment and social support, which is particularly impactful for home care workers who often work alone. Job satisfaction and work engagement also contribute to loyalty, aligning with literature that meaningful, fulfilling work and supportive conditions reduce turnover intentions. Age positively predicted loyalty, potentially reflecting preference among older workers for autonomous, stable roles and greater family responsibilities that favor organizational continuity. Practically, supervisors’ transformational behaviors—clear guidance, recognition, listening, and support for development—bolster workers’ autonomy, recognition, and sense of meaning, thereby elevating loyalty. The high explanatory power (adjusted R2=65.6%) indicates the model’s robustness in this context. Organizational strategies that cultivate OCB (e.g., fostering pride, defending the organization, proactive suggestions) and enhance satisfaction and engagement are likely to stabilize the workforce, improve service quality, and reduce costs associated with turnover. These results are relevant to long-term care policy emphasizing home-based services in Taiwan, where workforce stability underpins quality and safety for the elderly.

The study demonstrates that transformational leadership, job satisfaction, work engagement, and OCB significantly and positively affect home care workers’ employee loyalty, with OCB exerting the greatest influence. Transformational leadership has both direct and indirect effects on loyalty, partially mediated by work engagement, job satisfaction, and OCB, with the strongest mediation via OCB. Implications include: adopting transformational leadership practices (vision-setting, motivation, problem-solving, individualized support); investing in training to elevate professional skills and self-efficacy; encouraging OCB to strengthen organizational identification and loyalty; and cultivating meaningful, engaging work environments. Such strategies can stabilize and retain the home care workforce, enhance service quality and safety, and attract younger entrants to address staffing shortages.

The sample was restricted to home care workers from seven institutions in Taiwan, which may limit generalizability to different countries and welfare systems. The cross-sectional design precludes causal inference. The study focused on four predictors (job satisfaction, work engagement, OCB, transformational leadership), potentially omitting other relevant factors (e.g., personality traits, work motivation, incentive systems). Time and manpower constraints limited broader data collection. Future research should include cross-country comparisons, longitudinal designs, and additional variables to deepen understanding of determinants of loyalty.