WIXLIB

use, catheter use, mobility, loss of bladder orbowel control, and increased depression oranxiety. The analysis showed that an increasein turnover from medium (40-80 percent peryear) to high levels (more than 80 percent peryear) was associated with lower quality factorscores, although even higher levels of turnoverwere not associated with a further decrease inquality.In an earlier study, Castle and Engberg foundhigher quality of care was associated with lowernursing staff turnover in 854 nursing homes insix states (Castle and Engberg 2006).Bostick and colleagues conducted a systematicreview of 87 research articles and governmentdocuments published from 1975 to 2003 todetermine the link between staffing and qualitymeasures in nursing homes. The researchersfound a significant relationship between highstaff turnover and poor quality outcomes forresidents (Bostick et al. 2006). Higher turnoverrates in nursing homes have been associatedwith greater use of physical restraints, cathetersAAHSA TALENT CABINETand psychoactive drugs, as well as morecontractures, pressure ulcers and quality-ofcare deficiencies (Harahan and Stone 2009,233-53).High turnover rates also affect providers’financial health. Many providers are unawarehow much direct care worker turnover actuallycosts. An estimate of the minimum direct costof replacing a direct care worker is 2,500.This does not take into account the indirectcosts of turnover: lost productivity until areplacement is trained, lost client revenues and/or reimbursement, increases in worker injuries,clients’ physical and emotional stress, and adeterioration of working conditions possiblyleading to more turnover (Seavey 2005). Theestimate of the direct and indirect averageturnover cost is significant: 3,500 per directcare worker.Direct care worker turnover impacts long-termcare providers on many levels, and they wouldbenefit from strategies that improve retention.5

II.How the Report Is OrganizedThis report is organized into two main sections. Section III includes key research findings inthe professional literature that show which factors lead to an increase in direct care workerretention. Section IV describes key retention strategies and programs shown to have apositive impact on direct care worker retention.Both Sections III and IV cover the following areas:6 Competitive wages and health insurance benefits Culture change Workplace/job design, management practices and trained supervisors Comprehensive training Career advancement opportunities Importance of cultural competenceSection V includes additional tools and resources related to direct care worker retention.Section VI is the list of references.Direct Care Worker Retention: Strategies for Success

III.Research: What It Takes to IncreaseDirect Care Worker RetentionThis section presents the research studiesand evidence that show which factorssupport higher direct care workerretention. The factors we cover in this sectioninclude:A.Competitive wages and healthinsurance benefitsB.Overarching strategy of culture changeC.Overarching strategies of workplace/job design, management practices andtrained supervisorsD.Comprehensive training needed todeliver quality careE.Career advancement opportunities(peer mentoring, career ladders)F.The importance of cultural competenceThe Institute of Medicine (IOM) report,Retooling for an Aging America: Building theHealth Care Workforce, focused on similarfactors contributing to direct care worker retention: improving training, increasing financialincentives, and improving the work environment through empowerment strategies and culturechange (IOM 2008).A. Competitive Wages and Health Insurance BenefitsDirect care workers receive some of the lowest wages in the United States. According to PHI, themedian hourly wage in 2007 for all direct care workers was 10.48, significantly less than themedian wage of 15.10 for all U.S. workers (PHI 2009). About 45 percent of direct care workersare in households under 200 percent of the poverty line, making them eligible for state and federalpublic assistance programs. Two out of five direct care workers receive one or more public benefits(PHI 2009).Health insurance coverage for direct care workers is just as dismal. One in every four nursinghome workers and nearly one third of personal and home care aides lack health coverage, and only53 percent have coverage from their employer (PHI 2009).AAHSA TALENT CABINET7

Impact of Wages and Health Insuranceon Probability of Becoming a DirectCare Worker: Rodin looked at the effect ofwage increases and the availability of healthinsurance on the probability of workersbecoming certified nursing assistants (CNAs).He found that making health insuranceavailable to workers had a large positive impacton the probability they would choose tobecome CNAs. However, the combination ofincreased wages and health insurance wouldresult in the largest net gain in the number ofCNAs (Rodin 2005).Studies of Job Tenure (Length of Timeon Job): A study based on data from the 20048National Nursing Home Survey, the NationalNursing Assistant Survey and the Area ResourceFile looked at whether wages, benefits, trainingand organizational culture had an effect onincreasing the job tenure of CNAs in nursinghomes. Overall, it was the extrinsic rewardsof higher wages, benefits such as paid time offand a pension that were the most importantdeterminants of job tenure (Weiner et al.2009).Frontline health care workers enrolled inemployer health insurance plans have morethan twice the tenure of those withoutemployee coverage (Duffy 2004, as cited in PHI2008, The Invisible Care Gap).Better Wages and Health Insurance CanHelp Increase Retention: In several studies,higher wages and access to health insurancehave shown a significant impact on theretention of direct care workers.Using data from the 2004 National NursingAssistant Survey, Decker and colleaguesshowed that satisfaction with wages had thesecond strongest association with intrinsicjob satisfaction and overall job satisfaction(Decker, Harris-Kojetin and Bercovitz 2009).They also found that the higher intrinsic jobsatisfaction reported by nursing assistants, thelower their intent to leave. Thus, satisfactionwith wages affects intent to leave through itsdirect effect on intrinsic job satisfaction.Howes surveyed home care workers in aconsumer-directed program to investigate theimpact of wages and benefits on recruitmentand retention. She found that access to healthinsurance through their job was one of themajor reasons why workers took the joband why they stayed (Howes 2008). In anearlier article, Howes showed that when thewages of home care workers in San FranciscoCounty were doubled, the retention rates ofnew workers increased from 39 to 74 percent(Howes 2005).In a survey of 255 CNAs in 15 nursing homes,Bishop and colleagues found satisfaction withbenefits was consistently important in nursingassistants’ commitment to their jobs (Bishop etal. 2008).The Personal Assistance Services Council of LosAngeles County, which represents over 115,000In-Home Supportive Services consumerdirected home care workers, commissioned areport on the impact benefit programs haveon worker retention and stability. The reportfound that home care workers enrolled in theiremployer-sponsored health plan had a higherretention rate (56 percent) than workers whowere eligible but not enrolled (45 percent)(RTZ Associates, Inc. 2005).Some studies have not found as strong a linkbetween wages/health insurance and turnover.Parsons et al. examined job satisfactionand turnover among nursing assistants in astatewide sample of Louisiana nursing homes.While the researchers found that pay was themajor source of dissatisfaction, a multivariateanalysis showed that pay did not affect turnover(Parsons et al. 2003).Direct Care Worker Retention: Strategies for Success

While low wages and lack of health insurancebenefits have a documented influence ondirect care worker retention, they are notthe only factors having an impact. The nextsections look at how culture change, workplace/job design, management practices, trainedsupervisors, comprehensive training, careeropportunities and cultural competence playequally important roles.B. Overarching Strategy:Culture ChangeCulture change is a philosophy of care thatemphasizes person-centered care and staffempowerment, built around the concept ofhome. Culture change practices for staff includemany of the non-wage and benefit factors thatcontribute to retention: comprehensive andexpanded trainings, a focus on the relationshipsbetween direct care staff and their supervisors,and empowering direct care workers throughself-managed work teams or peer-mentoringprograms.How Is Culture Change Defined?The Pioneer Network, formed in 1997, hasbeen in the forefront of the culture changemovement. Its mission is to move aging servicesaway from an institutional model to modelsthat embrace flexibility and self-determinationfor the person receiving the care.On its Web site, the Pioneer Network definesculture change as:“ a national movement for the transformationof older adult services, based on person-directedvalues and practices where the voices of eldersand those working with them are consideredand respected. Core person-directed values arechoice, dignity, respect, self-determination andpurposeful living.”AAHSA TALENT CABINETIn 2006, the Commonwealth Fund broughttogether an expert panel to develop a workingdefinition of culture change. This definitionwas later used in a Centers for Medicare &Medicaid Services-funded project measuringculture change and in the CommonwealthFund’s 2007 National Survey of Nursing Homes(Colorado Foundation for Medical Care 2006;Doty, Koren and Sturla 2008)2. According tothe definition, a culture change nursing homeincludes the following: Resident-directed care and activities An environment designed to be a homerather than an institution Close relationships among residents, familymembers, staff and the community Work organized to support and empowerall staff to respond to residents’ needs anddesires Management that allows for collaborativeand decentralized decision making Processes that are measurement-based andused for continuous quality improvementResearch is beginning to show the business casefor adopting culture change. In an unpublishedstudy, Elliot compared nursing homesparticipating in the Pioneer Network versusnon-participating homes to determine whetherthere were differences in quality and financialoutcomes. She found that those nursing homesthat were early adopters of culture changeachieved better quality outcomes (as measuredby survey citations) and had better financialoutcomes (Elliot 2007, unpublished).2The 2007 Commonwealth Fund National Survey of NursingHomes assessed how far along nursing homes are in adoptingculture change. For more information about the survey andthe results, visit omes.aspx9

In the Commonwealth Fund’s 2007 NationalSurvey of Nursing Homes, Doty and colleaguesfound the more nursing homes embracedculture change principles, the greater theincrease in staff retention and occupancy ratesand the greater the decrease in operational costs(Doty, Koren and Sturla 2008).Rabig et al., in a study on four Green Houses in Mississippi, found staff absenteeism andturnover were lower than in the other nursingfacilities operated by the organization (Rabig etal. 2006).C. Overarching Strategies:Workplace/Job Design,Management Practices andTrained Supervisors10Changes in workplace/job design, managementpractices and supervisory training for directcare worker supervisors have all shown toimpact direct care worker satisfaction andretention rates.A seminal study of the managerial practicesthat characterize providers with lower turnoverand higher retention identified five practicesthat distinguish these providers (Eaton 2001): High quality leadership and management,offering recognition, meaning and feedback An organizational culture that values andrespects nursing staff, especially direct careworkers Positive human resource practices, includingflexibility, training and career ladders Thoughtful and effective organization andcare practices that help retain staff and buildrelationships Sufficient staffing ratios to allow for thedelivery of quality careStott et al. looked at the extent to whichmanagement practices, designed to increaserecruitment and retention of direct careworkers, were taking place in 132 providersparticipating in the Better Jobs Better Care(BJBC)3 demonstration projects (Stott et al.2007). The researchers looked at: Job design, which included participating incare planning, communicating about tasksand feedback Direct care worker training/professionaldevelopment, which included becominga higher-level direct care worker, alicensed practical nurse, a peer mentor orparticipating in training/orientation beyondthe basic requirements Supervisor training and developmentOverall, the researchers found that despitethe need to recruit and retain direct careworkers, these management practices, designedto increase recruitment and retention, werenot used consistently across the providerorganizations. Providers used job-designpractices more frequently than staff trainingand professional development.Bowers and her colleagues provided insightinto why poor management practices leaddirect care workers to leave their job. Theyconducted in-depth interviews with CNAs atthree nursing homes to better understand whythey quit (Bowers, Esmond and Jacobson2003). The CNAs confirmed the many factorsalready established in the literature as causesof turnover: dissatisfaction with organizationalpolicies and practices, training and orientationpractices, and low compensation. But it wasnot these actual policies and practices that ledCNAs to leave; it was what these policies and3Better Jobs Better Care (BJBC) was a four-year, 15.5 million research and demonstration grant program, designed to find waysto reduce the turnover rates of direct care workers and improveworkforce quality. BJBC was funded by the Robert Wood JohnsonFoundation and The Atlantic Philanthropies and was managed bythe Institute for the Future of Aging Services at AAHSA.Direct Care Worker Retention: Strategies for Success

practices represented to the CNAs—that theywere not appreciated, valued or respected bythe organization. CNAs pointed to the gapbetween what their organizations said theyvalued and what they actually practiced. TheCNAs saw their supervisors as the embodimentof the organization’s disrespect of themas workers and people, and as such, theirrelationship with their supervisors was centralto turnover.Supportive and Trained SupervisorsThe importance of supervisors to the retentionof direct care workers cannot be overstated.Numerous studies have noted that the qualityof the supervisory relationship between directcare workers and their nurse supervisors isan essential element to job satisfaction andretention of direct care staff.According to Stone, “Direct care workers whosework is valued and appreciated by supervisors,and who are listened to and encouraged toparticipate in care planning decisions, havehigher levels of job satisfaction and are morelikely to stay in their jobs” (Stone 2007).As part of the evaluation of the five BJBCstate demonstration projects, Kemper andhis associates surveyed 3,468 direct care staffworking with 122 long-term care providersto uncover the single most important thingtheir employer could do to improve their jobas direct care workers. Across the settings(nursing homes, assisted living facilities andhome care), workers called for more pay andimproved work relationships, especially withtheir supervisors (Kemper et al. 2008).Bishop et al. investigated whether CNAs weremore committed to their job when they feltrecognized for their knowledge and perceivedtheir jobs as having greater autonomy andteamwork (Bishop et al. 2008). The researcherssurveyed 255 CNAs in 15 MassachusettsAAHSA TALENT CABINETnursing homes. While satisfaction with wages,benefits and advancement opportunities wereall significantly related to nursing assistants’intent to stay on the job, good basic supervisionwas most important in affecting their jobcommitment and their intent to stay in theirjobs. When nursing assistants perceived theirsupervisors as respectful, helpful and providinggood feedback—in other words as providinggood basic supervision—the CNAs were morelikely to be committed to their jobs.In a study using data from the 2004 NationalNursing Assistant Survey, Bishop and hercolleagues found that nursing homes couldincrease job satisfaction by supporting goodrelationships between nursing assistants andtheir supervisors (Bishop et al. 2009).In another study using the 2004 NationalNursing Assistant Survey, Decker and associatesfound that nursing assistants’ assessments oftheir supervisors had an indirect effect on theirintent to leave and a direct correlation withtheir job satisfaction (Decker, Harris-Kojetinand Bercovitz 2009).Jervis’s study of the relationships betweennurses and nursing assistants showed that in anurban nursing home, multiple layers of tensionbrought on by the hierarchical structure and“chain of command” mentality existed betweennurses and nursing assistants (Jervis 2002).The home’s nurses, nursing supervisors andmanagement saw the high nursing assistantturnover rate (77 percent) as the result ofnursing assistants’ character defects, personalproblems and lack of job com

The Role of Direct Care Staff Direct care workers—nursing assistants or nurse aides, home health aides, home care aides and personal care workers and personal service attendants—form the centerpiece of the formal long-term care system (Stone and Weiner 2001; DHHS 2006; S