RECRUITING AND RETAINING FRONTLINE … are more likely to report that employees have little ... Recruiting and Retaining Frontline Workers in Long-Term Care: Usual Organizational Practices

Ohio Long-Term Care Research Project

RECRUITING ANDRETAINING FRONTLINEWORKERS IN LONG-TERMCARE: USUALORGANIZATIONALPRACTICES IN OHIO

Jane Karnes StrakerRobert C. Atchley

June 1999

Scripps Gerontology Center Miami University Oxford, Ohio 45056

Dr. Jane Karnes Straker is Director of Policy for the Ohio Long-Term CareResearch Project, Scripps Gerontology Center, Miami University, Oxford, Ohio.Dr. Straker has been involved in the evaluation of Ohio’s long-term care programs sincecoming to Miami in 1993. Dr. Straker has recently been a co-principal investigator on astudy of Ohio’s non-certified home health agencies and an examination of MDS qualityindicators. She is a co-author of Assessing Satisfaction in Health and Long-Term Care:Listening to the Voices of Consumers, forthcoming from Springer Publications. Herresearch interests include quality and consumer satisfaction in institutional andcommunity-based long-term care, autonomy in institutional settings, and long-term care

decision making.

Dr. Robert C. Atchley was Director of the Scripps Gerontology Center at MiamiUniversity from 1974 to 1998. He was also the first Director of the Ohio Long-Term CareResearch Project. He is now Chair of the Department of Gerontology at NaropaUniversity in Boulder, Colorado. Dr. Atchley’s recent publications included Continuityand Adaptation in Aging: Creating Positive Experiences, (Johns Hopkins UniversityPress, 1999) and Social Forces and Aging: An Introduction to Social Gerontology, 9th ed.,(Wadsworth Publishing, 2000).

This research was funded as part of a grant from the Ohio General Assembly, through the OhioBoard of Regents to the Ohio Long-Term Care Research Project. Reprints available from the ScrippsGerontology Center, Miami University, Oxford, OH 45056; (513) 529-2914; FAX (513) 529-1476;http://www.muohio.edu/scripps.

Recruiting and Retaining FrontlineWorkers in Long-Term Care:

Organizational Practices in Ohio

Jane Karnes StrakerRobert C. Atchley

Scripps Gerontology CenterMiami University

Oxford, OH 45056

June 1999

i

Executive Summary

The majority of care provided by Ohio’s nursing homes and home health agencies isdelivered by the occupational group we call “frontline workers”; home health and personal careaides, homemakers, dietary aides, and certified nursing aides or assistants. These workers on thefrontline deliver about 80% of the formal care provided to persons with disabilities who receiveassistance at home or in nursing facilities. The demand for workers in these occupations is expectedto increase dramatically over the next few years, but current long-term care providers are alreadyexperiencing problems recruiting enough workers to fill job vacancies, and retaining those workersonce they are hired.

Much of the research on recruitment and retention of frontline workers has relied ondemonstration projects or special interventions that provide additional funds for service providersto undertake special initiatives and projects. Little is known about the everyday practices of averageservice providers operating under their usual economic constraints.

To understand more about long-term care employers’ recruitment and retention practices inOhio, we conducted telephone interviews with administrators of 112 nursing homes and 100 homehealth agencies. Our sample included organizations from across the state providing a representativelook at a variety of providers.

Our findings show that there are differences within the long-term care industry; home healthagencies face different problems and use different solutions than do nursing homes. Our results alsoshow that there are differences in organizations with low and high frontline worker turnover ratesbeyond such factors as local labor markets, pay, and benefits packages. While factors such asemployee benefits are important in distinguishing organizations with low turnover rates from thosewith high turnover, other everyday practices that might be expected to have a negative impact onemployee morale also differentiate low and high turnover organizations. Organizations with highturnover are more likely to report that employees have little initiative or a poor work ethic; to morefrequently fire employees; and to hire questionable employees more frequently. Significantly lowerstaff: resident ratios are also found in nursing homes with high turnover rates. Organizations thathave an urban location or are part of a chain have particularly large problems.

Although this report is not a prescription for resolving the problem of frontline workerturnover, our findings suggest areas where organizations can begin the process of self-examinationand movement toward reducing turnover and making cost-effective decisions to recruit and retainfrontline long-term care workers.

ii

Acknowledgments

As with most applied research, this work could not have been accomplished without a debtof gratitude to “the kindness of strangers”—those individuals who agreed to help us by respondingto our telephone survey. Next, enough cannot be said about the excellent research assistanceprovided by Rebecca Utz and Kate Bridges who made significant contributions to the developmentof the interview schedule, conducted all of our telephone interviews, and managed all of our data.Marc Molea at the Ohio Department of Aging and Marisa Scala from the Scripps GerontologyCenter provided valuable assistance in our communications with the Ohio Paraprofessional ShortageTask Force, and members of the task force provided helpful comments and guidance. Clerical staffCheryl Johnson, Betty Williamson, and Jerrolyn Butterfield provided their usual expert assistancewith manuscript preparation. Finally, Marc Molea, Kathryn Watson, Robert Applebaum, and MarisaScala provided helpful comments on earlier versions of this report.

iii

Table of Contents

INTRODUCTION AND BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Research Instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Recruitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Employee Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Turnover Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Employee Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Retention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Employee Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Employee Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Turnover Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Effects of Turnover on Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

DISCUSSION AND IMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

iv

List of Figures and Tables

Figure 1Who Responded? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Figure 2Characteristics of Nursing Homes and Home Health Agencies

by Perceived Extent of Recruiting Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Figure 3Employee Benefits and Wages by Perceived Extent of Recruiting Problem . . . . . . . . . . 6

Figure 4Percentage of Respondents Reporting Top Reasons for Recruiting Problems

by Perceived Extent of Recruiting Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Figure 5Percentage of Respondents Reporting Top Three Best and Worst

Recruiting Strategies by Perceived Extent of Recruiting Problem . . . . . . . . . . . 8

Figure 6Percentage of Respondents Always Able to Attract Ideal Candidate or Never

Hire Questionable Employees by Perceived Extent of Recruiting Problem . . . . . 9

Figure 7Percentage of Respondents Reporting Top Three Best and Worst Selection

Strategies by Perceived Extent of Recruiting Problem . . . . . . . . . . . . . . . . . . . . 11

Figure 8Average Cost for Selecting an Employee by Perceived Extent of Recruiting Problem . . 11

Figure 9Average Computed and Reported Turnover Rates by Perceived Seriousness

of Turnover Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 10Characteristics of Nursing Homes and Home Health Agencies by

Low and High Computer Turnover Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 11Percentage of Respondents Reporting Top Reasons for Retention Problems

by Computed Turnover Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

v

Figure 12Percentage of Respondents Reporting Employee Perceptions Regarding

Best and Worst Aspects of their Job by Computed Turnover Rate . . . . . . . . . . 15

Figure 13Average Percentage of Employees Leaving for Different Reasons

by Computed Turnover Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Figure 14Percentage of Respondents Using Selected Employee Retention Strategies

by Computed Turnover Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Figure 15Percentage of Respondents Suggesting “Fantasy” Strategies for Improving

Turnover Rates by Computed Turnover Rate . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 16Average Cost of Turnover and Training Per Employee by

Computed Turnover Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Table 1Benefits Offered by Computed Turnover Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Table 2Orientation and Training Topics and Costs by Perceived Extent

of Retention Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Table 3Areas Included in Computation of Turnover Costs

by Computed Uniform Turnover Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Table 4Strategies for Coping with Staff Shortages by Computed Turnover Rate . . . . . . . . . . . 25

Recruiting and Retaining Frontline Workers in Long-Term Care: Usual Organizational Practices in Ohio

Scripps Gerontology Center Page 1

Introductionand

Background

Adequate staffing of frontlinepositions in long-term care is one of the mostserious challenges facing both institutionaland home-based long-term care serviceproviders. Frontline jobs such as nurse aidesor assistants, dietary aides, home health aides,and personal care assistants account for about80 percent of the direct services provided tonursing home residents and about 90 percentof service to clients of home care programs(Hughes, 1996). Despite the fact that frontlinepositions are crucial to the effective deliveryof long-term care and are among the fastest-growing job categories throughout the nation(U.S. Bureau of the Census, 1998), manylong-term care providers are plagued bypersistent difficulty attracting desirableapplicants, problems retaining frontline staff,and high turnover rates. In Ohio alone, thedemand for personal care aides is expected toincrease 85% between 1994 and 2005, and thedemand for home health aides is expected toincrease a similarly dramatic 75% during thesame time period (Ohio Bureau ofEmployment Services, 1996).

Nationally, data on turnover ratesshows wide variation. One national datasource suggests turnover rates average about45 percent for nursing homes and about 10percent for home health care programs(Hoechst Marion Roussel, 1996). Other datafrom the Institute of Medicine place averageannual nursing home turnover at 105%(Wilner and Wyatt, 1999). Some regions of

the country report average turnover of 50-75%in home health agencies (CommunicationConcepts, 1997) and other data suggest homecare turnover rates are about 40% annually(Surpin 1994, cited in Wilner & Wyatt, 1999).The range of turnover rates is very broad, withsome providers experiencing very littleturnover and some experiencing more than400 percent turnover annually (Harrington,1991). Because the long-term care populationis growing faster than the population as awhole, staffing will become an even moreserious problem in the future if long-term careproviders do not find more effective ways torecruit and retain frontline staff (Even,Ghosal, and Kunkel, 1998).

High staff turnover leads to impairedcontinuity of care, lower quality, andincreases the overhead costs ofprograms by increasing recruitmentand training costs.

Problems recruiting and retaining staffare a major cause of waiting lists in home careprograms (Glock, 1995), and many nursinghomes are exposing themselves to significantregulatory and liability risks because ofchronic short staffing. In addition, high staffturnover leads to impaired continuity of care,lower quality, and increases the overheadcosts of programs by increasing recruitmentand training costs. Costs of replacing nursingassistants, for example, have been estimated ataround $4,000 per replacement (Pillemer,1996).

A previous survey of the literature(Atchley, 1996) found that turnover problemswere attributed to low unemployment in locallabor markets, the extent of competition for

Page 2 Miami University

Methods

trained workers in local long-term care labormarkets, and substandard pay and benefits forfrontline work in long-term care. Other factorslinked to high turnover included the negativepublic image of nursing homes and the peoplewho work in them, inadequate training andongoing supervision, and job design thatexcludes input from frontline workers.However, most of the information on turnoverwas anecdotal and not based on systematicresearch. In addition, the literature onstrategies for coping with turnover camemainly from demonstration projects funded bygrants, which tended to have financialresources to try innovations that may bebeyond the capability of most programs undereveryday financial constraints.

The present study was conducted togather data on typical management practicesin the areas of recruitment, retention, andturnover from representative samples ofnursing facilities and certified home healthprograms. Our goal was to identify conditionsand management practices that differentiatedorganizations reporting minimal problems inrecruiting and retaining staff in frontlinepositions from those that reported seriousproblems.

Research Instrument

A structured telephone interviewschedule was developed based on a review ofthe literature and other instruments. Apreliminary version was reviewed by membersof the Ohio Department on Aging sponsoredOhio Long-Term Care Paraprofessional

Shortage Task Force and their comments andsuggestions were incorporated into a revisedinstrument. This instrument was pre-tested bythree home health agency administrators andtwo nursing home administrators suggested bymembers of the above Task Force. Weinformed them that the instrument was beingpre-tested and gathered their comments aboutthe instrument for its final revision. Slightlydifferent versions were developed for nursinghomes and home health agencies; forexample, we asked home health agencies toreport information about homemakers andasked nursing homes to report informationabout housekeepers. The interviews covered awide variety of topics pertaining to programand staff characteristics, as well asrecruitment, selection, training and retentionpractices. We also asked the respondents totell us the extent to which they experiencedproblems with recruitment, retention, andturnover as well as their method(s) if any, forcomputing turnover rates. We also collectedinformation we could use to compute uniformturnover rates that could be used to makecomparisons across programs. Finally,respondents were asked to estimate the effectsof staff shortages on the quality of care andwhat strategies they used to cope with shortstaffing. A copy of the completed nursinghome instrument is included in Appendix A;the home care instrument is only slightlydifferent as described above.

Sampling

A list of certified PASSPORT (Ohio's2176 Medicaid waiver home and community-based service program) home health providerswas obtained from the Ohio Department ofAging, and a list of licensed nursing homeswas obtained from the Ohio Department ofHealth. Because low Medicaid reimbursementis often blamed for turnover problems in long-



Findings

term care, we concentrated our efforts onthose organizations participating in theMedicaid program. The lists were stratified bythe county where the organization waslocated. Counties that were part of a PrimaryMetropolitan Statistical Area were deemedurban, all others were rural. A random sampleof 404 organizations was drawn, with 101rural and 101 urban organizations each drawnfrom both home health and nursing homeproviders.

Data Collection

Contact letters and a support letterfrom the Ohio Paraprofessional Shortage TaskForce were sent to each organization in thesample approximately a week before theywere contacted by telephone. The lettersintroduced the study and encouragedparticipation. We also provided a list of topicsthat would be covered in the interview so theadministrator or director could determine themost appropriate staff member to complete theinterview. (A copy of the contact letter isincluded in Appendix A.) Two trainedinterviewers contacted each organization in anattempt to complete the interview or toschedule a convenient later time for theinterview. This process was difficult becauseadministrators and directors were frequentlyunavailable. We established a limit of fiveattempts to reach the administrator to schedulean interview before considering theorganization “not reached.”

Of the original 404 organizations inthe sample, 42 had closed, merged, or werenot appropriate for the study. For example,one was a temporary agency rather than adirect service provider. Of the remaining 362organizations, 212 completed the interview fora response rate of 58.6%. About one quarter(24.3%) could not be reached after five

telephone calls, and 17% refused toparticipate.

As shown in Figure 1, our respondentswere mostly urban, for-profit organizations,reflecting the makeup of the long-term careindustry as a whole. About half of the nursinghomes were part of a chain, and about one-quarter of the home health organizations wereaffiliated with a hospital. No home healthorganizations were unionized, and no nursinghomes were affiliated with hospitals.

Recruitment

The first area of inquiry concernedeach organization’s problems withrecruitment. We asked respondents, “On ascale of 1 to 10, with 10 being a very seriousproblem, and 1 being no problem, how seriousa problem is recruitment of frontlineworkers?” Recruitment was rated as a seriousproblem by 43% of nursing facilities and 47%of home health agencies. For analyticalpurposes we divided organizations into thosewith serious problems (answering seven andabove) and those with minimal problems(answering three or below). The figures thatfollow show these comparisons across groupsand by type of organization.

Figure 2 compares the characteristicsof home health agencies and nursing homeswith and without recruitment problems.Nursing homes with serious problems weresignificantly more likely to be part of a chainthan those without problems (p=.02).(Significance simply reassures us that our


results are not due to chance.) Home healthagencies with problems are significantly morelikely to be urban (p=.04) than rural. No othercharacteristics were significant indifferentiating organizations with and withoutproblems.

Wages differ among providers, withorganizations with recruitingproblems paying higher full-timestarting wages than those withoutproblems.

We also examined employee benefitsand wages among organizations with andwithout recruiting problems. As shown inFigure 3, nursing homes and home healthagencies without recruiting problems have a

higher percentage of employees whoparticipate in the health insurance plan thanorganizations with problems. The percentageof employees receiving full benefits is similaramong all organizations. Wages differ amongproviders, with organizations with recruitingproblems paying higher full-time startingwages than those without problems, althoughthe differences are not significant. Contrary toconventional wisdom, employee benefitparticipation and starting full-time salaries arenot significantly related to organizationalrecruiting problems.

Organizations often have very goodinsights about the causes of problems, evenwhen they are unable to resolve them. Weasked employers to identify up to four reasonsfor recruiting problems in long-term care. Ingeneral, those with fewer problems also re-ported fewer reasons for recruiting problems.




Those with greater recruiting problems alsowere able to name more reasons for thoseproblems. As shown in Figure 4, employers’perceived reasons for problems differ amongorganizations. Nursing homes with andwithout recruiting problems were most likelyto attribute long-term care recruiting problemsto current low unemployment rates and ageneral lack of workers. Home health agencieswith problems were most likely to see lowwages as the cause, while home healthagencies with few problems were most likelyto see low unemployment rates as the causefor recruitment problems. A large percentage

of the organizations with problems attributethose problems to causes such as competition,the type or nature of the work, or a lack of awork ethic among employees. Competitionand the nature of the work are factors thatemployers can do little to change. On the otherhand, the perceived lack of a work ethicamong employees suggests some differencesin managerial attitudes that may affect jobsatisfaction for workers, and consequently,turnover problems.

We next asked long-term careemployers about the strategies they used to



recruit employees, their recruitment costs, andthen asked them to indicate which of theirrecruiting strategies was most effective andwhich was the least effective. Those withgreater recruitment problems used, onaverage, two more recruiting strategies thantheir counterparts without problems. Homehealth agencies used the fewest, with thosewithout problems using 4.1 recruitmentstrategies and those with problems using 6.3.Nursing homes without problems used 5.1strategies, while those with problems used 7.2strategies. There were no consistent differ-

ences as to particular strategies used by thosewith and without problems. Recruiting costsshowed significant differences acrossorganizations. Nursing homes withoutrecruiting problems spent, on average $549.72to recruit an employee, while nursing homeswith recruitment problems spent $518.81.Home health agencies without problems spentan average of $105, while those with problemsspent twice as much--$229.34. Interestingly,recruitment spending and recruitmentproblems show opposite relationships in homehealth agencies and nursing homes. Also,


there was not a significant relationshipbetween the number of strategies used and anorganization's ability to attract ideal jobcandidates.

As shown in Figure 5, nursingfacilities and home health agencies usedsimilar strategies for dealing with issues ofrecruitment. The strategies for recruiting newpersonnel that were most often cited aseffective were newspaper advertising and in-house referrals. However, about a third of

those who used newspaper ads said they wereamong the least effective strategies. Thisfinding suggests that the effectiveness ofnewspaper ads may vary by locality and typeof program. Open houses, job fairs, andcommunity outreach are examples of methodsreported in the literature to be effective thatare rarely if ever used by the random sampleof programs in the present study.

Recruitment problems may ultimatelyaffect the quality of the care provided. On a



scale of 1 to 10, with one being never and 10being always, we asked organizations howfrequently they were able to attract idealcandidates and how frequently they hiredquestionable employees. As shown inFigure 6, about half of all employers with fewrecruitment problems were always or almostalways (seven or above on a 10-point scale)able to attract ideal job candidates. Less thana fifth of organizations with problems wereregularly able to attract ideal candidates. Totheir credit, however, the majority oforganizations never or almost never (7 andabove on a 10-point scale) hired questionable

employees, regardless of the extent of theirrecruiting problems. When we asked the thirdof these employers who had hired question-able employees for their reasons, they mostoften reported hiring to fill the schedule. Aspreviously mentioned, one of the major causesfor waiting lists in home care is not havingstaff to provide the services. Nursing homesface sanctions and safety issues when they areshort-staffed. On the other hand, hiringquestionable employees today is likely tocontribute to future retention and turnoverproblems.


Employee Selection

If employers have trouble bringingprospective employees to the door, they maynot be as discriminating as employers who canchoose from a large pool of applicants.Because careful employee selection can elimi-nate later problems with retention, selectionand training are integral parts of the recruit-ment and retention problem. Part of a goodselection strategy is choosing workers whowill be satisfied in their jobs and will stay.

We asked organizations to describe theideal job candidate that they were trying toattract. Over one-third of home healthorganizations said their ideal candidate wascertified and/or had prior health careexperience. Less than 20% of nursing homesput these criteria first; nursing homes weremore likely to mention dependability as anideal applicant characteristic. Several nursinghome administrators mentioned that employ-ees new to the field begin work at nursinghomes where they receive their certificationtraining at no cost. Once they receivecertification, they move to home healthagencies. Because home health agencies aremore likely to look for certified employees,this strategy is probably an effective one foremployees, but quite problematic for thenursing homes providing training.

As shown in Figure 7, the majority ofall organizations felt that the in-personinterview was the best selection strategy.Checking previous work references was mostoften mentioned as the worst strategy,although a small proportion felt that workreferences were often the best strategy forselecting employees. Ohio’s recently requiredcriminal background check was also viewedas a poor selection strategy by a number ofemployers. Comments about the criminal

background check suggest that it does notwork as a selection strategy because there is atime lag of up to six months between hiringand receiving the results of the backgroundcheck. Several administrators suggested thatworkers with criminal records know when thebackground report is likely to come back andterminate their employment before they areactually discharged. Employers cannot divulgethe results of the check to subsequentemployers, thus these workers can move onto the next organization and work for severalmonths. Others questioned whether offensessuch as writing bad checks or drug possessiontruly indicate a worker’s likelihood to mistreatthose in their care.

Very few employers used aptitude tests(10.1%) or skill tests (26.8%) as part of theirselection strategy. Home health agencies wereabout twice as likely as nursing homes toemploy formal testing as part of their selectionprocess. This is particularly interesting, giventhat Figure 8 shows that home health agencieshave much lower selection costs than nursinghomes.

Turnover Rates

The following sections compareorganizations based on their turnover rates,rather than their perceived recruitmentproblems. We first asked them about theirperceptions of the seriousness of theirturnover problem. We also asked them toreport their turnover rate and we computed auniform turnover rate for each organizationusing information about the total number ofemployees, number of vacancies, and numberof employees that were hired in the last year.For these comparisons, 41 nursing homes and44 home health agencies had low turnoverrates (50% or below) and 48 nursing homesand 33 home health agencies had high




turnover rates (96% and above). Fiftyprograms had intermediate turnover rates andwere excluded from the analysis in order toemphasize contrasts between organizationswith low and high turnover.

Interestingly, perceiving turnover as aserious problem was very modestly correlatedwith having a high computed turnover rate(the average correlation for differentcategories of frontline workers was .20).Undoubtedly, this is related to the fact thatmost organizations had no objective data ontheir turnover rates with which to assess theextent of the problem. Even for organizationsthat computed a turnover rate (65.7% of thosesurveyed), the correlation between theirreported turnover rates and our calculationswas very modest. For example, the correlationbetween the organizations’ computed turnoverrate for nurse aides and our computed turnoverrate was only .33. This is largely due to thesmall proportion of organizations that used asound formula for computing turnover. Theformula that we used to compute turnoverrates (the number of employees who leftduring the year divided by the total number ofemployees x 100) was the most often-usedamong programs that computed turnover, butit was by no means the only formula. Amongthose who stated they knew theirorganization’s turnover rate, over one-quarter(29.6%) of organizations either didn’t knowhow their turnover rate was calculated orbased it on a personal estimate. Another16.9% based their turnover rate on the numberof employees that left in a year, divided byeither the number who stayed or the numberwho were hired. Both of these formulasproduce results that do not accurately reflectactual turnover rates. In order to makeaccurate comparisons among organizations wecomputed "uniform" turnover rates for allorganizations using the same formula (as

described above) rather than relying on theirreported turnover rates that were computed invery different ways.

Figure 9 shows the average reportedturnover rates and uniform computed turnoverrates for organizations that saw turnover as aserious problem and those that did not. In allcases, uniform computed turnover rates werehigher than reported turnover rates. Nursingfacilities were very likely to underestimatetheir turnover rate, and the nursing facilitiesthat saw turnover as a serious problem wereeven more likely to underestimate turnover--the average underestimate was 103.8 percent!When they reported turnover rates, homehealth agencies underestimated their turnoverrates by a smaller percentage, but a muchsmaller proportion of home health agenciesreported turnover rates (48%) compared withnursing facilities (66%).

Our first comparison based oncomputed turnover examines thecharacteristics of organizations with high andlow turnover rates. As shown in Figure 10,those with turnover problems are more likelyto be for-profit and urban. Both of thesedifferences approach significance for nursinghomes (p=.09) and the difference betweenprofit/non-profit home health agencies issignificant (p=.02). Nursing homes with highturnover are more likely to be part of a chain,and less likely to be unionized, although thesedifferences are not significant. Combined withthe factors related to perceived recruitmentproblems, being part of a chain and having anurban location are particularly problematic.

As we did with recruitment problems,we asked organizations to report up to fourreasons for their retention problems. Figure 11compares reasons for retention problems fornursing facilities and home health agencies



125.5

88.1

46.137.6

176.5

137.2

72.7

89.7

57.1

40.4

18.526.0

133.2

75.5

60.8 64.2

Organizations with # 50% turnover

Organizations with $ 97% turnover

Figure 9. Average Computed and Reported Turnover Rates by Perceived Seriousness of Turnover Problem

NursingHomes

HomeHealthAgencies

COMPUTED TURNOVER REPORTED TURNOVER

All Positions CNA / Home All Positions CNA / Home Health Aide Health Aide


with high and low computed turnover rates.Perceived poor employee work ethics,perceived lack of initiative, difficult nature ofthe work, and burnout were most often citedas the primary reasons for turnover byorganizations with high turnover rates, but notby organizations with low turnover rates.Thus, organizations with high turnover rateswere typified by an unfortunate combinationof unmotivated employees and a difficultwork situation prone to burnout. On the otherhand, low pay was seen as a cause of turnoverfor all types of organizations regardless ofturnover rate.

In an effort to understand howorganizations treated their employees oncethey were on the job, we asked aboutemployee satisfaction information, strategiesfor improving turnover problems, employeebenefits, and training. The next sections

discuss our findings in these areas, again usingcomparisons between organizations with lowand high uniform computed turnover.

Employee Satisfaction

More than three-quarters (80.5%) ofnursing homes and two-thirds (66.0%) ofhome health agencies have conducted at leastone employee satisfaction survey. Theproportion of organizations that survey theiremployees does not vary significantlyaccording to an organization’s turnover rate.

The topics included in the employeesatisfaction surveys were similar amongorganizations. Over half the nursing homessurveyed their employee‘s satisfaction withsalaries, benefits, hours/scheduling, employeeinput, work environment, pace of work/staffratios, and their relationships with super-



visors, colleagues, and residents/clients.Significantly, almost two-thirds (64.7%) of thenursing homes with low turnover rates askedtheir employees about their satisfaction withthe work environment. On the other hand, lessthan half (44.7%) of the nursing homes withhigh turnover covered the same topic. Overhalf of the home health organizations thatconducted employee satisfaction surveysincluded the same areas as nursing homes,with the addition of employee policies, andthe exclusion of relationships with colleaguesand the pace of the work. Despite what theliterature suggests about the importance of jobdesign, organizational climate, and job imageand status, fewer than half of all those whosurveyed their employees included thesetopics in their surveys.

Literature on consumer satisfactionsuggests that consumers should be surveyed

on those areas that are most relevant to them.Long-term care employees should beconsidered as consumers of theirorganization’s practices. Organizations mightbenefit from rethinking their employeesatisfaction instruments to include items thatmost affect employee satisfaction. This mightmove them one step closer to obtainingsatisfaction information that could be used toinfluence employee turnover. Interestingly,only about six out of every ten (58.3%)organizations that had conducted surveys usedthe survey information—the most frequent use(87.3%) was to develop employee policies andbenefits.

In addition to asking employers aboutthe areas covered by their surveys, we askedthem which aspects of the job employeesperceived most and least favorably. As shownin Figure 12, the best parts of the job were


resident/client relationships, and salaries.Salaries were also mentioned most frequentlyas the worst part of the job with hours andschedules close behind. About 10% of theorganizations with starting nurse aide salariesof $7.00 and over reported that salaries werethe best part of the job. Interestingly, 7.6% ofthe organizations with starting nurse aidesalaries of $6.37 and below (the lowest thirdof the pay range) also reported that salarieswere the best part of the job. On the otherhand, a third of the organizations in the lowsalary group reported salaries were the worstpart of the job. Salaries may be viewed as theworst part of the job when other factors alsocontribute to work satisfaction. In other cases,employees may feel that their only motivation

for work is the money, therefore it is the bestpart of the job.

We asked employers to indicate thereasons that their employees left once theywere on the job. Employers reported reasonsfor firings; other information was based onemployer recollections of exit interviews, orother available information about employeeresignations. Those employees who leavewithout notification are not included sincetheir reasons for resignation were unknown.Figure 13 shows the average percentage ofemployees leaving for different reasons bylevel of turnover. Organizations with highturnover rates were more likely to letemployees go for poor attendance or other



poor performance and also more likely to haveemployees quit right after the completion oftraining or within the first 10 days ofemployment; often without notification. Thesefindings suggest that organizations with highturnover rates attract a less viable pool of jobcandidates that are eventually terminated orselect employees whose expectations are notmet once they are on the job. On the otherhand, competition from other employers isabout equally prevalent as a cause of turnoveracross all types of organizations. Thus, it isprobably something in the management orworking conditions in a particularorganization rather than in the overall natureof frontline work that causes high turnoverrates. The finding that organizations with lowturnover rates are much more likely to havepeople leave for family reasons—an externalcircumstance, reinforces this.

Across all types of organizations, themost frequently mentioned retentionstrategies were improved employeebenefits, competitive salaries, andemployee recognition programs.

Retention Strategies

We asked long-term care employers toreport the strategies that they believed helpthem retain employees. Figure 14 shows acomparison of the most frequently mentionedstrategies by organization type and turnover.Across all types of organizations, the mostfrequently mentioned retention strategies wereimproved employee benefits, competitivesalaries, and employee recognition programs.Nursing homes with low turnover mentioned


benefits most often, while home healthorganizations with low turnover mentionedcompetitive salaries most often. Both nursinghomes and home health agencies with highturnover mentioned competitive salaries mostoften. Clearly, paying well, providing benefits,and recognizing employees represent theconventional wisdom for retaining goodemployees in long-term care, but differencesare also shown among some of the lessermentioned strategies. For example, bothnursing homes and home health agencies withlow turnover were more likely to mentionprograms to improve co-worker relationshipsthan their high turnover counterparts.Interestingly, both types of organizations withhigh turnover were more likely to use an open-door management style. We also counted thetotal number of retention strategies mentioned.On average, organizations with lower turnoverused one additional retention strategy

compared to their high turnover counterparts.(Low turnover nursing homes used 8.6; highturnover facilities used 7.5. Low turnoverhome health agencies used 7.6, high turnoveragencies used 6.6.) The answer to actuallyreducing turnover in long-term care appears torequire multiple strategies that address diverseaspects of the frontline worker’s job.

Employers were also asked to discussany additional strategies they would like touse, even if they were not currently usingthem. Figure 15 shows these “fantasy”strategies for improving turnover rates byorganization type and turnover rate. Better payand better benefits are still the predominantstrategies, regardless of organizational type orturnover. Home health agencies with highturnover were significantly more interested inproviding employee benefits; this reflects thefact that they offer fewer benefits than their



Table 1. Benefits Offered by Computed Turnover Rate

Nursing Homes Home Health

Lowest Rates Highest Rates Lowest Rates Highest Rates

Benefit Employer Paid Health Ins. Employee Paid Health Ins. Shared Cost Health Ins. Dental Insurance Paid Holidays Tuition Reimbursement Attendance Bonus Pension or 401K/403B Other Bonuses Day Care Paid Sick Leave Paid Vacation Transportation Life Insurance Flexible Schedules Uniform Allowance Meals Profit Sharing Counseling Services Vision Coverage

Avg. # of Benefits

7.32.4

90.285.497.648.839.080.543.9

7.395.1

100.02.4

65.914.619.529.3

9.812.246.3

8.9

11.12.2

84.474.587.522.743.872.952.1----81.389.6----53.24.3

10.627.78.5

10.644.7

7.9

23.52.9

73.561.477.341.715.947.727.3----72.781.877.340.938.613.64.54.5

15.947.7

7.3

13.6**22.7**63.6**40.6***62.5***12.5**28.1*40.6***37.53.1

50.0***75.0**78.1***18.8***37.5***12.53.1***3.29.4

21.9

6.0***

* p = # .05** p = # .01

*** p = # .001

Note: Significance was examined for differences among the four groups shown.

competition. Only low turnover nursinghomes were interested in offering additionalopportunities for employee input, although atleast one study has shown that the only factorthat had a significant impact on nursing hometurnover was the degree to which aides wereable to contribute their own opinions aboutresident care. Where aides participated in careplanning meetings, turnover was even lower(Wilner & Wyatt, 1999). Clearly, employeeinput could be given more importance by theemployers in our study.

Employee Benefits

Earlier in this section we reported ourfindings on starting salaries by turnover rateand organization type. Salary is an importantaspect of employee compensation, butemployee benefits also play an important rolein attracting and retaining employees. Often abenefits package is enough to determine anemployee’s choice of one organization overanother. Table 1 shows the complete list ofbenefits we asked about, by organizational


type and turnover rate. Paid vacation is themost commonly offered benefit offered by75% or more of all employer types.Transportation reimbursement is offered byover three-quarters of the home healthagencies; a lower number than expected giventhe extent of employee travel required. Healthinsurance that is cost-shared between theemployer and the employee is the predominanthealth insurance offering, and 14.5% of long-term care employers offer no health insuranceoption. Of the organizations without a healthoption, 83% are home health agencies.Clearly, the package of benefits commonlyoffered differs greatly between home healthorganizations and nursing facilities. Aspreviously shown, home health agenciesmentioned benefit improvement as a fantasyretention strategy much more often thannursing facilities. A closer examination of thebenefits offered suggests that home healthagencies will have to work hard to implementbenefit packages in proportions similar to theirnursing home counterparts. However, benefitsare clearly not a simple answer to employeeturnover. Nursing homes with higher turnoverrates were more likely to offer employer paidhealth insurance and bonuses than their lowturnover counterparts. However, the benefitspackage commonly offered by three-fourths ormore of both low and high-turnover nursinghomes includes shared-cost health insurance,dental insurance, paid holidays, a pension or a401k/403b, paid sick leave, and paid vacation.Two-thirds of those with low turnover alsooffer life insurance. These findings suggestthat although there are small distinctions inbenefit coverage related to employee turnover,the greatest distinctions are between the homehealth and nursing home segments of theindustry. In addition, as shown earlier inFigure 3, less than three-quarters of frontlineworkers actually are eligible for the fullbenefits package offered by employers.

Employee Training

Adequate employee training isimportant for quality of care, and providesemployees with the skills and tools necessaryfor success in their jobs. Research alsosuggests that training should cover ethical andinterpersonal aspects of care as well astechnical skills development (Feldman, 1994).We asked our respondents to describe thetopics covered in their orientation and trainingprograms, as well as their opinions about theadequacy of their training. As shown inTable 2, less than 2% of employers mentionedtopics other than technical, procedural, oradministrative skills. Yet, overall theseemployers perceived their training as morethan adequate—a strong majority ranked theirtraining 7 or above, with a 10 being "veryadequate." However, industrywide, someadditional work needs to be done in this area.Frontline workers must deal with difficult orabusive residents or unhappy families at thesame time they respectfully change a resident'sclothes or give a bath. Diamond (1992)describes the emotional stress of caregivingand notes the wishes of new nursing assistantsto, "know how better to perform the tasks thathad been so unnerving and how to startconversations with patients" (p. 21). Moreemphasis on handling the interpersonalaspects of care could help employeesmaximize what they view as the best part oftheir job—relationships with residents andclients.

Despite what is known about thedesirability of career ladders, jobredesign, and employee supportgroups very few employers use thesestrategies to reduce turnover.



Table 2. Orientation and Training Topics and Costsby Perceived Extent of Retention Problem


Little or NoProblem

SeriousProblem

Little or NoProblem

SeriousProblem

Topics Required (OSHA, fire safety, etc.) Organization Policies Tour of Facility/Agency Introduction of Managers Benefits/Paperwork Documentation of Work Care Skills CPR Other

Percentage Perceiving Training asAdequate (7 and above with 10 = very adequate)

88.5 69.2 38.5 19.2 30.8 ---- 3.8 2.5 ----

67.5

89.1 84.8 28.3 23.9 45.7 2.2 6.8 2.2 2.2

64.6

68.9 82.2 2.2

15.6 60.0 71.1 37.8 ---- 2.2

70.4

72.5*80.02.5**

10.055.075.0**42.5**10.0*2.5

75.8

* p = # .05** p = # .001


Overall, long-term care employers arefairly attentive to the needs and concerns oftheir workers once they are on the job.However, the findings reported here suggestthat more could be done. Despite what isknown about the desirability of career ladders,job redesign, and employee support groupsvery few employers use these strategies toreduce turnover. Training topics are limited inmost organizations, and when employeesatisfaction surveys are done, they are oftennot put to use to implement organizationalchange. Our findings suggest that strategiesthat are found successful in demonstrationsand special initiatives are not frequently

incorporated into the practices of the majorityof long-term care employers.

Turnover Costs

We asked our respondents whetherthey had ever computed an estimate of theirtotal turnover costs and if so, what turnovercost their organization per employee. Only17% of these long-term care employers hadever calculated the cost of turnover in theirorganization. There was little difference in theproportion of home health agencies or nursing


homes that knew turnover costs, however,both nursing homes and home health agencieswith turnover problems were more likely tohave examined their turnover costs. Forexample, nearly 20% of the nursing homeswith problems had examined their turnovercosts compared to only 9% of those withoutproblems. Clearly, a majority of these long-term care employers know little about whatturnover is costing their organizations. Thislack of knowledge has critical implications formustering resources to begin to solve turnoverissues.

Of those who had examined theirturnover costs, most had likely underestimatedthem. As shown in Figure 16, costs rangedfrom an average of $952 for home healthagencies with low turnover, to $2100 innursing homes with low turnover, whereasZahrt’s (1992) careful cost accountingestimates showed that in 1992 the cost of eachnursing facility front-line replacementaveraged about $3200.

Underestimates of the cost of turnoverseem to be linked mainly to including too fewcosts. For example, among organizations thathad some awareness of their turnover costs,nursing homes showed the highest costs,while still including only about half of theitems that should be considered in totalturnover costs (see Table 3). Overall,organizations are much more likely toconsider costs related to new hires than costsrelated to employees leaving. Training andorientation times are the most commonlyincluded items in turnover costs.

Accurate computations of turnoverrates and the costs of turnover areessential for making informedmanagerial decisions.

Accurate computations of turnoverrates and the costs of turnover are essential for



Table 3. Areas Included in Computation of Turnover Costsby Computed Uniform Turnover Rate


LowestRates

HighestRates

LowestRates

HighestRates

Cost/Savings of Employee Leaving Exit Interviewer’s Time Employee Wages During Exit Interview Administration/Paperwork Separation Pay Increase in Unemployment Tax Additional Overtime Temporary Help Wage Savings

Cost of New Hire Paperwork/Benefit Sign-up Advertising Interviewer’s Time Test Costs (Drug, Skill) Medical Exams Staff Orientation Time Time Checking References Background Checks Formal Training Informal Training Reduced Efficiency/Productivity

Avg. Number of Items Included in Cost

50.0 25.0 25.0 50.0 ----

25.0 25.0 25.0

50.0 50.0 50.0 75.0 75.0

100.0 50.0 75.0

100.0 75.0 ----

9.5

9.1 9.1

36.4 9.1 ----

36.4 9.1 ----

72.7 90.9 72.7 63.6 72.7 72.7 54.5 63.6 72.7 45.5 9.1

7.8

14.3 14.3 42.9 14.3 ----

28.6 ----

14.3

57.1 100.0 71.4 71.4 71.4 85.7 71.4 71.4 57.1 57.1 14.3

8.6

42.9 28.6 28.6 14.3 28.6 28.6 14.3 28.6

85.7 71.4 71.4 42.9 28.6

100.0 85.7 85.7 85.7 71.4 14.3

9.6

making informed managerial decisions. Forexample, suppose a nursing facility has auniform computed turnover rate of 200percent annually and a total of 60 frontlinepositions. If turnover cost $4,000 perreplacement and 120 replacements wereneeded annually, the annual cost of turnoverwould amount to $480,000, or $8,000 perposition. Given that a 40-hour per weekposition generally involves payment for 2,112

hours per year, the cost of turnover would be$3.78 per employee per hour. Armed withthese numbers, the employer might wellproject that an $1 hourly pay increase or fullpayment of an employee’s health insurancecould result in considerable savings. Supposea $1 increase in hourly pay reduced turnoverto “only” 100%. The annual net savings to theorganizations would amount to $113,280—nosmall sum. (Net savings=$240,000 that would


have been paid for 60 replacements at $4,000per replacement - $126,720 for the $1 per hourpay increase for 60 positions at 2,112 hoursper year.) Of course, the organization wouldwant to carefully calculate the results of thepay increase to compute its actual effects onturnover rates and costs of turnover.

Effects of Turnover on Quality of Care

The above example illustrates howturnover costs employers valuable dollars thatcould be spent elsewhere in the organization.Whether it is apparent or not, eventuallyturnover has an impact on quality of care forresidents and home care clients. At theminimum, turnover affects continuity of careand care recipient relationships. Severalstudies have shown that the main impact oncare recipients’ perceptions of quality is therelationship that they have with their paidcaregivers (Wilner & Wyatt, 1999).

In addition, staff turnover can oftenresult in staff shortages that require theremaining staff to do too much work in toolittle time. Turnover breeds more turnover asremaining staff lose morale, feel overworkedand undervalued, or even become injured fromlifting residents without a helper (Wilner &Wyatt, 1999).

We asked respondents whether theyfelt that turnover impacted the quality of thecare provided, and how they coped with staffshortages. About half (53.7%) of allorganizations felt that turnover had notaffected the quality of the care provided.Actual computed turnover rates and the typeof organization were not significantly relatedto whether organizations perceived qualityproblems related to turnover. Among thosewho admitted to turnover impacts on quality,the most common effect was that care

recipients received less personal time becausecare was rushed. This has a direct relationshipto the most satisfying part of the frontlineworker’s job—relationships with carerecipients. When care is depersonalized andrushed, employees cannot develop or maintainthe relationships with care recipients that areso important for both groups.

When we compare how organizationscope with staff shortages, nursing facilitieswith high turnover are more likely to usetemporary staffing from personnel agenciesthan those with low turnover rates who aremore successful at asking employees toincrease their scheduled hours (see Table 4).This is yet another indicator that morale ishigher in nursing facilities with low turnoverrates. There is no difference in the proportionswho increase workload on existing staff orwho ask volunteers to work extra.

Among home health agencies, thosewith high turnover rates are much more likelyto cope with staff shortages by limitingadmissions, increasing the workload forexisting staff, and increasing scheduled hours.Agencies with low turnover are much morelikely to pay overtime or ask their RNs andLPNs to fill in.



Table 4. Strategies for Coping with Staff Shortagesby Computed Turnover Rate


LowestRates

HighestRates

LowestRates

HighestRates

Strategies Limit Admissions Use Temps Paid Overtime Increase Workload Cancel Days Off Increase Scheduled Hours Use RNs, LPNs Ask for Volunteers to Work Extra Recognition for Those Who Work Extra Pay Bonuses Always Overstaff Schedule Pay Shift Differentials

Most Frequently Used Ask for Volunteers to Work Extra

Least Often Used Use Temps

---- 43.9 65.9 46.3 12.2 61.0 46.3 78.0 17.1 36.6 9.8

24.4

41.5

36.6

4.2 68.8 64.6 47.7 4.2

41.7 56.3 77.1 18.8 31.3 12.5 20.5

22.7

62.5

38.6 15.9 52.3 39.6 ----

54.5 54.5 65.9 6.8

11.4 2.3

16.7

39.6

9.1

75.8**9.1**

42.469.7----*63.639.457.66.1

27.1*7.2

33.3

24.2

3.0

* p = # .05** p = # .001



Discussion andImplications

Most of the factors that havedifferentiated high turnoverorganizations from those with lowturnover thus far seem to have beenr e l a t e d t o o r g a n i z a t i o n a lclimate—the perceived difficulty ofworking there and high potential forburnout. The average number offrontline full-time-equivalent staffper 100 residents is 74 in lowturnover nursing homes, compared to53 in nursing homes with highturnover.

Most of the factors that havedifferentiated high turnover organizationsfrom those with low turnover thus far seem tohave been related to organizationalclimate—the perceived difficulty of workingthere and high potential for burnout. To testthis assumption we compared the staff/carerecipient ratios across low and high turnoverorganizations. As anticipated, a significant(p < .001) difference is shown between lowand high turnover nursing homes. The averagenumber of frontline full-time-equivalent staffper 100 residents is 74 in low turnover nursinghomes, compared to 53 in nursing homes withhigh turnover. However, the same relationshipdoes not hold true for home healthagencies—those with the highest turnover alsohave the highest staff ratios. Home healthagencies use more part-time staff than donursing homes; the lower staff ratios amonglow turnover organizations may result in morescheduled hours and greater eligibility forbenefits for frontline workers in home careagencies.

In this study, most nursing homes andhome health agencies dramatically under-estimated the extent of their turnover problemand did not collect adequate data on the extentand cost of turnover. Consequently, long-termcare employers were in a poor position toevaluate the financial trade-off that might bemade. This is especially important wherecompetitive wages are an issue and for homehealth agencies, where lack of benefits is amajor factor characterizing high-turnoveragencies. Home care workers also do not havethe added stress of seeing the clients who arewaiting for care.

Interestingly, the findings also suggestthat economic factors are not a prime mover indifferentiating low and high turnoverorganizations. Instead, factors related to theorganizational climate, such as perceptions ofemployees having little initiative and a poorwork ethic, increased hiring of questionableemployees, and firing of employees combinewith problematic workloads to present apicture of qualitatively different workingconditions in high-turnover organizationscompared with those having low turnover. Forexample, Banaszak-Holl and Hines (1996)reported that nursing homes that includedaides in care planning had significantly lowerturnover rates. Good management alsonurtures friendly relationships, shows a moralcommitment to quality of care, and is"supportive, caring, understanding, andhelpful" (Wilner & Wyatt 1999, p. 41).



Despite higher expenditures ontraining and salaries, and the use ofmore recruitment strategies,organizations with high turnover aremore likely to attract a poorcandidate pool, fire employees, andlose employees after training or abrief stint of work.

Despite higher expenditures ontraining and salaries, and the use of morerecruitment strategies, organizations with highturnover are more likely to attract a poorcandidate pool, fire employees, and loseemployees after training or a brief stint ofwork. In addition, high turnover nursingfacilities have a higher proportion oftemporary staffing and high-turnover homehealth agencies are much more likely toarbitrarily increase workloads for existingstaff; both strategies could be expected tonegatively affect care quality and thecontinuity of relationships between workersand care recipients.

Organizations with low-turnoverwere more likely to conduct employeesatisfaction surveys, have employeesleave for personal or family reasons,and have programs to improve co-worker relationships.

Conversely, organizations with low-turnover were more likely to conductemployee satisfaction surveys, haveemployees leave for personal or familyreasons, and have programs to improve co-worker relationships. Qualitatively, these few

examples suggest a different approach tovaluing employees than is characterized byhigh turnover organizations.

In an economy where unemploymentis low and demand for entry-level workers ishigh, the long-term care industry must becompetitive with salaries and benefits toattract workers, and must also maximize theintrinsic rewards that can come from frontlinework. In 1996, waitresses and video storeclerks made higher average salaries than nurseaides in nursing homes. Short order cooks andchildcare workers received comparable pay(U.S. Bureau of Labor Statistics, 1999). Thus,a certain level of reimbursement must beprovided in order to attract employees. Thelong-term care industry has not come forwardto suggest standards for wages and benefits forfrontline workers, but some would suggestthis is a needed move (Wilner & Wyatt,1999).

Reimbursement from Medicare andMedicaid has an influence on, but does notdetermine the rates of pay and the kinds ofbenefits provided to frontline workers. Forexample, our findings are all from employersreceiving public funds for reimbursement butthey offer a wide range of salaries andbenefits. As stated before, minimum standardswould help to level the playing field for theindustry, as well as encourage new workers tobegin a career in frontline work. Certificationrequirements now include expected levels oftraining for frontline workers; other standardscould be imposed as well.

Long-term care consumers and theirfamilies also have a stake in improving thesituation of frontline workers. The lack ofindividualized care is frustrating forconsumers, but worker efficiency andproductivity is demanded by employers,particularly when they are short-staffed. These


two competing demands place frontlineworkers in a difficult position; one that canlead to frustration, burnout, and still moreturnover. Frustrated workers are less likely toprovide quality care. Overburdened workersare less likely to respond to non-routinerequests, respond quickly to routine requests,or to take the time to develop personalrelationships with care recipients. All of thesethings are important to consumers and theirfamilies. As consumers gain more practicalunderstanding about long-term care quality,they will learn to observe how employees aretreated, and how they go about their jobs. AsWilner & Wyatt state, "…if we permit themajority of caregivers to remain poorly paid,unappreciated, and poorly supported, we willalso have made our choice about what we canexpect for those in need of care" (1999, p. 55).

To keep employees once they arehired employers must provideadequate training to inspireconfidence on the job, adequate staffto prevent overload and burnout, andtime to maximize relationships withcare recipients.

As our findings show, many aspects offrontline work provide rewards. To keepemployees once they are hired employers mustprovide adequate training to inspireconfidence on the job, adequate staff toprevent overload and burnout, and time tomaximize relationships with care recipients. Alarge pool of workers remains loyal to theorganizations and the art of frontline work.Increasing the pool of long-stay frontlineworkers is an important goal for mostemployers. Strategies used by low turnover

organizations provide ideas of where otherorganizations can begin.

Data from this study cannot addressthe issue of which comes first—problems inthe work environment or problems withstaffing. Nevertheless, low-turnoverorganizations tend to exert more efforts withtheir existing employees, while organizationswith high turnover put more effort intobringing new employees to the door. Anorganization's reputation in the communityreflects the public perceptions of how it treatsits employees and probably has an importantinfluence on the pool of applicants for vacantpositions.



References

Atchley, Robert C. (1996). Frontline Workersin Long-Term Care: Recruitment, Retention,and Turnover Issues in an Era of RapidGrowth. Oxford, OH: Scripps GerontologyCenter.

Banaszak-Holl, Jane, & Marilyn A. Hines.(1996). Factors associated with nursing homestaff turnover. The Gerontologist 36: 512-517.

Communication Concepts. (1997). Trends.The growing aide shortage. 1.

Diamond, Timothy. (1992). Making GrayGold: Narratives of Nursing Home Care.Chicago: University of Chicago Press.

Even, William, Ghosal, Vivek, and Kunkel,Suzanne. (1998). Long-Term Care StaffingNeeds for Older People in Ohio. Oxford, OH:Scripps Gerontology Center.

Glock, Paul. (1995). Home Health Aide andHomemaker Survey Report. Columbus, OH:Ohio Department of Aging.

Harrington, Charlene. (1991). The nursinghome industry: A structural analysis. InMeredith Minkler & Carroll L. Estes (eds.),Critical Perspectives on Aging. Amityville,NY: Baywood.

Hoechst Marion Roussel. (1996). InstitutionalDigest. Kansas City, MO: Hoechst MarionRoussel.

Hughes, Susan. (1996). Home health. InConnie J. Evashwick (ed.), The Continuum ofLong-Term Care: An Integrated SystemsApproach. Albany, NY: Delmar.

Ohio Bureau of Employment Services. (1996).Ohio Job Outlook: 1994-2005. Columbus,OH: author.

Pillemer, Karl. (1996). Solving the FrontlineCrisis in Long-Term Care. Cambridge, MA:Frontline Publishing.

U.S. Bureau of the Census. (1998). StatisticalAbstract of the United States: 1998.www.census.gov. (May 28, 1999).

U.S. Bureau of Labor Statistics. (1999).1998-99 Occupational Outlook Handbook.http://stats.bls.gov/ocohome.htm. (May 28,1999).

Wilner, Mary Ann, & Wyatt, Ann. (1999).Paraprofessionals on the Frontlines:Improving Their Jobs—Improving the Qualityof Long-Term Care. Washington, DC:American Association of Retired Persons.

Zahrt, Linda M. (1992). The cost of turnover.Caring, April, 60-66.

Appendix

Documents

RECRUITING AND RETAINING FRONTLINE … are more likely to report that employees have little ... Recruiting and Retaining Frontline Workers in Long-Term Care: Usual Organizational Practices