With an aging mother who has had some health scares, I have seen first-hand the care in the hospital, rehabilitation, nursing and assisted living environments. And the direct care workers in these organizations mostly certified nursing assistants in long-term and home care, have hard jobs, are low paid, and nearly ever receive the rewards and recognition deserved. That is why employee retention is so hard to achieve in aging services.
When a position is viewed as simply a job and not a career, it is easy to see why people leave for better paying jobs outside the industry. Employee retention in aging services is a big issue that will become even bigger as the population ages. Let’s look at some strategies to help retain the best workforce.
According to a 2007 American Health Care Association (AHCA) survey, the turnover rate for certified nursing assistants in nursing homes was 65.6; for home health aides, one study estimated a 40 to 60 percent turnover in the first year.
It’s not hard to see why:
- low wages
- poor benefits often lacking health insurance
- no career progression
- physically and mentally demanding
- low respect
Consequences of Turnover
In the report, Direct Care Worker Retention: Strategies for Success from Leading Age and the Institute for the Future of Aging Services a study by Castle and associates was cited that stated “ high turnover rates of certified nursing assistants, licensed practical nurses and registered nurses, in general, are associated with worse quality of care for nursing home residents.” Higher turnover has been associated with greater use of restraints, catheters and psychoactive drugs, as well as more pressure ulcers and quality-of- care deficiencies.
It is not hard to manage the cost of replacing workers. But there is a larger revenue consequence as well. People expect quality and satisfaction in the healthcare they receive but that is the baseline, the cost of entry. What makes them recommend places is superior quality and incredible experiences. You can never achieve this without consistent assignment.
We previously reported on the face of the direct care worker. In 2009, the median hourly wage for all direct-care workers was $10.58. One in every four nursing home workers and more than a third of aides working in agency-based home care lacked health coverage. About 45 percent of direct-care workers live in households earning below 200 percent of the federal poverty level income, making them eligible for most state and federal public assistance programs. Nearly half of all direct-care workers (46 percent) live in households that receive one or more public benefits such as food stamps; Medicaid; or housing, child care, or energy assistance. The people who are caring for our elders are struggling to care for themselves.
Keys to Retention
It is probably not hard to guess some of the keys to retention:
- Better Pay
According to the National Nursing Assistant Survey satisfaction with wages had the second strongest association with intrinsic job satisfaction and overall job satisfaction. The higher intrinsic job satisfaction the lower their intent to leave.
- Availability of Health Insurance
The Leading Age / IFAS report also cited a report from the Personal Assistance Services Council of Los Angeles County that found that “home care workers enrolled in their employer-sponsored health plan had a higher retention rate (56 percent) than workers who were eligible but not enrolled (45 percent).”
- An Empowering Culture
We have reported on the culture change movement in long-term care. When there is a culture that looks at first addressing the employee experience that in turn affects the customer experience, there goes with it certain job satisfiers - training, mentoring, relationship building, career ladders, empowerment.
- Better Job Design and Supervision
Some of this will flow from embracing culture change - recognition and feedback, sufficient staffing ratios, career advancement and paths to follow, respect for the position, job flexibility, leadership development, greater autonomy and teamwork.
- Better Training
The federal government requires nurse aides and home health aides working in Medicare/Medicaid-certified agencies to have 75 hours of initial training. Many states have established additional training requirements. The Institute of Medicine has recommended that the minimum federal requirements for CNAs and home health aides be raised to 120 hours and include a demonstration of competence in caring for older adults as part of certification. Studies have shown that staff who were more satisfied with the quality of their training also had higher job satisfaction and were more likely to stay on the job.
- Career Advancement
In a study (Brannon et al. 2007) 3,039 workers from 50 nursing homes, 39 home care agencies, 40 assisted living facilities and 10 adult day services in five states participated in a survey that showed “the perceived lack of opportunity for advancement and the perception of work overload were most significantly related to intent to leave, particularly among home care agency and skilled nursing home staff.”
Of course some of this requires an investment of money, of time, of commitment. But it is absolutely necessary for many reasons. The demographics speak to the need. Healthcare reform is putting aging services on the radar. But not all providers will be the partners of choice in accountable care organizations. The providers that invest in recruiting and retaining the best workforce and who believe that it in turn leads to better care will be the ones rewarded when the reform dust lifts.