The keys to reducing turnover in long-term care
Eleanor Feldman Barbera, Ph.D.
"They keep giving me these new aides and they don't know what they're doing,” a disgruntled resident commented during a psychotherapy session.
“You're not the first person to tell me that,” I replied, looking for a way to acknowledge her experience without criticizing either the facility or the new aides. “You have the honor of training them.”
“Yes, if they'd listen,” she said with an edge in her voice. “But it's a lot of work.”
The turnover rate in long-term care is a significant problem, with rates ranging from 55% to 75% for nurses and aides and sometimes over 100% for aides alone. Having personally witnessed a great deal of turnover during my years in LTC, I was curious about why the rate is so high and what could be done about it. I turned to the research to find the answers.
Costs of turnover
I was dismayed by a study that suggested that the persistence of turnover over the years might be because nursing homes could save money by treating their staff like a never-ending supply of fast food workers and avoiding investment in training and retention practices.
To my great relief, I found data indicating that there are many costs associated with turnover, including increased hospital readmission rates, high employee replacement costs, loss of productivity, poorer quality of care, a decrease in staff and resident morale, increased work stress, job dissatisfaction, increased accident and absenteeism rates, increased overtime costs, and resident and family dissatisfaction. Aside from the moral reasons to reduce turnover, it's also worthwhile on a strictly monetary basis. An estimate of the per-worker cost of turnover in the general U.S. economy is about 20% of the worker's annual compensation amount.
Much of the literature looked at turnover in aides and nurses and while the findings weren't always consistent between studies, the following factors were associated with job dissatisfaction and workers leaving their employers.
Factors associated with turnover
· For-profit homes
· Deficiencies in pay
· Deficiencies in benefits
· High workload
· Poor staffing
· Poor working conditions
· Work schedule not meeting needs or expectations
· Lack of role clarity/low sense of control over job performance
· Lack of appreciation
· High self-esteem (for those who felt unappreciated)
· Age (younger workers were less satisfied than older workers)
· Length of experience (those with less experience more likely to leave their jobs)
On the other hand, these factors were associated with job satisfaction and staff retention:
Factors associated with staff retention
· Involvement in interdisciplinary care plan meetings
· Length of experience (those with more experience were more likely to remain on the job)
· Older workers (who tended to have more stable family situations)
· Performance of exemplary care demonstrated through performance of restorative care (for aides)
· Opportunities for professional growth
· Supervisory training
· Sufficient orientation (experienced workers felt new employees weren't properly oriented and prepared for the volume of work)
· Motivating positive feelings between aides and residents
· Perception of being valued by nurses and supervisors
· Being considered an important part of the care team
· Working as a team
· Positive relationships with coworkers
· Permanent assignments
Many studies concluded by offering recommendations to reduce turnover.
· Attract employees for whom it is an occupation of choice (by evaluating interests and motivation during the interview process)
· Create environments that encourage retention through:
· Opportunities for professional growth
· Supervisory training such as teaching supervisors coaching techniques
· Employee involvement in decision-making
· Employee recognition (see Employee recognition programs: What works)
· Allow staff participation in care planning
· Implement self-scheduling
· Clearly communicate work expectations and performance against objectives
· Address underperformance issues that affect others on the team
· Build teams and increase coworker support
· Minimize time spent on activities other than direct resident care
· Call aides by name
· Help staff cope with work stress
· Increase the number of workers per resident. (The most consistent complaint I've heard from my coworkers over the years has been about working short-staffed. Consider this finding from a 2007 Donoghue and Castle study: Increasing the number of aides per resident from 33 per 100 to 41 per 100 reduced CNA turnover from 65% to 41% and also lowered LPN and RN turnover.)
In general, the research indicated that LTC workers remain with this profession because they consider their work important and valuable. Not surprisingly, employee retention improves when workers are treated in kind as important and valuable.
Article resources you might find interesting:
Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is an accomplished speaker and consultant with over 17 years of experience as a psychologist in long-term care. This blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.