Dr. Jules Rosen

A study of direct care workers in Pennsylvania has revealed some surprising results about what makes certified nursing aides tick. The positive aspects of the CNA job perceptions are striking, with 82% reporting looking forward to coming to work most days, 80% endorsing strong loyalty toward their job, and more than 90% feeling their work makes the world a better place.

With this level of job satisfaction, it is surprising that the turnover rate is so high. The main reason people leave is described as management’s “disrespect.” This means not simply being impolite; it is management having unrealistic expectations of the direct care worker in completing his or her daily work. 

These results come from the first wave of data collection of a survey from the Center for Health and Care Work (CHCW) at the University of Pittsburgh that will encompass 1,400 direct care workers. They will be surveyed at nine-month intervals over 24 months to determine why workers stay, why workers leave and where they go after leaving. There has not been any previous study that has examined these outcomes.

We are starting with the assumption that different forces drive retention and turnover, and that understanding the dynamics will lead to interventions that can help stabilize this workforce.  

The problem of staff retention and turnover is well-known to administrators and directors of nursing in facilities across the United States. This issue now has emerged as a significant concern within the national agenda. The Institute of Medicine Report, “Retooling for an Aging America: Building the Health Care Workforce,” released in 2008,  addresses a looming crisis in healthcare for U.S. elders.  The report serves as a call to action and typically receive attention from the White House, on down.   

As a geriatric psychiatrist, educator, and researcher with a focus on improving the quality of nursing home care, I concluded several years ago that the success of quality improvement processes depends on business models in concert with medical and clinical practice decisions. The best medical practices imaginable are rendered worthless in the hands of an inexperienced or inadequately trained worker.

Several important national initiatives, including “Better Jobs, Better Care,” are addressing the connection between workforce stability and quality of care (Stone & Dawson, 2008). To contribute to this important workforce issue, we have recently created the Center for Health and Care Work (CHCW) as a joint initiative at the Katz Graduate School of Business at the University of Pittsburgh, and the University of Pittsburgh School of Medicine.  The CHCW has a primary aim of addressing the unique interactions of the business environment, direct care workforce and clinical outcomes.     

The myths (or what we think we know)

One of the initial challenges to the CHCW is to address the myths that permeate the long-term care industry, as well as academia. The first myth we needed to address is that we have a good grasp of why the staff turnover rate is as high as it is. I have heard administrators claim that the CNA staff will go work at McDonald’s for five cents per hour more. Recent data suggest that higher satisfaction with the workplace support, work schedule, work content and training is associated with lower turnover after one year (Castle, Engberg, Anderson, & Men, 2007).  Pay is rarely a driving force in turnover!  

However, what’s noteworthy is these data do not tell us why people actually leave or where they go. The truth of the matter is that we really do NOT know why CNAs leave their jobs.

The other side of this question that has also been inadequately addressed is, “Why do they stay?” If the work is so difficult and pay is so poor, why do some CNAs remain either at their job or within this profession for decades? We are systematically evaluating the positive and negative aspects of direct care work. In addition, we are assessing the impact of personal and family factors on tenure and turnover.

Study of direct-care workers

We are now conducting a two-year study designed to follow 1,400 direct care workers in Pennsylvania. As workers decide to leave or stay on a job, they will be interviewed at regular intervals to evaluate what factors contributed to their decision to stay or to leave. We will also learn if they leave the profession, or simply go to another job within the direct care worker field.  

As in earlier studies, we are interested in the key elements of job satisfaction. However, in contrast to earlier studies, we have learned from work in other caregiving arenas, such as childcare, that non-job related factors contribute significantly to turnover. Childcare or eldercare needs at home, marital changes, and health changes all may contribute to job instability among these workers.  Therefore, on-the-job and off-the-job factors will be assessed in each interview.

What have we learned so far?  

Initial Findings

Positive aspects of work  

1. As a whole, CNAs derive emotional satisfaction from their jobs and feel they are providing a much-needed service to those under their care.  

2. Factors that supported CNAs’ feeling successful at work include perceiving themselves as being a residents’ advocate, establishing personal relationships with residents and their families, feeling “called” to the work, and being able to “leave work at the door.”

3. Successfully handling difficult situations at work is supported by a strong sense of spirituality and religion.  Solid family, work and social supports are also described as important to helping them handle difficult work situations that help them get through the toughest days.

4. CNAs reported numerous positive examples of “crafting” their jobs to make them more personal or manageable to the individual CNA. Positive examples of crafting include developing personal and supportive relationships with residents, praying with patients, accessing extra resources in an effort to make patients more comfortable, and helping residents die with dignity by doing something “extra.”

Negative aspects of work  

1. CNAs reported leaving jobs if they felt disrespected by management or if they perceive management as incompetent.

2. CNAs described unrealistic expectations by management.  Specifically, the ability to do their job effectively is hampered by management’s persistent tolerance of understaffing, lack of mentorship, and inadequate education.

3. Few opportunities for career advancement within the CNA profession contribute to high turnover.

4. Negative examples of “crafting” include not washing their hands for the required amount of time between patients, as well as lifting bed-bound patients without the appropriate support in order to save time. These time-saving efforts lead to disciplinary action or injury.

5. Home life and personal responsibilities, such as child or elder care, financial problems, or difficult/conflicting obligations, have an impact on the CNAs’ ability to consistently report for work.


Quality care requires a stable workforce. These focus group findings provide an initial window into understanding how the CNAs view the positive and the negative aspects of their jobs. We are now in the process of collecting the data for our study that we look forward to sharing with the long-term care community. To learn more about the CHCW and the work we are doing, please visit our Web site at: http://www.business.pitt.edu/chcw/.

Reference List

Castle, N. G., Engberg, J., Anderson, R., & Men, A. (2007). Job satisfaction of nurse aides in nursing homes: Intent to leave and turnover. Gerontologist, 47, 193-204.

Stone, R. I. & Dawson, S. L. (2008). The origins of Better Jobs Better Care. Gerontologist, 48 Spec No 1, 5-13.

Jules Rosen, M.D., is a professor in the Department of Psychiatry and the Katz Graduate School of Business at the University of Pittsburgh Medical Center. He also is the chief of geriatric medical services at the University of Pittsburgh School of Medicine.