News Analysis — Providers get tough on turnover

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Grant program explores workplace practices to improve retention among frontline staff.

Linda Buehler has always enjoyed her job as a certified nursing assistant. But now she is not afraid to admit it.
"When I started as a direct care worker, I aspired to be a nurse," says Buehler, a CNA of nearly 30 years at Parkhouse at Providence Point, a nursing home in Royersford, PA. "Now I say, because I've had a wake-up call, I do this by choice. I like the hands-on with the residents. I want to be on the front line. That keeps me from going to nursing school."
The source of her "wake-up call" is a unique program called Better Jobs Better Care (BJBC), a four-year, $15.5 million research and demonstration program funded by the Robert Wood Johnson Foundation and The Atlantic Philanthropies.
The first national program of its kind, BJBC sought to create changes in long-term care provider practice and public policy. The goal? To alleviate the endemic and expensive problem of high turnover among direct care workers, while improving quality. Observers score the program a winner on nearly all counts.
"It's ridiculous to think that you're going to get quality without investing in the staff," said Robyn Stone, director of the program and executive director of the Institute for the Future of Aging Services at the American Association of Homes and Services for the Aging. Stone, along with Steven Dawson of the Paraprofessional Healthcare Institute, based in Bronx, NY, developed the project, which is housed at IFAS.
The program will conclude in December. It has made a strong, lasting impression, say providers who participated. And even as the money begins to dry up, Stone and others believe that the program created a knowledge base that facilities and the industry will be able to draw from for years to come.
Such lessons include the importance of policy and practice to cause change; the role of coalition building in implementing initiatives; and the impact of involving direct care workers in a facility's decision-making process.
Clear winner
Stone and Dawson did not hesitate when asked to name the program's proudest achievement.
As follow-up to a BJBC demonstration program, North Carolina became the first state to create a special licensure designation. It's called the New Organizational Vision Award and rewards facilities for attracting and keeping frontline staff. Standards fall under supportive workplaces, training, career development and balanced workloads.
"We hope everyone will build up upon it in North Carolina, and for it to be a model for other states, in terms of what it means to have a set of best practices," Dawson said.
North Carolina's program was a stunning feat for achieving one of the BJBC's program's foremost goals: using public policy and workplace practices to reduce high vacancy and turnover rates.
"All the activities were designed in a way to further both policy and practice," Stone said. "That was sort of a key tenet of the project."
The legislation will take effect in January. Another policy victory occurred in Vermont where the BJBC program was instrumental in the passage of a bill, the Direct Care Workforce Study, to examine wages, benefits, hours and other issues that affect turnover and quality of care.
Five state projects
Aside from the North Carolina example, lessons emerged from BJBC in its four other demonstration sites. These projects involved direct-care worker training, mentoring programs and resident-centered care initiatives.
Some examples:
• Pennsylvania's BJBC project promoted wage raises, mentoring programs and uniform training requirements through several coalitions in the state. Workers such as Buehler attended conferences on leadership training and brought back their knowledge to their facilities.
• In Vermont, COVE, a consumer advocacy organization, used BJBC grant funds to expand and improve training programs and enact measures for culture change.
• Iowa's program expanded peer mentor training programs at community colleges throughout the state and integrated peer mentors into provider organizations.
• Oregon sought to improve working relationships between direct care workers and supervisors, and between workers and residents and families. Direct care workers and supervisors attended the LEAP program, a workforce development program.
Pennsylvania's example illustrates one of the major lessons of the BJBC program: the importance of involving the direct care staff in workplace change and policy advocacy.
"I think we saw more and more the voice of the direct care workers is frequently not heard," director Stone said. "They don't tend to be on advisory boards. They don't tend to be involved in coalition activities."
Worker participation also paid off in Iowa. For example, CNAs are now more involved in the care planning process at Good Samaritan Village in Lemars, IA. The facility used its grant money to send CNAs to mentor conferences and leadership training in Des Moines, about three hours away.
As a result of the BJBC program, the facility has seen a drastic reduction in CNA turnover – from nearly 100% four years ago to less than 20% today. Morale is also higher, according to staff development director Martha Toben.
The importance of forming a coalition was another valuable piece of knowledge gleaned, Stone said, noting the success of the programs in Pennsylvania and in North Carolina.
"This has the potential to not only keep things going but to blossom into other things as well," she noted.
Indiana County, one region involved in five coalitions throughout Pennsylvania, assembled a coalition composed of stakeholders including healthcare, educational institutions and workforce development.
"By partnering, instead of six organizations duplicating services, we will have one," said Linda Bettinazzi, CEO of the Visiting Nurse Association and its sister organization, VNA Extended Home Care.
Consortium providers in the county shared the names of potential employees to help each other find workers. Westmoreland County Community College and Indiana County Technology Center developed a mentoring program for eight licensed practical nurses who were struggling with nursing school.
Stone pinpointed other revelations that emerged from the state demonstration projects:
• It is important to strengthen the leadership of nursing supervisors.
• Providers are motivated to make changes if they know the costs of turnover.
• A need exists for more training in communication skills, problem solving and team building skills among frontline caregivers.
And nursing home operators discovered their own lessons: "We liked to think we were good to our frontline staff," said Fran Schuda, director of nursing at Parkhouse at Providence Point. "The program helped to focus the spotlight on the needs and the increased attention we need to pay to our aide groups."
Keeping it going
As time and money for the project begin to thin, program leaders are looking back at what could have been done better, and looking ahead to questions of sustainability.
Aside from some policy successes such, BJBC in some ways fell short on this front, Stone said.
"It's hard to get policy change," she noted. "One thing we had hoped for was more quick policy intervention. The reality is policy change takes a long time."
How the programs will continue without grant funding is another possible challenge. In many cases, grant money was used to send workers to conferences for training and to subsidize a staff member to oversee the program within the facility.
"The challenge is to find funding," said Karen Reever, director of the state project in Pennsylvania. "Without staff, these things don't get promoted."
But training will continue at many facilities, such as Good Samaritan Village in Lemars, IA, which is looking for more grants for worker training. Vermont hopes to continue using its 40-hour curriculum for personal care attendants and a follow-up training program called Beyond Basics.
Expanding the framework
In many cases, states now have an infrastructure to continue training, conferences and collaboration between various entities. Pennsylvania is seeking nonprofit status for its project. Oregon is trying to institutionalize its Pioneer Network and other culture change initiatives at sites to keep the programs running.
"You don't want programs that are only propped up by grants because they'll die at the end," Stone said.
Other tools could be available to the general long-term care community, such as leadership and cultural competency training materials, assessment instruments, and peer mentoring programs,
Plenty of information is available to long-term care providers who are interested in improving the working conditions of direct care workers.
But Dawson, of the Paraprofessional Healthcare Institute, cautions it has to be a complete facility commitment, one of the most enduring lessons to emerge from BJBC.
"It requires an enormous investment, not so much money but real attention," he said. "If a conventional provider just hopes to pick up something here and there, I don't think it's going to matter. The problem is far more challenging than that. I think that any facility that is really dedicated to figuring this out, to investing in low turnover, then there's a lot of information and relationships that BJBC can offer." Studying up

Along with demonstration projects, research was a key component of Better Jobs Better Care. A total of eight research projects received grant funds. Summaries of some:
- A study at the Boston University School of Public Health explored cross-cultural relations within long-term care staff in 10 nursing facilities in eastern Massachusetts. It developed site-specific cultural competency interventions and measured their impact on job design, satisfaction and motivation of nursing assistants.
- Researchers at Brandeis University studied how organizational and management practices in long-term care organizations influence teamwork and caregiving relationships, and how these affect frontline workers and residents.
- Cornell University's Cornell Gerontology Research Institute studied the use of "retention specialists" in nursing homes, and examined how they affect retention and job satisfaction of certified nursing assistants and their contribution to better human resource policies.
To find out more about the research projects and Better Jobs Better Care, see the Web site at

Profile of a direct care worker

Gender: Nine out of 10 direct care workers are women.

Age: The average age of workers in nursing homes is 37.

Race/ethnicity: Slightly more than half of direct care workers are white and non-Hispanic. About one-third are black. The rest are Hispanic or other ethnicities.

Marital status/children: One-third (about 33%) of direct care workers in nursing homes are unmarried and living with children, compared to 11% of the total U.S. workforce.

Education: Half of those in nursing homes completed their formal education with a high school diploma or GED. A total of 27% attended college.

Source: William J. Scanlon, GAO Testimony: Nursing workforce: Recruitment and retention of nurses and nurse aides is a growing concern (General Accounting Office, May 2001)

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