6 Steps to Effective Employee Retention

Long-term care workforce turnover hampers care

Caretaker and older man having smoothies
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The buzzword in health care these days is person-centered care. That is the ability to provide care that honors and respects the choices and preferences of people while providing high quality and safe care. Consistent care, however, can only come when health workers have the time to get to know the person they care for every day. With the high rate of turnover in health care, particularly long-term care, that is not always possible. So we need to retain these workers. Here are six steps to effective employee retention.

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.

The turnover rate for certified nursing assistants in nursing homes was 65.6 percent; 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 health care 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.

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
    • Home care workers enrolled in their employer-sponsored health plan have 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.

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