Battling cost of turnover, job dissatisfaction
The latest hard-to-find information
With the demand for nursing home workers projected to increase by 45% and the number of home care workers projected to more than double in the next seven years, how can organizations find and keep front-line workers?
If you’re searching the literature for an answer to this $64,000 question, don’t expect to find a plethora of information.
"Although there is extensive literature on recruitment and retention of nurses, mostly in hospitals, it’s of questionable value in understanding the dynamics of unskilled long-term care workers," says Robert C. Atchley, PhD, directors of the Scripps Gerontology Center at Miami University in Oxford, OH.
Different staff have different issues
Registered nurses and licensed practical nurses respond to a different set of issues than nurse aides, personal care assistants, and home care workers, he explains. For example, professionals have the opportunity to climb career ladders and obtain promotions while most paraprofessionals do not.
That’s why Atchley decided to write a monograph that focused on staffing issues specific to nursing homes and home care organizations titled Front-line Workers in Long-Term Care: Recruitment, Retention, and Turnover Issues in an Era of Rapid Growth.
His review consists of mostly articles offering practical tips based on professional experience, a few descriptive studies, and a "very small number of carefully done analytical studies."
"We don’t have the luxury of waiting until systematic research can nail down predictable ways to identify people who are likely to become excellent workers committed to staying in front-line work," he says.
May not be solution for all
But relying on practice literature has one caveat: What works well in one situation may not work in another. "Solutions are often based on idealistic showcase or best practice programs that rely on a financial base of grant funding," he says. "So they are often difficult to apply under normal financial constraints."
Nevertheless, the literature review highlighted in the 21-page monograph outlines challenges and solutions for managers who are faced with recruitment, retention, and turnover issues. Challenges are broken down into two areas:
1. Compensation and benefits.
Front-line health care workers are America’s working poor, Atchley points out. "In 1995, starting nursing home aides and home care workers averaged about $11,000 per year," he says. "Experienced nursing home aides made $14,500 annually for full-time work, and experienced home care workers made about $12,600."
Such wages are just above the definition of poverty line as set by the U.S. Bureau of the Census.
"To make a living, many workers now are forced to work far more than a 40 hour week some of them double shifts," he says.
Most of them don’t receive benefits, either. "Because most organizations offer health benefits only to full-time employees, and some intentionally control the number of workers who qualify by limiting their hours, it is possible for a front-line worker to work more than 60 hours a week for two or more nursing homes or health care agencies and still not receive benefits," he says.
And even if the employees qualify for benefits, more than half of home care agencies require employees to share the cost, and most can’t afford to pay their share, he says.
"To attract and retain the types of workers wanted and needed, organizations will have to pay workers a living wage," he says.
Employer-paid health coverage also will make the benefits a "significant pull factor," he says.
2. The high cost of turnover.
Atchley’s literature review showed that each instance of turnover amounts to more than $3,000. (See chart, above, for specific breakdown.) Even that figure doesn’t include the "enormous attrition" that occurs during the recruitment process, he says.
For example, in one program designed to recruit, train, and place home care workers, the facility received 751 telephone inquiries and scheduled 683 people for interviews. But 49% failed to show up. Out of those 351 who did, 38% were not accepted for the training program. Of the 216 who were accepted, 82% did not start classes. Of the 133 who did, 70% did not graduate. Of the 106 who graduated, 57% had left the agency within six months after they were placed. At that point, only 46, or 6.1% of the original people who answered the ad remained.
So what’s the best way to identify and solicit candidates for open positions?
First, don’t depend on newspaper advertising, Atchley found. "Only about 10% of front-line workers are hired through job advertisement," he says.
Part of the problem may be a misleading ad. "It does little good to mislead candidates into taking jobs that they will quit as soon as they find out what the job is really like," he says. Instead, managers and human resource personnel should clearly state pragmatic realities of what is expected of employees and what employees can expect.
His review of the literature indicated that while open houses, job fairs, and newspaper advertisements may generate a large number of applicants, referrals from existing staff are the most efficient way to identify viable job candidates.
"Eighty-five percent of new employees in home care came from referrals from existing staff," he says. "One way to increase referrals is to offer bonuses to employees who refer someone who is hired and retained."
Include everyone in long-term care
Atchley also found that special outreach efforts are often needed to attract young people, older people, and low-income people to jobs in long-term care.
For example, managers can reach younger people by providing high school guidance counselors with up-to-date information on the types of jobs especially part time ones available in long-term care.
"Next to personal referral, schools were the second most effective source of new employees," Atchley says.
People over 60 that are physically able with low retirement incomes should also not be overlooked as a potential labor pool, he notes.
In addition, successful front-line workers can be created from low-income people with no employment history although moving people from welfare to work requires substantial training and support over an extended period.
The monograph also reviewed issues such as orientation of new employees, job design, training, supervision, and several other challenges.
[Editor’s note: For reprints of Front-line Workers in Long-Term Care: Recruitment, Retention, and Turnover Issues in an Era of Rapid Growth by Robert C. Atchley, contact the Scripps Gerontology Center, Miami University, Oxford, OH 45056. Telephone: (513) 529-2914. Reprints are free for non-profit organizations; $5 for others.]
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