Turnover Retention by w07PXmd

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									 TURNOVER

 Table 1. A Summary of Empirical Studies of Staff Turnover in Long-Term Care

          Article             Objectives                  Study Design                            Main Findings                            Discussion

Angelelli, J et al.       To examine:              Data for turnover analyses        Increased nursing home turnover in the      This study suggests
                                                    was collected by the NY State      late 1980s and early 1990s and a            greater job complexity,
―External Threats and  Nursing home                Dept. of Health (DOH).             decline in turnover since the early 90s.    increased specialization
Nursing Home             administrator             This facility information is       The authors attribute this trend to         and professionalization
Administrator            turnover from 1970-        obtained from the Online           greater job complexity and admin.           appear to have coincided
Turnover‖                1997 in New York           Survey and Certification of        responsibilities related to the growth of   with increased rates of
                         State.                     Automated Records (OSCAR)          sub acute care implemented by the           staff turnover in the 1980s
Health Care                                         from 1991-97.                      1988 Medicare Catastrophic Coverage         and early 1990s in NY
Management Review       Factors contributing      Setting: Licensed nursing          Act (MCCA) and the Omnibus                  State.
                         to turnover increase       home facilities in New York        Reconciliation Act (OBRA) of 1987
2001; 26(3) 52-62.       in the late 1980s          State.                             which changed the nursing home              ―…the high level of
                         and early 1990s.          Participants: Nursing home         administrator‘s role significantly.         administrator turnover
                                                    administrators.                   The authors suggest the decrease in         within a subset of facilities
                          To test the             Time period: 1970-1998.            admin turnover by 1997 suggests             suggests a need to
                           hypothesis that         Study population size: 832         many nursing homes had absorbed the         closely examine the
                           nursing home             facility histories; 4,746 ―job     initial shocks of OBRA and the post         effects of turnover in the
                           administrator            tenure periods.‖                   acute boom.                                 context of quality indicator
                           turnover during the     Data elements examined from       A larger proportion of hospital-based       measures and other time-
                           late 1980s and           the OSCAR system other             facilities (38/54) had more turnover        dependent facility
                           early 1990s was          than the turnover rate were        than did freestanding faculties             characteristics.‖
                           related to               structural characteristics of      (170/361).
                           institutional            nursing homes such as chain       Administrator turnover was 1.20 times       Limitations:
                           changes and              affiliation, rural location,       higher in facilities belonging to a chain    This study did not
                           reporting                hospital-based organization,       when compared to independent                include demographic data
                           requirements             and proprietary status.            nursing homes.                              about individual
                           resulting from the                                                                                      administrators that
                           1988 Medicare                                                                                           previous research has
                           Catastrophic                                                                                            found to be important.
                           Coverage Act             QE: II-3                                                                        There was no
                           (MCCA),                                                                                                 examination of whether
                           implementation of                                                                                       turnover was related to
                           the Omnibus                                                                                             ownership changes.
                           Reconciliation Act                                                                                       Only New York State
                           (OBRA provisions,                                                                                       facilities were considered
                           a boom in nursing
                           home utilization and                                                                                    SR: A
                           the increased acuity



                                                                              1
                           of nursing home
                           patients.




Brannon, D et al            Examines factors      Data from 3 sources was             Supervisors trained in management              The intent of the
                             that distinguish       merged to form a database            were more likely to be in the middle            research was to
                             nursing facilities     for the analysis: The 1995           referent group. Authors assume this             explore an alternative
“An Exploration of           with very high         On-Line Survey Certification         relates to low turnover facilities              empirical approach to
Job, Organizational,         and very low           of Automated Records                 deficient in productive, possibly               viewing turnover in
                             turnover rates         (OSCAR) file, the most               involuntary turnover. Extreme staff             light of known
and Environmental
                             from a middle          closely matched county-level         stability may reflect an absence of             predictors. The
Factors Associated           referent group,        Area Resource File (ARF),            functional management resulting in low          purpose was to
With High and Low            exploring the          and a cross sectional survey         performance expectation.                        reintroduce to the
Nursing Assistant            possibility that       of DONs from the sample             Higher RN turnover was associated               turnover literature the
Turnover.”                   high and low           facilities.                          with lower risk of being in the very low        possibility that not all
                             turnover are          Settings: 360 facilities             aide turnover group and higher risk of          staff turnover is
                             discrete               stratified by ownership, size,       being in the high aide turnover group.          equally damaging to
The Gerontologist            phenomena with         and urban locations, from 8         The greater the number of people who            nursing facilities.
                             different              states that were universal in        reported directly to the administrator,        Future research
2002; 42(2):159-68           antecedents.           their computerization of the         the more likely the facility was to be in       should address the
                                                    mandated nursing home                the low-turnover group. Organizations           question of whether
                                                    Resident Assessment                  with less middle management were                there are
                                                    Instrument/Minimum Data              more likely to have very low turnover.          circumstances where
                                                    Set.                                A union contract was associated with a          instability works to
                                                   Participants: DONs were              10-fold increase in the likelihood of a         produce quality
                                                    interviewed by telephone with        facility would be in the very low               nursing home care or
                                                    an 80% response (N=288)              turnover category.                              whether the level of
                                                   Time period: late 1995-1996.        Facilities serving as clinical training         instability is
                                                   Analysis designed to examine         sites were more than 3 times as likely          incompatible with
                                                    job, organizational and              to be in the high-turnover group. This          quality LTC. A range
                                                    environmental factors                is attributed to these facilities hiring,       of facility turnover
                                                    associated with both low (less       providing certification training and then       rates should be
                                                    than 6.6% in 6/mo) and high          losing a disproportionate number of             identified that is
                                                    (more than 64% in 6/mo)              NAs to other healthcare facilities.             neither too high nor
                                                    turnover rates among                Investor-owned facilities were                  too low in terms of
                                                    nonprofessional nursing              significantly more vulnerable to very           quality of care and
                                                    assistants at the facility level     high staff turnover than were                   financial outcomes.
                                                    in a multistate sample.              nonprofits.
                                                   Approach is exploratory in                                                       Limitations
                                                    that there is no prior body of                                                     Research was limited
                                                    work to guide the                                                                     because it did not
                                                    development of directional                                                            test a single




                                                                                2
  hypotheses for very low v.            theoretical
  very high turnover.                   perspective. The
 Assumed neither very high             overall predictive
  nor very low turnover is              validity of the model
  desirable.                            tested should not be
 Arbitrarily grouped turnover          used for comparison
  rates into 3 categories,              purposes.
  recognizing since no
  guidelines for turnover rates
  were found in the literature or
  in consultation with industry      SR: A
  trade associations.
 30 facilities were placed in the
  range of low reported
  turnover, 74 in the high range
  and 189 were reported in the
  middle referent group.

 Examined Job Factors:
1) Close supervision of NAs
2) Management training for
supervisors or performance
based rewards
3) Involvement of NAs in care
planning
4) Staffing ratios

 Organizational Factors:
1) Nurse practitioners on staff
2) Lower aide-to-professional
staff ratio
3) Longer tenured DON
4) More inservice offerings for
NAs
5) Formal relationships with
hospitals
6) Non-profit
7) Part of a multifacility chain
8) Reliance on Medicaid funding
9) Smaller administrator span of
control
10) Have union contracts
11) Serve as training sites
12) Have no recent ownership



                              3
                                                      change

                                                       Market Environmental
                                                        Factors:
                                                      1) Unemployment rate per
                                                      capita income.



                                                     E: II-2



Castle NG.                 To examine the        To test the hypothesis that high      423 facilities responded to the survey.       This study offers preliminary
                           association between   levels of top management turnover                                                   evidence that the turnover of
“Turnover Begets           turnover of caregiversare associated with high levels of      Top management turnover is significantly top managers may have an
Turnover”                                        resident caregiver turnover and its
                           and turnover of nursing                                        associated with high caregiver turnover. important influence on
                           home top management.  correlate, hypothesis that low levels    A 10% increase in top management           caregiver turnover in nursing
The Gerontologist 2005;45                        of top management turnover are           turnover is associated with a 21%          homes.
(2): 186-195                                     associated with low levels of            increase in the odds that a facility will
                          Top managers           resident caregiver turnover, an          have high nurse aide turnover.             The commitment top
                          examined were          analysis of data from a survey of                                                   managers display to the
                          administrators and                                             Top management turnover is significantly
                                                 419 nursing facilities and the Online                                               organization clearly
                          DONs; caregivers                                                associated with low caregiver turnover. A
                                                 Survey, Certification, and Reporting                                                influences other staff. This
                          examined were RNs,                                              10% increase in top management
                                                 (OSCAR) system was                                                                  suggests that strategies to
                          LPNs, and nurse aides. performed.Primary data were              turnover rates is associated with an 8%
                                                                                                                                     reduce top management
                                                                                          decrease in the odds that a facility will
                                                 collected from facilities in Kansas,                                                turnover should be
                                                                                          have low nurse aides turnover rates.
                                                 Maine, Mississippi, South Dakota                                                    developed and implemented.
                                                 and Texas.                              Top management turnover is significantly
                                                                                          associated with high RN and LPN            The author suggests that
                                                 Top management turnover data             turnover. .A 10% increase in top           strategies cited in the
                                                 were from 1997, and caregiver data       management turnover is associated with literature merit consideration
                                                 were from 1998 because the               a 30% increase in the odds that a facility including:
                                                 research hypothesis posited that         will have high RN and LPN turnover.
                                                 top management turnover                 No significant association between top         Fair compensation and
                                                 influences subsequent caregiver          management turnover and low RN and              termination practices
                                                 turnover.                                LPN turnover was identified.                   Executive development
                                                                                                                                          programs
                                                                                         In addition, ADLs, for- profit status,         Formalized transfer
                                                                                          private-pay census and number of                policies
                                                                                          nursing home beds in the county were           Encouraging
                                                                                          associated with caregiver turnover.             organizational
                                                                                         Numbers of RN and LPN FTEs,                     commitment and ―fit‖
                                                                                          dementia, facility size and chain



                                                                                  4
                                                                                           membership also were associated with       Limitations
                                                                                           high caregiver turnover but not low
                                                                                           turnover.                                         Potential measurement
                                                 QE: II-2                                                                                     errors attributable to
                                                                                       The number of FTE nurses aides, and
                                                                                        facility occupancy rates were significantly           extent to which
                                                                                        associated with low caregiver turnover                caregiver turnover was
                                                                                        but not high caregiver turnover.                      measured or estimated.
                                                                                                                                             Lack of distinction
                                                                                                                                              between voluntary and
                                                                                                                                              involuntary turnover.


                                                                                                                                      SR: A



Fitzpatrick, Peter G.   To examine the              Literature review and survey        The extent of the CNA shortage was                  The author offers
                        extent, implication          aim to illuminate the                put at 200,000 nationwide in 1999                    proposals to ease the
                        and causes of the            immediate and long-term              and factors such as the aging                        high CNA turnover
“Turnover of            turnover rate among          consequences of the high             population and Alzheimer‘s patients                  rate:
Certified Nursing
                        CNAs at LTC                  turnover rate of CNAs in LTC.        (who require more intensive care) has               1) Enhance CNA
                        facilities.                                                       led to a projection of the shortage                  training accompanied
Assistants: A Major
                                                    Survey of 200 CNAs to                increasing to 14 million by 2050.                    by a higher hourly
Problem for Long-        Proposals to correct       identify their reasons for        Causes of high CNA turnover rates                      wage: Since LTC
term Care                 the problems.              leaving institutions, yielded      include salary and working conditions:                 facilities are
Facilities.”                                         too few responses. Since          Nursing administrators report                          financially pressed
                                                     most institutions do not or        increasing wages rarely results in                     the author suggests
                        QE:III                       cannot perform exit interviews     higher rates of permanence, since it                   the implementation of
Hospital Topics                                      the author examined the            leads to bidding wars among facilities                 a Medicaid pass-
2002; 80(2) 21-25                                    nature of the job and              competing for the same CNA pool.                       through minimum
                                                     reviewed other studies.           ―The major component of working                        CNA wage.
                                                                                        conditions producing job dissatisfaction               Reallocating part of
                                                    Time period: Most references       is probably inadequate training.‖                      the 43% Medicaid
                                                     cited are recent (past 5           Evidence of more training affecting                    pays for LTC to go
                                                     years), but one study cited        turnover is cited in the case of Genesis               directly to CNA
                                                     goes back to 1978.                 Eldercare which trained CNAs above                     wages coupled with
                                                                                        the federal mandate and has achieved                   better training will
                                                                                        a 90% retention rate among CNAs that                   reduce CNA turnover.
                                                                                        participated in the program.                          2) States should go
                                                                                                                                               beyond the federally
                                                                                       Implications of high CNA turnover                      mandated ratio and
                                                                                        include compromised continuity of                      reduce the required
                                                                                        care. Continuity of care effects patient               staff-to-patient,
                                                                                        satisfaction, which in turn effects                    stating that with the



                                                                               5
    marketing and profitability (although       improvement of
    the author finds the exact amount           wages and training
    unexplained thus far) of the LTC            the available pool of
    market.                                     CNAs will grow
                                                allowing institutions to
                                                hire more CNAs and
                                                establish more
                                                realistic ratios.
                                               3) Since lack of
                                                respect is often-cited
                                                as a reason why
                                                CNAs leave their
                                                jobs, the professional
                                                staff in general and
                                                the nursing staff in
                                                particular must be
                                                trained to think of
                                                CNAs as colleagues,
                                                not servants.
                                               4) Mechanisms
                                                should be put in place
                                                to provide CNAs
                                                opportunities to
                                                advance in their
                                                healthcare careers.
                                               5) The LTC facilities
                                                should have CNAs
                                                work in teams of two,
                                                to help diffuse the
                                                heavy workload and
                                                provide comradeship
                                                that would reduce
                                                stress levels of the
                                                job.


                                            SR: A




6
Flynn, L                   To analyze the        Third phase of a study funded         Response rate of 61% = responses             Home care leaders
                            findings of a            by the American Nurses               from 403 home care nurses                     should utilize these
“The importance of          study that asked         Foundation.                          representing 6 geographical regions           results to develop and
work environment:           home care             Survey mailed to 660 home              of the US.                                    implement systems
evidence-based              nurses to rate the       care nurses randomly                89.3% white mean age 46.8 years,              and processes that
strategies for              importance of            selected from mailing lists          and a mean of 22.2 years of nursing           can maintain these
                            specific agency          obtained from the American           experience.                                   workplace traits.
enhancing nurse
                            work                     Nurses Assn and American            Mean ratings ranged from 3.81 to             A ―fit‖ between
retention.”                 environment              Nurses Credentialing                 2.09 on the 4-point scale. 10 agency          structure and process
                            traits as                Center.                              traits with the highest mean                  factors is critical to
Home Healthc Nurs           predicators of job    Questionnaire consisted of 49          importance scores in order of rating          achieve positive
                            satisfaction and         items from the Nursing Work          are:                                          outcomes, job
2005 Jun; 23(6): 366-       retention.               Index – Revised (NWI-R)                                                            satisfaction, and
71; quiz 385-7                                       and used a summative                Supportive supervisory staff                  ultimately, job
                                                     rating scale of 1-4 (1-             Clinically competent co-workers               retention.
                                                     strongly disagree that the          ―not being placed in position of having      ―Structure‖ traits
                                                     trait is important, 4-strongly       to do things that are against my              closely fit the findings
                                                     agree that the trait is              nursing judgment‖                             from the NWI-R –
                                                     important).                         good nurse manager                            clinically competent
                                                  Internal consistency                  good orientation program for newly            nurses, orientation
                                                     coefficient of .96 indicated         employed nurses                               programs, plan of
                                                     good reliability of the index       freedom to make patient care and              care, staffing levels.
                                                     in this sample.                      work decisions                               ―Process‖ traits
                                                                                         administration is responsive to               similar to those from
                                                                                          employee concerns                             the NWI-R –
                                                                                         good relationships with other                 supportive mangers,
                                                 QE: II-3                                 departments                                   respect for self-
                                                                                                                                        judgment, autonomy,
                                                                                         Plan of Care is accessible and
                                                                                                                                        responsive
                                                                                          current for all patients
                                                                                                                                        administration, good
                                                                                         Enough RNs on staff to provide
                                                                                                                                        relationships between
                                                                                          quality care.
                                                                                                                                        nursing and other
                                                                                                                                        departments within
                                                                                      Evidence-based strategies for nurse
                                                                                                                                        the organization.
                                                                                      retention:
                                                                                              Use valued work environment
                                                                                                                                       These characteristics
                                                                                               traits when establishing systems
                                                                                                                                        not only contribute to
                                                                                               and process
                                                                                                                                        nurses‘ job
                                                                                              Responsive administration                satisfaction, but also
                                                                                               critical in understanding the            are associated with
                                                                                               concerns of home care nurses             positive patient
                                                                                              Strong personal relationship with        outcomes and higher
                                                                                               nursing administrators necessary         level of patient
                                                                                               for personal and professional



                                                                               7
                                                                                               recognition                             satisfaction.
                                                                                              Ongoing management programs,
                                                                                               support groups, communication,
                                                                                               and reasonable workloads result
                                                                                               in positive management-             SR: A
                                                                                               employee relationships




Jervis LL                    To explore the     Study looks at three levels of           Analysis revealed problems in the          Nurses in LTC had
                              hierarchical       nursing staff at this urban nursing       relationships between NAs and               high levels of job
“Working in and               relationships      home:                                     nurses.                                     satisfaction as did
around the „chain of          between nurse       top staff — the Administrator,         Pyramid-shaped power structure              mid-level managers.
command‟: power               managers, staff        the Director of Nursing               utilized the ‗chain of command‘ in         Some nurses feel the
relations among               nurses, and            (DON), the Staff                      which differently ranked job-holders        profession has
                              nursing                Development Coordinator               are assigned rank-specific duties and       attached a stigma to
nursing staff in an
                              assistants in an    mid-level nurse-supervisors             are held accountable to individuals         those working in
urban nursing                 urban nursing          — RNs and LPNs                        higher in the staff hierarchy. Orders       nursing homes.
home.”                        home.               bottom-level nursing staff –            are passed down the chain, and             Hierarchical structure
                                                     Nursing assistants (NA)               problems and questions directed up          in nursing homes
Nursing. 2002; 9(1):12-                           Setting is a 78-bed, for-profit         the chain.                                  breeds feelings of
23.                                                  nursing home. 64                     Top staff has large degree of               inferiority among
                                                     employees are 72% female,             autonomy and job satisfaction. They         LPNs toward higher
                                                     with 53% people of color,             are responsible for supervision and         ranking staff nurses.
                                                     predominantly Black.                  personnel and financial management,        NAs experienced
                                                  48% of the staff is in the              and are most likely to view the             minimal autonomy on
                                                     nursing dept.                         nursing home as a ―business‖.               the job and had to
                                                  Enthographic research                  RNs are responsible for patient             deal with the physical
                                                     consisting of 21 months of            assessment, care planning, and              problems of the
                                                     participant observation of            supervision of lower staff.                 patients as well as
                                                     daily work patterns.                 LPNs have 1 year of vocational              the attitudes of their
                                                  Semistructured, audiotaped              training and manage the units, handle       families.
                                                     interviews with 14 residents          paperwork, assist in treatment, and        Low wages, low
                                                     and 16 staff members, and             supervise TMAs (Trained Medication          status, and poor
                                                     medical record reviews for            Aides) and NAs.                             treatment by higher-
                                                     the 14 residents who                 NAs take a 75- hour training course         level staff contributed
                                                     participated in the interview         and certification test. They are            to low job satisfaction.
                                                     process.                              responsible for the care, feeding and      Top staff did not see
                                                  Supplemented with informal              transporting of patients.                   the relationship
                                                     conversations with clientele         Nursing hierarchy was racialized,           between disciplinary
                                                     and staff.                            classed, and gendered. Top were             environment and high
                                                  Majority of staff interviewed           RNs and all white, middle staff was         turnover rates.



                                                                                8
                                                   were female, white, with an          mostly female and racially mixed,            Blamed turnover on
                                                   average age of 42.                   NAs were almost all black women.             lack of commitment
                                                 Average tenure was 4 years.          77% turnover rate of all employees           and used hierarchy
                                                                                        annually. National average for NA            and discipline in
                                                                                        ranges from 40% to 200%.                     attempts to control
                                                QE: II-3                               Top staff reported that high turnover        NAs.
                                                                                        and low retention of NAs is due to          Low retention and
                                                                                        their personal problems, pathological        high turnover are
                                                                                        family structures, and individual            direct results of poor
                                                                                        character defects. They see NAs as           management style.
                                                                                        uncommitted and irresponsible.
                                                                                       Some acknowledged that the duties
                                                                                        of the NA are unpleasant and the
                                                                                        compensation and benefits were           SR: B
                                                                                        suboptimal and probably contributed
                                                                                        to turnover rates.




Karlin, NJ, et al      To examine:                 Thirty facilities in Colorado    Or the 36 participants, 32 were white, 1   Limitations
                                                    and Massachusetts                 was black and 3 were Hispanic. Of the
                        Issues facing              consented to GNP                  34 reporting gender, 31 (91%) were            The small number of
“Issues of               geriatric nurse            participation in responding       female. Mean age was 45.1 years.               respondents may
Attraction,              practitioners              anonymously to a survey          Twenty-eight (80%) were employed in            have affected the
                         (GNPs) as primary          questionnaire.                    skilled nursing facilities.                    validity and reliability
Retention, and           care providers,                                             Fifty-eight percent had Master‘s               of these findings.
Affective States for     focusing on factors       Thirty-six GNPs responded to      Degrees, 97.2% were certified or had
Geriatric Nurse          GNPs say                   a questionnaire adapted from      some degree.                                  Future samples
Practitioners in         contribute to the          a previous form investigating    Sixty-six percent said primary care            should be larger to
Long-term Care.”         attraction and             what attracts someone to          management was their major nursing             allow for a greater
                         retention of GNPs          geriatric nursing, factors        responsibility, 13.8% served as DONs,          number of
                         in the field, the          keeping GNPs satisfied with       13.8% indicated leadership                     comparisons, and
Geriatr Nurs             overall mood of the        LTC and deterrents to             responsibilities, and 2.7% were acting         representations from
                         providers, and other       attracting nurses to LTC.         executive directors.                           a variety of work
2002; 23(6): 324-29      issues involving       ,                                    The highest mean scores for attraction         settings will further
                         these practitioners.      Questionnaire also asked;         to LTC were positive experiences with          validate findings.
                                                    number of years in current        patients and care versus cure
                          Unlike previous          position, number of years in      orientation. The next two highest
                           research, this           last position, professional       mean scores were having a position of
                           study sought to          activities, and basic             authority and role model or mentor.
                           identify results         demographic information.         The highest means scores for factors       SR: B
                           based on overall                                           that keep GNPs satisfied with LTC
                           importance and          The Profile of Moods States       were appreciation from families,



                                                                                9
                            relevance of            (POMS) was administered to          primary care responsibility, and
                            each, rather than       all participants to gauge their     appreciation from patients.
                            forcing one issue       mood. POMS consists of a           Respondent‘s number of years in
                            to become more          65-item adjective checklist,        nursing was positively associated with
                            relevant than           respondents indicate on a           appreciation from patients. More years
                            another.                scale of 0-4 (0=not at all,         in nursing, indicated a higher
                                                    4=extremely) how much a             importance placed on appreciation
                                                    particular adjective fits her       from patients.
                                                    personally. Items divided          A major deterrent to attracting clinically
                                                    into 6 subscales;                   competent nurses to LTC was lack of
                                                    tension/anxiety,                    staff.
                                                    vigor/activity,                    A correlation was suggested between
                                                    depression/dejection,               the number of professional
                                                    anger/hostility,                    conventions and a lower TMDS,
                                                    fatigue/inertia, and                indicating engaging in professional
                                                    confusion/bewilderment.             activities predicts TMDS on the POMS.
                                                    The 6 subscales calculate
                                                    the Total Mood Disturbance
                                                    Score (TMDS): high scores
                                                    indicate mood disturbance.



                                                QE: II-3




Parsons S, et al           To examine job      Survey questionnaire contained           1660 nursing assistants were mailed           Findings from this
                            satisfaction and    67 questions in a mixed format            surveys with SASE for return mailing.          study are consistent
“Determinants of            turnover among       Two sections – employee and            Response rate was 33.1% (550                   with those cited in a
satisfaction and            nursing                 work characteristics, and             surveys returned).                             literature review.
turnover among              assistants in           work issues                          70 facilities out of 259 members of           General NA
nursing assistants:         nursing homes.       First section (25 questions)            the Louisiana Nursing Home                     population is female,
The results of a           To determine            included demographic                  Association participated. 83% are              predominantly Black,
                            overall level of        information, moonlighting,            for profit, 17% non-profit.                    head of one-person
statewide survey.”
                            job satisfaction        work status and schedule,            Average facilities had 125 beds and            households, minimum
                           To identify work        employment history and                89 FTE staff.                                  wage earners with a
J Gerontol Nurs.            issues                  tenure, salary, and caring for       95.6% of those responding were                 high school education
                            associated with         other family members.                 women, 75.4% were Black. 45%                   or less.
2003 Mar; 29(3):51-5.       greatest             Second section contained a              were not married, 38.5% were                  Past studies have
                            satisfaction and        list of 35 work issues in a           married, and 16.8% were divorced or            linked age, education,
                            dissatisfaction         Likert-type format                    widowed.                                       and marital status to




                                                                              10
   To analyze the        (1=strongly disagree,                Average age was 36.9 years, 73.6%              job tenure. Less
    association           5=strongly agree). These              were high school graduates with                education and
    between               were subdivided into 5 major          67.4% planning to further their                marriage increases
    employee              categories examining                  education.                                     tenure.
    characteristics,      extrinsic and intrinsic work         90% were employed full-time, and              Inexperience, poor
    work issues,          issues such as task rewards,          50% of those participating worked              job orientation and
    turnover, and         supervision and                       day shifts.                                    training influence the
    satisfaction.         management issues, and               Length of stay on the current job              desire to leave a
                          overall satisfaction.                 ranged from 1 week to 30 years, with           position.
                        Additional section had a list of       the average 4.6 years.                        RNs who felt
                          questions and participants           16.5% were moonlighting and 46.6%              overworked and
                          were asked to identify the            were looking for an additional job.            limited career
                          most important work issue            Almost 80% had experience taking               development, poor
                          from a list of 14 issues, the         care of an older family member, and            supervision, low
                          major problem with the job,           94.9% said it was rewarding.                   recognition, feelings
                          and the major reason for             More than one half said that their             of incompetence, and
                          staying in the job.                   patients changed at least one a                low pay had higher
                        Two random samples were                month, and 52.5% said they would               turnover rates.
                          drawn from the 70                     prefer no change in their patient             Results of this study
                          participating facilities; the         population.                                    indicated that lower
                          first sample included every          29.1% planned to quit and 33.8%                overall job
                          third facility, and all NAs in        said they were looking for another job         satisfaction led to
                          all shifts; for the second            to replace the current one.                    increased turnover,
                          sample, the remaining                60.3% were either satisfied or very            and increased
                          facilities were randomly              satisfied with their jobs.                     satisfaction with work
                          selected with evening and            54% would choose the same type of              issues resulted in a
                          night shifts.                         work if starting over.                         decrease in the intent
                                                               A close relationship with their patients       to quit.
                                                                was the most important variable
                       QE: II-2                                                                            Nursing home
                                                                measuring worker satisfaction. Also
                                                                important was their affect on patients,    management should
                                                                the belief that the job was important,     consider the following to
                                                                and their own competence in                increase job satisfaction
                                                                providing care to their patients.          and reduce turnover:
                                                               Managerial and organizational work             Professional growth
                                                                issues and pay and benefits were                strategies
                                                                variables that caused the most                 Employee
                                                                dissatisfaction.                                involvement and
                                                               Almost half of those participating              participation
                                                                reported not having enough input in            Autonomy, feedback,
                                                                decision making and autonomy, and               and keeping
                                                                were dissatisfied with pay, health              employees informed
                                                                insurance, sick leave benefits, and            Supervisory training
                                                                lack of recognition and appreciation.          Employee recognition



                                                    11
                                                                                    44% said that their most important
                                                                                     work issue was their relationship with
                                                                                     patients, and that was the reason for    SR: A
                                                                                     staying on the job as reported by
                                                                                     35.2%.
                                                                                    The second most important as
                                                                                     reported by 20% was the relationship
                                                                                     with coworkers.
                                                                                    44.9% singled out pay as the major
                                                                                     problem with their job.




Pennington, K, et al   To examine the          Audio taped interviews of 12      The researchers found the overriding           The author
                       experiences and          CNAs in 6 Colorado nursing         theme of the interviews to be, ―we love        concludes,‖ The CNAs
                       explore certified        homes were conducted with          our job.‖                                      have a story to tell,
“The Role of the       nursing assistants       minimum structure, to elicit      Patterns of thought and behavior fell          and it is time for
                       (CNA) perceptions        the CNA‘s point of view.           nto 3 categories that centered on              nursing home
Certifies Nursing
                       and values.             Sample: Eleven females, 1          attributes of the CNA, working                 leadership to listen
Assistants in                                                                                                                     and learn.‖
                                                male, ages 22-61. Five             conditions, and future success of the
Nursing Homes.”                                 white non-Hispanic, 4 African      CNA and the nursing home.
                                                American, 2 Hispanic, 1           CNA attributes identified were self-       Limitation
                                                American Indian. Seven of          respect, hard worker, love for seniors,
J Nurs Adm                                      the participants were the sole     and satisfaction with job.                 The sample size of the
                                                income source for their           Working conditions found relevant to       study is too small to be
2003; 33(11): 578-82                            families. Nine worked day          the CNA‘s were involved leadership,        considered generalizable,
                                                shifts, 3 evening. Most had        teamwork, clean environment, and the       but the researchers
                                                never worked with the              need for respect.                          believe further
                                                elderly, 4 CNAs had from 5 to     Future success of CNAs and nursing         investigation would
                                                37 years experience working        homes were itemized as long-term           provide valuable insight
                                                with the elderly. All had          employment at facility, providing for      into workforce, workflow
                                                taken CNA training and             special needs of residents, screening      and work future issues
                                                examinations.                      of psychiatric admissions and careful
                                               Care provided was observed         hiring and mentoring of staff.             SR: B
                                                through a 30-minute tour of
                                                each nursing home, during
                                                which field notes were
                                                recorded depicting the CNA‘s
                                                activities.
                                               Author notes, ―Credibility and
                                                internal validity were
                                                addressed by triangulation of
                                                data with the lead author‘s



                                                                         12
                                                          experiences as a teacher.‖
                                                         Interviews and field notes
                                                          were transcribed and Atlas/Ti
                                                          software was used to
                                                          organize and code the
                                                          interviews for analysis.
                                                         Transcripts were coded using
                                                          recurring words or phrases,
                                                          then superimposed for
                                                          intrarater reliability. Codes
                                                          were grouped into categories
                                                          and domains were identified
                                                          to examine the relationship of
                                                          the codes within each family.
                                                          Observation field notes were
                                                          also coded. The author
                                                          asserts that, ―This qualitative
                                                          analysis produced several
                                                          patterns and an overriding
                                                          cultural theme.‖

                                                      QE: II-3



                                  To explore what is    Qualitative existential-       NAs experience their work in themes of         Results suggest that
Secrest J, et al.                  meaningful to CNAs     phenomenological study         family, pride, order and the stress associated increasing retention may
                                   in long-term care                                     with working in an environment fraught with relate to enhancing
 “The meaning of work              facilities and to    Purposive sample of 11 CNAs hostility, disrespect and lack of control.         experiences of:
for nursing assistants             identify their        employed in 4 LTC facilities
who stay in long-term              motivations for       willing and able to articulate  Those who stayed in their jobs felt:             belonging and family
care.”                             remaining on the      their experiences                                                                pride and control
                                   job.                                                    Sense of purpose and belonging
 Journal of Clinical Nursing                            In-depth interviews with the      Pride in work                               and by minimizing
2005; 14(8b): 90-97                                      subjects were analyzed in a                                                    experiences of:
                                                         part-to-whole dialectic within    Sense of
                                                         an interpretive research group.      control                                     hostility
                                                     QE: II-2                                                                             disrespect
                                                                                                                                          lack of control
                                                                                                                                        Recommended strategies to
                                                                                                                                        improve retention include:

                                                                                                                                     Implementing King‘s theory
                                                                                                                                     to improve congruence



                                                                                     13
                                                                                                                                 between perceptions and
                                                                                                                                 roles by:

                                                                                                                                     Involving NAs in
                                                                                                                                      decision-making

                                                                                                                                   Creating a climate of
                                                                                                                                    openness, respect and
                                                                                                                                    ongoing communication
                                                                                                                                  SR: B



Takase, M, et al         Reviews              Introduces a theoretical model       Person-environment fit theorizes that            ―The person-
                          quantitative            of the person-environment fit       there can be satisfaction and less               environment
“Nurses‟ job              nursing studies         – how an employee                   intent to leave if there is a compatible         relationship
dissatisfaction and       that measure            perceives compatibility or          relationship between personal                    occurs…nurses
turnover intention:       nurses‘ job             comfort within an                   orientation/needs and environmental              interact with their
Methodological            dissatisfaction         organization and within             characteristics.                                 environment through
myths and an              and turnover            his/her environment.               Other studies show significant                   their work…nurse and
                          intention and        Examines how the                      relationships between environmental              environment
alternative               myths that may                                                                                               (organization)
                                                  fit/congruence between              characteristics and job dissatisfaction
approach.”                prevent the             nurses and their                    or turnover intention, but more critical         measure needs
                          development of          environment affects their           are the studies view nurses as agents            against each other‘s
Nursing and Health        more qualitative        occupational behaviors.             who passively respond to their                   abilities to reinforce
Sciences                  evaluations          Correlational analysis like           environment                                      them.‖
                         Proposes a              Pearson may be used to             Job Demand-Control-Support Model                Person-environment
2005; 7: 209-17           person-                 measure employees‘ fit and          results indicate that perceived levels           fit theories allow for
                          environment fit         work behavior                       of job demands, social support, and              interventions based
                          theory instead of    Commensurate well-validated           independence to effect job                       on needs and
                          the nurse-              tools may be used to                satisfaction and have an impact on               perceptions.
                          environment             measure personal                    burnout.
                          models                  preferences and                    Studies using Index of Work
                          discussed in            environmental                       Satisfaction reveal nurses satisfied        Limitations
                          other studies.          characteristics. Examples of        with level of autonomy which was
                                                  these are: Minnesota                important to their job satisfaction but         The effectiveness of
                                                  Importance Questionnaire,           dissatisfied with their task                     the person-fit theory
                                                  Minnesota Job Description           requirements and pay.                            is undetermined.
                                                  Questionnaire, Vocational          Nurses‘ Job Satisfaction and the
                                                  Preference Inventory and            Perceived Importance Questionnaire              Studies necessary to
                                                  Self-Direction Search,              found nurses unhappy with salary                 evaluate how much
                                                  Holland‘s Theory of                 and promotion opportunities which                environmental
                                                  Personality Types and Work          ranked high in importance.                       characteristics satisfy
                                                  Environments,                      Job dissatisfaction may result from              nurses‘ professional



                                                                          14
                                                     Organizational Culture              nurses‘ perceptions of high                   and personal needs.
                                                     Profile                             environmental demands as well as
                                                                                         when the environment fails to meet        SR: A
                                                                                         their personal and professional needs
                                                                                         for growth and development.
                                                 QE: III




Tellis-Nayak, V.         To identify the root   A 2005 survey of current and       Three out of five DONs surveyed said they DONs with prior training
                         causes of DON          past DONs in Virginia yielded a    had thought seriously about quitting in the    were simultaneously more
“Who Will Care for the   turnover in LTC        40% return rate of completed       previous six months.                           satisfied and frustrated with
Caregivers?”             facilities.            surveys.                           More than half would leave immediately, if it their jobs and they were also
                                                The 103 current DON                were possible. One in five would leave long- more likely to think about
Health Progress 2005;                           respondents were females (95%)     term care altogether. One in six plan to leave quitting and plan to exit in 5
86(6): 46                                       of European American descent       the field within the next two years. More than years – especially those with
                                                (85%) and over age 40 (80%)        half said they would leave it within five      advanced degrees.
                                                                                   years.
                                                Education                                                                         Younger DONs leave, and
                                                                                   Major Sources of DON Satisfaction              the average age of DONs
                                                 no college degree (15%)                                                         rises. Better-qualified DONs
                                                 associate degree (40%)            Relationships with residents (52.4%)         seek other careers, and the
                                                 diploma nurses (21%)              Relationship with administrator (47.6%) average educational level of
                                                    associate nursing degree                                                      DONs falls.
                                                                                    Making a difference in people‘s lives
                                                    (44%)                               (47.6%)
                                                 bachelor's of nursing science     Relationship with families (41.7%)
                                                                                                                                  Among those who remain,
                                                    degrees (28%)                                                                 many will not recommend
                                                                                    Appreciation/support from                    their position to others; half
                                                 master's of nursing science           administrator (39.2%)
                                                    degrees (6%)                                                                  will quit when they can, or
                                                                                    Relationship with staff (37.9%)              will likely be gone in five
                                                                                    Relationship with peers and colleagues years.
                                                Tenure
                                                                                        (24.3%)
                                                                                    Opportunities for professional               Recommendations to
                                                 About half had been DONs for          development (21.4%)
                                                   five years or less.                                                            Enhance Retention
                                                 One in five had served as        DONs want to do more:
                                                   DON for less than a year in                                                    The author exhorts LTC
                                                   her nursing facility.                                                          owners and managers to
                                                                                      Direct care (27.2%)                        reconfigure the DON role to
                                                                                      QI (21.9%)                                 eliminate or minimize HR



                                                                              15
Professional Activities               Clinical issues (16.7%)                   and bureaucratic
                                      Family relations (8.8%)                   responsibilities.
 Half had not attended a single
   professional meeting or         DONs want to do less:                         Curricula for DONs should
   educational session in the                                                    emphasize skills needed to
   previous two years.                Staff supervision/ management (31%)       manage time and budgets
                                      HR (20.7%)                                and implement CQI.
 Over half held no membership        Documentation (14.7%)
    in any national or state          Corporate reports (10.3%)                 Peer monitoring and
    professional association;                                                    mentoring.
    28% percent belonged to        DONs are frustrated by:
    one association; and 18%                                                     Heightened visibility of the
    belonged to more than one.        Staffing problems (32.4%)                 pivotal role nurse-leaders
QE: III                                                                          play in nurturing and
                                      State survey process (15.75%)
                                                                                 sustaining a culture of
                                      LTC regulation (10.8%)
                                                                                 quality.
                                   DONs want training in:
                                                                                 Systematic identification,
                                                                                 integration, and
                                      Implementing resident-centered care       dissemination of innovative
                                        (28.8%)                                  ideas, successful models,
                                      Leading and managing (24.6%)              and best practices for DONs.
                                      Dealing with families (22%)
                                      Managing time effectively (22%)          Redesign the state survey
                                      Adopting good clinical practices (21.4%) process such that it ―affirms
                                      Dealing with staff issues (21.2%)        excellence, rewards
                                                                                achievement, mentors the
                                                                                underachievers, prods the
                                                                                mediocre, and punishes the
                                                                                chronically delinquent."

                                                                                 Develop simple, effective
                                                                                 ways to track the
                                                                                 satisfaction, turnover,
                                                                                 stability, and length of
                                                                                 service among DONs.



                                                                                 SR: B




                             16
Thompson, T., Brown,      To identify the trends    403 DONs (Director of                   Survey questions attempted to                 Top reason that
H.                          and factors that          Nursing) in SNFs in North               measure:                                       DONs stayed was
                            contribute to the         Carolina were mailed a                  1. relationship between educational            good pay/benefits,
“Turnover of licensed       turnover of licensed      cover letter, questionnaire,                level of DON and turnover of               followed by good
nurses in skilled           nurses in SNFs            and SASE to return the                      licensed nurses                            work environment,
nursing facilities.”        (skilled nursing          questionnaire.                          2. relationship between length of              and teamwork/peer
                            facilities) in North    Reminder letter was faxed 4                  time the DON had been on the               support.
Nurs Econ. 2002; 20(2):     Carolina.                 weeks later                                 job and turnover of licensed              DONs attribute high
66-69; 82.                                          3 categories of questions on                 nurses                                     turnover of licensed
                                                      the survey: demographics                3. relationship between salary of              nurses to low
                                                      of the DON, info on the                     licensed nurses and turnover               salary/benefits, poor
                                                      facility, and facility‘s staffing           rates.                                     nurse/patient ratios,
                                                      patterns including acuity               4. whether opportunities for                   scheduling conflicts,
                                                      level salaries, benefits, and               advancement and personal                   and
                                                      turnover of licensed nurses.                growth existed                             moving/relocation.
                                                                                              5. the size of the facility, profit/non-      Variables can be
                                                                                                  profit status, or urban/rural              controlled – facility
                                                                                                  location affected turnover                 owners can keep staff
                                                                                                                                             by offering better
                                                                                             83 responses out of 403 sent – 21%             salaries and benefits,
                                                                                              return rate                                    and provide more
                                                                                             Full-time RN turnover rates ranged             funding to hire more
                                                                                              from 0-250%; part-time 0-120%                  staff leading to better
                                                                                             Full-time LPN turnover rates ranged            ratios; nursing
                                                                                              from 0-150%; part-time were highest            leaders can keep staff
                                                                                              at 500%.                                       by developing a good
                                                                                             Mean turnover rate of licensed nurses          work environment, a
                                                                                              116.7%                                         supportive team
                                                                                                                                             approach, and
                                                                                             No significant relationship between            flexibility.
                                                                                              the mean turnover rate and the
                                                                                              education level or tenure of the DON.
                                                                                                                                         SR: A
                                                                                             No significant relationship between
                                                                                              the salaries of LPNs and RNs and the
                                                                                              mean turnover rate.

                                                                                             No significant relationship between
                                                                                              turnover rate and opportunity for
                                                                                              advancement, financial classification,
                                                                                              or location of the SNF.

                                                                                             Size does matter! The larger the



                                                                                   17
                                                                                 SNF, the higher the turnover rate.


                                                                             LIMITATIONS: 21% response rate is a
                                                                             statistically low representation of the
                                                                             surveyed population and may not
                                                                             accurately reflect the opinions of the
                                                                             group as a whole.


                                                                             QE: II-3




RETENTION

Table 2. A Summary of Empirical Studies of Staff Retention in Long-Term Care

        Article          Objectives              Study Design                              Main Findings                     Discussion

Anders, K.T.         To examine:          Open-ended interviews with         Subjects assert turnover rates reduced   Revamping the
                                           managers and CEOs of                by their various programs, but no        recruitment effort is
                      Strategies for      nursing homes about                 measures are presented.                  deemed an effective
“How do you bait       retaining           programs to recruit and retain                                               strategy for enhancing
the hook? Creative     employees and       employees.                                                                   retention.
Strategies for         CNAs at nursing    Settings: A 290-bed skilled
                       homes.              and sub acute facility; a chain
employee
                                           of 285 nursing home facilities;
retention.”                                a Home for Veterans; a 181-
                                           bed long term acute care
                                           hospital.                                                                    SR: C
Contemporary                              Participants: a CEO: a DON;
Longterm Care                              a Director of Education and
                                           Training; a VP.
2001; 24(3):24-8                          Programs and strategies:
                                          Recruiting from within.
                                          Promoting professional
                                           development and education.
                                          Online education through a



                                                                     18
                                               resource center.
                                              Offering a complete course in
                                               care giving specifics to CNAs
                                               that culminates in graduation
                                               with pay incentive and a new
                                               title –Caregiver I, with the
                                               opportunity to move on to
                                               Caregiver II.
                                              Teambuilding and
                                               management skills to build
                                               loyalty.
                                              CEO meets all applicants
                                               before they interview with
                                               department heads to establish
                                               rapport.
                                              Team-building exercises for
                                               new employees and in-
                                               service refreshers of all
                                               employees.
                                              Recognition programs to
                                               reward good performance.

Beck, C et al         To examine:             An experimental nursing            ―Despite an intensive organizational         Although the
                                               home (EH) and a control             change intervention at the EH, the           researchers claim to be
                       Whether an action      nursing home (CH) with              differences between the homes were           studying staff turnover,
                        research               similar characteristics             not as significant as expected.‖             no outcome in this area
―Sustaining a best-
                        organizational         including high staff turnover                                                    is mentioned, other
care practice in a      intervention           (EH, 80%-120%, CH, 43%-            ―We believe that similar attempts to         than the initial research
nursing home.‖          fostering              142%) were studied over a 4         improve the quality of care will have        question, however
                        participatory          year period.                        limited efficacy unless problems             qualitative changes
Journal for             management            Settings: Two urban nursing         endemic to the nursing home industry         such as improved
Healthcare Quality      practices would        homes considered                    are corrected.‖                              communication among
                        sustain a nursing      representative of most in US:                                                    staff at weekly
2005; 27(4):5-16.       best-care practice     privately owned for-profit, 50-    ―Participatory management sounded            management team
                        protocol in a          199 beds, nearly all white          acceptable in theory but was viewed as       meetings were
                        nursing home.          female residents.                   less acceptable in practice.‖                observed.
                                              Participants: Four groups:
                                               managers, family members,          ―No financial incentive from the             The baseline and 6 mo.
                                               residents, and all other            regulatory agencies motivates providers      measurements set forth
                                               employees.                          to rise above the standard. This             as part of the study
                                              Time period: 30-mo.                 insensitivity to differential quality must   design are not reported.
                                               organizational development          be addressed.‖
                                               phase; 8-mo. prompt-voiding
                                               (PV) training phase; 6-mo PV       ―Outcomes fell short of the researcher‘s



                                                                          19
  sustaining phase.                  expectations, but the EH made some   SR: A
                                     positive sustained changes, even
 The aim of the study was to        though the specific best-practice
  determine whether the EH,          protocol was not among them.‖
  that received an intervention
  of increased participatory
  management practices would
  sustain a best-practice
  protocol (PV) longer than the
  CH, that did not receive the
  intervention.

 Research questions: 1) was
  the staff turnover rate lower at
  the EH? 2) Did the EH
  participants have more
  positive perceptions of the
  care and work environment?



 Baseline measures and 6-mo.
  intervals included:

        Demographic data
        Personnel turnover
         rated
        Work Stressor
         Inventory (Schaefer &
         Moos, 1993)
        Nursing care survey
         (researcher developed)
        Family involvement
         scale (researcher
         developed)
        Family satisfaction
         scale (researcher
         developed)
        Resident Experience
         and Assessment of Life
         (REAL) (Urman &
         Uman, 1997)




                             20
                                                QE: II-2



D‘Eramo, A., et al                               Efforts to create a course on        Overall, learner satisfaction was high.       Conclusions are
                       To describe a             CTs for NAs are described in         An unexpected finding was none of the          tempered by the
                        course on                 a four stage-teaching model:          NAs in the sample met the criteria for         small sample size
                        complementary             planning, development,                extreme burnout. MBI scores were               and may not be
―A Program on
                        therapies (CTs)           implementation and                    seemingly unaffected by participation          generalizable to
Complementary           intended to improve       evaluation.                                                                          facilities in other
                                                                                        in the series.
Therapies for Long-     nursing assistants                                              Post training focus groups provided           geographic regions,
Term Care Nursing       (NAs) quality of life    Settings: Two VA medical              much of the lessons learned:                   but the authors are
Assistants.‖            by helping them           centers (on rural, one urban)        1) Middle-management personnel                 confident in
                        plan, develop                                                   involvement is necessary to ensure             reporting NAs find
                        implement and            Time period: NAs invited to           attendance.                                    participation in CTs
Geriatric Nursing       evaluate CTs.             participate in 5-session series      2) Administrators must describe and            valuable and
2001; 22(4) 201-201                               offered in 90-minute blocks           define each therapy when recruiting            worthwhile.
                                                  every week for 5 consecutive          participants.                                 No evidence was
                                                  weeks.                               3) Programs may be ―sold‖ as                   found to suggest
                                                                                        recruitment and retention interventions.       CTs affect NAs
                                                Participants: 5 NAs at the rural       4) A needs assessment is essential to          level of stress and
                                                site, 12 at the urban site.             decide which CTs to offer.                     burnout, though
                                                                                       5) Tai chi may be a good alternative to        they were rated
                                                Pretest-posttest design to              yoga.                                          worthwhile.
                                                measure learner satisfaction,          6) Program coordination is essential.         Authors suggest
                                                burnout and long-term effects of       7) Focus groups should inform                  future studies are
                                                training.                               decisions.                                     needed to establish
                                                                                                                                       impact such
                                                                                       8) Resources must be found to hire
                                                 Participants were asked to            quality instructors.
                                                                                                                                       courses may have
                                                  evaluate each session,                                                               on recruitment and
                                                                                       9) Optimum timing for the classes is
                                                  including 18 items with Likert-                                                      retention.
                                                                                        essential.
                                                  type response categories.
                                                                                       10) Homogeneous versus                     SR: A
                                                                                        heterogeneous groups should be
                                                 Participants completed the
                                                                                        considered (NAs only, not other LTC
                                                  Maslach Burnout Inventory
                                                                                        staff).
                                                  (MBI) at the beginning of the
                                                                                       11) Spirituality was the favored
                                                  1st session and on the last
                                                                                        session.
                                                  day after the series as well as
                                                  several months after the             12) NAs may be taught how to use
                                                  series.                               CTs with elderly patients.

                                                 A post training focus group



                                                                             21
                                                 was conducted at each site.

                                                All evaluation data was
                                                 entered into Statistical
                                                 Package for the Social
                                                 Sciences (SPSS) files.
                                                 Evaluation data were
                                                 analyzed using frequency
                                                 distributions and chi square
                                                 analysis.

                                               QE: II-1



Deutschman, M        To examine:                Two interventions:                The videotaped interviews from the           The article ends with a
                                                1) Videotaped interviews with      organizations identified as quality in       lengthy discussion and
                      Insights from two         staff discussing what              organization and culture shared these        summary of culture
                       specific                  motivates some nursing             common qualities:                            change within nursing
“Interventions to      interventions             homes to strive for quality                                                     homes. The medical
                       developed to assist       beyond deficiency-free status.   1) Generally adapt well to change by           model most are
Nurture Excellence
                       facilities to harness    Settings: Three New York         encouraging innovation and continuous          founded on has been
in the Nursing         the talents of their                                       improvement.                                   characterized as
                                                 State LTC facilities.
Home Culture.”         employees, while         Participants: administrators,    2) Clear communication of their model of       dehumanizing, creating
                       adapting to change        DONs, family members,            care.                                          dependence and
                       and building a            CNAs, residents and other        3) They find the time and resources to         powerlessness. The
Journal                culture dedicated to      stakeholders -- medical          perform what they value as important,          author offers ideas on
Gerontological         excellence.               directors, therapeutic           despite the paperwork.                         implementing changes
Nursing                                          specialists, social workers,     4) They encourage creativity and risk-         and key points in
                                                 and charge nurses.               taking.                                        developing excellence.
2001; 27(8): 37-43                              2) A workshop involving a        5) They acknowledge recruitment and            A specific example of
                                                 theatrical performance of        selection of staff members who share the       homes that have
                                                 common communication             same values is critical because they do not    reduced staff turnover
                                                 scenarios in nursing homes.      just share a written philosophy, they try to   is mentioned and the
                                                Setting: A one day workshop      live it in their daily decision-making.        high cost of an inability
                                                 held in 1997 at Buffalo State    6) They to do not appear to just ―pay lip      to retain experienced
                                                 College.                         service‖ to culture change while still         personnel is
                                                Participants: Seven nursing      perpetuating the medical model.                acknowledged.
                                                 homes participated. The          7) Leaders take an active role in
                                                 administrator, DON, a CNA,       demonstrating that all jobs are equally
                                                 and 3 other staff members        important.
                                                                                  8) All administrators and DONs were            SR: A
                                                 from each facility were asked
                                                 to attend. A facility            visible, accessible and involved with the
                                                 administrator provided data      residents.




                                                                           22
                                                 on turnover, absenteeism,
                                                 call-ins, and workers‘                  The workshop was successful based
                                                 compensation claims.                     on participant evaluations.
                                                Two scenarios, 15 minutes               Follow-up visits 4-6 weeks later at
                                                 long -- a patient care                   each facility found very few participants
                                                 conference, and an                       used the notebooks for monitoring their
                                                 interaction between a                    own behavior.
                                                 resident, her daughter and a            Some facilities implemented an action
                                                 CNA.                                     plan following the program.
                                                After each scenario the                 Three facilities applied for grant to
                                                 professional actors stayed in            integrate the theatrical performance
                                                 character while the audience             into ongoing in-service sessions.
                                                 asked questions about their             A follow-up survey was sent 1 year
                                                 behavior and discussed                   later to each participant.
                                                 values, attitudes and                    Administrators were asked for updated
                                                 communication.                           data on turnover, absenteeism, call-ins
                                                The workshop included                    and worker compensation claims.
                                                 viewing two videotapes of                There were no significant differences
                                                 excellent facilities to provide          within facilities 1 year later on any of
                                                 insight about best practices             these variables.
                                                 that any facility could                 Of the 39 participants sent surveys,
                                                 implement.                               only 14 responded, representing too
                                                The team from each facility              small a sample to make
                                                 then met to develop an action            generalizations about the program.
                                                 plan for their facility‘s specific
                                                 issues. Participants were
                                                 given a notebook in which to
                                                 document their own
                                                 productive and
                                                 counterproductive
                                                 communication work
                                                 behaviors during the next 2
                                                 weeks.

                                             QE:II-3



Ellenbecker, C.H.       To describe a        The model is derived from               Retention is defined as the extent to            Author concludes
                         theoretical model     empirical evidence of job                which nurses stay in their present jobs.          the proposed
                         of job retention      retention for home health care           Intent to stay is a nurse‘s perception of         model be used to
“A theoretical           for home health       nurses.                                  the possibility of leaving or staying the         guide research that
model of job             care nurses.         Model describes relationship             present job. Studies examining both               explores gaps in
                                               of job satisfaction and                  have found a strong relationship                  knowledge of intent
retention for home


                                                                              23
health care nurses.”     individual nurse                      between these two variables.                      to stay and
                         characteristics to intent to         Job satisfaction emerged as the                   retention among
J Advanced Nursing       stay and job satisfaction.            strongest predictor of intent to stay and         home health care
                        Proposes job satisfaction is          retention.                                        nurses.
2004; 47(3): 303-310     directly related to retention;       Job satisfaction is defined as a positive        Changes in the
                         job satisfaction and individual       affective orientation toward employment,          home health care
                         nurse characteristics are             and encompasses intrinsic and extrinsic           environment as
                         indirectly related to retention       characteristics.                                  well as the
                         through intent to stay; tenure       Intrinsic characteristics of job                  changing nature of
                         (the number of years in the           satisfaction include:                             job satisfaction
                         present job) is indirectly           autonomy and independence in patient              warrant a better
                         related to retention through          relationships                                     understanding of
                         autonomy, as an intrinsic            autonomy in the profession                        the variables that
                         characteristic of job                group cohesion with peers and                     contribute to a
                         satisfaction, and intent to stay      physicians                                        nurse‘s decision to
                         is directly related to retention.    organizational characteristics.                   stay or leave a job.
                        Each component of the                These characteristics are directly related
                         model: retention; job                 to intent to stay and retention and
                         satisfaction (intrinsic and           indirectly related to retention through       SR: B
                         extrinsic characteristics); and       intent to stay.
                         individual nurse                     Extrinsic characteristics of job
                         characteristics, is defined and       satisfaction include:
                         examined in the context of the
                                                              stress and work load
                         home health nursing and
                                                              autonomy and control of work hours
                         relevant literature.
                                                              autonomy and control of work activities
                                                              salary and benefits
                       QE: III                                perception of and real opportunities for
                                                               jobs elsewhere.
                                                              Extrinsic characteristics have been less
                                                               investigated, than intrinsic
                                                               characteristics, but evidence suggests
                                                               they are important in understanding
                                                               nurses‘ intent to stay in their present
                                                               jobs.
                                                              Individual nurse characteristics studies
                                                               in relation to intent to stay and
                                                               retentions include age, tenure, family
                                                               income, marital status, race, job
                                                               position, kinship relationship and
                                                               gender. Although there is strong
                                                               evidence these characteristics influence
                                                               intent to stay and retention, that which is
                                                               known comes from investigations of
                                                               nurses in hospital settings. No studies



                                                     24
                                                                                              have looked at the home health care
                                                                                              setting.



Flesner MK, Rantz MJ.     To present Person          PCC aims to enable residents to      The authors report that turnover is no longer a The authors posit that the
                          Centered Care (PCC), a live as autonomously as possible. problem ―in a Missouri county that has low             transition from
 “Mutual Empowerment model of management Its tenets are:                                  unemployment‖ and attribute this to             conventional institutional
and Respect: Effect on practices implemented                                                                                              model to a ―responsive,
Nursing home quality” in a Missouri LTC                A philosophical shift from          Workers‘ satisfying relationships with       resident-centered
                          facility.                     emphasis on physical care to         residents                                    homelike approach‖
J Nurs Care Qual 2004; 19                               emphasis on helping residents                                                     benefits residents and
                                                                                            An environment that emphasizes
(3): 193-6.                This anecdotal report        live satisfying lives                                                             workers.
                                                                                             domesticity and normality and fosters
                          states that PCC
                                                       Creation of individualized living    autonomy for residents and staff
                          demonstrated not only                                                                                           SR:B
                                                        spaces
                          to enhance the quality of                                         Workers are empowered to participate in
                          care and quality of life in  Empowering staff to serve as         organizational and clinical decision making
                          the LTC setting but also      advocates for residents
                                                                                            Workers have authority to determine how
                          to reduce turnover and  Respect for residents‘ life-long          best to meet residents‘ needs
                          operating costs.              routines, preferences and needs
                                                       Creating opportunities for
                                                        residents to experience
                                                        personal growth and a sense of
                                                        contribution
                                                       Fostering continuing
                                                        connections to the community-
                                                        at-large


                                                     QE: III



 Hegeman, C.                 To examine:                GSR is a 5 part peer-              FLTC researchers found nursing homes           The GSR program has
                                                         mentoring program including:        that implemented the program had a             generated positive
                              A CNA mentoring         1) Training materials that tell       statistically significant improvement in       responses from the
 “Turnover                     program, ―Growing       managers how to operate the           retention, while a control group did not.      LTC centers that have
 Turnaround.”                  Strong Roots,‖          project.                             Retention was defined as the                   participated and is
                               (GSR) developed         2) A one-hour workshop for            percentage of CNAs hired at the                deemed a critical tool in
                               by the Foundation       supervisors, to ensure their          beginning of the project and remained at       the struggle to maintain
                               for Long Term Care      support.                              the facility at the time of data collection.   a qualified and caring
 Health Progress               (FLTC), Albany NY,      3) Six hours of mentor training.     Average retention rate in the GSR group        LTC workforce.
                               a non-profit            4) Three to nine hours of             3 months after implementation was
 2005; 86(6):25-30



                                                                                    25
research and          booster training for mentors.           84%, up 25% from 59% prior to the
education entity      5) A newsletter for mentors, to         program.
affiliated with the   help them maintain interest in        In the same 3-month period the control        SR: A
New York              the project.                            group retention rate increased from 38%
Association of                                                percent to 48%, a 10% increase in
Homes and              Program Basics:                       retention.
Services for the      1) Person assigned to                 Data on longer periods was inconclusive
Aging.                coordinate the program in the           due to problems with data collection.
                      LTC center participates in 3          FTLC is currently gathering data on
                      hours of orientation with facility      GSR implementation at 22 additional
                      administrators.                         LTC centers, more longitudinal findings
                      2) Each nursing home selects            will be made available when the study is
                      its own mentors.                        completed in fall 2006.
                      3) Mentoring takes place after        The cost to the employer of CNA
                      the CNA certification is                mentoring includes:
                      complete to supplement the           1) Hiring professional trainers
                      usual training of new CNAs.          2) Mentor preparation costs including a full
                      4) RN supervisors are oriented       day of paid time during training and a half-
                      to the project so they know CNA      day of paid time during booster sessions (1-
                      mentoring is important in            3 recommended).
                      building a better CNA workforce,     3) Mentor compensation through a
                      even though it takes CNAs            temporary or permanent salary increase,
                      away from their units.               honorarium or some other incentive.
                      5) Mentors do not teach or re-
                      teach clinical skills, those         4) Most significant costs are for ―backfill,‘
                      remain the responsibility of the     arranging for someone to perform a
                      in-service educator.                 mentor‘s duties when he or she is in
                      6) Each mentor-mentee team           training or working with a mentee.
                      maintains an active relationship
                      for 4 or more weeks.                     The cost of the GSR program is
                         A typical schedule for the            estimated to be $4000, if the CNA is
                        GSR program is:                         trained but then quickly leaves.
                         Day One: The mentee                  This figure is used to calculate the
                        ―shadows‖ the experienced,              cost savings the program will produce
                        CNA mentor, observing and               by increased retention and suggests
                        asking questions. Mentor                the program will pay for itself or
                        emphasizes delivering warm              provide some savings.
                        compassionate care, good time
                        management, handling of
                        inherent frustrations of the job
                        and introduces mentee to other
                        staff members.
                         Days 2-5: The mentee begins
                        to take care of residents, with




                                                   26
                                                 mentor assisting and modeling
                                                 good care.
                                                  Weeks 3-4: The time the
                                                 mentor spends with the mentee
                                                 decreases incrementally, so by
                                                 week 4 the time is down to one
                                                 hr/wk, and that hour is focused
                                                 on helping the mentee adjust to
                                                 the work environment and
                                                 search out answers to care
                                                 questions.

                                                  FTLC researchers conducted
                                                 evaluations on GSR over a 3-
                                                 month period using a control
                                                 group.



                                               QE: II-1




Izzo J.               To offer LTC facilities The strategies presented             Strategies to increase staff retention:    The retention
                      strategies for           appear to be based on the                                                      strategies advocated
                      retaining quality staff. cumulative experience of the          Encourage work-life balance – the       have been
“Finders keepers: Six                          author, a consultant to                author cites turnover reductions by as demonstrated as
secrets to attracting                          businesses about employee              much as 50% following the               effective in the relevant
and retaining great                            retention and organizational           introduction of social supports in the  literature.
employees”                                     leadership.                            form of benefits such as dependent
                                                                                      care leave, childcare subsidies,
                                              QE: III                                 eldercare programs and flexible work
Contemp Longterm                                                                      hours
Care 2002;25 (10): 46                                                                                                        SR:A
                                                                                     Promote the higher purpose of the
                                                                                      work the LTC facility performs and its
                                                                                      benefits to individuals and society.
                                                                                     Foster personal growth and
                                                                                      development by instituting regular
                                                                                      conversations with workers about their
                                                                                      personal and career goals.



                                                                           27
                                                                              Create opportunities for staff to learn
                                                                               new job skills and life skills (e.g., help
                                                                               obtaining GED, career development
                                                                               programs)
                                                                              Treat employees as partners to
                                                                               enhance engagement. Involve them in
                                                                               decision making and hiring decisions
                                                                               and encourage autonomy.
                                                                              Foster a sense of community by
                                                                               getting to know employees personally.
                                                                               One facility has managers take new
                                                                               employees out to dinner in order to get
                                                                               to know them personally.
                                                                              Build trust using straightforward
                                                                               communication, accept criticism and
                                                                               hold all workers accountable to
                                                                               organizational values.



Lescoe-Long, M          To gain insight     Interview Q & A format with       Job satisfaction and intrinsic rewards         Nursing homes –
                         into how a study       Co-Principal Investigator.       of the work critical to success.                structured,
“Why they leave: a       sponsored by the                                       Keys to increased retention: Evaluation         bureaucratic
new approach to          KAHSA (Kansas                                           of recruitment goals,                           medical caregiving
staff retention.”        Association of                                         new hire orientation programs                   organizations
                         Homes and                                               mentoring programs                              instead of
                         Services for the                                       more communication and shared                   communities for
                         Aging) relates                                          decision making                                 residents. Primary
Nursing Homes Long       human behavior                                         career ladders                                  vision is in conflict
Term Care                to nursing home                                        training and constructive feedback              with the structure of
Management               staff retention                                         from supervisors                                the work.
2000;49(10):71-75        patterns.          QE: III                                                                         .
                                                                                 Early turnover (leave within the first 90      ―Community‖
                                                                                 days of employment).of NAs                      concept in a
                                                                                 associated with:                                nursing home
                                                                                         inadequate job preparation             revolves around the
                                                                                          and inability to manage OTJ            well-being of
                                                                                          situations                             residents.
                                                                                         organizational bureaucracy            Lack of
                                                                                          cuts aides out of the power            understanding of
                                                                                          structure and they feel they           different roles



                                                                        28
             are undervalued.                       causes job
            individual‘s need for extrinsic        dissatisfaction
             rewards (e.g., higher pay).             Feeling of
            too many supervisors,                  powerlessness by
            treated as servants by                 aides leads to
             management, residents and              reduction in
             residents‘ families.                   efficient
                                                    productivity, but
     NA retention associated with:                  may be viewed by
            maturity and more education            supervisors as
            more experience with                   laziness.
             dependent individuals                  Interpersonal skill
            Desire for ―family-type‖               development
             atmosphere with personal               needed to identify
             attachment                             and resolve anger
                                                    and conflict.
        KAHSA study found that pay
         structure for frontline employees is      Focus on changing
         very low – work is intrinsically           organizational and
         rewarding but needs reasonable             job-related policies
         compensation.                              does not guarantee
                                                    that employees will
                                                    adapt to the
                                                    changes. Human
                                                    perception of
                                                    valuable,
                                                    appropriate, and
                                                    justifiable behavior
                                                    must be
                                                    considered.



                                                SR: A




29
Martin, CA            To examine:             Recommends nursing managers               Author cites:                               Author believes
                                              assume the roles of Chief                 The number one reason people leave           embracing the
                       Review of best        Retention Officers by:                     organizations is the number one              rigors of becoming
“Turn on the            practices for nurse                                              reason they stay: the relationship           a Chief Retention
                        managers aiming to       Beginning retention planning on        they have with their immediate               Officer will end
staying power.”
                        improve recruitment       day one by making it part of           manager.                                     recruitment worries
                        and retention.            every new-hire orientation and        First year nurses begin to think about       and will bring the
                                                  holding formal orientation             leaving 180 days into their job and          people, ―knocking
Nurs Manage                                       retention conversations every          half of them do after the first year.        down the door of
2004; 35(3); 21-26,                               2-3 months. Conversations             Most people use only 20-25% of their         your department
27 quiz.                                          should ask what attracted the          talents and skills at work.                  scrambling to get
                                                  new-hires to the organization         American Hospital Association                in.‖
                                                  and what will keep them                strongly recommends health care
                                                  engaged, motivated, and                redesign ‗the role of front-line
                                                  productive. The conversations          supervisors so that they‘re on-site
                                                  should identify the issues most        and have the time to effectively
                                                  important to workers‘                  coach, mentor, reward, assess            SR: A
                                                  willingness to stay in the             performance, and hold individual
                                                  position should as well as             accountable for results.‖
                                                  concerns that would prompt
                                                  them to leave. Retention
                                                  conferences should be
                                                  documented to facilitate
                                                  tracking responses.
                                               Maximizing staff knowledge,
                                                  experience, and skills by
                                                  holding team meetings to ask
                                                  participants which tasks they‘d
                                                  like to spend more time doing
                                                  and which talents or skills they
                                                  are not using that would benefit
                                                  the team. This process aims to
                                                  encourage individuals to
                                                  maximize their strengths and
                                                  create a job that is a
                                                  customized professional
                                                  opportunity.
                                               Becoming coaching-style
                                                  manager using these
                                                  techniques:
                                              1) Hold workers accountable to
                                              high performance standards,



                                                                           30
                                                       creating a culture of excellence.
                                                       Schedule 10-minute meetings with
                                                       each team member 2-3 times a
                                                       week to provide coaching on goal
                                                       setting, deadline, performance
                                                       standards, etc. Keep written
                                                       contemporaneous records for each
                                                       person.
                                                       2) Follow up with clear, honest,
                                                       balanced feedback. Make coaching
                                                       part of every feedback discussion.
                                                       3) Customize incentives and use
                                                       them to drive high performance.
                                                       Find out what you can offer and
                                                       listen to team members to find out
                                                       is important to them, recognizing
                                                       that what motivates them this
                                                       month may not next month and that
                                                       ongoing negotiations are necessary
                                                       to drive high performance.




                                                       QE: III



Riggs CJ, Rantz MJ.      To present a paradigm of     Model development was based on a Factors influencing staff reduction included: The proposed model
                         staff support in nursing     comprehensive review of research                                                       advocates strengthening
“A Model of Staff        homes that views the         literature describing:                   Organizational Characteristics                workplace supports to
Support to Improve       nursing home as a social                                                                                            help staff fulfill their work
Retention in Long-       system consisting of long-      Staff retention                        Open, flexible organizational structures and social obligations.
Term Care”               term care consumers and                                                  that foster shared participation in        Examples of such support
                                                         Social exchange theory, which
                         employees.                                                               decision making                            include:
                                                           posits reciprocity of interpersonal
Nursing Administration
                                                           relationships                         Equity in implementation of human
Quarterly 2001;19 (4)                                                                                                                          Flexible scheduling
                                                                                                  resource policies
                                                         King‘s dynamic interacting
                                                                                                                                               Child care assistance
                                                           systems                               Access to formal and informal support
                                                                                                  systems; training in problem-solving skills  Affordable health care
                                                      Staff retention was conceptualized as  Effective supervision, interpersonal               benefits
                                                      a function of the intersection between      relationships, mentoring, accurate           Shared development of
                                                      sets of economic, organizational,           assessment of employee values and              policies and standards



                                                                                     31
                                               work role, and individual worker         attitudes                                       to help achieve
                                               factors.                                                                                 organizational
                                                                                     Open communication
                                               QE: III                                                                                  objectives
                                                                                   Job Characteristics
                                                                                                                                    Flexible and non-
                                                                                                                                     punitive approach to
                                                                                     Completing a task in its entirety
                                                                                                                                     errors
                                                                                     The impact of the job on others
                                                                                     Performing activities that require different It also emphasizes the
                                                                                      aptitudes                                    importance of respectful
                                                                                                                                   communication and
                                                                                   Individual Characteristics                      openly valuing workers‘
                                                                                                                                   contributions.
                                                                                     Positive attitude toward older adults
                                                                                                                                   SR: B
                                                                                     Value care giving
                                                                                     Have adequate social support




Rudolph, G               To present a           Author interviewed CNAs and            In order to keep good employees           ―The 10
                          summary of ways          RNs from hospitals, agency             happy and committed to their jobs,        Commandments of
“How you gonna            to reduce employee       and home health care staff,            employers should respond to their         Retaining Staff‖
keep „em down on          turnover in the          prison workers, and overnight          needs, respect their dignity, and give
the farm?”                nursing industry.        nannies.                               them a sense of autonomy.                      Respect
                                                                                         Main reason for employment stability            employees
                                                                                          is proximity to homes and children.            Honor differences
Contemporary                                                                             A family-oriented facility was                 Never lie
Longterm Care 2001;                             QE: III                                   important so staff could bring their           Be fair in giving
24(1) 43-44                                                                               children to work during emergencies.            honest wages
                                                                                         A primary care system where staff              Give bonuses to
                                                                                          members get to know their patients              recognize good
                                                                                          encourages staff retention.                     performance
                                                                                         Unit managers with a sense of humor            Encourage a sense
                                                                                          who respect their staff and recognize           of community
                                                                                          their worth help reduce turnover.              Offer more benefits
                                                                                         Employees respond to managers who               for time accrued
                                                                                          listen and are responsive to their             Make an example
                                                                                          concerns.                                       of good behavior
                                                                                                                                          and employee
                                                                                                                                          loyalty
                                                                                                                                         Encourage staff
                                                                                                                                          autonomy



                                                                             32
                                                                                                                                 Listen and respond
                                                                                                                                  to employee
                                                                                                                                  concerns




                                                                                                                              SR: B



Weitzel, T et al.   To examine:                The Functional Model of Elder      Positive patient outcomes, including      When implementing the
                                                Care (FMEC) was developed by        decreased length of stay and fewer        model the nursing
                     A functional model of     CNAs with guidance from the         patients discharged to nursing homes.     administration found the
“Satisfaction and     care for hospitalized     Professionals Improving Care to    CNA turnover was reduced from 175%        CNAs were not
Retention of          elders focused on         Hospitalized Elders (PICHE)         in 2000 to 50% in 2001 and 37%in          changing their practices
                      improving nutrition       coordinator and the                 2002.                                     after attending the
CNAs Working
                      and toileting and         gerontological clinical nurse      A CNA satisfaction survey was             training sessions
Within a              promoting mobility.       specialist.                                                                   because most of their
                                                                                    developed in which CNAs rated
Functional Model                               Setting: Developed at a 37-bed      satisfaction with the new model of care   time was consumed
of Elder Care.”      Whether                   medical unit.                       on a 5-point Likert scale. Overall        with bathing and bed
                      implementation of the    Participants: CNAs, patients,       satisfaction score was 1.47.              making on a daily basis,
                      model improved            nursing administration.            Reduction of time CNAs spend in           leaving little time for
Holistic Nursing      CNAs satisfaction and    Education: CNAs attended 4          activities of bathing and bed making,     feeding, toileting,
Practice 2004;        reduced employee          (4hr) sessions on geriatric         allows them to devote more attention      turning, providing skin
18(6):309-312         turnover.                 syndromes.                          to activities that help the patients      care, or promoting
                                               Time period: No time period is      maintain functional status.               mobility.
                                                specified. There is a reference
                                                to CNA turnover statistics for                                                Most nursing staff are
                                                2000, 2001 and 2003.                                                          taught that daily bathing
                                               Study population: Elderly                                                     and bed making is
                                                patients and CNAs caring for                                                  fundamental to good
                                                them.                                                                         nursing care, but this
                                               The FMEC was practiced with                                                   model advocates
                                                these changes in daily patient                                                bathing and bed making
                                                care:                                                                         on an every other day
                                                                                                                              basis as a way of
                                               Complete bed bath and bed
                                                                                                                              freeing time CNAs can
                                                changes every other day
                                                                                                                              then use to help
                                                instead of everyday (unless
                                                                                                                              patients maintain
                                                patient is soiled or requests
                                                                                                                              functional status and
                                                additional bathing).
                                                                                                                              therefore improving job
                                               Routine vital signs taken at
                                                                                                                              satisfaction amongst
                                                alternate hours rather than
                                                                                                                              CNAs.



                                                                        33
                                                       traditional hours to avoid sleep
                                                       disruptions at night.                                                          The authors conclude
                                                      Increased patient activity.                                                    the model has been
                                                      Improving nutrition and                                                        shown to be effective on
                                                       hydration.                                                                     a medical unit of a 500-
                                                      Maintaining skin integrity.                                                    bed tertiary hospital, but
                                                      Promoting continence.                                                          this is the first mention
                                                      Promoting sleep and rest.                                                      of the size of the
                                                                                                                                      hospital other than the
                                                                                                                                      model being developed
                                                   QE: II-3                                                                           at a 37-bed medical
                                                                                                                                      unit.


                                                                                                                                      SR: B


                                                                                                                                      .
Zinn, L                   To implement job         Achieve – a job-retention               A 50% reduction in turnover of entry-      Achieve places
                           retention programs         program developed by                    level staff at the 5 pilot program          advisers onsite in
                           for entry-level            Towards Employment, a non-              locations.                                  long-term care
“Tackling staff            employees in long-         profit organization in Ohio, was       To broaden its service market and           facilities to assist
turnover: A novel          term care settings         developed to assist low-wage,           utilize more evaluation techniques in       employees with
approach.”                 that focus on              entry-level workers to stay on          2002 Achieve joined the ERA                 practical issues as
                           personal success           the job.                                (Employment, Retention and                  well as providing
                           and skill building to     Pairs new hires with social             Advancement) demonstration project          job skills.
Nursing Homes Long         reduce                     workers (Achieve Advisors)              funded by the Dept. of Health &            Motivational
Term Care                  absenteeism and            available onsite and by                 Human Services – a national study of        programs such as
Management, vol. 53,       employee turnover.         telephone 24/7.                         programs designed to help low-wage          ―Lunch & Learn‖
no.3                                                11 long-term care facilities, both       workers maintain and advance in the         provide workers
                                                      nonprofit and for-profit in Ohio        labor market.                               with certificates of
50-57, March 2004                                     are in the program.                    The DHHS Achieve study is looking           recognition and
                                                    Achieve Advisers conduct                 at 22 nursing homes randomly                prizes for
                                                      ―lunch and learn‖ sessions              assigned to either participate or act       attendance.
                                                      every other week to teach core          as controls. Preliminary data shows        Supervisors are
                                                      competency skills.                      retention rates for program                 trained in conflict
                                                    Achieve Advisers offer training          participants average 96% after 30           resolution and open
                                                      to supervisors on how to deal           days of employment, 87% after 60            communication
                                                      with entry-level staff.                 days, and 82% after 90 days.               Challenges to the
                                                     Achieve Advisers provide                                                            success of the
                                                      supportive services to new                                                          program included
                                                      hires such as assistance with                                                       offering services
                                                      childcare, transportation,                                                          and sessions to
                                                      uniforms, starting a GED                                                            multiple shift



                                                                                  34
                                                  program and repairing their                                                    schedules and
                                                  credit.                                                                        working around
                                                Achieve helps employees to                                                      resident needs.
                                                  develop short and long-term                                                   Achieve marketed
                                                  career plans so they are                                                       its services as a
                                                  motivated to stay on the job.                                                  benefit to prevent
                                                  QE:II-3                                                                        negative
                                                                                                                                 perceptions about
                                                                                                                                 program
                                                                                                                                 participation and
                                                                                                                                 provides
                                                                                                                                 information and
                                                                                                                                 print materials at
                                                                                                                                 new-employee
                                                                                                                                 orientations.

                                                                                                                                 SR: A




The U.S. Preventive Services Rating Scheme assesses the quality of evidence in research studies. The QE rating is based on experimental
design and overall quality. Randomized controlled trials received the highest ratings (QE = I), while other well-designed studies received a lower
score (QE = II-1, II-2, or II-3). The QE rating is based on the quality, consistency, reproducibility and relevance of the studies. Information about
harmful effects also must be presented.

The strength of recommendation is summarized on a rating scale (A to E) that characterizes the total scientific literature available to address the
topic. The SR rating is influenced primarily by the science. Other factors considered when making a SR determination are the burden of suffering,
cost issues and policy concerns.

QE = quality of evidence
SR = strength of recommendation




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