Turnover Retention

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









35