The One-Two Punch of High Wages and Empowerment on CNA Retention

Understanding Multilevel Factors Related to Retention Among the Direct Care Workforce: Incorporating Lessons Learned in Considering Innovative Interventions

GOAL

This article explores how broad, contextual factors may be influential in the retention of direct care workers (DCWs; i.e., entry-level caregivers) who provide vital support to patients in healthcare settings. We reflect on lessons learned from an evaluation of a multisite intervention to improve retention among DCWs employed primarily in hospital settings at three health systems.

METHODS

We evaluated a multitiered program for entry-level caregivers that included a risk assessment, a 4-day curriculum, and follow-up sessions, as well as workforce coaching at the three health systems. As part of our evaluation, we collected data on roughly 3,000 DCWs from the three health systems; the information included hiring date, any transfer date, and any termination date for each new DCW, as well as demographic information, position characteristics, and termination status and reasons for any termination. In addition, we collected information about organizational characteristics, including staffing and number of employees. We also conducted interviews with 56 DCWs and 21 staff members who implemented a retention program across each of the three health systems and remotely conducted virtual observations of the curriculum sessions at each system.

PRINCIPAL FINDINGS

Although the program we evaluated focused on individual-level factors that may affect retention, our findings revealed other broader, contextual challenges faced by DCWs that they said would have an impact on their willingness to stay in their positions. These challenges included (1) job-related factors including limited compensation, aspects of the job itself, and the inability to advance in one's position; (2) health system challenges including the mission, policies, staffing, and organizational culture; and (3) external factors including federal policies and the ongoing COVID-19 pandemic.

PRACTICAL APPLICATIONS

As the direct care workforce continues to grow, interventions to improve retention should consider the interconnectedness of these multilevel factors rather than solely individual-level factors. In addition, further research is needed to rigorously evaluate any potential intervention and consider how such an approach can target DCWs in hospital-based settings who are most affected by the multilevel challenges identified. Finally, any intervention to improve retention must be also aligned to ensure equity, especially in this population of low-wage DCWs, many of whom are marginalized women and individuals of color.

Contextual Forces Shaping Home-Based Health Care Services Between 2010 and 2020: Insights From the Social-Ecological Model and Organizational Theory

Demands for home-based care have surged alongside population aging, preferences for aging in place, policy-driven reforms incentivizing lower hospital utilization, and public concerns around coronavirus disease 2019 transmissions in institutional care settings. However, at both macro and micro levels, sociopolitical, and infrastructural contexts are not aligned with the operational needs of home health care organizations, presenting obstacles to home health care equity. We integrate the social-ecological model and organizational theory to highlight contextual forces shaping the delivery of home-based care services between 2010 and 2020. Placing home-based health care organizations at the center of observation, we discuss patterns and trends of service delivery as systematic organizational behaviors reflecting the organizations' adaptations and responses to their surrounding forces. In this light, we consider the implications of provision and access to home care services for health equity, discuss topics that are understudied, and provide recommendations for home-based health care organizations to advance home health care equity. The article represents a synthesis of recent literature and our research and industry experiences.

Growth of Private Pay Senior Housing Communities in Metropolitan Statistical Areas in the United States: 2015-2019

Older adults needing assistance with activities of daily living can receive support in various settings. Senior housing communities, such as independent living, assisted living, and continuing care retirement communities, are an increasingly popular option for adults not requiring nursing home-level care. However, limited research exists due to a dearth of data on these types of communities. We use a proprietary data set to describe the market of private pay senior housing and community-level characteristics in 140 metropolitan statistical areas, from 2015 to 2019. Although the number of senior housing communities increased substantially, the supply of senior housing options supporting the continuum of care has not necessarily kept up with population growth. Describing the supply of senior housing communities across the spectrum of levels of care provides a more complete description of the formal noninstitutional long-term care supply among the 140 most populated metropolitan statistical areas.

Does Higher Worker Retention Buffer Against Consumer Complaints? Evidence From Ohio Nursing Homes

BACKGROUND AND OBJECTIVES

This study examined the relationship between nursing home (NH) quality using consumer complaints and certified nursing assistant (CNA) annual retention rates among Ohio freestanding NHs (n = 691).

RESEARCH DESIGN AND METHODS

Core variables came from the 2017 Ohio Biennial Survey of Long-term Care Facilities and Centers for Medicare and Medicaid Services Automated Survey Processing Environment Complaints/Incidents Tracking System. To compare NHs, 4 quartiles of CNA retention rates were created: low (0%-48%), medium (49%-60%), high (61%-72%), and very high retention (73%-100%). Negative binomial regressions were estimated on total, substantiated, and unsubstantiated allegations and complaints. All regressions controlled for facility and county-level factors and clustered facilities by county.

RESULTS

NHs in the top 50% (high and very high) of retention received 1.92 fewer allegations than those in the bottom 50%, representing a 19% difference; this trend was significant and negative across all outcomes. Using quartiles revealed a nonlinear pattern: high-retention NHs received the fewest number of allegations and complaints. The differences between high and low retention on allegations, substantiated, and unsubstantied allegations were 33% (3.73 fewer), 34% (0.51 fewer), and 32% (3.12 fewer), respectively. Unexpectedly, very high-retention NHs received more unsubstantiated allegations than high-retention NHs.

DISCUSSION AND IMPLICATIONS

While higher-retention should result in fewer complaints, our results indicate that some turnover may be desirable because the very high-retention NHs performed slightly worse than those with high retention. Among the remaining facilities, fewer complaints may be achieved by improving CNA retention through higher wages, career advancement, and better training.

The Effect of Nurse Aide Retention on Ohio's Nursing Home Resident Care Experience Scores: A Facility-Level Analysis

This study examined whether certified nurse aide (CNA) retention was positively related to nursing home (NH) resident care experiences at the organizational-level. The 2017 Ohio Biennial Survey of Long-Term Care Facilities and the 2017 Ohio Nursing Home Resident Satisfaction Survey provided the key variables. Quartiles of CNA retention (0-48%, 49-60%, 61-72%, 73-100%) were created from the analysis sample (N = 667). Regression analyses clustered NHs within counties and controlled for structural characteristics, financial resources, empowered managers, resilience, quality of work-life, resident, and community characteristics. NHs in Quartile 3 of CNA retention had higher environment scores by 1.36 percentage points compared to Quartile 1 (p < .05). NHs in Quartile 4 had lower facility culture scores by 1.31 percentage points than NHs in Quartiles 1-3 (p < .05); this pattern repeated when Quartiles 3 and 4 were compared on other outcomes. Future research should explore NHs with very high CNA retention to improve understanding of the measure.

In Their Own Words: The Challenges Experienced by Certified Nursing Assistants and Administrators During the COVID-19 Pandemic

This qualitative study aimed to provide an in-depth understanding of the challenges experienced by certified nursing assistants and administrators during the unprecedented COVID-19 crisis. We conducted 6 administrator interviews and 10 remote focus groups with day and evening CNAs at 5 nursing homes (N = 56) in downstate New York. Content analysis was conducted, and emerging themes were identified across sites and roles. Results showed numerous challenges for both CNAs and administrators including many that were personal. These personal challenges included feeling helpless, anxious, or fearful; experience of COVID illness; and balancing high concurrent demands of work and family. There were also many operational challenges such as a lack of COVID testing capacity, information, and consistent guidance and support, staffing and equipment. Understanding these challenges can facilitate goals to promote future safety, skill refinement, and enhanced resilience in the workforce.

Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic

Objective

To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID‐19.

Study setting

Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020.

Study design

Semi‐structured interviews and focus groups exploring staffing challenges during COVID‐19, strategies used to address them, and recommendations moving forward.

Data collection

We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles.

Principal findings

CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work–life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place.

Conclusions

Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy‐level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person‐centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID‐related innovations (self‐managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry‐wide structural practices that target CNA recruitment and retention.

Association between wages and nursing staff turnover in Iowa nursing homes

Background and Objectives

Nursing staff turnover is a substantial concern for nursing homes that care for millions of older individuals, especially during the COVID-19 pandemic. Low pay is considered as one of the key reasons for high turnover. However, we do not know whether increasing wages can lead to lower turnover. In this study, we fill this gap in our understanding by analyzing the relationship between wages and nursing staff turnover.

Research Design and Methods

We obtained data on hourly wages (Medicare Cost Reports), turnover (Iowa Department of Human Services), and nursing home and resident characteristics (Nursing Home Compare and LTCFocus) from 2013 to 2017. We summarized the characteristics of nursing homes as well as turnover trends over time. Next, we used pooled OLS and facility fixed effects regressions to examine the relationship between wages and turnover adjusting for nursing home and resident characteristics.

Results

Among the 396 nursing homes in Iowa, average hourly wage was $27.0 for registered nurse (RNs), $21.6 for licensed practical nurses (LPNs), and $14.1 for certified nurse aides (CNAs) during 2013 to 2017. Average turnover rates were increasing over time for all staff types and in 2017, turnover rates were 46.0% for RNs, 44.4% for LPNs, and 64.7% for CNAs. In both pooled OLS and facility fixed effects regressions, higher wages were associated with lower turnover of CNAs but not LPNs or RNs. The magnitude of the effect of wages on turnover for CNAs was lower in facility fixed effects regressions.

Discussion and Implications

We found significant relationship between hourly wages and turnover for CNAs but not for LPNs or RNs. Focusing on higher wages alone may not lead to lower turnover of all types of nursing staff in nursing homes. We should also focus on non-wage factors related to turnover.

Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports

Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.