Retention of Community Health Workers in the Public Health Workforce: Public Health Workforce Interests and Needs Survey, 2017 and 2021

Objectives. To investigate the organizational factors contributing to the intent of community health workers (CHWs) to quit their jobs in local and state health departments in the United States. Methods. We used the 2017 (n = 844) and 2021 (n = 1014) Public Health Workforce Interests and Needs Survey data sets to predict CHWs' intent to leave with Stata 17 balanced repeated replication survey estimations. Results. CHWs dissatisfied with organizational support, pay, or job security had high probabilities of reporting an intent to leave (50%, P < .01; 39%, P < .01; and 42%, P < .01, respectively) relative to satisfied or neutral workers (24%, P < .01; 21%, P < .01; and 26%, P < .01, respectively). Conclusions. Improving organizational support, pay satisfaction, and job security satisfaction in public health agencies can significantly improve CHW retention, potentially lowering overall organizational costs, enhancing organizational morale, and promoting community health. Public Health Implications. Our findings shed light on actionable ways to improve CHW retention, including assessing training needs; prioritizing diversity, equity, and inclusion; and improving communication between management and workers. (Am J Public Health. 2024;114(1):44-47. https://doi.org/10.2105/AJPH.2023.307462).

Tracking Turnover Among Health Care Workers During the COVID-19 Pandemic

Question

Which health care workers were at highest risk of leaving the workforce during the COVID-19 pandemic compared with prepandemic levels?

Findings

This observational cross-sectional study among 125 717 health care workers found that long-term care workers and physicians saw an upward trend in turnover rates. Health care workers employed as health aides and assistants, those of historically marginalized racial and ethnic groups, and those with young children, particularly women, had persistently high turnover rates and were experiencing a slow recovery.

Meaning

These findings suggest that turnover rates are returning to prepandemic levels across most groups of health care workers, yet the recovery is uneven; targeted solutions are needed to ensure an adequate health care workforce is available to meet patient demand.

Importance

The health care sector lost millions of workers during the COVID-19 pandemic and job recovery has been slow, particularly in long-term care.

Objective

To identify which health care workers were at highest risk of exiting the health care workforce during the COVID-19 pandemic.

Design, Setting, and Participants

This was an observational cross-sectional study conducted among individuals employed full-time in health care jobs from 2019 to 2021 in the US. Using the data from the Current Population Survey (CPS), we compared turnover rates before the pandemic (preperiod, January 2019-March 2020; 71 843 observations from CPS) with the first 9 months (postperiod 1, April 2020-December 2020; 38 556 observations) and latter 8 months of the pandemic (postperiod 2, January 2021-October 2021; 44 389 observations).

Main Outcomes and Measures

Health care workforce exits (also referred to as turnover) defined as a health care worker's response to the CPS as being unemployed or out of the labor force in a month subsequent to a month when they reported being actively employed in the health care workforce. The probability of exiting the health care workforce was estimated using a logistic regression model controlling for health care occupation, health care setting, being female, having a child younger than 5 years old in the household, race and ethnicity, age and age squared, citizenship status, being married, having less than a bachelor’s degree, living in a metropolitan area, identifier for those reporting employment status at the first peak of COVID-19, and select interaction terms with time periods (postperiods 1 and 2). Data analyses were conducted from March 1, 2021, to January 31, 2022.

Results

The study population comprised 125 717 unique health care workers with a mean (SD) age of 42.3 (12.1) years; 96 802 (77.0%) were women; 84 733 (67.4%) were White individuals. Estimated health care turnover rates peaked in postperiod 1, but largely recovered by postperiod 2, except for among long-term care workers and physicians. We found a 4-fold difference in turnover rates between physicians and health aides or assistants. Rates were also higher for health workers with young children (<5 years), for both sexes and highest among women. By race and ethnicity, persistently higher turnover rates were found among American Indian/Alaska Native/Pacific Islander workers; White workers had persistently lower rates; and Black and Latino workers experienced the slowest job recovery rates.

Conclusions and Relevance

The findings of this observational cross-sectional study suggest that although much of the health care workforce is on track to recover to prepandemic turnover rates, these rates have been persistently high and slow to recover among long-term care workers, health aides and assistants, workers of minoritized racial and ethnic groups, and women with young children. Given the high demand for long-term care workers, targeted attention is needed to recruit job-seeking health care workers and to retain those currently in these jobs to lessen turnover.

Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.

Contingency, employment intentions, and retention of vulnerable low-wage workers: an examination of nursing assistants in nursing homes

PURPOSE OF THE STUDY

While theories of job turnover generally assume a strong correlation between job satisfaction, intention, and retention, such models may be limited in explaining turnover of low-wage health care workers. Low-wage workers likely have a lower ability to act on their employment intentions or plans due to a lack of resources that serve to cushion higher wage workers. In this study, we examine the relationship between job satisfaction, intention, and retention of nursing assistants in nursing homes and the role that "contingency factors" play in employment intentions and retention. We conceptualize "contingency factors" as resource-related constraints (e.g., being a single mother) that likely influence employment trajectories of individuals but can be independent of job satisfaction or intent.

DESIGN AND METHODS

We use survey data from 315 nursing assistants in 18 nursing homes in a U.S. southern state to model employment intentions and retention.

RESULTS

We find that job satisfaction and other perceived job characteristics (e.g., workload and perceived quality of care) are significant predictors of an individual's intent to stay in their job, the occupation of nursing assistant, and the field of long-term care. However, we find that job satisfaction and employment intentions are not significant predictors of retention. Instead, "contingency factors" such as being a primary breadwinner and individual characteristics (e.g., tenure and past health care experience) appear to be stronger factors in the retention of nursing assistants.

IMPLICATIONS

Our findings have implications for understanding turnover among low-wage health care workers and the use of proxies such as employment intentions in measuring turnover.

Caregiving in a patient's place of residence: turnover of direct care workers in home care and hospice agencies

OBJECTIVE

High turnover and staff shortages among home care and hospice workers may compromise the quality and availability of in-home care. This study explores turnover rates of direct care workers for home care and hospice agencies.

METHODS

OLS (ordinary least square) regression models are run using organizational data from 93 home care agencies and 29 hospice agencies in North Carolina.

RESULTS

Home care agencies have higher total turnover rates than hospice agencies, but profit status may be an important covariate. Higher unemployment rates are associated with lower voluntary turnover. Agencies that do not offer health benefits experience higher involuntary turnover.

CONCLUSION

Differences in turnover between hospice and home health agencies suggest that organizational characteristics of hospice care contribute to lower turnover rates. However, the variation in turnover rates is not fully explained by the proposed multivariate models. Future research should explore individual and structural-level variables that affect voluntary and involuntary turnover in these settings.

Strengthening the Long-Term Care Workforce

Given high rates of turnover among direct care workers in long-term care settings, it is important to identify factors affecting organizational-level turnover rates. In this study, the authors examine the impact of a workforce intervention program (Workforce Improvement for Nursing Assistants: Supporting Training, Education, and Payment for Upgrading Performance [WIN A STEP UP]) on turnover rates of direct care workers in nursing homes. Using data collected yearly between 2002 and 2006 from 405 nursing homes in North Carolina, the authors employ random effects modeling to predict a dichotomous outcome of “above-average” versus “below-average” turnover. Results indicate that nursing homes participating in the WIN A STEP UP program are 15% more likely to have below-average turnover than are nonparticipating nursing homes. Organizational factors such as ownership type and Medicaid participation also influenced turnover, whereas labor market factors had no independent effects. The results suggest that workforce development projects that increase the training of direct care workers and provide associated rewards show some potential to lower turnover rates of the direct care workforce.