1. The University of Georgia Workforce Retention in Addiction Treatment: Findings from the National Treatment Center Study Paul M. Roman, Principal Investigator Co-Investigators: Aaron Johnson, Hannah K. Knudsen, and Lori J. Ducharme This research is supported by NIDA Research Grants R01DA13110, R01DA14482, & R01DA14976

2. The University of Georgia Goals of This Session To briefly outline the research design of the National Treatment Center Study To describe the addiction workforce, including counselors and program leaders To present data and information on counselor turnover at the organizational-level To discuss burnout and turnover intention among program leaders To outline how programs may reduce counselor burnout and turnover intention

3. The University of Georgia The National Treatment Center Study: An Overview

4. The University of Georgia Key Goals of the NTCS To document the range of treatment services available in the American substance abuse treatment system –Levels of care, use of medications, types of therapies, wraparound services To understand issues related to workforce retention, including both counselors and program leaders

5. The University of Georgia Types of Treatment Organizations in the NTCS This presentation focuses on: –Publicly funded programs –Privately funded programs –Therapeutic communities (TCs) –Centers affiliated with NIDA’s Clinical Trials Network Recently we added methadone programs, but data are not yet available for analysis

6. The University of Georgia Public Centers Nationally representative sample of 362 public centers –80% response rate Eligibility for study defined by funding sources: –> 50% of revenues from government grants/contracts –Includes government-owned facilities and non- profit programs that rely on public funding –Average center receives 84% of its funding from public sources

7. The University of Georgia Private Centers Nationally representative sample of 403 private centers –88% response rate Eligibility for study defined by funding sources: –< 50% of revenues from government grants/contracts –Includes for-profit facilities and non-profit programs that rely on private funding (e.g. insurance, self-paying clients) –Average center receives less than 20% of its funding from public sources

8. The University of Georgia Therapeutic Communities Nationally representative sample of 380 TCs –83% response rate Programs only required to identify themselves as TCs –Captures the spectrum of programs that report using this treatment model –Interviews include measures such as De Leon’s “Essential Elements” and membership in Therapeutic Communities of America to see how closely programs adhere to the classic TC models

9. The University of Georgia NIDA’s Clinical Trials Network The CTN is a research network that links university-based researchers with community- based treatment programs in order to: –Conduct multi-site clinical trials of treatment techniques –Improve addiction treatment quality by moving evidence-based techniques into practice 240 CTN-affiliated treatment programs participated in the NTCS –92% response rate

10. The University of Georgia Types of Programs NOT in the NTCS Programs based in correctional settings VA programs Halfway houses & transitional housing DUI services Counselors in private practice

11. The University of Georgia Basic Research Methods Data collected from mid-2002 to early 2004 Three levels of data collection –Organizations  Face-to-face interviews with administrators & clinical directors  Organizational structure, availability of services, staffing –Leaders  Mailback questionnaire  Leadership style, organizational strategy, burnout, turnover intention, demographic characteristics –Counselors  Mailback questionnaire  Job characteristics, attitudes toward innovations, burnout, turnover intention, demographic characteristics

12. The University of Georgia The Addiction Workforce: Characteristics of Leaders

13. The University of Georgia Average Leader Age & Tenure The average leader is about 50 years old –Private center average = 49.9 years –Public center average = 49.7 years  In a recent survey of American full-time workers, the average age of managers was 42.6 years The average leader has worked for their center for nearly 10 years –Private center average = 9.4 years –Public center average = 9.4 years  In a recent survey of American full-time workers, the average manager had worked for their organization for 10.9 years On average, leaders have worked 18-19 years in the behavioral health field –Private center average = 19.5 years –Public center average = 18.8 years

14. The University of Georgia Leader Characteristics: Gender Nearly half of program leaders are female.

15. The University of Georgia Leader Characteristics: Racial/Ethnic Minorities Public centers are more likely than private centers to have a leader with minority background.

16. The University of Georgia Leader Characteristics: Educational Attainment The majority of leaders have at least a Master’s-level degree.

17. The University of Georgia Leader Characteristics: Personal Recovery Status About one-third of leaders are personally in recovery from substance abuse.

18. The University of Georgia Average Leader Salary The average leader earns between $55,000 and $65,000 per year Leaders of private centers earn more ($64,496) than leaders of public centers ($56,010)

19. The University of Georgia Workforce Retention “At the Top”: Turnover Intention and Emotional Exhaustion Among Program Leaders

20. The University of Georgia Turnover in the Context of Leadership There has been growing concern about high rates of turnover among counselors at treatment programs Relatively little is known about turnover among program leaders Turnover of leaders may be even more disruptive to centers –High costs to recruit new leaders –Increases uncertainties for program staff –Disrupts inter-organizational linkages

21. The University of Georgia Past-Year Change in Center Administrators About 24.0% of centers reported a change in the administration of their center within one year.

22. The University of Georgia The Concept of Turnover Intention Studies of turnover are challenging to conduct –Most surveys of employees are done just once, so researchers can’t measure actual turnover But turnover intention has been identified as the best predictor of actual turnover over time –“I am seriously thinking about quitting my job.” –“I am actively looking for a job at another center.”

23. The University of Georgia Burnout & Emotional Exhaustion Emotional exhaustion as central concept of burnout –“I feel emotionally drained from my work.” –“I feel frustrated by my job.” Certain jobs are at higher risk of burnout, particularly those that involve “constantly dealing with other people and their problems” (Cordes & Dougherty, 1993) –Doesn’t that sound like the central task of management? –They have to deal with funding agencies, coordinate with other agencies, manage employees, etc.

24. The University of Georgia Change in Administrator One Year Later Emotional Exhaustion + Greater emotional exhaustion and greater turnover intention is linked to greater odds of turnover one year later. Turnover Intention Change in Administrator One Year Later +

25. The University of Georgia What are the sources of turnover intention & emotional exhaustion for program leaders?

26. The University of Georgia Organizational Strategy Long tradition of studying how perceptions of being “in control” can enhance employee well-being –Control over making the “big decisions” –Control over uncertainties Two aspects of organizational strategy are linked to this idea of “control”: –Bold decision-making orientation –Long-term strategic planning

27. The University of Georgia Bold Decision-Making Orientation “When confronted with decision-making situations, this center typically adopts a bold, aggressive posture in order to maximize the probability of exploiting opportunities.” –In other words…managers have the power to take risks Leaders were less likely to be planning to quit when this orientation towards bold decision-making was higher

28. The University of Georgia Long-Term Strategic Planning Long-term strategic planning may help managers anticipate future challenges & plan solutions in advance –Includes financial planning, market research and anticipating where clients will be coming from in the long-term –Enhances sense of control over the many uncertainties of program management Results show that long-term strategic planning reduces emotional exhaustion

29. The University of Georgia Performance Pressures as a Stressor Another common theme in job stress studies is that work-related pressure increases burnout and turnover intention For managers, pressures may be related to the financial performance of the organization –Generating high revenues, minimizing costs, high patient census Greater emphasis on these types of performance increases both emotional exhaustion and turnover intention

30. The University of Georgia Participative Management of Staff Long line of research shows that participative management is good for staff –Allowing employees to make decisions about how to perform their jobs –Providing information to employees about management’s decisions & asking for their input But is it good for managers too?

31. The University of Georgia Centralized Decision-Making Centralized decision-making as the opposite of participative management –“There can be little action taken here until a supervisor approves a decision.” –“Even small matters have to be referred to someone higher up for approval.” While control over “big decisions” may be good, not letting employees have control over the “small decisions” may increase stress: –Higher emotional exhaustion –Higher turnover intention

32. The University of Georgia Involving Employees in Decision-Making Managers can actively involve employees in the decision-making process –“I make sure all employee concerns are heard before job decisions are made.” –“I try to clarify decisions and provide additional information when requested by employees.” Managers that involve employees more in the decision-making process reported: –Lower emotional exhaustion –Lower turnover intention

33. The University of Georgia Summary Organizational strategy matters in terms of the well-being of program managers –They need control over big decisions –Long-term planning can help –Too much emphasis on (financial) performance may be detrimental Participative management strategies—where employees are more involved in decision- making process—may have important benefits for the well-being of program leaders

34. The University of Georgia The Addiction Workforce: Characteristics of Counselors

35. The University of Georgia Key Questions about the Counseling Workforce Is there substantial “graying” of the counseling workforce? Is counseling becoming a “female occupation”? To what extent are racial and ethnic minorities represented in the counseling workforce? Is there evidence of greater workforce professionalism?

36. The University of Georgia Average Counselor Age & Tenure The average counselor is in their mid-40s –Private center average = 46.4 years –Public center average = 44.6 years –TC average = 43.5 years  The average American full-time worker is about 40.4 years old The average counselor has worked for their center for about 4-5 years –Private center average = 5.3 years –Public center average = 4.8 years –TC average = 4.3 years  The average American full-time worker has worked for their current employer for 8.4 years

37. The University of Georgia Counselor Characteristics: Gender The majority of counselors are female.

38. The University of Georgia Counselor Characteristics: Racial/Ethnic Minorities Private centers employ a significantly smaller percentage of minority counselors.

39. The University of Georgia Counselor Characteristics: Educational Attainment Private center counselors are more likely to have a Master’s-level degree than counselors in public centers & TCs.

40. The University of Georgia Counselor Characteristics: Certification in Addictions Counseling About half of the workforce is certified in addictions counseling, but TC counselors are less likely to have this credential.

41. The University of Georgia Counselor Characteristics: Personal Recovery Status About half of the workforce is personally in recovery from substance abuse.

42. The University of Georgia Counselor Turnover: Associations with Organizational Characteristics

43. The University of Georgia Counselor Turnover in Addiction Treatment Programs Previous research shows annual turnover rates range from 18% to 50% (Gallon et al., 2003; Johnson et al, 2002; McLellan et al, 2003). Current data shows range between 13% and 21% depending on type of program Significantly higher than national average across all occupations (11%) Higher than teachers (13%) and nurses (12%) – occupations known for high turnover

44. The University of Georgia Comparing Voluntary Turnover Public centers and TCs have significantly higher turnover than private centers (p<.001)

45. The University of Georgia What do we know about the differences between these types of programs that might explain differences in counselor turnover?

46. The University of Georgia Private Centers vs. Public Centers and Therapeutic Communities (TCs) Private centers –Higher % with primary alcoholism diagnosis –Higher % counselors with Master’s degree –Higher average salaries Public centers and TCs –Higher % relapsers and CJ referrals –Higher % minority clients –Higher % with primary cocaine diagnosis –Higher % minority counselors

47. The University of Georgia Results Analysis using data from private centers Higher levels of turnover associated with: –For profit status –Larger capacity –Composition of workforce –Prior Turnover Rate Lower levels of turnover associated with: –Counselor-management relations

48. The University of Georgia Explanation of Results – Workforce Composition Aspects of workforce affecting turnover –Higher percentage of female counselors = higher turnover –Higher percentage of counselors in recovery = higher turnover –Higher percentage of minority counselors and counselors certified in addictions = lower turnover

49. The University of Georgia Explanation of Results – Counselor- management relations Participatory management –Center hears employee concerns before making decision –Receive sufficient notice of changes affecting work –Effective channels of communication between employees/management Organizational commitment –Willing to put in extra effort to help center succeed –Proud to tell others I am part of this center –This is best of all possible centers for which to work

50. The University of Georgia What doesn’t impact turnover? The diversity of services offered Counselor education level Counselor salaries The types of patients being treated –Relapsers, CJ Clients, Indigent, Specific drugs

51. The University of Georgia Take Home Message Turnover breeds turnover – programs with high rates have a difficult time reducing turnover Difficult clients are not the issue Money is not the issue - Increasing counselor salaries will not reduce turnover The lowest turnover rates are in programs that successfully create a smaller “family” type culture in which counselors feel that they are able to communicate with management and are included in important decisions. The result is a workforce committed to the program and willing to work hard to see it succeed.

52. The University of Georgia Workforce Retention: Counselors and Turnover Intention

53. The University of Georgia What management practices are associated with lower turnover intention?

54. The University of Georgia The Importance of Organizational Commitment One idea is that if employees are committed to the organization, then they won’t leave –Organizational commitment as pride in working at the center & willingness to put forth extra effort to ensure the center’s success Employees will be more committed to the organization if they feel that the organization is committed to them –The norm of reciprocity Support for these arguments in a study of private center counselors (Knudsen et al., 2003, Journal of Substance Abuse Treatment, 24:129-135)

55. The University of Georgia Management Practices That Build Organizational Commitment Job Autonomy—authority to make decisions about how to do one’s job –“I have enough freedom over how I do my job.” Counselors with greater control over their jobs are: –More committed –Less likely to be planning to quit

56. The University of Georgia Commitment-Building Management Practices (continued) Support for Creativity—managers encourage counselors to express their opinions and to try new ideas –“Employees are encouraged to develop their own ideas, even if they deviate from those of the center’s management.” Counselors are more committed when they feel that their center supports their creativity

57. The University of Georgia Commitment-Building Management Practices (continued) Performance-Based Rewards—the center rewards hard work with recognition, promotions, and raises –“The amount of recognition I receive when I do a good job is satisfactory.” –“If I perform my job well, I am more likely to be promoted.” Counselors are more committed when centers reward job performance.

58. The University of Georgia What else reduces turnover intention?

59. The University of Georgia Fairness in the Workplace Perceptions about justice and fairness within the organization are important predictors of turnover intention –Sample of TC counselors (Knudsen et al., in press, JSAT) Procedural justice: fair processes –“Job decisions are applied consistently across all affected employees.” –“When decisions are made, all the people who will be affected are asked for their ideas.” Distributive justice: fair outcomes –“The workload at this center is fairly distributed.” –“Where you work, the amount of pay employees receive is distributed fairly.”

60. The University of Georgia The Importance of Workplace Fairness Turnover intention is lower when: –Procedures are perceived to be just –Outcomes (pay, workload, etc) are perceived to be fairly distributed In addition, justice is linked to counselor burnout Burnout is higher when: –Procedures are perceived to be unfair –Outcomes are unfairly distributed

61. The University of Georgia What does all this mean?

62. The University of Georgia Workforce retention can be improved through management practices Managers may benefit by thinking about whether they: –Give counselors enough control over their jobs –Support creativity –Reward strong job performance –Solicit opinions from counselors before making decisions –Apply decisions consistently –Ensure that both workload and rewards are distributed fairly

63. The University of Georgia Clinical Supervision: Promising Results for Reducing Turnover Intention

64. The University of Georgia Clinical Supervision: Is It a “Best Practice”? High-quality clinical supervision as having two parts: –Supervisor can provide good advice because of his/her expertise and training –Supervisor does provide work-related advice that improves the counselor’s ability to treat clients To date, there is little research on whether high- quality clinical supervision may reduce counselor turnover –Such evidence might suggest that high-quality clinical supervision is a “best practice” in program management CTN counselor sample was used to address this issue

65. The University of Georgia Turnover IntentionClinical Supervision -.23*** Higher quality clinical supervision is associated with lower turnover intention.

66. The University of Georgia Why is clinical supervision associated with turnover intention? Is it because the quality of clinical supervision associated is linked to: –Job autonomy, –Procedural justice, and –Distributive justice? Is it because clinical supervision predict counselors’ organizational commitment and emotional exhaustion?

67. The University of Georgia Distributive Justice Job Autonomy Procedural JusticeClinical Supervision.42***.39***.55*** Clinical supervision is associated with perceptions of autonomy and justice.

68. The University of Georgia Clinical Supervision Job Autonomy Procedural Justice Distributive Justice Organizational Commitment Emotional Exhaustion.176*** Clinical supervision is only directly associated with commitment

69. The University of Georgia Clinical Supervision Job Autonomy Procedural Justice Distributive Justice Organizational Commitment Emotional Exhaustion Turnover Intention.27*** -.48*** Turnover intention is associated with commitment and emotional exhaustion

70. The University of Georgia Summary of Results High-quality clinical supervision appears to improve perceptions that the workplace is fair, which then improves commitment and reduces emotional exhaustion By increasing commitment and reducing emotional exhaustion, turnover intention is lower The model suggests that high-quality clinical supervision may be a “best practice” of program management

71. The University of Georgia In conclusion…

72. The University of Georgia Conclusions Workforce retention is indeed a key issue facing the substance abuse treatment field –Both for program leaders and counselors Attention to organizational strategy and management styles may yield improvement in turnover –Emotional exhaustion and turnover intention can be reduced

73. The University of Georgia Conclusions (continued) In general, treatment programs may benefit from: –Encouraging staff to be involved in decision-making processes –Distributing workloads and rewards fairly –Improving the quality of clinical supervision

74. The University of Georgia Questions and Discussion

75. The University of Georgia Items for Discussion Based on your experience in your own programs, what have been some of the main factors contributing to the loss of counseling staff? Based on your experience, is the loss of management/supervisory level staff a problem for your program? Are the factors related to the loss of management level staff similar to those of counseling staff? Have any of you taken steps within your own program that resulted in improved workforce retention?