1. Staying the Course: Facility and Profession Retention among Nursing Assistants in Nursing Homes Sally C. Stearns, PhD Laura D’Arcy, MPA The University of North Carolina at Chapel Hill Support provided by National Institute on Aging AcademyHealth 2008 Annual Research Meeting Washington, DC June 9, 2008

2. Overview Nursing homes face substantial turnover in staff, especially nursing assistants (NAs) –US annual turnover rate for NAs: 71% –NA turnover costs $4 billion per year Why so costly? –Replacement costs, lost productivity, compromised quality, and lowered morale

3. Prior Studies of Causes of Facility Turnover Early: –NAs concerned with job security, interactive aspects of jobs, and growth potential (Atchinson 1998, Parsons et al 2003). Additional factors studied more recently: –NA turnover lower with higher administrative expenditures and wages (Kash et al. 2006) –Castle and colleagues (2005, 2006, 2007): Top management turnover, for-profit, larger size, work schedule, and lower staffing, quality, training, and benefits correlated with higher turnover –Job satisfaction an important antecedent of intent to leave; both are important antecedents of turnover (Castle et al 2007 and Wagner 2007)

4. Definitions of Turnover Some distinctions important –Voluntary versus involuntary –May reflect elimination of poor performers –May indicate poor facility quality Turnover hard to measure in cross-sectional data sets. Alternatives are: –Job satisfaction –Intent to leave

5. Gaps in Literature Prior studies of facility turnover based on: –Facility data only –Small samples of NAs Limited study of some important factors –Injuries and devices related to lifting patients No known prior studies of intent to stay in the NA profession

6. Research Question/Contributions Are the same factors associated with: –NA intent to leave current facility/job? –NA intent to leave NA profession? Specific focus on: –NA assessments of supervision/work schedule, injury/training, pay/benefits –Unobserved facility factors (e.g., management quality) Use nationally representative NA survey

7. Figure 1: Conceptual Model Job Satisfaction and Organizational Commitment Intent to Leave Current Job or Facility NA Personal and Socio-economic Characteristics NA Reported Job Characteristics Supervision/Schedule Training/Safety Benefits Turnover (Facility and NA Profession) Facility & Area Characteristics (Observed and unobserved) Intent to Leave NA Profession

8. Data: National Nursing Assistant Survey 2004 NNAS 2004 conducted by NCHS provides data on: –what draws people to NA careers and to work in nursing homes –what contributes to satisfaction and likelihood of staying in jobs Sample from 2004 National Nursing Home Survey –790 homes (out of 1500) selected to participate in the NNAS –582 homes (76%) provided contact information for 4,542 NAs –3,017 NAs (71%) completed an interview –Combined response rate of 53% –Missing data reduced analysis sample to 2,328 observations NNAS –Panel of multiple NA respondents per facility strengthens analysis –Public use versions NNHS and NNAS can not be merged due to confidentiality

9. Dependent Variables Three dichotomous intent to leave measures –Intent to leave facility/job (2 measures) Broad: NA is very or somewhat likely to leave current job in next year Strong: Same as above plus currently looking for a job –Intent to leave profession: NA does not expect next job to be as a NA But could not tell if leaving health professions

10. Key Explanatory Variables NA assessments of: –Supervisor quality, whether NA is respected, whether NA has enough time for duties –Quality of training, input into training topics, injury experience, and lifting equipment availability –Benefits (wages; paid time off for holidays, vacation/personal days, sick days; HI available) Observed facility characteristics –Bedsize, ownership, urban/rural Facility fixed effects for unobserved facility characteristics (average 4 NAs per facility)

11. Other Controls Income Age Gender Race/ethnicity Education Marital Status Young children at home Citizenship Full time vs. part time

12. Methods OLS (Linear probability models) instead of logit for final models Tested OLS models with and without facility fixed effects Used survey weights and robust standard errors

13. Descriptive Statistics Intent to Leave –Broad intent to leave facility: 43% –Strong intent to leave facility:20% –Intent to leave profession:48% Surprisingly little correlation between intent to leave facility/job and profession Surprisingly high within-facility variation in NA reports of benefits, scheduling, safety, etc.

14. Main Results: Impacts on Intent to Leave

15. Summary of Results Facility and profession retention affected by substantially different factors –Facility policies and NA perceptions of job aspects critical for facility retention –Profession retention associated only with socio- demographic factors Lack of effect of wages due to study design? Facility fixed effects –Only significant in intent to leave facility analysis –Reflect both facility and area characteristics

16. Policy Implications Facilities can undertake specific actions to reduce their turnover (intent to leave) –Injury prevention and training –Pay and flexible holidays –Important unmeasured facility policies Profession retention more encompassing –Need to make profession financially competitive –Within-profession promotion and responsibility undoubtedly important