Stayers, Leavers, and Switchers Among Certified Nursing Assistants in Nursing Homes: A Longitudinal Investigation of Turnover Intent, Staff Retention, and Turnover

The recruitment and retention of direct care workers (DCWs) in the U.S. long-term care industry have been the subject of numerous studies over several decades (Castle, Engberg, Anderson, & Men, 2007; Lagnado, 2008; Span, 2009). The Institute of Medicine Report, Retooling for an Aging America, identifies an unstable direct care workforce as a primary challenge that must be addressed to care for the growing number of aging baby boomers in the Unites States (Committee on the Future Health Care Workforce for Older Americans, I. o. M., 2008). Staff turnover not only increases the financial burden of caring for elders (Seavey, 2004), but it also interferes with quality of care (Castle, Engberg, & Men, 2007) and quality improvement initiatives (Rosen et al., 2005). Earlier studies that focused on certified nursing assistants (CNAs) in nursing homes have linked a number of constructs, including job satisfaction, with intent to leave the job (Castle, Degenholtz, & Rosen, 2006; Parsons, Simmons, Penn, & Furlough, 2003) and actual quitting (Castle, Engberg, Anderson, et al., 2007; Kiyak, Namazi, & Kahana, 1997) or have evaluated the impact of organizational factors on administrator-reported staff turnover (Banaszak-Holl & Hines, 1996; Brannon, Zinn, Mor, & Davis, 2002; Brennan & Moos, 1990). In this article, we examine the impact of employee work attitudes and job factors on intentions to leave the job and on actual turnover. CNA turnover rates reported in the literature are high: A scholarly review by Castle (2006) reported annual CNA turnover rates between 23% and 346%. However, such findings must be interpreted with caution in light of the limitations of the research on CNA turnover. Virtually, all previous studies use cross-sectional data provided by nursing home administrators who employ inconsistent and variable methods to determine turnover. Furthermore, these studies fail to differentiate between part-time and full-time employees, even though prior research suggests that part-time employees are likely to be very different than full-time employees in terms of job satisfaction and job behaviors (Eberhardt & Shani, 1984; Feldman, 1990; Werbel, 1985). Finally, nearly all report turnover rates rather than retention rates, which are not reciprocal (Castle, 2006). Public policy discussions of high turnover rates, the increasing costs of care due to turnover, and discrepancies reported in the academic literature regarding the stability of this workforce warrant a fresh approach to this problem. Rather than rely on cross-sectional data or self-reports by facility managers, we conducted a longitudinal study of CNAs using telephone surveys completed at baseline and then 12 months later to determine the actual behavior among CNAs in terms of staying with or leaving their jobs. Unlike earlier studies, participants in this study were randomly selected from a statewide database of CNAs rather than by their association with participating facilities and were followed longitudinally. Also differing from previous studies, our respondents were working at least 30 hr per week in a single facility, limiting the number of part-time workers participating. This study addresses the following regarding CNAs employed in nursing homes: (a) the annual rate of turnover and of retention, (b) factors at baseline that differ between workers who stayed at their original job (stayers), switched to another facility (switchers), or left the eldercare workforce entirely (leavers) 12 months later, (c) cross-sectional differences between these groups at follow-up, (d) longitudinal differences at baseline and follow-up within each group, and (e) a retrospective assessment of reasons for leaving. We expect that attitudinal and job-related factors at baseline will differ among stayers, switchers, and leavers. As shown in Figure 1, we hypothesize that differences in these job-related attitudes and factors will manifest as differences in participants’ intentions to stay at their job or turnover. In the subsequent time period, turnover intentions can result in the action of switching or leaving (i.e., actual turnover). For the purpose of this study, we are primarily interested in job-related attitude factors (i.e., job satisfaction, emotional distress, supervisor respect, and coworker respect) and job factors (i.e., paid sick and vacation days, health insurance, and promotion opportunities), both of which have the potential of being modified through administrative actions (Price & Mueller, 1981; Werbel, 1985). Figure 1. A conceptual model of turnover among certified nursing aides.