The care home environment: Special insights

A high turnover of staff within long-term care facilities is a persistent issue that can impact the quality of resident care. Mark Atkin of ScHARR, University of Sheffield, discusses a new approach to addressing staff retention issues.

The long-term care industry relies on nurses and care assistants to deliver care in nursing and residential homes. Recently in the UK (and elsewhere), shortages of nursing staff and high turnover rates have made successful staff retention a priority for many long-term care facilities.

High turnover of care staff

High turnover amongst nurses and nursing assistants is widely regarded to have a negative impact on the quality of care provided within a healthcare facility, as reported in both Europe and North America. Annual turnover of nursing home staff during the 1990s in the USA ranged between 40 per cent and 96 per cent and the UK has experienced similar issues with the staffing of nurses and care assistants, with the problem first coming to prominence in the late 1980s.

The costs of turnover

Staff attrition creates increased operational costs in the form of recruitment and orientation of new staff. Furthermore, turnover can also interrupt the continuity of care provided by disrupting the workforce. Overtime payments and agency fees may be necessary to provide cover for vacancies, and productivity losses are also indirect costs of turnover. During transition periods before new staff are appointed, an additional burden is placed on remaining staff. This can result in a stressful climate leading to further turnover, and hence the problem perpetuates. High staff turnover results in financial cost, as well as reducing productivity and potentially compromising the quality of care delivered. Long-term care facilities must address this issue to ensure that care delivery is maintained at a high standard.

Why do care staff leave?

The issue of high staff turnover is widely recognised to be complex and multi-factorial. There are many local issues that may be relevant to individual facilities, and it is becoming more apparent that competition for staff from other industries, principally retail, is a constant drain on the pool of available care staff. By systematically reviewing research literature from long-term and other healthcare environments, the University of Sheffield’s School of Health and Related Research (ScHARR) and School of Nursing and Midwifery has developed a model that attempts to represent the complex nature of staff turnover. And, the model suggests how these factors might interact to influence staff retention.

Factors influencing care staff turnover

Figure 1 proposes how a range of factors may interact to result in staff turnover. The model is evidence-based and has been developed by examining current research carried out in this field. Content analysis of the key themes within more than 150 research papers has influenced the design of the model. The model therefore represents a useful resource as guidance for best practice in relation to staff retention. Each one of the four key phases that have been identified is briefly discussed in the following section.

Phase I: Organisational culture

Research suggests that certain features of an organisation have an influence on the turnover of care staff. These are:

Leadership style. The way in which managers lead their workforce is vitally important to future staff retention in healthcare environments. Key aspects of leadership behaviour include effective communication with staff, and ensuring adequate staffing levels to manage staff workloads. Involvement of staff in decision-making has been shown to be highly regarded by nurses and care assistants.
Organisational structure. It is clear that dissatisfaction with pay and benefits are a persistent cause of care staff leaving their jobs, although many reports suggest that a large proportion of care staff do not regard pay as the most important aspect. Several socio-demographic characteristics of the staff of a provider organisation correlate with turnover in long-term care. These include age (with turnover higher among younger staff) and length of time employed (with turnover lower in staff who have worked for longest).

Phase II: Quality of working life

The components of an organisation’s culture interact to define the quality of working life, which is largely determined by two key factors:

The work environment. Features of the workplace that have been found to influence retention include the strength of working relationships and the ‘group cohesion’ of nurses and nursing assistants. There is a link between successful retention and staff who report a positive atmosphere in the work environment. Long-term care facilities that are able to achieve such positive environments also observe increased satisfaction from residents and their relatives.
Intrinsic rewards. There is evidence to suggest that ‘non-monetary’ rewards are a vital part of successful staff retention. Care staff who feel appreciated for their work and who receive appropriate recognition for their efforts are much less likely to leave their job. The type of recognition given to staff has an important effect on staff satisfaction, with written recognition being regarded most highly. The notion of being able to work with a degree of autonomy also contributes to job satisfaction, particularly in the case of nurses.

Phase III: ‘Turnover intention’

Research suggests that turnover is largely due to the following two main drivers:

Staff experiences. The quality of working life contributes to key experiences for staff, including job satisfaction, motivation and commitment. These have all been associated with turnover intention. In particular, high job satisfaction is associated with increased commitment to an organisation and lower staff turnover. Staff experiences have a profound effect on the morale of the workforce in a healthcare environment.
External factors. Competition from other local employers is a persistent threat to successful staff retention, especially from retail establishments. A link has been demonstrated between local employment opportunities and staff turnover. However, satisfied staff are less likely to leave, regardless of local opportunities.

Phase IV: Outcomes of turnover

The main consequences of staff turnover include impact on costs and quality of care.

Turnover costs. Agency spend, the cost of re-recruitment and the training of new staff are costly immediate effects of staff turnover. Of additional importance is the disruption to the workload and morale of remaining staff. Research literature strongly suggests that recruitment should be more targeted in order to ensure that workers have a clear understanding of what the role of working in long-term care requires before they start work.
Quality of care. As well as financial implications, there are important knock-on effects of high staff turnover. It is known that long-term care residents clearly prefer a stable workforce with which they can become familiar. Lower staffing levels as a result of staff leaving also puts pressure on the quality of care delivery.

An approach to examining the ‘retention status’ within care homes

Anchor Homes are currently engaged in a collaborative project with the University of Sheffield’s School of Nursing and Midwifery and ScHARR aimed at reducing staff turnover.

A development in the project includes the ‘Retention Strategy Assessment Tool’ (RSAT), designed between the partners in a collaborative effort.

The RSAT tool

The key components of the conceptual model (figure 1) have been used to develop an audit tool in the form of a staff questionnaire. Staff within a care home are invited to complete this questionnaire, in order to provide workforce information with respect to the identified factors. Upon analysis of the RSAT, the tool will highlight any areas that staff report dissatisfaction with, providing management with targeted constructive information on which to base retention strategies.

The connectivity of factors: turning the cogs

By understanding the nature of the factors that combine to result in care staff turnover, future workforce planning can be better informed in the implem-entation of targeted corrective strategies. The model presented here will form the basis of an assessment of Anchor’s current workforce which will aim to provide important and constructive information to address the issue of care staff turnover.

Development of targeted retention strategies

The RSAT allows strengths that exist in retaining high quality nursing and care staff to be highlighted, enabling management to consider how these features may be consolidated in future. Similarly, it will provide constructive information on any areas that could be improved to limit future staff turnover. Importantly, the tool will generate tailor-made development plans for individual facilities by highlighting where priority areas may lie.

Desired outcomes

This research project, funded by the Knowledge Transfer Partnership Initiative, has developed a targeted way of assessing care homes with respect to their ’retention status’. The information gained from such assessments is vital to understand the connectivity of the many factors which result in disruptive staff turnover. More importantly, the assessments provide useful, targeted feedback for care home managers and administrators – providing logical, constructive information on which future workforce strategies can be based. Such an approach to tackling the issue of high staff retention also allows the possibility of establishing the ‘weighting’ of the key factors, and hence where the priorities should be for corrective steps.

The research process developed in this study has allowed the team to define an evidence-based conceptual model that describes the complex situation of staff turnover in long-term care facilities. It acts as a form of best-practice guidance and a useful educational aid in the development of managers of long-term care facilities.

The research project team in the School of Health and Related Research and the School of Nursing and Midwifery of the University of Sheffield is now focusing on an intervention study which will look to implement key retention strategies and utilise the assessment tool described. In doing so, it aims to address a persistent issue to the industry and ultimately contribute to the enhancement of the quality of care to older people.

Mark Atkin is a project manager at the School of Health and Related Research (ScHARR) at the University of Sheffield, currently working in partnership with the Anchor Trust. He can contacted via e-mail: m.atkin@sheffield.ac.uk