Decreasing CNA Turnover Rates

Abstract

The primary rationale for the selection of this project is the need to reduce the turnover rates of Certified Nursing Assistants in my home health agency. The turnover rates of CNAs remain a long-term care issue affecting the delivery of quality care. The current turnover rates range from 56% to 75% for the CNA’s. This research study seeks to probe whether CNA’s empowerment procedures are associated with the retention of CNAs. In an effort to gather an evidence-based knowledge for this study, data from nursing homes and home health agencies will be used.  After an adjustment for the covariates, an efficient staff empowerment initiative score was established to be positively associated with the higher levels of retention. In comparison with the low empowerment section, nursing institutions with scores that were perceived to be medium had a 45% chance of having higher CNA retention rate; while those with higher empowerment scores were considered to have a 65% likelihood of having a higher CNA retention rate. Greater opportunities for nursing institutions in regard to CNA empowerment are therefore associated with long-term CNA retention. This research reveals that staffing empowerment measures are worthwhile from a CNA staffing retention point of view.

Decreasing CNA turnover rates

The U.S. will have over 88.5 million people aged over 65 years by 2050, double the 2010’s 40.2 million estimates (Hummel, 2017), with an estimated increase in the demand for CNAs in the range of 5.7-6.5 million (Meyer, Raffle & Ware 2014). The need for nursing homes is also expected to rise. Such postulates, compounded by the cost of training a CNA, and beliefs that CNA stability positively impacts the quality of care afforded to nursing home residents have ignited long-standing interest in CNAs turnover and retention in long-term care facilities (Institute of Medicine, 2008; Squillace et al., 2008). As Bowers and Nolet, (2011) note, the correlation between CNA staff stability and care quality is premised on the idea notions that staff staying for more extended periods at a facility establish a relationship with both colleagues and residents thus are familiar with the residents’ needs (Donoghue, 2010). Importantly then, appraising whether CNA’s empowerment procedures result in this correlation cannot be overstated.

Systematic Problem Identification

Adequately skilled CNAs are highly required to meet the increasing demands of the aging population in long-term nursing homes that are unable to provide basic geriatric services (Lerner et al., 2014; Ammons & Kelly, 2015). CNAs account for 66% of the total healthcare workforce segment in long-term health care (Hummel, 2017). CNAs who characteristically spend 6-8hours in contact with residents, function in one of the most core and influential capacities in nursing homes (Hummel, 2017)

By 2020, the need for CNAs will increase by 20% and 39% by 2024 (Hummel, 2017). Such amplification in demand for these staff and the facilities in which they operate is paired with the opposing realities of them having one of the highest turnover rates for any long-term care work-related position (Ammons & Kelly, 2015). This is compounded by the cost of recruiting, orienting and training a new CNA into a nursing facility, which is estimated to be $30,000 (Squillace et al., 2008). Such facts are a recipe for crisis and prerequisites for approaches for nursing facilities to retain their CNAs, including staff empowerment measures.

Assessment of Researching the Existing Knowledge-Base

The stability of staff in literature is measured as staff turnover (the % of quitting staff in specified periods (usually a year)) and staff retentions (the % of remnant staff within the same period) (Bowers & Nolet, 2011; Donoghue, 2010). As Hummel, (2017) reports, the estimated annual CNAs turnover rates range between 23.8% to 74.5%; in 2012, the turnover rate was 52%, with 47,000 vacant positions for skilled labor being reported in nursing facilities. In Castle and Engberg’s (2005) research in four states, a yearly 85.8% turnover rate was realized in 354 facilities while the 2010 CNA turnover rates as reported by AHCA (2014) was 42.6%. National CNA retention rates as estimated by Donoghue (2010) were 62.5%.

Employment practices that are empowerment focused have been proposed as one of the means of enhancing CNA job stability and satisfaction (Hummel, 2017). The approaches have been linked to staying intent, higher job satisfaction, and lower turnover rates. These include developing more supportive facility culture and the development of greater CNA opportunities (Bowers & Nolet, 2011). Best exemplifying this includes offering educational and training opportunities, practice implementation reflecting staff valuing, staff involvement in the planning of care and participation of staff in day to day and managerial decision making (Koren 2010).

Probst, Baek, and Laditka, (2010) research postulate positive associations between organizational climate, sufficient time for tasks, good hourly earnings, good supervisor behavior and staff valuation with job satisfaction. Approaches implementing team empowerment gave CNAs authority to make decisions on their work, leading to modest positive effects on CNA job satisfaction, performance, improved procedures, cooperation, coordination and better resident care (Yeatts & Cready, 2007). The study also revealed a minimal likelihood of CNAs exposed to empowerment for getting fired or quitting.

The clinical significance of CNAs is enormous. CNAs are considered paraprofessional performing multiple tasks with and for residents. Most of the work of CNAs is associated with the physical care of residents (Squillace et al., 2008). CNAs are also trained to provide non-physical support, including the ability to recognize changes in behavior and social interaction decrements among residents (Hummel, 2017). Additionally, they also offer support to resident family members, making their retention in a nursing home important.

Adaptation of Existing Practice

In practice, the implementation of cultural changes within organizations is one of the leading fronts changing staff empowerment (Banaszak-Holl et al., 2013). Movements advocating for cultural change are expansive and mainly focus on the improvement care and life quality for residents in nursing facilities (Zimmerman, Shier & Saliba, 2014). CNA empowerment presents residents with a homelike atmosphere, direction, close contact, decision making based on collaboration and processes aimed at improving quality of care (Koren, 2010). Implementation of the principles of staff empowerment follows the postulates of being organized to support the empowerment of all staff responding to the needs and desires of residents (Hummel, 2017).

Conduct a Clinical Trial and Evaluation

Evaluation of the effectiveness of this approaches will employ the postulates of (Berridge, Tyler & Miller, 2018) and (Banaszak-Holl et al., 2013).  A culture change survey of nursing home directors and administrators at similar nursing homes will be conducted via mail, phone and online at a sample of nursing homes implementing the approach. The survey will use a stratified sampling design. The survey will examine two culture change domains: staff empowerment practices (choices and decisions) and the physical environment. Survey questions will be designed to be on the area of interest, that is, the domains of staff empowerment practices and retention rates. Analysis of data obtained will follow the postulates of Tyler et al., (2013).

That, as Berridge, Tyler & Miller, (2018) postulates, nursing homes which identify themselves as adopters of change implemented strategies such as the cross-training of staff, provided leadership training opportunities, and engaged nurse assistants in decision making on assignment residents. Then for the sample of facilities implementing staff empowerment practices, the evaluation will be based on CNA tracking information as provided by participating facilities, pre and post job satisfaction surveys and CNA exit interviews. Qualitative measures will be undertaken through valuations; observations made on project variables will be detailed.

Decision: Adoption, Modification, Rejection

Relationships between organizational cultural changes and the stability and satisfaction of CNAs is complex (Bowers & Nolet, 2011). Implementations of changes may be hard in the face of more permanent staff with long institutional relationships and memory as they tend to be attached to a familiar, different model (Donoghue, 2010). An uphill task would be the achievement of staff buy-ins (Tyler et al., 2013). Strategies (below) to involve CNAs and assure buy-ins require extensive training and strong communication (Hummel, 2017). Modification: going beyond the federally recommended staff-residence rations in the face of looming large workload issues, residence dissatisfaction, and CNA turnover. More realistic ratios have to be established in the face of growing CNA pools due to improved wages and better training.

Plan for Diffusion of Innovation to Other Areas

Findings from the research will be diffused to training institutions to offer adequate training (Hummel, 2017). The development of highly specific and meaningful training programs for CNAs can help address turnover problems. Such training has to be imperatively accompanied by between hourly pay. The acquisition of better trained CNAs only reasonably requires more than minimum wage to guarantee long-term stay. Financially constrained nursing facilities can strongly argue their case for additional resources for wages (Hagerty & Buelow, 2017).

Maintenance Mechanisms

Strategies to overcome resistance to change in part will entail the use of change agents with characteristics similar to the targets of change which has been postulated to improve the reception of change (Berridge, Tyler & Miller, 2018). A second option involves the use of dramatic symbols and ceremonies signaling disengagement from the past (Parkin, 2009). Organizations have been known to burn old policies and tear down buildings to demonstrate their disengagement from the past and the embracement of the future. The approach best works when fundamentally supported by widespread communication about the change and ensuring that staff and administrators understand the rationale (Hagerty & Buelow, 2017).

The critical importance of involving persons affected by the change cannot be overstressed. If CNAs feel involved in the planning and implementation of the change are invited to participate and voice their views in the process, they will be much more likely to commit to the changes and engage colleagues to do the same (Hummel, 2017). Similarly, it is critical to get a person on board who have substantial credibility or leadership in the organization. They are likely to be influential by creating by-ins particularly among CNAs resisting change (Parkin, 2009). Finally, change is likely to be far less successful when an organization fails to commit sufficient resources to see it through. Whether these resources are new training for the new process or finances, failure to invest in what it takes for success readily invites resistance.

Evaluation and Dissemination Plan

A culture change survey of nursing homes implementing the approach will be conducted to examine staff empowerment practices to appraise the post-implementation retention rates, as based on the postulates of Berridge, Tyler, and Miller, (2018). Targeted dissemination and diffusion of research findings will employ multifaceted dissemination strategies, emphasizing on media and channels that are most effective for stakeholders – nursing home administrators and directors, funding organizations, CNAs training institutions and CNAS. Based on the postulates of knowledge uptake, theoretically-informed frameworks will be used to guide research finding dissemination through presentations at conferences, posters, institutional websites, and podcasts.

In conclusion, CNA empowerment practices implemented by new-culture-adopting nursing homes are positively associated with retention cannot be ignored, more so as they are indicative of how they may be used to enhance staff stability. This new and vital knowledge on changing the culture of an organization can confer benefits to both nursing facilities and the care afforded to residents. It is expected that the findings of the research will benefit nursing facilities that seek the achievement of higher retention rates of CNAs.

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