Frontline workers in long-term care : recruitment ... · long-term care with no one to provide it....

Scripps Gerontology Center

Scripps Gerontology Center Publications

Miami University Year

Frontline workers in long-term care :

recruitment, retention, and turnover

issues in an era of rapid growth

Robert AtchleyMiami University, [email protected]

This paper is posted at Scholarly Commons at Miami University.

http://sc.lib.muohio.edu/scripps reports/15

Ohio Long-Term Care Research Project

FRONTLINE WORKERSIN LONG-TERM CARE:RECRUITMENT,RETENTION, ANDTURNOVER ISSUESIN AN ERA OF RAPIDGROWTH

Robert C. Atchley

September 1996

Scripps Gerontology Center Miami University Oxford, Ohio 45056

Robert C. Atchley is Director of the Scripps Gerontology Center andDistinguished Professor of Gerontology at Miami University, Oxford, Ohio.Professor Atchley has published more than a dozen books, including SocialForces and Aging, The Sociology of Retirement, Families in Later Life (withLillian Troll and Sheila Miller), and Aging: Continuity and Change. He also hascontributed more than 70 articles and book chapters to the social scienceliterature on aging. His major research interests include long-term care,adjustment to retirement, family issues and aging, and adult development,especially spiritual development.

This research was funded by a grant from the State of Ohio, Board of Regents, Ohio Long-TermCare Research Project. Reprints available from the Scripps Gerontology Center, MiamiUniversity, Oxford, OH 45056; (513) 529-2914; FAX (513) 529-1476.

Frontline Workers in Long-Term Care:Recruitment, Retention, and Turnover Issues

in an Era of Rapid Growth

Robert C. Atchley

Scripps Gerontology CenterMiami University

Oxford, OH 45056

September 1996

Executive Summary

Frontline workers in long-term care are the paraprofessionals, such as nurse aides,personal care workers, home health aides, and homemaker service workers, who provide morethan 80 percent of the direct care to nursing home residents and more than 90 percent of formalservices delivered by home care programs.

There is a shortage of frontline workers in long-term care and this shortage is projectedto reach crisis proportions very soon. In fact, chronic short-staffing of nursing homes and waitinglists stemming from a shortage of home care workers are already a reality in many localities. Theprimary goal of this report is to summarize our information base concerning how best to recruitand retain high quality frontline staff in long-term care.

Low pay and lack of health insurance are obvious obstacles to increasing the number offrontline workers in long-term care, especially in tight local labor markets where jobs in othersectors of the economy are more attractive than in long-term care. Frontline workers in long-termcare are among the lowest paid workers in the economy, and many have annual earnings belowthe poverty level. Few have health insurance coverage.

Job satisfaction is almost as important as pay and benefits as a determinant of whetheremployees stay in long-term care. The major predictors of job satisfaction are:

• a continuous employee orientation process that establishes and maintains an employee'ssense of belonging and knowing what is going on within the organization,

• sufficient training to do an adequate job,

• job designs that emphasize genuine two-way communication and shared decision makingbetween supervisors and frontline workers, and

• frequent and supportive supervision that fits the needs of various types of employees.

In a larger context, recruiting and retaining frontline workers in long-term care is mademore difficult by a mentality among policy makers that emphasizes cost containment and pays toolittle attention to the long-term consequences of "balancing the budget at the expense of frontlineworkers." If we do not find a way to pay a living wage to frontline workers and to provide dignityon the job, we are unlikely to be able to meet future needs for long-term care.

Recruiting and retaining the large number of quality frontline workers that will be neededto care for a growing population of disabled elders is likely to be one of the greatest challengesfacing our aging society.

Acknowledgements

The author wishes to acknowledge financial support from the Ohio Long-Term CareResearch Project. Jane Karnes Straker, Marisa Scala, Sheila Atchley, and Lawrence Weiss allmade helpful comments and identified literature that improved this report. Finally, Andrea Nevinsof the Brookdale Center on Aging very generously shared her extensive files of hard-to-findliterature on staff recruitment and retention in the field of aging.

Table of Contents

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

TERMINOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

A DYNAMIC PROCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Labor Market Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Organizational Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4The Nature of Frontline Work in Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 5The Cost of Turnover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Push and Pull Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Trends and Problems in the Field of Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . 8

AREAS FOR IMPROVEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Compensation and Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Identifying and Soliciting Job Candidates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Selecting Personnel to be Hired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Orientation of New Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Job Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Continuing Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Information on Reasons for Turnover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Organizational Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Public Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

HOW TO KNOW IF EFFORTS HAVE PAID OFF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

SUGGESTIONS FOR FURTHER READING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Frontline Workers in Long-Term Care: Recruitment, Retention, & Turnover Issues in an Era of Rapid Growth

Scripps Gerontology Center Page 1

Introduction

Current experience and populationprojections both lead to an alarmingconclusion: Unless we find new solutions tothe problems of recruiting and retainingeffective frontline workers in long-term care,the rapidly rising demand for long-term careservices of all kinds will far outstrip thelabor supply, leaving thousands needinglong-term care with no one to provide it.

Crown, Ahlburg, and MacAdam(1995) cited numerous examples of states,including Ohio, that have issued alerts tolocal agencies concerning shortages ofparaprofessional frontline workers in long-term care, especially home care workers butalso nursing home aides and personal careworkers in assisted living as well. The OhioDepartment of Aging surveyed home careagencies and found that 30 percent had clientwaiting lists attributable to shortages of homecare workers (Glock, 1995). Both home careand institutional providers report difficulty inrecruiting. High rates of turnover in frontlinelong-term care positions are common(Marion Merrell Dow, 1995; Feldman, 1994).

Silvestri (1993) projected that nation-ally paraprofessional work both in nursinghomes and in home care would be among thetop 12 occupations with expanding needs forworkers from 1992 to 2005. Specifically, heprojected a need for nearly 600,000 addi-tional nurse aides for institutional care andover 475,000 additional homemaker andhome health workers. In percentage terms,the number of frontline nursing homeworkers was projected to increase by 45

percent and the number of home careworkers was projected to more than double.More than 75 percent of this projectedincrease was due to increased demand andless than 25 percent was attributed to theneed to replace workers who leave. Giventhat turnover rates are high among front-lineworkers in long-term care, Silvestri's projec-tions probably underestimate future recruit-ing needs.

Traditionally, frontline long-term careworkers, especially in home care, have comeprimarily from a limited labor pool: un-married, middle-aged women with a highschool education or less (Cantor andChichin, 1990; Crown, 1994; Glock, 1995).To meet staffing needs of the future,organizations will have to reach out to othergroups. As they do so, it is important tobuild on already-existing knowledge andexperience about recruitment, retention, andturnover.

The primary goal of this report is tosummarize our information base concerninghow best to recruit and retain high qualityfrontline staff in long-term care. Unfor-tunately, because registered nurses andlicensed practical nurses can be expected torespond to different sets of issues than nurseaides, personal care assistants, and homecare workers (Cohen and Hudecek, 1993;Atchley, 1992), the extensive literature onrecruitment and retention of nurses, mostlyin hospital situations, is of questionable valuein understanding the dynamics of staffrecruitment and retention of unskilled long-term care workers.

Instead, we focus our review onpublished articles that specifically deal withnursing home or home care organizations.This literature consists of a very smallnumber of carefully done analytical studies,

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a few descriptive studies, and a large numberof articles offering practical tips based onprofessional experience. We do not have theluxury of waiting until systematic researchcan nail down predictable ways to identifypeople who are likely to become excellentworkers committed to staying in frontlinework in the field of long-term care. We mustalso look at the practice literature. But inusing the educated guesses of professionalsworking in the field, we introduce infor-mation that may work well in one situationbut not in another. Solutions offered areoften based on idealistic showcase or "bestpractice" programs that rely on a financialbase of grant funding, which means that theyare often difficult to apply under normalfinancial constraints. Therefore, the infor-mation in this report should be taken as aninventory of potentially useful ideas thatremain to be tested in most long-term caresituations. The best way to use this infor-mation is to start with a specific organi-zation's highest-priority needs, developmodest trial solutions that seem to addressthose needs, and use systematic feedbackfrom actual experience to decide on nextsteps.

Paraprofessions provide 80 percentof the direct care given to residentsof nursing homes and over 90percent of the formal direct caregiven to home-care clients.

TERMINOLOGY

We first need to make sure we have acommon vocabulary. This report focuses onfrontline workers in long-term care, thepeople whose paraprofessional work provides80 percent of the direct care given toresidents of nursing homes and over 90percent of the formal direct care given tohome-care clients. An amazing variety oflabels are used for these positions. In nursinghomes they can be called nurse aides,resident care technicians, nursing assistants,or geriatric nursing assistants. In home care,they may be called home health aides, homecare aides, personal care assistants, homecare workers, or homemaker serviceworkers. In some areas, the term certified ispart of the occupational title, to indicate thatemployees have completed a specifiedtraining program.

Recruitment consists of all the stepstaken by an organization to identify potentialapplicants, solicit and process applications,and hire new staff. Retention refers mainly toan organization's capacity to keep high-quality workers. Retention rates are bestmeasured longitudinally, by looking at theproportion of people hired within a givenperiod who are still with the organization atsome time in the future. Most managersbelieve that retention is related to variousforms of compensation, such as pay or fringebenefits, and rewards, such as promotionsand selective training opportunities. Reten-tion is also thought to be related to aspects ofthe organizational environment, such asorganizational culture, philosophy of super-vision, and organizational support foremployee education, autonomy, and partici-pation in decision making.



Turnover rates average about 45percent in nursing homes and 10percent in home care programs, butthe range is enormous.

Turnover rates are usually expressedas a percentage and are computed by dividingall of an organization's new hires in a giventime period (usually one year) by theiraverage number of positions during that timeperiod. Turnover rates average about 45percent in nursing homes and 10 percent inhome care programs, but the range isenormous (Marion Merrell Dow, 1995).Some organizations have as little as 5 percentannual turnover; others have well over 200percent turnover annually. High turnoverrates can be misleading, however, because anorganization can have a large core of stableand effective workers and at the same timehave a few positions where turnover isextremely high, which could result in a highannual turnover rate. To allow for thispossibility, it is advisable to also compute thepercentage of positions for which there isturnover in a given year.

Some turnover is inevitable. Peopleget promoted; people die; people move;people retire. Staff members who are valuedby their employer but who voluntarily quitconstitute a type of turnover that probablymost concerns managers of long-term careprograms. Another particularly problematiccategory consists of newly-trained workerswho quit within a short time, which results ina loss of the organization's recruitment,orientation, and training investment in thosepeople. As we will see, hiring staff is anexpensive process. In any case, continuity ofcare is essential in monitoring clients'changing needs as well as clients' responses

to care interventions. Therefore, highturnover of personnel most directly able toobserve the care recipients is counter-productive to adequate long-term care.

A DYNAMIC PROCESS

Recruitment, retention, and turnoverare obviously interrelated. Some of thefactors that attract staff to join anorganization are the same factors that attractthem to stay. An effective recruitmentprocess that selects workers whose personalgoals match those of the organization islikely to produce high rates of retention andlow turnover rates. On the other hand, arecruitment process that hires a large numberof people whose goals do not match those ofthe organization is likely to have a high level ofturnover and low retention.

Labor Market Issues

For frontline jobs in long-term care,recruitment, retention, and turnover arerelated to local conditions in both the long-term care labor market and in the overalllocal labor market. Local labor markets arequite variable across the United States andwithin states. When the general local labormarket is tight, there are more jobs thanqualified people, which means that peoplewho are motivated by occupational prestige,opportunity for advancement, or higher payand better benefits are more likely to findbetter opportunities outside long-term care,which in turn means that recruitment andretention become more difficult in long-termcare. Likewise, when the local long-termcare labor market is expanding, competitionamong providers for new staff intensifies,recruiting cannot be very selective (becauseof high labor demand and low labor supply),and retaining existing staff can also becomemore difficult. When there are more people

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looking for work than there are jobs,recruiting can be more selective. For exam-ple, this sometimes happens temporarilywhen local hospitals downsize and cut nurseaide positions.

Individuals enter the frontline long-term care labor market in several ways: theymay not have the skills required for better-paying jobs in other labor markets, they mayhave had positive experiences of long-termcare previously, or they may be entering thelabor market for the first time in midlife andmay have heard of opportunities in long-termcare. Some people are in the market forfrontline jobs in long-term care to gainexperience that will be useful for a laterprofessional career in long-term care. Someenter this labor market because jobs arescarce in other labor markets, and they tendto leave long-term care if opportunities inother markets open up. People already work-ing in the field are also potential candidatesfor job openings.

Organizational Characteristics

Most long-term care organizations donot have the luxury of being highly selectivewhen it comes to hiring frontline workers.Selectivity is possible mainly for the mostattractive organizations. Management lore inlong-term care contains a number of general-izations about what makes organizationsattractive or unattractive. Within the long-term care labor market, the attractiveness ofspecific organizations is thought to be relatedto the reputation of the organization amongfrontline workers, competitive pay and bene-fits, and a management philosophy that en-courages employee development and allowsfrontline workers to gradually grow intogiving more input, participating in decisionmaking, and taking more responsibility. Fororganizations, unattractiveness is associated

with a poor reputation among frontlineworkers, an authoritarian managementphilosophy, pay and benefits below themarket average, and policies that put littleinvestment into employee growth anddevelopment. However logical these ideasmay appear, it is important to note that, likemany ideas in management culture, theseideas have not been tested through systematicresearch.

The economic realities of long-termcare place significant constraints onthe extent to which organizationscan be attractive in terms of pay andbenefits, especially in competitionwith organizations outside the long-term care labor market.

The economic realities of long-termcare place significant constraints on theextent to which organizations can beattractive in terms of pay and benefits,especially in competition with organizationsoutside the long-term care labor market. Forexample, Glock (1995) found that withsubstantially less time invested in training,workers could earn as much in the fast-foodindustry as in home care. And the nationalaverage wage of starting frontline workers innursing homes ($5.53 in 1995) was less thanthe average paid to restaurant workers(Marion Merrell Dow, 1995; Glock, 1995).However, there is still a range of pay andbenefits within local long-term care labormarkets, which means that some organi-zations will be relatively attractive on thatdimension. For example, Glock (1995) foundthat hourly pay rates for home health aides inOhio ranged from $4.25 (minimum wage) to$11.00.



Organizations also vary a great dealin terms of providing access to healthbenefits. Most organizations offer healthbenefits only to full-time employees, andsome intentionally limit the number of hoursto control the number of workers qualifyingfor benefits. Thus, frontline employees, over95 percent of whom are women, can workmore than 60 hours per week for two ormore nursing homes or home care agenciesand still not qualify for health benefits.Home care workers often do not receivehealth or retirement benefits because two-thirds of them work part-time (Glock, 1995).In addition, even if employees qualify forhealth benefits, more than half of home careagencies require employees to share the cost(Glock, 1995), and most home care workerscannot afford to pay their share.

More organizations can be attractivein terms of their reputation for consideratetreatment of staff and their commitment tostaff training and development, althoughthese functions are also subject to financialconstraints. Organizational policies thatemphasize personal care of the clients asmuch as performance of instrumental tasksare particularly attractive to frontline work-ers, both in institutional settings and in homecare.

The Nature of Frontline Work in Long-TermCare

Although frontline jobs in long-termcare are often considered "dead end," manyworkers value the warm personal relation-ships they develop with clients or residentsand get a sense of pride and accomplishmentfrom serving a population that very muchneeds their services (Feldman, 1994; Eustisand Fischer, 1991). Helmer, Olson, andHeim (1993) found that 91 percent of thenurse aides they surveyed felt that the work

they did was "really important" and 66percent felt proud to talk to other peopleabout their work.

Issues in retention and turnover areslightly different for home care workerscompared with nursing home workers. Homecare workers tend to be somewhat older andhave a wider range of education than nursinghome workers (Crown, 1994). They alsotend to have more flexibility in their jobsbecause they are less closely supervised. Yee(1994) reported that home care workers andclients commonly negotiate scheduling, workpriorities, and tasks in ways that can divergesubstantially from the official care plan. Bycontrast, nursing home workers usually workunder the watchful eyes of supervisors andmust contend with bureaucratic organizationsthat focus on high worker productivitymeasured in terms of an assembly-line typeschedule of tasks to be performed anddocumented during each shift. In general,nursing home workers appear to be muchmore likely to experience inflexibleschedules and severe time pressures on thejob than are home care workers.

As a result of these differences,turnover of front-line workers in home careorganizations tends to be lower than fornursing homes. For example, Close et al.(1994) reported that 65 percent of nursinghomes had annual turnover rates above 25percent, whereas only 17 percent of homecare agencies had more than 25 percentturnover. Based on a survey of employers,Marion Merrell Dow (1993, 1994) reportedaverage annual turnover of 44 to 48 percentfor nurse aide positions and only 10 to 12percent for home health aides.

Regarding reasons for leaving,Gilbert (1991) found that 78 percent of homecare workers who resigned cited working

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conditions as a reason for resignation. Themost important negative aspects of workingconditions were lack of opportunities foradvancement, instability of working hours,emotional strain of the job, and lack of inputinto the development of care plans. Feldman(1994) reported that isolation from peers andinadequate supervision were also importantnegative elements of working conditions.Among Gilbert's respondents, pay andbenefits were cited as reasons for resignationby 55 and 50 percent respectively. Lack ofrecognition and burnout were also cited by athird or more of those who resigned. Thus,there were many reasons for leaving homecare, and economic factors were not seen asthe only important problems.

Eustis and Fischer (1991) found thathome care workers were often caughtbetween the formal standards of theiremployers and the informal relationshipsthey developed with their clients. Manyhome care workers provided companionshipand other services on their own time. Homecare workers tended to get involved in thepersonal lives of the clients and in theirfamily relationships as well. Eustis andFischer found that over half of the home careworkers in their study had friendlikerelationships with their clients. This qualityof relationship is most important to theclients and to the home care workers as well,but unfortunately home care agencies andfunding authorities often see instrumentaltasks as the most important component ofhome care. Certainly there must be a balancebetween the "doing for" and "being with"components of the home care relationship,but to retain workers in home care, agenciesand funders may have to allow more time forcompanionship and relax the emphasis oninstrumental tasks.

In contrast to home care workers,nursing home workers on the front-line have difficulty finding time torespond in more than a cursoryfashion to the individual needs ofresidents.

In contrast to home care workers,nursing home workers on the frontline havedifficulty finding time to respond in morethan a cursory fashion to the individual needsof residents. For example, Bowers andBecker (1992) found that successful nurseaides who stayed in their jobs had to learn tofocus on tasks, not people. To get the workdone "well enough to stay out of trouble,"workers had to learn to unobtrusively cutcorners, often in violation of standards ofresident care. For instance, they cut cornersby ignoring resident call buttons, "batching"residents for efficient feeding, and changingincontinent residents on a schedule ratherthan as needed. New nurse aides tended to bemore responsive to resident requests, and ifthey could not learn to ignore these requests,they did not last because they could not gettheir required work done. New workers whocould not learn to juggle multiple tasks werealso unsuccessful. In addition, some newworkers could not tolerate putting theresidents' socioemotional needs last andtended to quit. To "succeed," to remainemployed as a nurse aide, Bowers andBecker found that employees had to developthick skins with regard to the socioemotionalneeds of the residents. They simply did nothave the time to devote to those concerns.

Like home care workers, nursinghome aides who left were dissatisfied withworking conditions as well as pay and



benefits. Nursing home workers often quitearly in their tenure, some in response to theheavy demands of the job, some to pursuebetter opportunities, and some from disillu-sionment caused by the gap between whatthey saw as the ideal of frontline care and therealities of work in many nursing homes. Ofcourse, others leave because they do not likethe work or are discharged because they arenot doing an adequate job.

The total cost associated with eachinstance of turnover amounted to$3,362.

The Cost of Turnover

Turnover is expensive. Zahrt (1992)carefully documented the costs of replacinghome care workers. She found that, for eachreplacement hired, recruitment (advertising,outreach, printing brochures, interviewingtime, and time to check references) cost$398. Orientation expenses (staff, materials,and travel) amounted to $675. Trainingexpenses (certification training, practicum,and competency evaluation) were $1,859. Inaddition, the exit interview for the workerbeing replaced cost $31. The total costassociated with each instance of turnoveramounted to $3,362. Obviously, high turn-over represents a substantial financial loss tothe organization. In addition to the financialcosts of hiring, there are financial costsassociated with lost productivity during thetime it takes newly-hired workers tocomplete the learning curve.

Zahrt's estimates do not include theenormous attrition that can occur in therecruitment process. For example, White(1994) described the results of program

designed to recruit, train, and place homecare workers. Out of 751 telephone inquiriesabout the program, 683 were scheduled forinterviews, 351 actually showed up for theirscheduled interview, 216 were accepted forthe training program, 133 actually startedclasses, and 106 graduated. Of the 106 whograduated, only 46 were still with the agency6 months after they were placed.

Push and Pull Factors

It is useful to think of recruitment andretention as processes that respond to various"push" and "pull" factors. Push factors areelements of a person's current situation thatlead her or him to want to make a change.For example, low job satisfaction, frustrationwith ineffective management or overlybureaucratic organizational processes, lowpay, and lack of benefits are common pushfactors in long-term care. Pull factors attractan individual. Pull factors that can attractworkers to stay with their current employersinclude high job satisfaction, consideratemanagement (especially supervisors), above-average pay, health benefits, opportunitiesfor advancement, and retirement pensionprograms. Of course, these same factors mayexert a pull toward another organization thatthe worker sees as ranking higher onsignificant pull factors.

Although most workers respond tothe same set of push and pull factors,workers vary a great deal in the weightattached to specific factors. To retain aworker, it is useful to know which of thepush-pull factors are at the top of his or herpriority list.

The difficult situation facing thoseresponsible for long-term care staff recruit-ment and retention in frontline positions ispartly the result of the poor image of this

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type of work among the general public. Acreative Oregon program produced a seriesof 30-second television public serviceannouncements about the value of long-termcare work (Human Resources & Aging,1993). Much more effort is needed alongthese lines. Perhaps after a decade or so ofbeing deluged with television messages, thepublic might come to know about thedifference good long-term care can make andthe pride most frontline workers take indoing it.

Frontline workers in long-term careare among the lowest paid people inAmerica. For 1989, Crown (1994) found aconsiderable disparity between the medianhourly wage among home care workers($4.22) compared with nursing home aides($5.29) and with hospital aides ($7.12).Because of low wages and less than full-timehours for a large proportion of frontlineworkers, the median individual earnings ofworkers in both nursing homes and homecare were below the poverty level. To attractand retain the types of workers wanted andneeded, organizations will have to payworkers a living wage. To make a living,many home care workers now are forced towork far more than 40 hours a week (Cantorand Chichin, 1990). Many nursing homeworkers also work considerable overtime.Some work double shifts. Because front-lineworkers in long-term care are seldomunionized (Close et al., 1994), overtimeseldom brings premium pay.

Trends and Problems in the Field of Long-Term Care

One reason that the assisted livingmodel of institutional care is growing rapidlythroughout the country, whereas nursinghome growth is nonexistent in many states,is the emphasis in assisted living on the

relationship between the client and thefrontline worker. In the assisted livingmodel, clients and staff negotiate whatservices will receive the highest priority,which can be much more flexible than thelock-step model of nurse aide ADL tasks thattypifies nursing homes. The additional timefor relationships is created by an agreed-uponde-emphasis of instrumental tasks. Thus, if aperson only wants a bath every other day,then staff time is created that can be used inother ways.

Workers are willing to forego someamount of pay for greater control over theirworking conditions. For example, turnover islow among home care workers even thoughthey could make significantly more moneydoing the same work in nursing homes. Iffrontline jobs in nursing homes or in homecare were redesigned to encourage jobadvancement through training and increasedparticipation in decision making and takingon more responsibility, then more workerswould be attracted to these jobs. But teamapproaches to human services are notefficient. They are satisfying to the workersbut time-consuming because teams have tomeet and participatory meetings take muchmore time than authoritarian meetings. Inaddition, these meetings take frontline staffaway from their assigned care duties. Thus,job redesign is needed in long-term care, butit is not likely to reduce the number ofworkers needed. In fact, just the opposite.

There is considerable tension betweenthe images of good care used by profession-als and those used by managers, governmentofficials, and politicians. Professionals seecare as ideally consisting of a highlyindividualized program of service beingperformed by an empowered frontlineworker who has the knowledge and skills tobe able to operate independently and deal



with complex work (Feldman, 1994).However, such workers in today's labormarket expect at least $15 per hour, clearlya substantial departure from current frontlinemarket wages in long-term care. Managers,government officials, and politicians, on theother hand, are still operating with anindustrial mind-set. They think in terms ofstandard service packages, standardized jobdescriptions, quantitative approaches tomeasuring worker productivity and evalu-ating worker performance, and cost contain-ment by increasing demands on workerproductivity, which in caregiving cannot beachieved by automation. Feldman (1994:7)referred to this combination of policy stancesas "balancing the budget at the expense offrontline workers." These attitudes tend toexacerbate problems of recruiting andretaining effective front-line workers in long-term care.

The nursing home and home careindustries are converging and arebeginning to compete for people inthe same labor pool, which will tendto increase the shortage of frontlineworkers.

Feldman (1994) also pointed outseveral trends in long-term care that willinfluence recruitment, retention and turn-over. First, with middle-class jobs disappear-ing at a much faster rate than they are beingcreated, many people displaced from middle-class jobs are being forced to consideremployment at modest pay rates. Those whowant to feel that their work is accomplishingsomething worthwhile might be attracted tolong-term care. Second, as hospitals de-emphasize inpatient hospital care, they have

begun offering subacute care and variousforms of community-based care. Nursinghomes have increasingly specialized inrehabilitation and subacute care and havebranched out into home care. As a result, thenursing home and home care industries areconverging and are beginning to compete forpeople in the same labor pool, which willtend to increase the shortage of frontlineworkers. Third, funders increasingly empha-size managed care, which involvesproductivity standards and standardized careplans, which reduces the attractiveness offrontline work. Fourth, pressures are in-creasing to allow more consumer choice andconsumer direction of services. Obviously,trends three and four are on a collisioncourse, and frontline workers will probablybe pressured by both sides in the conflict.

AREAS FOR IMPROVEMENT

In this section, we look at varioussuggestions contained in the literature forimproving various aspects of recruitment andretention of frontline workers in long-termcare. Problems with recruitment andretention are thought to be related to severalareas of operations: compensation andbenefits, identifying and soliciting candidatesfor open positions, selecting personnel to behired, orientation of new employees, jobdesign, training, supervision, organizationalsupport, and public relations. All of theseissues are part of the process of getting theright people for the job and keeping them byensuring that their jobs are satisfying andrewarding. We will look at each of these areasin turn.

Compensation and Benefits

As we documented above, averagewages for front-line workers put them in thelow-income category and, because of their

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part-time work, many are working poor. In1995, starting nursing home aides and homecare workers averaged about $11,000 peryear. Experienced nursing home aides made$14,500 annually for full-time work andexperienced home care workers made about$12,600 (Marion Merrell Dow, 1995). Thepoverty level in 1995 for a two-personhousehold with the householder under age 65was just over $10,000 (U.S. Bureau of theCensus, 1996).

Given that much institutional care isfinanced by Medicaid and home-based long-term care is financed byboth Medicare and Medicaid, theoutlook for improving compensationin an era of government costcontainment is not good.

Both state and federal governmentsare under intense pressure to contain thegrowing costs of Medicare and Medicaid.Given that much institutional care is financedby Medicaid and home-based long-term careis financed by both Medicare and Medicaid,the outlook for improving compensation inan era of government cost containment is notgood. In addition, when additional resourcesdo become available, organizations tend toincrease professional compensation first anddefer increases for frontline workers.

But are there viable alternatives toraising pay? If pay does not rise to a levelthat attracts good workers, thousands ofpeople will be going without needed care,which will almost certainly exert heavypolitical pressure. Some professionals in thefield expect new models of care, such asassisted living and managed care, to decrease

costs. However, the need to increasecompensation for frontline workers mayoffset any potential cost savings. To meetstaffing needs, especially in nursing homes,where minimum staffing levels are mandatedby licensing regulations, organizations havehad to increase compensation in order to stayin business. Waiting lists in home careprograms can be expected to exert compar-able pressures to increase compensation.Indeed, the once-substantial gap betweenhourly wages of nursing home and homecare workers has narrowed substantially(Feldman, 1994).

Employers may need to pick up theentire cost of health coverage inorder to make health benefits asignificant pull factor.

On the benefit side, there is alsosignificant room for improvement. But withhealth benefits becoming more problematiceven in the upper reaches of the occupationalstructure, the likelihood of substantial gainsin health coverage for frontline long-termcare workers seems slim. Nevertheless, withthe advent of local health care alliances andhealth maintenance organizations, healthcoverage may become less expensive forsmall employers, which in turn couldimprove access to health coverage forfrontline workers in long-term care. Em-ployers may need to pick up the entire costof health coverage in order to make healthbenefits a significant pull factor.

Employer pensions are not likely tobecome more available. At the wage leveland in labor market sector of most frontlinelong-term care workers, Social Security is



customarily the sole source of future retire-ment benefits. However, organizations withemployer-funded retirement pension pro-grams will continue to enjoy a significantpull factor.

In one study, 85 percent of newemployees in home care came frompersonal referrals.

Identifying and Soliciting JobCandidates

Open houses for potential frontlineworkers, job fairs, and newspaper adver-tising generate a large number of applicants,but referrals from existing staff are the mostefficient way to identify viable jobcandidates. Glock (1995) reported that 85percent of new employees in home care camefrom personal referrals. One way to increasereferrals is to offer bonuses to employeeswho refer someone who is hired andretained.

Only about 10 percent of frontlineworkers are hired through job advertisements(Glock, 1995). However, effective ads stresselements of the job that attract applicants--themeaningfulness and importance of the work,competitive pay and benefits, flexiblescheduling, advancement opportunities, andcongenial work environment.

In recruiting, accurately describe thejob. It does little good to mislead candidatesinto taking jobs that they will quit as soon asthey find out what the job is really like.What is expected of employees and whatemployees can expect are pragmatic realitiesthat need to be clearly stated in advertisingand in job interviews.

Special outreach efforts are oftenneeded to attract very young people,older people, and low-income peopleto jobs in long-term care.

Special outreach efforts are oftenneeded to attract very young people, olderpeople, and low-income people to jobs inlong-term care. Young people can beattracted to long-term care by working withhigh school guidance counselors to insure thatthey have up-to-date information on thetypes of jobs, especially part-time jobs,available in long-term care and the qualifi-cations successful applicants need. Someschool vocational programs offer courses thatqualify students for work in long-term care.Many young people who have full-time jobsin long-term care today began as part-timeworkers while they were still in school.Service learning programs give studentsacademic credit for engaging in volunteerwork with local agencies, and theseprograms are an excellent way to exposeyoung people to long-term careenvironments. Glock (1995) reported thatnext to personal re-ferrals, schools were thesecond most effective source of newemployees.

Most managers in long-term care donot think of people over 60 as a potentiallabor pool, but this may be a mistake. Aprogram in Indiana successfully recruited,trained and placed more than 20 older peopleas either certified nurse aides or home healthaides (Human Resources & Aging, 1994a).Such programs would probably be attractiveto physically able elders with low retirementincomes.

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Low-income people with noemployment history can becomesuccessful frontline workers. On theother hand, a process that effectivelymoves people from welfare to workoften requires substantial trainingand support over an extended timeperiod.

Currently there is an emphasis onmoving people from welfare to work. In thispolicy climate, programs that train AFDCrecipients for work in long-term care can beattractive. For example, one program firstscreened applicants using the Test of AdultBasic Education, then it assigned each traineeto a counselor who worked closely with themto develop an individualized plan foraccomplishing the transition from welfare towork. Trainees were then put through a 60-hour basic life skills and work maturitycourse. Then they were ready to go througha 90-hour course and 40-hour practicumleading to qualification as a nurse aide,personal care assistant, or home care aide.After completing the program, graduateswere assigned a peer mentor, someone justabove them on the career ladder, whoencouraged the graduate to continuouslyimprove. This program was successful, withan 82 percent retention rate for the first 90days following graduation (Human Resources& Aging, 1994b). Most of the substantialcosts of this program were financed throughthe Job Training Partnership Act. Anotherapproach assigned qualified AFDC recipientsor applicants to paid "long-term careapprenticeships" that after a year qualified anindividual to be hired permanently. Theseindividuals were paid a "training wage." The

success of these programs suggest that low-income people with no employment historycan become successful frontline workers. Onthe other hand, a process that effectivelymoves people from welfare to work oftenrequires substantial training and support overan extended time period.

Selecting Personnel to Be Hired

Previous job performance is one ofthe best predictors of future job performance.Employers are also responsible for screeningout applicants whose backgrounds reveal thatthey might pose a risk to coworkers, clientsor residents. Therefore, getting and verifyingreference information from previous em-ployers and doing background checks areimportant in screening applicants. To dobackground and reference checks requireswritten permission from the applicant.

Job interviews are probably the mostimportant determinant of who gets hired byan organization. Good job interviews aresemi-structured. They cover a predeterminedset of basics such as general background,past performance, and problem solvingability but allow applicants flexibility inshowing how their background and personalgoals relate to the job for which they areapplying. The interviewer poses generalquestions and then spends most of theinterview listening to the applicant'sanswers. Careful listening is a key to pickingup subtle clues that can identify applicantswhose qualifications fit the organization andwhose goals can be met by the organization.This latter point is especially important inpredicting potential for retention.



Good orientation programs tend toestablish a healthy and vital ongoingconnection between the new em-ployee and the organization.

Orientation of New Employees

The new employee's orientationexperience sets the stage for all that follows.Good orientation programs tend to establisha healthy and vital ongoing connectionbetween the new employee and theorganization. New employees' first-dayorientation creates for many an enduringimage of the organization's attitude towardemployees. Most programs use a check-listof items that all employees need to knowbefore they begin work. When orientation isseen as an ongoing process, details of allaspects of orientation do not have to beaddressed in the initial orientation. Forexample, payroll information needs to bedealt with on the first day, but if healthbenefits do not become available until theemployee has been with the organization forsix months, then details of the health planneed not be given until they become relevant.Effective orientation programs produceemployees who feel valued, are motivated todo a good job, know where to go to getinformation, and are clear about theirresponsibilities and opportunities. Feedbackfrom employees is an important indicator ofthe effectiveness of orientation programs.Effective orientation has been linked to lowerturnover (Iannone and Bye, 1993).

Continuous job design is based onexternal changes in standards, rules,and guidelines, but it also usesfeedback from the employees torefine and change operationaldefinitions of frontline jobs.

Job Design

General job design is usually doneprior to soliciting applicants and hiring staff.But jobs seldom remain static for long,which means that long-term care organi-zations need mechanisms for continuous jobdesign. Continuous job design is based onexternal changes in standards, rules, andguidelines, but it also uses feedback from theemployees to refine and change operationaldefinitions of frontline jobs. One area wherejob design in frontline positions isconsistently deficient is in allowing frontlinepersonnel an opportunity to make suggestionswith regard to resident or client care plans.This problem is compounded by staffingplans that rotate frontline workers to adifferent set of clients periodically. Thisprevents the development and maintenance ofthe relationship and knowledge needed tocontribute to care planning.

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Labels such as "basic nursingassistant", "nursing assistant", and"senior nursing assistant" linked todifferences in compensation canacknowledge differences in expecta-tions and rewards and create percep-tible opportunities for advancement.

Another neglected area is the creationof opportunities for advancement. Glock(1995) reported that 75 percent of home careagencies offered no advancement oppor-tunities for their frontline workers. Creatingadvancement opportunities can be done byencouraging frontline staff to continue theireducations and qualify for higher-levelpositions. Advancement opportunities canalso be created by formally recognizing thatsome frontline workers have moreknowledge and skills than others. Thus,labels such as "basic nursing assistant","nursing assistant", and "senior nursingassistant" linked to differences in compen-sation can acknowledge differences inexpectations and rewards and createperceptible opportunities for advancement.

Training

Many long-term care organizationsprovide little training beyond that requiredlegally to employ people as front-lineworkers. Nursing home jobs require at leasta minimum number of hours of initialtraining to become certified and annual in-service training on a prescribed set of topics,such as infection control and fire safety.However, states vary a great deal on thetraining requirements for home care workersand some have no minimum requirements.

Job satisfaction comes in largemeasure from knowing what isexpected and being able to do it.

There is no question that jobsatisfaction is linked to preparation. Jobsatisfaction comes in large measure fromknowing what is expected and being able todo it. Most workers need training ininterpersonal relationships, communicationand negotiation as well as in technical aspectsof their jobs. Most effective training infrontline long-term care jobs is on-the-jobtraining, where a new employee works for atime alongside an experienced employee tolearn the job. Group question-answersessions with an exemplary front-line workerare useful periodically even for experiencedworkers. Classroom training is oftennegatively evaluated by frontline workers inlong-term care, often because it is either"above their heads" or has no obviousapplication in their everyday work.

In addition to its capacity to improveemployee performance, training also hassymbolic value as an indicator of theorganization's concern for the worker(Brannon and Smyer, 1994). Nevertheless,most employers offer little training beyondthat required by regulatory agencies.

To be effective, training must be welldesigned and given by seasoned trainers. Forexample, Waung (1995) reported thattraining on how to cope with problem aspectsof the job heightened sensitivity to negativeaspects of the job and resulted in greaterworker attrition.



Most two-way, face-to-facecommunication between theorganization and the employeeoccurs in the process of supervision.

Continuing Communication

Employees can easily lose whatevergrasp of overall organizational goals anddirections they might have gained in theirorientation or apprenticeship period. Yetfrequent meetings are expensive and difficultto schedule. A low-key organizationalemployees' newsletter that outlines generalpolicies, communicates changes that affectemployees, and provides a schedule ofimportant upcoming events can be animportant bridge to employees. Com-munication from employees is alsoimportant. For example, employees could begiven a periodic opportunity to do a check-list evaluation of the organization,supervision, and overall agency admin-istration. But realistically, most two-way,face-to-face communication between theorganization and the employee occurs in theprocess of supervision.

Supervision

Supervision means very differentthings to different people. Some supervisorssee themselves as accountability officers whoenforce care standards and make sure thatmostly unmotivated employees perform thework they are being paid to do. Othersupervisors assume that most workers wantto work and to do a good job. They seethemselves as colleagues, teachers, andmotivators. Still others see themselves asneeding to be sometimes a disciplinarian,sometimes a coach, and sometimes a

cheerleader, depending on the particularemployee. Organizations need to thinkcarefully about what model of supervisionthey want to use, because this decisioninfluences the type of people they want tohire as supervisors.

Frontline employees are not givenenough constructive feedback onhow they could improve their perfor-mance.

The research on frontline workers inlong-term care clearly documents a wide-spread perception that frontline employees donot get enough positive supervision. That is,they are not given enough constructivefeedback on how they could improve theirperformance. "Problem employees" appearto get the most attention from supervisors.Of course, most supervisors have many otherthings to do in addition to supervision, and ifworkers are doing an adequate job, it is easyto get into the habit of ignoring them. Butsupervisors who do this run the risk of losingworkers who begin to feel unappreciated andunsupported. Lack of recognition is a majorcause of job dissatisfaction in long-term care(Feldman, 1994). Frequent supervision neednot be seen as a mistrustful looking over theemployee's shoulder. Instead, it can be afrequent opportunity to provide constructivefeedback and acknowledgement of a job welldone.

Fairness is a crucial element ofsupervision. Employees want to be able totrust that the supervisory process isequitable, consistent, and respectful. Breaksin trust can cause unwanted employeeturnover.

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Supervision also involves resolvingconflict among frontline employees. Innursing homes, for example, conflictbetween nurse aides or between nurse aidesand dietary aides is common. Supervisorsneed training in how to prevent and resolveconflict among the employees. An atmo-sphere of continuous conflict is conducive tohigh turnover.

Information on Reasons for Turnover

Although some turnover is unavoid-able, to get an effective overview of whyemployees are resigning, organizations needto collect information from everyone whoresigns or simply stops coming to work. Ifthere are conditions that are "push" factors inthe organization, managers need to knowwhat they are. Glock (1995) reported that 60percent of people who left home care cited"personal reasons," a vague category thatconveys little information to the organi-zation. Exit interviews attempt to go beyondthe socially desirable reasons for resignation,such as "personal reasons," to identifyunderlying causes of job dissatisfaction, ifapplicable. Organizational Support

Organizational support includes allo-cation of management time and financialresources to such supporting activities astraining, developing specializations andcareer tracks within long-term care,providing support to employees who have todeal with particularly difficult clients orresidents, helping staff deal with theemotional stresses, and helping home careworkers deal with the isolation they oftenfeel. Managers may feel that they do nothave the time or money to put into theseactivities, but these costs need to beconsidered in the context of the costs of

replacing workers who leave for lack oforganizational support.

Public Relations

Most frontline workers in long-termcare are proud of the job they do and feelthat it is important. But at the same time,they know that most people in thecommunity see their jobs as veryundesirable. Public relations activities areintended to create a positive image in theminds of the public. Public relations is badlyneeded for frontline workers in long-termcare. As yet we do not know how long itwould take to create a more positive image,but everyone seems to agree that publicopinion in this area has nowhere to go butup. A better image of the importance andvalue of frontline work in long-term carecould be expected to improve bothrecruitment and retention of effective staff.

HOW TO KNOW IF EFFORTS HAVEPAID OFF

On one point we can be absolutelycertain. If organizations do not plan inadvance to evaluate the results of steps theytake to improve recruitment and retentionthey will be in a poor position to evaluate theresults. They will not be able to know if theirefforts paid off.

Evaluation plans need not beelaborate. For example, if a strategy isdesigned to reduce turnover, then turnoverrates could be compared before and after theimplementation of the new strategy. If wagesare raised, using the rationale that increasedretention will lower recruiting costs, thenretention rates and recruiting costs before thewage raise could be compared with retention



rates and recruiting costs after the wageraise.

The period when an operationalchange is being designed is the time to thinkcarefully about what outcomes will indicatewhether the change paid off and how tomeasure these outcomes. For instance, if anew recruitment approach is to beimplemented, then recruitment rates areneeded before and after the change. Theorganization would want to collect and retaininformation on all contacts by potentialemployees both before and after imple-menting the new recruitment approach. Thisinformation is not routinely kept byemployers, so special efforts might beneeded to collect and retain it.

Carefully documented results ofefforts to improve recruitment and retentionare precious few at this point, so it is alsoimportant to communicate both positive andnegative results to colleagues. It is importantto know which approaches do not work aswell as which approaches prove effective.

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Conclusion

There is a shortage of frontlineworkers in long-term care and this shortageis projected to reach crisis proportions verysoon. Indeed, chronic short-staffing ofnursing homes and waiting lists stemmingfrom a shortage of home care workers are areality in many areas already.

Low pay and lack of health insuranceare obvious obstacles to increasing thenumber of frontline workers in long-termcare. The public's perceptions of this kind ofwork as distasteful and the people who do itas marginal have a negative effect onrecruiting that is less obvious. Tight locallabor markets in many parts of the countrymay also undercut both recruitment and re-tention of frontline long-term care personnel.

In addition to pay and benefits, jobsatisfaction is a major determinant ofretention in long-term care. In turn, themajor predictors of job satisfaction are: acontinuous orientation process that estab-lishes and maintains an employee's sense ofbelong and knowing what is going on withinthe organization, sufficient training to do anadequate job, job designs that emphasizegenuine two-way communication and shareddecision making between supervisors andfrontline workers, and frequent andsupportive supervision that fits the needs ofvarious types of employees.

Unfortunately, most long-term careorganizations are scrambling to just get thejob done from day to day, and a harriedsupervisory and administrative staff is not ina good position to address many of the

problems that hamper recruiting and thatresult in high turnover of frontline workers.But they will have to find the time or bereplaced by new organizations with a moreaggressive stance toward finding andretaining the needed frontline workers.

Our failure to find ways to financeadequate long-term care services lies at theroot of most of the issues presented in thisreport. This situation is not apt to changeanytime soon. In today's political climate,policy makers want to minimize spending forprograms such as Medicaid and Medicare.Basic health insurance coverage is becomingless adequate, and long-term care insurancefor the mass of the population is unlikely.The number of people who can afford tofinance their own long-term care is extremelylimited, and as the population ages, theproportion who outlive their money is likelyto increase.

So to whom can we look to solve theproblems of recruiting and retaining anadequate supply of frontline workers in long-term care? Perhaps we will have to lookinside ourselves.



SUGGESTIONS FOR FURTHERREADING

Brannon, Diane, and Streit, Andrea.(undated). Job Redesign Manual for NursingHomes. University Park, PA: PennsylvaniaState University College of Health andHuman Development. (A how-to manual onjob design. Could be adapted to home care aswell.)

Cantor, Marjorie H., and Chichin, Eileen R.(1990). Stress and Strain Among HomecareWorkers of the Frail Elderly. New York:Brookdale Research Institute on Aging. (Anextensive research report, but oftenapplicable mainly to the situation inManhattan.)

Feldman, Penny Hollander. (ed.) (1994).Frontline Workers in Long-Term Care.Generations, vol.18, no. 3. (A collection of18 articles by knowledgeable figures in thefield of long-term care.)

Iannone, Joane M., and Bye, MargaretGorley. (1993). An Orientation Manual ForLong-Term Care Facilities. New York:Springer. (An extensive discussion of avariety of issues and types of employeeorientation. Principles could be adapted forhome care agencies.)

Human Resources and Aging. Newsletterdealing with personnel issues concerning careof an aging population. Published by theEldercare Institute for Human Resources atthe Brookdale Center on Aging, HunterCollege, City University of New York.

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References

Atchley, Sheila J. (1992). What Do NursesWant: Critical Factors in Recruiting andRetaining RNs in Long-Term Care. Oxford,OH: Scripps Gerontology Center.

Bowers, Barbara, and Becker, Marion.(1992). Nurse's aides in nursing homes: Therelationship between organization andquality. The Gerontologist, 32, 3, 360-366.

Brannon, Diane, and Smyer, Michael A.(1994). Good work and good care in nursinghomes. Generations, 18, 3, 34-38.

Cantor, Marjorie H., and Chichin, Eileen R.(1990). Stress and Strain Among HomecareWorkers of the Frail Elderly. New York:Brookdale Research Institute on Aging.

Close, Liz, Estes, Carroll L., Linkins, KarenW., and Binney, Elizabeth A. (1994). Apolitical economy perspective on frontlineworkers in long-term care. Generations, 18,3, 23-28.

Cohen, Aaron, and Hudecek, Nadine.(1993). Organizational commitment-turnoverrelationship across occupational groups: Ameta-analysis. Group and OrganizationalManagement, 18, 2, 188-213.

Crown, William H. (1994). A nationalprofile of homecare, nursing home, andhospital aides. Generations, 18, 3, 29-33.

Crown, William H., Ahlburg, Dennis A.,and MacAdam, Margaret. (1995). Thedemographic and employment characteristicsof home care aides: A comparison withnursing home aides, hospital aides, and otherworkers. The Gerontologist, 35, 2, 162-170.

Eustis, Nancy N., and Fischer, Lucy Rose.(1991). Relationships between home careclients and their workers: Implications forquality of care. The Gerontologist, 31, 4,447-456.

Eustis, Nancy N., Fischer, Lucy Rose, andKane, Rosalie. (1994). The homecareworker: On the frontline of quality.Generations, 18, 3, 43-49.

Feldman, Penny Hollander. (1994). "Deadend" work or motivating job? Prospects forfrontline paraprofessional workers in long-term care. Generations, 18, 3, 7-12.

Glock, Paul. (1995). Home Health Aide andHomemaker Survey Report. Columbus, OH:Ohio Department of Aging.

Gilbert, Nancy J. (1991). Home care workerresignations: A study of the majorcontributing factors. Home Health CareServices Quarterly, 12, 1, 69-83.

Helmer, F. Theodore, Olson, Shirley F., andHeim, Richard I. (1993). Strategies for nurseaide job satisfaction. The Journal ofLong-Term Care Administration, Summer,10-14.

Human Resources & Aging. (1993). Whowill care? Oregon has an answer. 3, 1, 4.

Human Resources & Aging. (1994a). Fouremployment programs for older adults. 3, 3,3-5.



Human Resources & Aging. (1994b).Recruiting low-income workers for directcare services: Projects and resources. 3, 2,5-7.

Iannone, Joane M., and Bye, MargaretGorley. (1993). An Orientation Manual forLong-Term Care Facilities. New York:Springer.

Marion Merrell Dow. (1992). Managed CareDigest, Long Term Care Edition. KansasCity, MO.



Marion Merrell Dow. (1995). InstitutionalDigest. Kansas City, MO.

Silvestri, George T. (1993). The Americanwork force, 1992-2005. Monthly LaborReview, November, pp. 58-86.

U.S. Bureau of the Census. (1996). Income,Poverty, and Valuation of Noncash Benefits.Current Population Reports, Series P-60,No. 189.

White, Monika. (1994). Homecareconsortium addresses frontline worker issues.Generations, 18, 3, 54-56.

Waung, Marie. (1995). The effects of self-regulatory coping orientation on newcomeradjustment and job survival. PersonnelPsychology, 48, 3, 633-650.

Yee, Donna L. (1994). Will new settingsoffer better work environments forparaprofessionals? Generations, 18, 3,59-64.

Zahrt, Linda M. (1992). The cost ofturnover in a home care agency. Caring,April, 60-66.

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