Workforce Issues in Long-Term Care

Although many long-term care workers are highly committed to their work and derive satisfaction from it, research has extensively documented the many difficulties of the job. These factors have been found to be related to high rates of perceived job stress and burnout, and lower levels of job satisfaction. In the contemporary tight labor market, these problems lead to high rates of turnover in all positions.

Estimates of turnover of nursing home staff are quite high, with annual CNA turnover at 97 percent, RN turnover at 52.5 percent, and overall staff turnover at 69 percent (Harrington et al.). Although estimates differ, turnover is also a problem in home care. For this reason, understanding and reducing employee turnover in long-term care settings has become a major undertaking for both researchers and practitioners. As in other health care settings, turnover and short staffing have been found to have many negative consequences, including reduced employee efficiency and lower morale among employees who stay on the job (Cohen-Mansfield). More important, such staffing problems lead to decreased quality of care for residents (Wunderlich et al.; Harrington et al.).

The following are some major causes of stress, burnout, dissatisfaction, and turnover among long-term care workers.

Excessive work pressure. In surveys, many nursing assistants say that they routinely do not have enough time to complete their basic tasks. This sense of time pressure takes the enjoyment out of their work. Nursing assistants report that when time is short, they are not able to do more personal, satisfying tasks, such walking with residents, talking to them, helping with grooming, and so forth. As caregiving work is reduced to the most difficult and least gratifying tasks, and staff feel that they do not have time to complete even these tasks, job stress and burnout increase.

Understaffing. Work pressure is exacerbated by chronic understaffing in many long-term care facilities. The pressure caused by staff shortages is very severe, and leads to stress and burnout. Conversely, adequate staffing has been found to be the major factor leading to high staff morale. Wilner (1994) found that a major source of dissatisfaction and stress was working with too few other nursing assistants, or with new staff who were not adequately trained. Nursing assistants were especially anxious about injury to themselves, to the new staff member, and to the residents in these situations.

Problems in supervision. Studies show that problems with supervisors are a major cause of job stress and burnout. Conflicts with supervisors are very stressful to frontline long-term care workers. Helmer and colleagues showed the extent of such dissatisfaction. Their survey of nursing assistants found that 71 percent wished administrators and nurses would show them more respect; only 37 percent felt they received sufficient recognition and appreciation for their work. Further, only 36 percent felt that management made them feel ‘‘in on things.’’

Lack of appropriate training. Despite the view that frontline long-term care work is ‘‘unskilled labor,’’ the job is in fact both technically and interpersonally complex. As noted earlier, the training given to nursing assistants and home health aides is very limited. Further, it focuses almost exclusively on the technical aspects of care, although there is evidence that difficulties in dealing with the psychosocial aspects of nursing home work are causes of stress and burnout.

Wages. Funding for nursing assistants comes primarily from Medicaid and Medicare. In many cases, the wages offered keep some workers near the poverty level. In 1998, the mean hourly wage of CNAs was $8.32, and for HHAs it was $8.17. For the purposes of comparison, in the same year telemarketers earned an average of $9.40 per hour, and elevator operators an average of $14.77 (Bureau of Labor Statistics, 1998). Thus, wages for long-term care workers remain comparatively low, considering the difficult nature of the job. Further, some long-term care providers still do not provide CNAs with health benefits. When such benefits are offered, the premiums the CNAs must pay are often prohibitively high for them to participate.

Injury. It is acknowledged that CNAs are at high risk of injury. Indeed, rates of injury in nursing and personal care homes exceed that of private industry in total by a significant amount. CNAs are particularly prone to injury from heavy lifting (Wunderlich et al.).