Factors Contributing to Turnover Among Home Care Aides for Frail Older Adults

Background and Purpose: The paraprofessional workforce has been described as the centerpiece of our long-term care system. Direct-care workers are often the members of interdisciplinary teams with whom social workers interact most frequently. Even during this recession, retention of these important workers remains challenging for many facilities and home care agencies. When a worker terminates employment, there is the possibility of a reduction in quality of care or potentially no care at all. This paper reports on a mixed-method longitudinal study investigating retention and turnover among home care workers providing personal care to elders and people with disabilities. The longitudinal design of this inquiry improves upon previous cross-sectional studies on this topic which have relied on the variable “intent to leave” as a proxy for actual turnover.

Methods: In October 2008, a 12-page questionnaire was mailed to all personal care workers (n=496) employed by 11 participating home care agencies representing all 12 counties of a rural New England state. Completed surveys were returned by 261 workers (response rate of 52.6%). During the 18 months of data collection 90 workers (34.5%) left their employment. At the time of termination, study participants received a second survey (5 pages) and completed a telephone interview of 16 open-ended questions regarding job experience and reasons for termination. The survey instruments included measures of job satisfaction, burnout, empowerment and overall health. Logistic regression was performed on quantitative data and thematic analysis was conducted on transcripts of telephone interviews.

Results: Binary logistic regression analysis (χ2 (9) = 31.72, p<.01) indicates factors at Time 1 predicting turnover 18 months later include younger age, lack of health insurance, lower mental health, and, surprisingly, stronger feelings of personal accomplishment regarding the work. Analysis of qualitative data from telephone interviews with these terminated workers reinforces the finding that workers quit the work while continuing to enjoy it. More than half (53.4%) reported more positive aspects to the job (e.g., helping elders is rewarding, flexible schedule works) than negative aspects (e.g., wages are too low, some clients are stressful).

Implications: Assuring quality and consistent care to frail elders living at home is of paramount concern to gerontological social workers and thus advocacy for improved job conditions and interventions to reduce burnout for these important direct-care workers is essential. For example, social work advocacy for the recently introduced Direct Care Workforce Empowerment Act would support national efforts to advance the profile of the direct-care workforce. One key finding of this study is that turnover is higher among younger workers than older workers. Home care agencies may do well to increase recruitment of older workers, many of whom are interested in meaningful part-time employment. Moreover, the Patient Protection and Affordability Care Act may decrease the rate of uninsured home care workers through Medicaid expansion and tax credits to small agencies, thereby reducing turnover; thus advocacy to maintain this health care reform is key. Implications related to increasing retention of these valuable workers and the role of social workers in that process will be explored.