U.S. Department of Health and Human Services

Frontline Supervisor Survey Report

Executive Summary

Peter Kemper, Diane Brannon, Brigitt Heier, Jungyoon Kim, Candy Warner, Joe Vasey and Amy Stott

Pennsylvania State University, Center for Health Care and Policy Research

September 9, 2008

This report was prepared under contract #HHSP23320044303EC between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Pennsylvania State University. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Marie Squillace, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Marie.Squillace@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

High turnover of direct care workers (DCWs) in long-term care increases labor costs and adversely affects quality of care. Poor supervision and work relationships are leading sources of reported dissatisfaction among DCWs and affect their turnover decision. Supervisors therefore play an essential role in changes designed to improve DCWs’ jobs and reduce turnover.

Frontline supervisors are the individuals through whom organizational innovations are transferred from the idea stage to the reality of direct care work. Given the hierarchical nature and service intensity of long-term care, any changes in policy or managerial practice must be passed down through several layers, across shifts, and in some cases, across sub-units. Thus, supervisors can facilitate, slow, or completely block intended change. Supervisors of DCWs form a layer within the hierarchy that is hard to define and often ignored in research on job improvement. Because of their unique frontline position, supervisors’ perspectives on management practices and their own jobs are important to understand for both policy and practice.

To develop an evidence base for high-quality supervision to inform long-term care policy, the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation funded a survey of supervisors from provider organizations participating in the Better Jobs Better Care (BJBC) demonstration (http://www.bjbc.org). BJBC was an initiative that tested innovative policies and practice models designed to improve the quality of DCW jobs and reduce turnover.

The survey of supervisors contributes to better understanding the nature and influence of long-term care supervision on the stability of the direct care workforce by providing information on supervisors’ responsibilities and characteristics and comparing them across settings. This report addresses three sets of questions:

1. What are supervisors’ roles and responsibilities? How do they differ across settings?

2. What are the characteristics of supervisors? How do they assess their jobs? Do they differ across settings?

3. Do supervisors and clinical managers agree about management practices where they work?

METHODS

To identify the population of supervisors, we developed a Supervisor Identification Instrument. This instrument listed nine tasks, or supervisory responsibilities. Clinical managers at each provider participating in BJBC were asked to identify staff members who were responsible for performing any of these supervisory tasks.

Each supervisor identified received a packet that included: (1) a cover letter explaining the survey and providing the information for informed consent; (2) an 11-page, paper-and-pencil survey with 132 items related to supervisory responsibilities; provider management practices; and job quality, satisfaction, problems, and rewards; (3) a $2 cash incentive; and (4) a postage paid business reply envelope. Sixty percent responded to the survey.

SUPERVISORS' ROLES

Providers identified employees in multiple positions as playing a role in supervision of DCWs -- from administrative heads to DCWs themselves. Supervisors also shared many of the supervisory responsibilities, and most supervisors had some role in all responsibilities except scheduling and conducting on-the-job clinical training.

Supervision of DCWs differed across settings, particularly between home care and facility-based settings. Supervision in skilled nursing facilities was similar to that in assisted living facilities, except that supervisors in skilled nursing facilities more often recommended training, initiated discipline, and documented performance problems. Home care provider organizations, however, proved to be quite different from facility-based care providers in the positions supervisors held and the responsibilities they performed. These differences reflect home care’s greater reliance on part-time and on-call workers, more complex scheduling requirements, and predominant use of telephone rather than in-person communication.

SUPERVISOR CHARACTERISTICS AND ASSESSMENTS OF THEIR JOBS

The supervisors reported relatively high levels of education and clinical training, and they felt confident in their ability to do their jobs. This was most apparent in skilled nursing facilities, where wages, satisfaction with income, and health insurance enrollment were greatest. The opposite was true in assisted living facilities where supervisors had the least education and clinical training and the lowest wage, satisfaction level with salary, and health insurance enrollment. The vast majority of supervisors had experience as DCWs, suggesting that supervision is an opportunity for advancement for DCWs and that improving DCWs’ jobs may also create a larger pool of potential supervisors.

Supervisors reported a high level of satisfaction with their jobs and found many aspects of the job rewarding. Overload and poor supervision were the most identified job problems, especially in skilled nursing facilities where supervisors were somewhat less satisfied with their jobs than supervisors in assisted living and home care.

SUPERVISORS' AND MANAGERS' PERCEPTIONS OF MANAGEMENT PRACTICES, COMMITMENT TO BJBC, AND READINESS FOR CHANGE

In general, clinical managers had more favorable assessments of the organization’s managerial practices and processes than did supervisors, particularly on scales measuring DCW training, management communication, and organizational readiness for change. Despite home care’s geographically dispersed delivery mode, supervisors’ and clinical managers’ perceptions differed less than in the other settings.

Agreement among supervisors was relatively low. On most of the scales, assisted living facilities were characterized by lower levels of supervisor agreement than skilled nursing or home care providers.

In general, agreement between supervisors and their clinical managers was similar to that among supervisors. Across all types of providers levels of agreement were higher for communication about tasks and organizational readiness for change. Agreement was somewhat lower for scales measuring DCW participation in care planning, DCW training, and management communication.

Analysis of change in management practices and processes in North Carolina found that neither clinical managers nor supervisors identified substantial changes. The one exception was an increase in DCW training, reported by both clinical managers and supervisors.

IMPLICATIONS

Our experience conducting the Supervisor Survey demonstrated that, although challenging, identifying a population of supervisors from different settings and surveying them is feasible. Because job titles and the responsibilities associated with those titles vary across settings and within individual providers, researchers should define and identify supervisors based on the supervisory responsibilities they perform.

Our analysis found that many positions in long-term care organizations play some role in supervision of DCWs and that many supervisory responsibilities are shared among supervisors. This implies that efforts to improve supervision should target multiple levels within an organization and should be customized to the particular structure of the organization.

The consistent differences across settings found in this analysis, particularly differences between home care and facility-based settings, imply that policy and practice efforts to improve supervision should differ across settings. For example, supervisor training in home care should recognize the importance of scheduling and phone communication, and adapt training for those with primarily scheduling and formal supervision responsibilities and those who supervise the clinical care of individual clients. More generally, policy, practice, and research on supervision in long-term care should take into account differences in the acuity of the residents being cared for and varying supervisory hierarchies across settings.