We review both published reports and articles, unpublished conference presentations and working papers reporting results of research and evaluations on recruiting, retaining, and sustaining a quality frontline workforce in nursing homes, home care, and assisted living facilities. The review updates research findings reported in a seminal piece by Stone (2001) to better understand the problems facing the frontline LTC workforce and to identify effective solutions to chronic shortages, high turnover, and training needs. Studies on the relationship between LTC staffing levels and quality of care were not included, as they are beyond the scope of this paper; however, studies that examine links between staffing levels and worker satisfaction or turnover rates are included in this review.
Research and evaluation reports and articles completed or initiated between 1999 and 2003 were identified using Internet searches, personal communication with researchers, and database searches (e.g., PubMed). Search terms used when conducting web site and database searches included: LTC workforce, recruiting, labor force, nurse aides, job tenure, employment practices, work environment, aging services personnel, paraprofessional personnel, and intervention strategies. While published articles in peer-reviewed journals generally were preferred, unpublished reports and interim progress reports were included if based on sound research methods. We include studies that use qualitative and/or quantitative methods. Initiatives that were at an early stage of development in the Stone (2001) article were investigated to determine if the research or evaluation was now complete. We also obtained relevant working papers and presentations at professional conferences (e.g., American Society on Aging, Gerontological Society of America) and made personal communications.
The studies abstracted and analyzed for this report fall into two main categories: (1) empirical research (i.e., results of surveys and qualitative studies) on direct care workers that describe their working conditions or further elucidate the causes of turnover; and (2) evaluations of the implementation and impact of public and private initiatives designed to improve the recruitment and retention of direct care workers (e.g., wage and/or benefit enhancements, new training programs, and revised certification requirements).
Section IV reviews studies on characteristics of direct care workers and the wages and health insurance benefits available. Section V synthesizes research on factors contributing to high turnover and chronic shortages. Section VI summarizes findings from evaluations of interventions designed to improve recruitment and retention of direct care workers. Section VII discusses the implications of these recent findings for public policies and provider practices that seek to expand and stabilize the labor pool of direct care workers, and for future research intended to support these initiatives.
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