Health care workers serving older patients have high rates of turnover, and maintaining adequate levels of staffing within the industry overall is a persistent challenge. This challenge is especially pronounced among direct-care workers, who have a number of immediate, less stressful job alternatives, such as those offered by the food and hospitality industries. In 2006, for example, personal- and home-care aides had median wages of $8.54 per hour while counter attendants in cafeterias, food concessions, and coffee shops had median wage-and-salary earnings of $7.76 per hour (including tips) (BLS, 2008b).

One study found that 40 percent to 60 percent of home health aides leave after less than 1 year on a job, and 80 percent to 90 percent leave within the first 2 years (PHI, 2005). Staff turnover in assisted-living settings ranges from 21 percent to 135 percent, with an average of 42 percent (Maas and Buckwalter, 2006). In nursing homes CNA turnover averages 71 percent per year, and the turnover rate in many states is much higher (Decker et al., 2003). Turnover may have negative effects on the quality of patient care and may also increase employer costs because of the need for continuous recruitment and training. A study of direct-care workers in Pennsylvania estimated annual recurring training costs due to turnover to be almost $24 million for nursing homes and almost $5 million for home health and home-care agencies (Leon et al., 2001). It has been estimated that turnover among direct-care workers in the United States costs providers a total of $4.1 billion per year (Seavey, 2004).

While many direct-care workers find the work of caring for frail older individuals to be rewarding, the appeal of these professions is weakened by a number of other factors including low wages, few (if any) benefits, high physical and emotional demands, and a significant potential for on-the-job injury (Newcomer and Scherzer, 2006; Pennington et al., 2003). Job dissatisfaction among these workers can also result from factors related to the work environment including poor relationships with supervisors, a lack of respect from other health professionals, and few opportunities for advancement (Fleming et al., 2003; Stone, 2000). Not surprisingly, high job dissatisfaction has been associated with increased turnover (Castle et al., 2007). Conversely, improved job satisfaction can result in a greater intent to stay.

Researchers examining the predictors of high turnover in nursing homes have identified a number of key variables, including low staffing ratios, for-profit ownership, and higher numbers of beds (Castle and Engberg, 2006); low reimbursement rates, a high Medicaid census, low wages, and low administrative expenses (Kash et al., 2006); and inadequate benefits and not having a good social environment at work (Grau et al., 1991). One study

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