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Caring for the Elderly:
Addressing Quality of Life and Worker Retention

The number of elderly Americans is rising rapidly, and providing them with quality care has become a high priority for family members as well as medical professionals. Two recent studies completed by a team of researchers including Vikas Mittal, PhD, J. Hugh Liedtke Professor of Marketing at Rice University’s Jones Graduate School of Business address key issues affecting caring for the elderly:  the relationship between physical health and quality of life in nursing home populations and the challenges of retaining health care workers trained to care for these patients.
 
“Forty years ago the national focus was on taking care of children,” observed Dr. Mittal. “Now we see more and more people struggling to care for elderly family members. It is critical for us to better understand the psychological as well as physical health of these individuals so that we can provide them with the best possible care. It’s also important to figure out a way to retain qualified health care workers trained to work with elderly people.”
 
Study #1: Health Care Worker Retention 
 
A recent report by the Institute of Medicine lists a shortage in the direct care workforce as a prime concern. Problems of shortage are compounded by high turnover – 40 percent to 100 percent annually. According to the IOM, high turnover disrupts patient care protocols, resulting in a decline in the overall quality of care and quality of life for elderly patients.
 
The study addressed reasons direct care workers leave and stay at their jobs. People generally assume that “fixing” the reasons employees give for leaving will result in higher retention rates. But this study -- somewhat counter-intuitively -- found that the same basic job is experienced very differently by different people. “Leavers” were more likely to focus on negative aspects of the job, such as rude supervisory behavior, job challenges and lack of flexibility. “Stayers,” on the other hand, described many of the same experiences, but they were far more focused on positive aspects of the job, such as relationships with patients and family members and job flexibility.
 
“A major problem in nursing homes is that staff members responsible for providing direct care to elderly patients have very a high turnover rate,” said Mittal. “Maintaining a well-trained staff is a constant challenge because these employees tend to leave after a short period of time. When there is constant turnover the quality of care inevitably suffers. It’s expensive to recruit and train employees, and these efforts are wasted when workers leave these jobs, often to move to new ones where the cycle of training begins again.”
 
Implications
 
This study provides valuable information on why employees leave jobs as well as why they stay. Mittal suggests that the next set of studies should focus on how to decrease turnover in the direct care worker population. As nursing homes begin to shift their cultural focus more toward “person-centered” care, workforce stability will become increasingly important.
 
Study #2: New Focus on Quality of Life 
 
While there has been significant research on the physical health of elderly patients, few studies have examined changes in quality of life in the nursing home setting. This study, which featured interviews with patients 65 years or older in two nursing homes, examines the association between changes in clinical health factors and perceived qualify of life.
 
“A lot of people look at the care of elderly people in terms of clinical outcomes such as ulcers, depression and pain,” said Mittal. “The conventional thinking has been that clinical measures equal quality of life. In other words, if you heal the patient’s physical condition, their quality of life will automatically improve. We found that this isn’t always the case. While there is an overall connection between physical health and self-reported quality of life, not every finding was consistent.”
 
Implications
 
This study makes an important contribution to the literature on health status among nursing home residents. Although results indicate that improving clinical outcomes can lead to better quality of life for nursing home residents, psychological factors have yet to be incorporated into standard nursing home treatment procedures.
 
“The U.S. Government mandates the MDS (Minimum Data Set) database for monitoring the health of nursing home patients as well as the quality of the facility itself,” said Mittal. “All measurements are based on clinical factors, and the system is completely devoid of psychological factors. This is a very limiting approach because it treats the elderly person as a set of symptoms and not a whole individual.”
 
Although this and other studies suggest racial and cultural implications for nursing home patients, this sample was too small for valid conclusions. This type of information will prove extremely useful, especially in states such as Texas that are culturally diverse.
To reach such specific conclusions, researchers will need to design more long-term studies with a larger set of patients across more nursing homes.
 
The Association Between Changes in Health Status and Nursing Home Resident Quality of Life,” published in The Gerontologist, Vol. 48, No. 5, 584-592, was co-authored by Howard B. Degenholtz, Graduate School of Public Health, University of Pittsburgh; Jules Rosen, Department of Health Policy & Management, University of Pittsburg; Nicholas Castle, Department of Psychiatry, University of Pittsburg; Darren Lieu, Department of Behavioral and Community Health Sciences, University of Pittsburgh; and Vikas Mittal, Jones Graduate School of Business, Rice University.
 
A Dual-Driver Model of Retention and Turnover in the Direct Care Workforce” has been conditionally accepted for The Gerontologist. The study was written by Vikas Mittal, Jones Graduate School of Business, Rice University; Jules Rosen, School of Medicine, University of Pittsburgh; and Carrie Leana, Katz Graduate School of Business, University of Pittsburgh.
 
To receive a copy of the published study, contact Julia Nguyen at julianguyen@rice.edu , or 713.348.5387 or my cell at 713.906.4598.