Health Care assistants' experiences and perceptions about determinants of Staff turnover in CHT Bernadette Rest Home & Hospital

The New Zealand's population is ageing and it is expected that older people aged 65 has been doubled since 1986 . It is expected that this number will be doubled again by the year 2036 (Statistics New Zealand,2013). Therefore, demand and scope of age care industry is ought to be increased in the coming years. Staff retention and job satisfaction plays a very important role to sustain skilled and efficient health care workers and to provide a quality of care to the care recipients ( Karantzas,2012 ;Steinmetz,2014).But, aged care sector is experiencing a high turnover of direct health care workers ranging from 30 to 86 % ( Gray & Muramatsu,2013) .Therefore, this literature review aimed to find out why caregivers in New Zealand are leaving their jobs and how the staff turnover among health care assistants can be minimized ?The various electronic sources like books, online articles and databases used to gather available information about the selected topic. The general information about staff turnover in health care workers was gathered and then specific keywords used to find out the specific information about perceptions of health care assistants about staff turnover. Seven published articles between year 2005 to 2015 were used to find out the gaps in research and to obtain established information about the topic.During literature search, most of the researchers has described job satisfaction and stress as the significant factor that cause staff turnover. Some researchers described education training,sex,ethinicity and work characteristics as the important factors that make the health care assistants to leave the job. But, it was found that very less information is available about health care assistants opinions, attitudes and experiences about their jobs and factors that cause increased turnover among them because very less qualitative research has been conducted in this area. Hence, this systematic literature review will highlight the main contributing factors for high turnover perceived by the health caregivers within an old age care home in New Zealand context and will propose a research methodology on the basis of framed research questions.

LITERATURE REVEIW-

The main themes identified during the literature are-

JOB SATISFACTION ,STRESS AND TURNOVER-Kartal (2012) conducted a research to find out the causes of burnout and staff turnover among caregivers. He explained the prevalent of three types of burnouts among caregivers and that were job commitment inadequacy i.e. emotional burnout, depersonalization i.e. negative feelings about service users and negativity about professional and personal accomplishments. He conducted this study on younger and more educated nurses and caregivers. This study revealed that burnout in the caregivers who worked in the elderly nursing homes was mainly associated with their personal factors like well-being, self efficacy and stress coping mechanisms used by them. It has also been found by this research that higher the education, more effective coping mechanisms used by the participants.Zimmerman (2005) interviewed 154 direct care workers from 31 residential care homes and 10 nursing homes. He found that job satisfaction and attitude towards providing dementia care were other person centered attitudes found among the participants. Researcher used characteristics of care provider and facility as independent variable and attitudes, stress and satisfaction as dependent variable. He analyze the data by using simple descriptive analysis and 90 % of care providers were found to be female. The average age of caregivers was found to be 40 years and most of them worked for 1 or 2 years. Stress was found to be more among carers working in nursing homes than carers working in less than 16 bedded residential care homes that provides more familiar and home like environment. He found that stress was found to be most significant problem among care workers who have worked for 1 or 2 years than the workers who have worked longer.

Male workers, young workers and who have worked for less than 2 years reported more stress. The researcher fond young workers and male carers as two main groups who are at more risk to leave the job. But, it aroused other unanswered areas about what are the main reasons that cause more stress among young and newly joined caregivers. In addition to this,workload,type of residents (e.g. un cooperative, dementia residents etc ) were some of the other factors that were perceived as a causative factors for emotional stress among care workers. They reported that these factors contributes to job dissatisfaction and drive them to seek other jobs. The research conducted by Bill (2007) reported that the expectations of aged care workers about whether to leave or remain in job largely depend upon their work experience mainly satisfaction they received from their job. Most of the care workers reported caring as a physical demanding and less appealing job.Moreover,they also reported that this job offers less career prospectus and carers are paid very less.However,some care workers found and described caring as a rewarding and fulfilling profession. In this study, researcher compared the work tenure,wages,job satisfaction, work contract and education etc of Australian workforce with aged care workforce. It was found that care workers were paid less wages than other Australian workforce.Moreover,turnover rate among personal carers was found to be extremely high than other workforce. Main factors that cause care workers to leave the job as perceived by them were shift characteristics, type of contract, whether they received enough working hours or not, wages etc. Some workers revealed working environment or work experience as a key factor. Job satisfaction was also a main factor that cause them to leave the job as reported by caregivers. Some carers revealed their personal characteristics as a reason to leave the job while others organizational characteristics ( e,g. size of care facility) as a main causative factorKarantzas (2012) also found work stressors and job satisfaction as two most significant factors that directly cause care workers to leave their jobs.EDUCATION,TRAINING AND TURNOVER-Zimmerman(2005) also supported the effect of education on job satisfaction. He identified the need of training to retain the careworkers.Because it was found that care workers who have attained dementia care training were found to be more satisfied with job, reported person centered care and had shown no dementia-sensitive attitude while caregivers with no job training were not satisfied and reported dementia sensitive attitude.Moreover,education and ethnicity was another factors that impact on job satisfaction and caring attitude of the caregivers. Higher the education, more dementia sensitive attitude found among care workers. however,asian care workers did not report such attitude. Bill (2007) also supported that the education found to be a most contributory factor towards job retention or turnover as care workers with low education experienced limited affect on their expectations and were considered to have less turnover than carers with more secondary education.

Kartal (2012) also provided the similar findings about impact of education and training on job satisfaction and turnover. He concluded that nurses who have similar qualification as per the job required and who received required trainings for the job found to be more satisfied. Moreover, less emotional burnout, high self efficacy and low depressive emotional stress was evidenced among nursing staff participants.ORGANIZATIONAL CHARACTERISTICS,MOTIVATION & TURNOVER Bill(2007) reported that management can play a significant role in staff retention as the most prevalent staff turnover factors are in the hands of management. for e.g. management can motivate the staff with intrinsic motivation.Karantzas (2012) found support received by the supervisor at work indirectly effect the intentions of the staff to leave work. .He used self-report questionnaire to collect the data from all care staff. He included 208 care staff including allied health professionals,nurses,health care assistants and managers in his study. He conducted this study to assess the reasons behind staff turnover among aged care staff. He also examined the stressors, stress level, job satisfaction and commitment found among workers and the support they received through their supervisors to see the effect of these factors on staff turnover. This study also supported that aged care workers can be retained at work by minimizing the stress at work and providing good support by the supervisor. These both factors are again under the control of management as described by bill (2007) in the research discussed earlier.Steinmetz (2014) used three models to find out the impact of working time and wages on intentions of the staff to remain at work. He conducted this study in three different context that were Germany, Netherlands and Belgium. This study also revealed job dissatisfaction that prevent the employees to stay at their job. Moreover, part time job, overtime and long commuting time also leads to reduction in intention of the employee to continue same job, Other factors noticed by the researchers that leads the staff to leave work were high or moderate education, being a woman and job promotion etc. Moreover, employees with low wages were found to have more intentions to leave the work due to wage dissatisfaction, Wage satisfaction and attention to overcome working time issues were two solutions described by the researcher.Gray & Muramatsu (2013) also supported that work stress causes direct care workers to think to leave the job. He conducted a cross-sectional survey to 323 direct care workers from five community based organizations that provides services to the people. find out the work related factors and social and personal resources that caused stress among direct care workers. It was predicted that work overload was the most significant contributing factor to leave the job among carers whereas social supervisory support was found to be less contributing factor. Howes (2008) conducted a survey to find out what makes the care staff most motivated from increased wages, flexibility of work or commitment towards work ?He mailed the survey to 2,260 workers selected randomly from eight urban and rural countries of California to find out the impact of increased wages and other benefits to the employees at the retention of staff. Regression analysis method was used to analyze the results. The study found that wages and health benefits were found as main factor to stay within a job by 25 % of respondents of the survey whereas 66 % reported commitment and 41 % mentioned the job flexibility as important factors that lead them to take the job. Almost 50 % of the participants reported part time job, job flexibility or both together as most important reason to describe why they take this caring job.

The following research questions aroused after reviewing seven articles related to the chosen topic. These are-1.What health care assistants think the most important reason that cause them to leave the job ?2.What makes them satisfied from work- Intrinsic motivation or increased wages ? 3.How they think management can support them to stay at work ?The present qualitative study will aim to know about the perceptions of health care assistants of CHT Bernadette rest home and hospital which is situated at Bayfair,Mount maunganui, Tauranga, New Zealand. The author has chosen this location to conduct the study within New Zealand context. This is because, no research on perceptions of health care assistant about determinants of staff turnover has been found in New Zealand context.Moreover,turnover of the health care assistants of mentioned organization was found to be increased suddenly after the previous organization left over and handover the company to CHT . Therefore, the author wants to locate the main reason behind increased turnover of organization as per their own perspectives. PROPOSED RESEARCH METHODOLOGY -Data Collection Method- Cormack (2000, P-399) explained that Qualitative research is concerned with individuals understanding, motives and their interaction within the social environment. Moreover, qualitative method provides thorough knowledge and understanding about human complex behaviors and this approach emphasize on individuals experiences and perceptions( Schneider et al,2013,p-104) .Therefore, this approach is well adopted for this study as it is concerned with human experiences.A semi- structured in-depth interview will be organized followed by a focus group study to clarify or challenge the findings obtained through interviews. In-depth interviewing is that type of qualitative research in which questions are used to acquire as much information about topic as possible .Therefore, semi-structured questions and focus group would be used to collect data . focus group study provides in-depth information about topic area. Moreover, non-verbal behaviors can also be obtained while participants discussed about a particular topic in a group( Schneider & Whitehead,2013).

Sampling- Purposive sampling will be used to target Health care assistants of the organization. All health care assistants would be selected as samples. There are 24 health care assistants of organization.Therefore,sample size would be 24. All participants would be involved in semi-structured interview . The ideal size of the group for focus group study is between 8 to 10 people as determined by the researchers. Therefore, out of 24 participants, 10 would be called for the focus group discussion voluntarily.Procedure & Ethical approval of study-The study will be conducted at CHT, Bernadette Rest Home and hospital,Bayfair,Maunt maunganui,Tauranga, New Zealand. Since the author is working part-time there so it would be easy to conduct the research.Firstly,author will take ethical approval from the management to conduct the study ( as guided by the ethical approval procedure of Waiariki institute of technology, see attached ethic application). After ethical approval, author will request the name of all health care assistants and their duty rosters to arrange interview timings. Author will aware the staff about this research by displaying the information on staff room notice board. An informed consent would be obtained from the manager and the participants and written information about the procedure and aim of the study will be given to them prior to study The semi-structured questions will be handed over to the manager for approval and place and timing of interviews would be decided as per convenient for the participants and approved by the management. An individual interview for all participants would be for 20 minutes ,whereas focus group discussion would be scheduled for 1 hour and 30 minutes.

The primary analysis of the data would be started from the beginning of data collection. The data would be stored in the form of audio tapes during interviews and focus group and a separate diary would be maintained for the non verbal observations of the participants and would be noted after each interview. Finally, all data would be analyzed to generate themes and conduct thematic analysis and contrast and compare the opinions, experiences and observations. Finally, coding would be done to get the final findings of the research. The entire result will take 4 months.

The dissemination of the findings of research would be done by arranging a 1 hour presentation as approved by the management and all participants would be welcomed to join that presentation. Moreover, a copy of the final paper would be given to the manager. The whole research will take around 4 months.Conclusion-There are various research gaps found in the selected area of study. The author has used articles and other online sources to get available information about the topic by reviewing studies that has been conducted in different areas of the world like America,Germany,Neitherlands, Australia etc.Firstly,study conducted by Zimmerman (2005) fail to describe about the effectiveness of training to reduce staff turnover and how it reduce stress and improve stress coping mechanisms among less experienced health care assistants. The findings of the literature described about the importance of supervisory activities to reduce staff turnover but researchers did not explain how management can improve supervisory activities within an organization and what is the effect of poor management on turnover( Gray & Muramatsu,2013;Bill,2007).Most of the researches are based on all health care workers and there was no study found in the context of New Zealand. Most of the studies have selected female workers as participants. however, male workers are found to be under more stress and less satisfied to work in caring profession (Kartal,2012).There was inconsistencies found among different researchers opinion some of them has described stress as the most contributing factors whereas others have described job satisfaction. Thus, author has found various areas where future research is required as guided by the published literature. This study will benefit to the health care assistants to give them opportunity to share their feelings and to put forward their perceived reason to quit the job. Moreover, it will also contribute for human resource management and for the managers to inculcate new strategies for the specific organization and other health care industries to reduce staff turnover.