Introduction
Nursing assistants currently comprise up to 66% of the healthcare workforce (Brady, 2016), and the occupation is expected to expand by 18% over a 10 year period ending in 2024 (U.S. Department of Labor Statistics, 2018). Despite the growing nationwide demand for nursing assistants, nursing assistant turnover across all settings is consistently higher than other healthcare positions, with annual rates as high as 36% (Brady, 2016). According to Brown et al. (2013), nursing assistant turnover has been linked to an estimated $4.1 billion dollars in national healthcare costs. The Institute of Medicine states that an unstable direct-care workforce is a serious healthcare issue that must be addressed to ensure that healthcare organizations are able to meet the future needs of the growing elderly population (Brady, 2016).
Background
High turnover rates have been attributed to a variety of factors within the nursing assistant workforce, including poor job satisfaction, limited growth opportunities, and poor wages (Brown et al., 2013; Lerner et al., 2011). Nursing assistants are typically the least compensated healthcare professionals, with a national average salary of $28,500 per year (Gion & Abitz, 2019). Nursing assistants provide 80% of direct patient care, performing duties such as feeding, bathing, toileting, dressing, grooming, transferring, vital signs, and changing linens (Walton & Rogers, 2017). Nursing assistants are a vital component of the interdisciplinary team and desire adequate compensation for their work and advancement potential (Brown et al., 2013). Healthcare leaders must seek to develop strategies to empower nursing assistants while improving job satisfaction and wages in this employee population to stabilize the nursing assistant workforce (Berridge et al., 2018).
Advanced training programs have been found to enhance job satisfaction in the nursing assistant population (Lerner et al., 2011). Although nursing assistants spend the majority of their time performing direct patient care, they have the least amount of education and training (Gion & Abitz, 2019). A longitudinal cohort study by Brown et al. (2013) demonstrated that an educational program, consisting of anatomy and physiology, infection control, and skills laboratories, for nursing assistants reduced turnover, improved job satisfaction, and decreased patient falls. Remsburg et al. (2001) developed a career ladder composed of advanced training in various clinical skills, including phlebotomy, electrocardiograms, and catheter insertion, leading to increased retention rates during the first 2 years following the training.
Staff recognition is an important component of nursing assistant career ladders (Gion & Abitz, 2019; Lerner et al., 2011; Parsons et al., 2003). Parsons et al. (2003) surveyed 550 nursing assistants and found they were most dissatisfied with appreciation and recognition. According to Lerner et al. (2011), nursing assistants' perception of being valued by nurses and nurse leaders is a vital component of overall job satisfaction. Although career ladder programs may vary among institutions, their main objective is increasing job satisfaction (Bitanga & Austria, 2013; Garcia et al., 2003). Senecal et al. (2020) found that job satisfaction and intent to stay were threatened by the lack of advancement opportunities. Rehabilitation nursing technicians, nursing assistants who specialize in performing care duties aligned with therapeutic goals, are crucial members of the interdisciplinary team in inpatient rehabilitation. Rehabilitation nursing technicians support an environment that focuses on patient safety and patient-centered treatment.
Rationale
In our local clinical setting, a 76-bed acute inpatient rehabilitation hospital, rehabilitation nursing technicians comprised 40% of the nursing department's workforce. Rehabilitation nursing technician turnover in 2019 was 35%. The employee engagement index for rehabilitation nursing technicians, as indicated on the annual employee engagement survey, was 78% favorable in 2019. Job satisfaction for rehabilitation nursing technicians, as indicated on the annual employee engagement survey, was 74% favorable. Specific items of opportunity were related to employee development, communication, and intent to stay. Mediocre engagement and high turnover rates make this employee population a target for innovation and intervention.
Evidence in the literature supports the development of a rehabilitation nursing technician career ladder for inpatient rehabilitation. Existing studies show that nursing assistant career ladders that include education and training added job responsibilities and those that incorporate employee recognition effectively improved job satisfaction and reduced turnover (Maier, 2002; Remsburg et al., 2001). Research demonstrated that when designed and implemented effectively, clinical ladder programs yield positive outcomes for patients, staff, and healthcare organizations (Moore et al., 2019).
Specific Aims
The purpose of this pilot study was to implement a career ladder for rehabilitation nursing technicians. The first aim of the rehabilitation nursing technician career ladder was to increase employee engagement by 5% over 1 year. Employee engagement was measured using an engagement index, a standard measure that includes pride, referral behavior, intent to stay, intrinsic motivation, and overall satisfaction. The annual employee engagement survey was chosen by the corporation that owns the rehabilitation hospital as a validated tool available through Perceptyx. The tool targets the population of interest and addresses major concerns for employee satisfaction. The study team, including the chief nursing officer, nurse manager, and nurse educator, used the tool because it was available for all employees and was a method to study the outcome of the rehabilitation nursing technician career ladder. It enabled tracking of blinded employee engagement data across time. Employees are strongly encouraged to participate in the survey to provide feedback to hospital leadership. Hospital leadership aggregate results to guide improvement and positive change. Other aims included improving overall job satisfaction for rehabilitation nursing technicians on the employee engagement survey by 5% over 1 year and reducing annualized rehabilitation nursing technician turnover by 10%.
Methods
Context
The rehabilitation nursing technician career ladder program was implemented in a 76-bed acute inpatient rehabilitation hospital in the southeast United States. The study was reviewed by the local institutional review board and deemed to be exempt as it is a quality improvement project not meeting the definition of human subjects research. All employees at the rehabilitation hospital were invited and encouraged to participate in the annual engagement survey, although participation was not required. Qualifications to participate in the career ladder included uninterrupted full-time status of 6 months or longer; 2019 annual performance evaluation level of strong, very strong, or excellent; and absence of disciplinary action within the past year. Exclusion criteria were full-time status of less than 6 months, 2019 annual performance evaluation of moderate or weak, and disciplinary action within the previous year. Based on eligibility requirements, 12 out of 21 rehabilitation nursing technicians were invited and agreed to participate in the first cohort of the evaluation of the career ladder program.
Measures
The annual employee engagement survey took place 5 months after the rehabilitation nursing technicians joined the cohort (Figure 1). The computerized third-party survey was open for 1 month, and staff were able to complete the survey at their own convenience. Hospital leadership was able to access the results of the survey electronically approximately 1 month after the survey closed. The engagement survey was deemed a highly reliable tool, with the employee engagement index yielding a Cronbach's alpha of .921 and the overall job satisfaction item yielding a Cronbach's alpha of .865.
Interventions
The chief nursing officer, the nurse manager, and the nurse educator implemented the three-tier nursing assistant career ladder, consisting of three core components: online learning modules, added job responsibilities, and online continuing education. This pilot study focused on rehabilitation nursing technicians who qualified to enter the career ladder and could advance from Rehabilitation Nursing Technician (RNT) to Rehabilitation Nursing Technician 1 (RNT1; Figure 1).
The hospital educator, a certified registered rehabilitation nurse with over 14 years of experience in the rehab setting, wrote the content of the career ladder course with contributions from the interdisciplinary team. A 40-question multiple-choice pretest was written at a fifth-grade reading level to assess baseline knowledge. The 2-day (16-hour) career ladder course included a variety of topics selected to enhance the knowledge and skill set of rehabilitation nursing technicians (Table 1). An identical 40-question multiple-choice posttest was to be administered following the course, with a passing score of 90% required to advance on the ladder.
Several modifications to the original intervention took place. The 2-day career ladder course scheduled in May of 2020 did not occur because of social distancing and staffing constraints related to the onset of the COVID-19 pandemic. Instead, the content was converted to self-paced online learning modules. In addition, the corporation that owned the rehabilitation hospital finalized a nursing assistant career ladder in May of 2020 to streamline programs across all of the company's rehabilitation hospitals. The hospital continued with the original career ladder, with a slight variation in rehabilitation nursing technician job titles. RNT1 became the job title for entry-level RNTs. Therefore, the RNTs' job titles automatically changed to RNT1, and they were promoted to RNT2 upon ladder advancement (Figure 1), with the potential to advance to RNT3 and RNT4 in future cohorts.
Career ladder participants had initial meetings with the nurse manager to discuss assignments of additional duties on the nursing unit. Potential additional duties included being a new hire preceptor or bath, mobility, patient experience, fall, skin care, documentation, and hand hygiene champions. Monthly meetings took place between the rehabilitation nursing technicians and the nurse manager and/or direct supervisor to ensure responsibilities were being met. Rehabilitation nursing technicians were given a 5% raise with advancement on the ladder. The promotional raises occurred in June of 2020 and did not replace the employees' annual merit increases scheduled for October of 2020. Rehabilitation nursing technicians qualify to advance a tier on the ladder annually if job requirements and responsibilities are met.
Study of the Interventions
The project used a between-subjects pre-post test design with two independent groups to evaluate employee engagement and job satisfaction. Participants in the pre and post groups reflected all rehabilitation nursing technicians (n = 44). The pre-intervention group consisted of all rehabilitation nursing technicians who participated in the 2019 employee engagement survey (n = 23). The post-intervention group consisted of all rehabilitation nursing technicians who participated in the 2020 employee engagement survey (n = 21) and included the 12 rehabilitation nursing technicians who elected to participate in the career ladder component of the intervention.
Blinded Likert scale data were extracted for each rehabilitation nursing technician who participated in the survey for the engagement category. The Likert scale data were grouped into two categories (0, 1). Scores 1, 2, and 3 were coded as unfavorable (0), and scores 4 and 5 were coded as favorable (1).
Data Analysis
Descriptive analysis from the engagement survey data was used to characterize participants' demographics, including age, gender, length of service, and shift worked. A chi-square test was used to evaluate employee engagement in rehabilitation nursing technicians pre- and post-implementation of the career ladder (Aim 1) and job satisfaction of rehabilitation nursing technicians pre- and post-implementation of the career ladder (Aim 2). Descriptive statistics (counts, means, and standard deviations) and a statistical control chart were used to evaluate annualized rehabilitation nursing technician turnover, and total loss turnover was tracked monthly from January 2020 through December 2020. Nondirectional statistical tests were performed with the level of significance set at .05 (two tailed). All analyses were conducted using SPSS Version 23.
Results
The results reflected improvement in the three outcome measures post-intervention based on the interventions and associated measures (Table 2). The first aim was to increase the employee engagement index for rehabilitation nursing technicians on the employee engagement survey by 5% over 1 year; this aim was met as the score increased by 8%. The questions that comprised the engagement index included the following: My work gives me a feeling of personal accomplishment (decreased by 1%); I am proud to work for this company/hospital (increased by 8%); I intend to stay with this company/hospital for 12 months (increased by 7%); Overall, I am satisfied with my job (increased by 12%); This company/hospital is a great place to work (increased 12%).
The second aim was to increase overall job satisfaction by 5%; this aim was met as the score increased by 12%. The last aim was to reduce rehabilitation nursing technician turnover by 10%; this goal was not met as the turnover rate decreased by 4%.
Although raw scores were improved, the differences were not statistically significant (Table 2). A chi-square test of independence was performed to examine the engagement index pre- and post-implementation of the career ladder, [chi]2(1, N = 44) = 0.410, p = .701. A chi-square test of independence was performed to examine job satisfaction pre- and post-implementation of the career ladder, [chi]2(1, N = 44) = 0.940, p = .462. A Mann-Whitney test indicated the 2020 turnover (M = 0) was not statistically different from the 2019 turnover rate (M = 0), U = 70.000, p = .894 (Figure 2).
Discussion
The rehabilitation nursing technician career ladder positively impacted engagement and job satisfaction and decreased annual turnover by 4% during an unprecedented year for healthcare providers because of the COVID-19 pandemic. The improved engagement scores, reduction in turnover overall, and continued interest in the ladder are generalizable observations that we can attribute directly to the career ladder program, despite inability to demonstrate statistical significance because of the small sample size. Importantly, the findings underscore the importance of an organizational commitment to the role of the rehabilitation nursing technician and the value of demonstrating this commitment in a financially tangible way. Senecal et al. (2020) acknowledged low compensation as a barrier to staff retention and identified intrinsic fulfillment including competence, self-confidence, and recognition as means to mitigate turnover. The career ladder program was able to address both compensation and the intrinsic needs of rehabilitation nursing technicians.
A unique aspect of this study was the target population, rehabilitation nursing technicians. This role is traditionally an unstable component of the overall employee population (Trinkoff et al., 2013). COVID-19 and the fear of remaining in the workplace affected several of the rehabilitation nursing technicians and contributed to unrest. The generalizability in this case was limited due to these external factors. In spite of these factors, direct anecdotal feedback was received from the rehabilitation nursing technicians regarding the extent to which they valued the intervention, the overall program, and the effort made to improve their job satisfaction.
Among the few studies evaluating the impact of career ladders on nursing assistants (Maier, 2002; Remsburg et al., 2001), the studies are similar in that they improved job satisfaction and increased retention rates. Although our findings were similar to earlier studies, the timing of this study was unique. The COVID-19 pandemic had a negative impact on frontline staff, with early studies demonstrating high levels of depression, anxiety, insomnia, and distress among this employee population (Berkow et al., 2020). Rehabilitation nursing technicians are at particular risk of these symptoms because they spend the majority of their time performing direct patient care. The project was implemented during a difficult time at the hospital, when morale was strained because of the stress and uncertainty of the pandemic.
Several rehabilitation nursing technicians voiced appreciation that the hospital had developed a program just for them. Rehabilitation nursing technicians demonstrated pride and excitement at the ability to advance in the career ladder. In addition, the ladder impacted not just those who participated but the entire employee group. Several rehabilitation nursing technicians who were ineligible to advance on the ladder showed interest in participating in the next cohort scheduled to begin in May of 2021.
Although rehabilitation nursing technician turnover decreased in this study, it remained below the project goal of 10%, which had been established as a target for workforce stability. The impact of the pandemic must be considered as fear, psychological distress, and burnout affected frontline staff and contributed to turnover risk (Labrague & de los Santos, 2020; Travers et al., 2020; White et al., 2021). Although the reduction in turnover was small, any turnover reduction could be considered a win.
The direct costs of the ladder minimally increased the salaries and wages of the hospital. The cost-benefit of retaining experienced rehabilitation nursing technicians far exceeded the potential cost of hiring and training new rehabilitation nursing technicians, although a full cost analysis was not conducted as part of this study. Although 192 education hours (12 participants with 16 hours total) were budgeted for the 2-day classroom learning, that cost was eliminated with the transition to self-study learning modules.
Limitations
This study had several limitations. The COVID-19 pandemic significantly threatens the internal and external validity of the study. It is difficult to state whether the intervention would yield similar results in other settings, situations, or environments because of the unprecedented circumstances. Healthcare workers were subjected to tremendous strain, as they struggled to deal with rapidly evolving guidance from the Centers for Disease Control and Prevention, personal protective equipment shortages, and staff exposures and illnesses. One must consider that had the study taken place during a different time period, results may have been different. Finally, the small sample size was a threat to the internal validity of the study. Evaluation of the intervention on a broader scale across multiple facilities would yield stronger results.
Conclusion
Rehabilitation nursing technicians are crucial members of the interdisciplinary team, spending the majority of their time in direct bedside care. However, they often feel undervalued, underpaid, and underrecognized by other members of the interdisciplinary team and administration, which contributes to high turnover rates. Previous studies have found career ladders to be a potential approach for mitigating these challenges, as they have been shown to improve employee engagement and job satisfaction while reducing turnover. In our study evaluating career ladder application to practice, we found career ladders to be sustainable, feasible, of minimal impact on labor or costs, and of benefit to the job performance of current employees. Although the career ladder in the study was developed specifically for rehabilitation nursing technicians in the rehabilitation setting, the framework could easily be adjusted to meet the needs of alternate healthcare settings. Further research in this area is warranted with a larger sample size.
Conflict of Interest
All authors declare no conflict of interest.
Funding
No external funding was obtained for this study.
References